New Composite Material

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Yesterday, I came across this press release from John Hopkins regarding a new composite material which may someday be used to restore damaged soft tissue.  (photo credit)

The liquid material is a composite of biological and synthetic molecules which is injected under the skin.  Transdermal light is then used to "set" the material into a more solid structure.

The results of the early experiments in rats and humans has been reported in the July 27 issue of Science Translational Medicine (full reference below).

It is hoped that the new liquid material is a biosynthetic soft tissue replacement composed of poly(ethylene glycol) (PEG) and hyaluronic acid (HA).

From the press release

"Implanted biological materials can mimic the texture of soft tissue, but are usually broken down by the body too fast, while synthetic materials tend to be more permanent but can be rejected by the immune system and typically don't meld well with surrounding natural tissue," says Jennifer Elisseeff, Ph.D., Jules Stein Professor of Ophthalmology and director of the Translational Tissue Engineering Center at the Johns Hopkins University School of Medicine. "Our composite material has the best of both worlds, with the biological component enhancing compatibility with the body and the synthetic component contributing to durability."

The researchers created their composite material from hyaluronic acid (HA), a natural component in skin of young people that confers elasticity, and polyethylene glycol (PEG), a synthetic molecule used successfully as surgical glue in operations and known not to cause severe immune reactions. The PEG can be "cross-linked"—or made to form sturdy chemical bonds between many individual molecules—using energy from light, which traps the HA molecules with it. Such cross-linking makes the implant hold its shape and not ooze away from the injection site, Elisseeff says.

To develop the best PEG-HA composite with the highest long-term stability, the researchers injected different concentrations of PEG and HA under the skin and into the back muscle of rats, shone a green LED light on them to "gel" the material, and used magnetic resonance imaging (MRI) to monitor the persistence of the implant over time. The implants were examined at 47 and 110 days with MRIs and removed. Direct measurements and MRIs of the implants showed that the ones created from HA and the highest tested concentration of PEG with HA stayed put and were the same size over time compared to injections of only HA, which shrank over time.

The researchers evaluated the safety and persistence of the PEG-HA implants with a 12-week experiment in three volunteers already undergoing abdominoplasty, or "tummy tucks." Technicians injected about five drops of PEG-HA or HA alone under the belly skin. None of the participants experienced hospitalization, disability or death directly related to the implant, which was about 8 mm long—or about as wide as a pinky fingernail. However, the participants said they sensed heat and pain during the gel setting process. Twelve-weeks after implantation, MRI revealed no loss of implant size in patients. Removal of the implants and inspection of the surrounding tissue revealed mild to moderate inflammation due to the presence of certain types of white blood cells. The researchers said the same inflammatory response was seen in rats, although the types of white blood cells responding to implant differed between the rodents and humans, a difference the researchers attribute to the back muscles— the target tissue in the rats—being different than human belly fat.

It will be interesting to watch how this develops.




REFERENCE
New Composite Material May Restore Damaged Soft Tissue; John Hopkins Medicine, August 1, 2011

Photoactivated Composite Biomaterial for Soft Tissue Restoration in Rodents and in Humans; Hillel AT, Unterman S, Nahas Z, Reid B, Coburn JM,  Axelman J, Chae JJ, Guo Q, Trow R, Thomas A, Hou Z, Lichtsteiner S, Sutton D, Matheson C, Walker P, David N, Mori S, Taube JM, and Elisseeff JH; Sci Transl Med 27 July 2011: Vol. 3, Issue 93, p. 93ra67; DOI: 10.1126/scitranslmed.3002331

Shark Skin &

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Did you happen to catch the CBS Sunday Morning piece by David Pogue  “How Shark Skin May Help Save Lives”? 

Turns out nothing grows on a shark’s skin.  Not barnacles.  Not bacteria.  This is why biomedical engineer Tony Brennan, University of Florida, is studying shark skin.

Initially, Brennan studied shark skin as a way to help the Navy solve the huge and expensive problem of barnacle buildup on their ships.

When he studied shark denticles under the electron microscope, he discovered why.

"I said, "Wow!, That shark pattern, I'd never seen it before,'" he said. And he believes that has something to do with no bacterial growth.

Brennan wondered if he could re-create the shark skin surface on plastic sheets.

"Sharks' denticles are set up like a diamond pattern," he said, showing Pogue a clear plastic sheet he called a Sharklet, which also had a diamond pattern. Its microscopic pattern of ridges mimics the denticles of shark skin.  (photo credit)

And when you stick it on ships, sure enough - NOTHING GROWS.

Dr. Shravanthi Reddy, director of research for Sharklet, is testing Sharklet to see if it can repel bacteria the way shark skin repels algae and barnacles.

Two pieces of plastic - one smooth, one patterned with Sharklet - are subjected to bacteria and incubated for 24 hours.

The electron microscope reveals the astounding results. The plain plastic is covered with a bacteria film - "Just these big clumps of bacteria all piled up on one another," Dr. Reddy said.

And on the Sharklet surface? "You might see one or two cells, but you don't see that big clumping the way you see it on the smooth surface," said Dr. Reddy. "What's really interesting is that there are no chemical differences between the surfaces. It's the same material. No differences, other than the physical shape."

If Sharklet really works, it could be used to cover many of the ordinary surfaces in a hospital and doctors office  -- bedside tables, door panels, stethoscopes, and as Dr. Reddy notes

"Those wristbands, have you ever seen anyone clean those wristbands?" said Dr. Reddy. "Never, right? And they're on the patient the whole time they're in the hospital."

As a way to fight community based MRSA and flu, it could be used to cover gym surfaces, desks in schools, play grounds.

The topic is to be explored further in tonight in the PBS "Nova" series, "Making Stuff."

Shout Outs

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. 

Captain Atopic is the host for this week’s Grand Rounds.  It’s a musical edition, “With a Little Help From My Friends.”  You can read this week’s edition here.

Welcome to another edition of Grand Rounds! This week, Grand Rounds 6:43 pays tribute to our friends, with a little help from Messrs Lennon and McCartney (with Ringo on vocals...)

What would you think if I sang out of tune,
Would you stand up and walk out on me.
Lend me your ears and I'll sing you a song,
And I'll try not to sing out of key.

……………………………………….

Thanks to @gastromom for the heads up on this NYTimes article:  Guns in Frail Hands

She is a 90-year-old widow with mild Alzheimer’s disease, and her son is begging her, for safety’s sake, to give up something she considers essential to her independence and sense of control.

“You can’t take it away from me,” she told him recently. “It’s all I’ve got.”

This may sound like a classic confrontation with an elderly mother who won’t give up her car. But it’s in fact about a loaded .38 caliber handgun that she keeps wrapped in a scarf in her top dresser drawer in a Southern California retirement community…..

Like cars, guns symbolize independence and individualism to many Americans. In states where gun ownership is a way of life, the elderly population is as likely as anyone to be armed and, in the view of many family members and professionals who care for them, possibly dangerous. ……………..

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Fellow med-blogger Sterile Eye has one of his photos in this Legions Magazine article by Sharon Adams:   Then And Now – Medical

From Carbolic Acid to Antibiotics

Today, nobody expects anyone to die of a broken leg, having a baby or from suffering a minor wound. But 150 years ago, these could be death sentences. Broken legs and wounded arms were often amputated, and nearly half of all amputees died. Childbed fever was the second most likely cause of death of women of childbearing age.

Infection was a major killer until Louis Pasteur discovered the connection between bacteria and disease in the mid-1800s. Some physicians like England’s Joseph Lister (yes, the mouthwash was named for him), embraced the idea of keeping patients’ environment—and their doctors and the equipment they use—clean in order to prevent transmission of germs. In 1865, Lister began spraying wounds, tools and the patient with carbolic acid to kill germs……….

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A tweet from @DrJenGunter:  “Study at UCSF looking to recruit moms carrying babies with spina bifida - http://tinyurl.com/3adz9of”

….. Recently, some doctors have started operating to close the defect during pregnancy, in hopes that protecting the spinal cord as early as possibly will minimize injury. However, it is really not known if it is better to operate on a baby with spina bifida during pregnancy or immediately after birth. The National Institutes of Health is currently enrolling pregnant mothers carrying a baby with spina bifida in a study called MOMS (management of myelomeningocele study) to answer that very question……

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ABC News’ Person of the Week this past week: Surgery on Sunday-- Doctors Give Free Health Care to the Uninsured

It's Sunday and Dr. Andrew Moore isn't taking a day off in his Lexington, Kentucky, neighborhood. Instead, he scrubs in and spends his day tending to a carpenter's torn ligament and removing another man's hernia. Moore does all of this for free.

Person of the Week Stan Brock has provided free health care for 25 years………..

Moore founded Surgery on Sunday in 2005. It's a nonprofit organization where doctors and nurses volunteer their services for free the third Sunday of every month, working in donated surgical space at Lexington Surgery Center.

Together, they are this week's "World News" person of the week……………

……………………………………

TBTAM has been interviewed by Womens Health.gov

I was privileged to be the featured interview this month at the Spotlight on Women's Health series at Womenshealth.gov, the website of the Office of Women's Health. Thanks to the editors for their thoughtful questions and  for the opportunity to speak to women about HPV, healthy living and, of course, cooking!

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I started another blog devoted only to my handwork:  Ramona’s Handwork.  I don’t want to loose my non-medical friends from this blog, but neither do I want to “frighten” them with images from some of my medical posts.  So if you only want to see my handwork, then please bookmark my new blog. 

………………………………….

Dr Anonymous’ BTR show will be on summer break until late August.

Upcoming shows (9pm ET)

7/29: Reports from 4th year Student Kevin Bernstein and 3rd year FamMed Resident Gerry Tolbert at 2010 AAFP Resident and Student Conference
8/5: Pre-Med Student Erin Breedlove
8/12: Pre-Med Student @InsaneMo
8/19: 4th Year Med Student @DrJonathan
8/26: Dr. A Show 3rd Anniversary

ASPS Task Force Updates Position on Fat Grafting

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I have written about fat grafting to the breast previously here and here. 

The Fat Graft Task Force of the American Society of Plastic Surgeons (ASPS) convened to try to answer the question of whether fat grafting compromises breast cancer detection and/or results in potentially catastrophic sequelae in patients?  Their conclusion:  there is no indication that fat grafting is an unsafe procedure with qualifications that more research is needed.

Sydney R Coleman, MD is quoted in the Cosmetic Surgery Times article, "In review of the multitude of evidence-based results of clinical trials, case series and reports, the Task Force found that there is no evidence that indicates that fat grafting is an unsafe procedure.  Nevertheless, the report did say that in order for the Task Force to make concrete recommendations for or against fat grafting for specific applications, high-quality randomized controlled trials would be needed to further evaluate safety and efficacy."

The following conclusions are from the February 2009 Task Force Report:

CONCLUSIONS
Clinical Applications
Based on a review of the current literature and a lack of strong data, the Task Force cannot make specific recommendations for the clinical use of fat grafts. Although fat grafts may be considered for use in the breast and other sites, the specific techniques of graft harvesting, preparation, and injection are not standardized. The results therefore may vary depending on the surgeon’s technique and experience with the procedure. Although there are little data to provide evidence for long-term safety and efficacy of fat grafting, the reported complications suggest that there are associated risks. Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting. There is a potential risk of fat grafts interfering with breast physical examination or breast cancer detection; however, the limited data available suggests that fat grafts may not interfere with radiologic imaging in detecting breast cancer.

Future Research
The Task Force believes autologous fat grafting is a promising and clinically relevant research topic. The current fat grafting literature is limited primarily to case studies, leaving a tremendous need for high-quality clinical studies. While this evidence-based review resulted in few, if any, new data that would prompt a substantial change in the current state of fat grafting, the lack of new information poses two important questions: (1) are current methods of fat grafting still the "gold standard," or (2) is more research needed and should funding be directed toward new studies? For many aspects of fat grafting, the Task Force found the latter to be true and has
suggested the following areas for future research:

• Randomized controlled trials to assess safety and efficacy of fat grafting for different indications
• Randomized controlled trials to assess safety and efficacy of specific fat grafting techniques
• Studies to further assess the effect of fat grafting on breast cancer detection and treatment.
• Studies to identify risk factors and improve patient selection for procedures involving fat grafting.
• Studies to investigate aspects of cell/tissue viability and graft survival, as well as long term storage and banking of fat grafts.
    

REFERENCES
ASPS' Fat Graft Task Force updates position on safety of autologous fat grafting; Cosmetic Surgery Times, Aug 1, 2009; Ilya Petrou, MD
Current Applications and Safety of Autologous Fat Grafts: A Report (pdf); American Society of Plastic Surgeons; Feb 2009
Fat Transfer/Fat Graft and Fat Injection:  ASPS Guiding Principles (pdf); January 2009


Related Posts

Fat Injections for Breast Augmentation (November 6, 2008)
Complications After Autologous Fat Injections to the Breast – an Article Review (April 2, 2009)
Recent NPR Stories on Plastic Surgery (June 3, 2009)

Scar-free surgery?

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

H/T to MedGadget for bring this research to my attention.  Wow!  I know it is not ready for primetime, but still – wow!  Currently, this isn’t the case (no scar-free tummy tucks or facelifts), but the possibility may exist in the future.

Michael Berger over at Nanowerk profiles the work of Japanese scientists who created adhesive ultrathin "nanosheets" which are able to bind tissue together.  Their goal was to create a material that can help avoid suturing or stapling of fragile tissue during surgery.   (photo credit)

Shinji Takeoka tells Nanowerk. "We found that our ultra-thin PLLA nanosheet has an excellent sealing efficacy for gastric incision as a novel wound dressing that does not require adhesive agents. Furthermore, the sealing operation repaired the incision completely without scars and tissue adhesion. This approach would constitute an ideal candidate for an alternative to conventional suture/ligation procedures, from the perspective not only of a minimally invasive surgical technique but also reduction of operation times."

Takeoka and colleagues have published their findings in a recent paper in Advanced Materials ("Free-Standing Biodegradable Poly(lactic acid) Nanosheet for Sealing Operations in Surgery").

My First Research Experience

Updated 3/2017--photos and all links (except to my article) removed as many are no longer active and it was easier than checking each one.

Dr Cris, Scalpel's Edge, will be hosting SurgeXperiences on August 31, 2008, and has asked for a "research bent" post. I must admit I have not done much research during my training or in practice. Between my first and second years of medical school (summer of 1979) I had the opportunity to work in the Biomedical Research Division at Ames Research Center, Moffett Field, California. It was my chance to work for NASA and I took it! I didn't have good enough eyesight to be an astronaut (very near-sighted), but I could have a small brush with them. Well, not really, I never meet any astronauts.

I spent that summer helping collect data for an anti-gravity experiment. The experiment was to try to

determine whether a different body position during bedrest (BR) could induce physiological responses that would be closer to those observed after exposure to weightlessness.

I helped collect and enter data -- age, height, weight, BSA, body fat, heart rate, systolic blood pressure, etc. I helped in lower body negative pressure testing. The findings from the study were:

1)BR resulted in a general decrease of exercise tolerance in both groups
2) the negative 6 degrees BR appeared to simulate the effects of weightlessness more effectively than horizontal BR when comparable space flight data were presented.

I enjoyed my summer and got my name on my first published paper.

Effects of antiorthostatic bedrest on the cardiorespiratory responses to exercise; Aviat Space Environ Med. 1981 Apr;52(4):251-5; Convertino VA, Bisson R, Bates R, Goldwater D, Sandler H.

New Nerve Reseach

This information is from the Lahey Magazine Summer 2008 Edition, pp 6-7. Only part of it is reprinted here. The entire article can be read here (pdf file).

Led by David J. Bryan, MD—an MIT-Harvard lecturer and specialist in hand surgery and microsurgery in Lahey’s Department of Plastic and Reconstructive Surgery—the team recently presented results from original research on the use of tissue-engineered conduits in peripheral nerve (sciatic nerve) models. The study, funded by a grant from longtime Lahey benefactor Leisa V. Clayton, demonstrated that artificially engineered nerve tissue can perform as well as, and possibly better than, standard live-tissue nerve grafts in restoring lost peripheral nerve function.

The current standard of care calls for using live nerve tissue taken from other parts of the body. According to Bryan, autologous (self-donated) nerve grafts have limitations in terms of availability, side effects—mainly loss of sensation in the donor site—and clinical effectiveness. To overcome these challenges, the Lahey team collaborated with an outside engineering group to create a custom-made, bioengineered blend of synthetic polymers and proteins using sophisticated spinning equipment.

Electrospinning—an application of the emerging field of nanotechnology—allows researchers to create minute quantities of a desired cellular fiber for use in peripheral nerve tissue grafts. The artificial material created at Lahey has all the desired qualities needed for the ideal nerve graft: biocompatibility, porosity, biodegradability and the ability to promote growth of new blood vessels in damaged nerve tissue. Bryan reports that nanotechnology has allowed his research team to make great strides in understanding how nerve cells communicate, grow and regain function. Proteins—organic compounds that play a vital role in all basic cell processes—are the key to understanding the inner working of nerve tissue, he explains. Looking to the future, Bryan is extremely excited about the emerging field of proteomics, the study of proteins in living cell tissue.

Amputations, Prosthetics, and War

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Chris' request for "your impressions of the effect of war on surgery, of surgery on war, ...." for the next SurgeXperience is the source of inspiration for this post.

I have never been in the military so I have no direct experience. My father (see picture at right, died in 1966) was in the army. He was an orthotist, a specialist in designing and fitting orthopedic braces. I think my father would be absolutely amazed by the advances in the field. I know I am.

Prosthetists, on the other hand, specialize in designing and making artificial limbs. Wars through the ages have greatly influenced the need for and design of artificial limbs. This has been true for both the upper and lower extremities.

Amputation surgery is one of the oldest known surgically performed procedures. The surgical principles originally described by Hippocrates remain true today. There have been refinements of surgical technique such as hemostasis, anesthesia, and improved perioperative conditions have occurred. You can find a nice review of the history of amputation surgery here. Here are some of the highlights:

• 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

Even without war, there are amputations that occur due to trauma and disease (mostly peripheral vascular disease, but also cancer and infection). This graft is from the National Limb Loss Information Center Fact Sheet, revised 2006.

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)

Post-amputation, assuming wound healing is going well, then it becomes important to train the patient to perform ADL and ROM exercises and to improve strength and mobility. Prevention of contractures is important. During this time, a program to prepare the residual limb for the prosthesis should be initiated. A skin desensitization program (both upper and lower extremities)consists of the following:

• 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

A rigid, removable dressing may be used over the residual limb during this phase. The rigid dressing serves the following functions:

• 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

Prosthetics

Ideally, a prosthesis must be comfortable to wear, easy to put on and remove, light weight, durable, and cosmetically pleasing. A prosthesis must function well mechanically and require only reasonable maintenance. Prosthetic use largely depends on the motivation of the individual, as none of the above characteristics matter if the patient will not wear the prosthesis. The second and third reference articles are good discussions on the various types of prosthetics.

Some history of prosthetics I found in various articles:
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.

300 B.C.

• 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.

During the Middle Ages and the Renaissance

• 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.

In 1917, the Artificial Limb Manufacturers and Brace Association was formed. It has evolved into the American Orthotic and Prosthetic Association (AOPA -- a trade association of companies in O&P).

Antipersonnel mines (landmines) were first used on a wide scale in World War II. Since then they have been used in many conflicts, including in the Vietnam War, the Korean War, the first Gulf War. Precursors of the weapon are said to have first been used in the American Civil War in the 1800s.

In 1945, the National Academy of Sciences established the Artificial Limb Program in response to the plight of WWII amputee. Much emphasis was placed on investigating the movement of normal human limbs so that prostheses could be designed to appear as life-like as possible.

1946 - Suction socket and patellar tendon-bearing prosthesis

In 1952, the National Research Council Committee on Prosthetics Research and Development led officials at the VA to conclude that a totally new service delivery system for artificial limbs was required to assure the highest quality of functional gain for limb-wounded veterans. To implement this, special training programs were set up at NYU and UCLA to bring in limb-fitting personnel for an intensive 12-week training course that led to certification for applications of the new technologies to VA standards. On completion of the course a "limb fitter" became a Certified Prosthetist, a status subsequently required by the VA for reimbursement of services to veterans. The program continued for more than two years until the national need was met. The information was later transferred to various medical school prosthetics and orthotics training centers throughout the world. [It is my understanding that UCLA was teaching upper extremity prosthetics, and NYU lower extremity prosthetics.  The American Board for Certification in Orthotics and Prosthetics was founded in 1948.  "Certified Prosthetist" is registered to ABC. --personal correspondence with Al Pike, CP)

 

1950's -- RGP initiated the use of fiberglass materials
**"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) 

In the 1980's-- Companies began to turn away from fiberglass and begin to the use of flexible, thermoplastic materials which reduce the weight of the prosthesis and maximize comfort. The two piece socket design has given amputees a more freedom of movement and energy than before. The custom, total-contact, suction design has practically eliminated pistoning in the socket, increased stability and the ability to maximize energy storing potential. 

**Fiberglass along with carbon fiber are still used today to make light, one piece sockets for prostheses. (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,”

Currently, Landmines World-Wide

• 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)

Currently, January 2008--Sports
I am amazed by this story. It shows just how far prosthetics have come. Maybe we are getting to the "Six Million Dollar Man".

South African double amputee Oscar Pistorius, who runs with carbon fibre blades attached to his legs, will not be allowed to compete in Beijing.

A report commissioned by the International Association of Athletics Federations says the prosthetics used by Pistorius gave him an advantage over other runners.

"Pistorius was able to run with his prosthetic blades at the same speed as the able-bodied sprinters with about 25 percent less energy expenditure," the report concluded.

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.

Motion Control, Inc.

• 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."

OSSUR

• 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.

Endolite

• 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.

Ohio Willow Wood

• 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.
REFERENCES
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)

Spit for the Cure

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

The local Susan G Komen Race for the Cure is this Saturday in Little Rock, AR. The University of Arkansas Medical Sciences (UAMS) is using the event to collect saliva samples from thousands of women. The samples will be used to used to create a DNA database for future studies related to breast cancer risk and treatment. Participants in "Spit for the Cure" will be asked to answer a short questionaire. All information is to be kept confidential and the samples are to be labeled by number not name. The leading researchers are Susan Kadlubar, PhD, assistant professor of environmental and occupational health in the UAMS College of Public Health, V. Suzanne Klimberg, M.D., director of the breast cancer program at the UAMS Winthrop P. Rockefeller Cancer Institute (formerly the Arkansas Cancer Research Center), and Kristy Bondurant, Ph.D., postdoctoral fellow. (photo credit)

“It has become clear that an individual’s inherited profile and environmental exposures will decide, to a large degree, that individual’s risk of developing breast cancer. We are working to obtain DNA samples from a representative group of Arkansas women that will be used to advance breast cancer research in a variety of areas.” Suzanne Klimberg, MD

A rare chance to spit in public and it be sociable acceptable.
Trail Manners by Wendy Bumgardner
Manners and Etiquette in the Antebellum South