Wednesday, February 13, 2008

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 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.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

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

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."

  • 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.
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.
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)

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)


HP said...

A very interesting read. Will be back to read more. Many thanks for visiting my blog. Loved the Matisse quilt.

rlbates said...

Thanks so very much.

Unknown said...

Whew, Ramona you have my head spinning,

so many links and so much info!

I read a memoir last year about a young woman with a prosthetic leg and MUCH about it stays with me, about her own experiences as a person minus a part plus how unregulated and kind of random getting prosthetic limbs seems to be... if new to you to, check out Emily Rapp's "Poster Child: A Memoir".

Øystein said...

Very interesting!

I'm currently filming a lot of surgery for osteosarcomas, which, mostly as a last resort, include amputation.

Love all your articles btw. They both give a good overview and in-depth understanding!

rlbates said...

Thank Laundress and SterileEye. I learn so much writing these posts. Thanks the info on Emily Rapp. I'll check it out.

T. said...

Dr. Bates, this is a totally fantastic tour de force. Thank you!

I'm so glad too that you featured Pistorius. I've seen another person who wears a similar type of device, I think her name is Amee Mullens - also an athlete.

Your articles are a joy to learn from.

rlbates said...

Thank you T. I often worry that I "get carried away". Thanks

Doctor David said...

What a great post! Though I'm not a surgeon and don't take care of trauma patients, I do have several who have had amputations for osteosarcoma. The results I've seen are remarkable. My favorite is the 17 year old who was so devastated when we first talked about amputation and now dances in her school dance troupe and is taking up tennis! And the improvements continue: This article in last week's issue of Science discusses a "biomechanical energy harvester" to help power medical prosthetics ( Maybe the Bionic Man really is within reach.

rlbates said...

Dr David, that young girl must have a wonderful spirit!!!

Doctor David said...

She's an amazing kid! They all are, actually. Another amputee I care for did stand-up comedy in NYC during college and is now a webmaster. Another is the mother of 3 kids, one of whom also has cancer. None of them have ever let their "disability" slow them down!

Øystein said...

Here is a site with instructional videos of some lower extremity amputations.

rlbates said...

Thank you SterileEye!

Novastar said...

I was doing a project on Prosthetics and this helped a lot! Thank You

Novastar said...

I used this in a school project, it was very helpful! Thank You and I have cited you properly.