Developments in the 20th Century

Most sockets were made of block leather tightened by lacing or carved in wood until Marcel Desoutter, an above-knee amputee as a result of an aeroplane accident, was stimulated to manufacture, in cooperation with his brother Charles, an aeronautical engineer, a lighter prosthesis of sheet aluminium in 1912, the first successful light metal prosthesis (Fig. 13.13).31 This design was followed by the Hanger aluminium limb for above-knee prostheses, leading to their almost universal adoption in Britain by the mid-20th century. For above-knee amputees, Desoutter introduced limb suspension with a freely mobile pelvic joint superior to previous suspension from the shoulder. Hanger's similar pelvic suspension depended on active movement of the stump to introduce more-positive control than was possible by shoulder suspension alone. Pelvic suspension also led to modern knee control mechanisms including the knee brake which improved efficiency and grace in walking for above-knee amputees.

World War I proved a turning point in the provision of improved artificial limbs, free of charge, for the vast numbers of young military amputees hoping to return to employment despite mutilating war injuries. Before this war, Little concluded that amputations were comparatively rare operations in Britain, quoting figures at one London hospital in 1913, where of 5483 major operations performed only 34 were amputations. By contrast, as a result of World War I, official British statistics recorded 41,300 surviving military amputees of which 72.5% involved the lower extremity.32 Of these, 24,000 attended Queen Mary's Hospital, Roehampton, which became a national centre for prosthetic provision and continues in the 21st century; smaller centres were established elsewhere in Britain. This vast volume of work finally drew together limb-fitters who cooperated with each other and, more importantly, compelled surgeons to consider the opinions and expertise of limb-fitters and limb-makers to the benefit of patients' interests rather than their own narrow focus on surgical detail. Similar cooperation was achieved in the United States where Thomas and Haddan stated that before World War I:

"... the limbmakers in this country, as in all others, were an unorganised group of rugged individuals, each going his own way, rarely speaking to his competitor, and much less consulting with him. There was little or no cooperation between the limbmakers and surgeons .. ."33

In October 1917, the Surgeon-General of the U.S. Army issued an invitation to all limb-makers to meet in Washington and discuss the problems of supplying prostheses to war veterans. Thomas and Haddan believed this meeting contributed more to the development of prosthetic science than any preceding event, laying foundation to the Association of Limb Manufacturers of America, with increased cooperation and research between limb-makers, brace-makers and surgeons to the mutual benefit of amputees. This collaboration strengthened in World War II when, in 1944, the National Research Council of Canada hosted an international conference on amputation and artificial limbs, attended by representatives of many allied nations, with far-reaching scientific results as well as stimulating agencies to provide prostheses for those unable to purchase them.33 In the United Kingdom, the formation of the National Health Service in 1946 also ensured a completely free service of prosthetic provision and of any revision surgery. In 1953, Gillis calculated that of Britain's 35,343 amputees due to war injuries, 23,740 (67%) were from World War I or before and 11,945 (33%) from World War II, including civilians.34 He commented:

"The making of artificial limbs has a long history, most of it, unfortunately, very scantily recorded... there is no doubt that the improvement in limb-fitting and limb-making which has been the feature of the last 50 years has been due to the close integration of surgical and mechanical skill. This is not to say there is room for complacency. There is still much to be learned and much to be done."35

Vitali et al. observed that since World War II a scientific and technological explosion had taken place, leading to major changes in prosthetic design throughout the world, owing much to the introduction of plastics enabling accurate reproduction of sockets made from these light materials. They added:

"The Committee on Prostheses, Braces and Technical Aids of the International Society for the Welfare of Cripples (later to become the International Society of Prosthetics and Orthotics), together with the International Association of Orthotists and Prosthetists, have promoted the speedy exchange of information internationally. As a result surgeons and therapists are better informed and the modern prosthetist is not just craft-trained at the bench but technically trained, using techniques and devices from many countries."36

They also noted that until about 1960 most artificial limbs were exoskeletal, that is,hollowed to receive the stump with an external body shape which also bore weight in the case of the leg or the forces of arm movement, fundamentally little changed for centuries. Since 1960, most limbs have become endoskeletal with a central post for weight-bearing or arm actions, combined with a cosmetic cover of light material such as plastic, carbon fibre and composite materials (Figs. 13.14 and 13.15) and, in some instances, the use of pneumatic (gas) and electric control devices. At the same time, stimulated by these evolving prosthetic advances, amputation procedures have been revised or old procedures have been reintroduced. Thus, ankle and knee joint disarticulations, previously disapproved by prosthetists for difficulty in fitting, are now endorsed thanks to the use of lateral skin flaps, modern prosthetic materials and a four-bar linkage knee joint. For above-knee amputation, the long posterior skin flap of Verduin, first introduced in 1695 (see Chapter 6),is now back in favour, as is the reattachment of muscles over the bone end to improve the stump's power and also its vascularity.

Since the 1960s, the advantage of patellar tendon-bearing sockets for below-knee amputations has resulted in the abandonment of thigh corsets and, after hip disarticulation the introduc-

1912 Aluminium Made Prosthetic

Fig. 13.13. Desoutter light aluminium prosthesis for short thigh stumps with pelvic supporting band and, originally, a fixed ankle but later given some movement with rubber buffers, c. 1912. (From Little EM. Artificial Limbs and Amputation Stumps: A Practical Handbook. London: Lewis, 1922: fig. 217.1)

Fig. 13.13. Desoutter light aluminium prosthesis for short thigh stumps with pelvic supporting band and, originally, a fixed ankle but later given some movement with rubber buffers, c. 1912. (From Little EM. Artificial Limbs and Amputation Stumps: A Practical Handbook. London: Lewis, 1922: fig. 217.1)

tion of weight-bearing on the ischium, with a socket embracing the whole pelvis, has removed the need for massive body harnesses. With respect to artificial arms, Vitalli et al., in 1986, considered recent improvements were minor although socket fitting had improved with electric and myoelectric controls which, nevertheless, were still in their infancy whilst further work, to improve sensory feedback as well as mechanics, was much needed.37 They concluded:

"Amputation, in which speed and skill used to be a matter of pride, had come to be regarded by many surgeons as a sign of failure and a last resort to be avoided if possible. Now most amputations are by surgeons who use amputations as the treatment of choice when it is indicated, representing a major change of attitude towards the procedure." And: "The science and art of amputation and prosthetics have changed and are continuing to change. There is reason to believe that the future will see further advances leading to changes in amputation surgery, socket configuration and controls."3

A decade later, Murdoch and Wilson claimed their book Amputation: Surgical Practice and Patient Management was firmly focussed on the operating surgeon,yet it also illuminated the latest research and expectations of artificial limbs. Drawing together the experience of some 35 authors of many disciplines, from Europe, the United States and Canada, they insisted no surgeon should amputate without a full understanding of the biomechanical and prosthetic factors consequent to his surgery.39 In a brief historical introduction, emphasising the important stimulus of World War II and its war veterans in the United States, they praised the work of the Committee on Prosthetics Research and Development of the National Academy of Science who had formed teams of orthopaedic surgeons, engineers and prosthetists in various parts of the country and in Canada, assigning each with specific tasks to improve the life quality of amputees. The Committee urged:

"Surgical techniques were considered as much a part of the programme as development ofdevices because it was soon realised that the function of the prosthesis could be no better than the function provided by the stump."10

In 1963, Weiss of Poland described methods of measuring the effects of myoplastic surgery for revised stumps and, incidentally, drew attention to walking mobilisation of patients the day after surgery, using rigid dressings and temporary pylons. As a consequence, myoplasty and osteoplasty were given greater worldwide significance in managing peripheral vascular problems, enabling both the knee to be saved more frequently and early mobilisation encouraged, all of which resulted in a complete reversal of the former ratio of three above-knee amputations for one below-knee amputation in the United States by the early 1970s. At the same time, encouraged by the work of Brand with leprosy patients, foot infections were treated more conservatively, preserving all practical length, applying rigid dressings and prescribing special shoes.41 Further progress related to Syme's

Disarticulation
Fig 13.14. Sprinting amputee on Otto Bock design leg, after knee disarticulation. (Copyright of Dorset Orthopaedic Co. Ltd.)

ankle disarticulation which had fallen out of favour in many countries, but not in the United States, Canada or Scotland, largely because of ungainly prostheses for stumps considered too long for an ankle joint,despite their capacity to weight-bear. By employing new plastic laminates,prostheses developed in the United States and Canada became lighter, stronger and greatly improved in appearance, with the result that Syme's amputation has become more widely undertaken. Knee disarticulation has followed a similar course,being revived by replicating knee movements with the innovative Orthopaedic Hospital, Copenhagen (OHC) pros thesis which places the centre of knee rotation into the shank of the prosthetic limb,hence eliminating the former bulky "outside" knee joint. As a result, both knee disarticulation and low femoral amputations are more acceptable and,moreover,the longer stump provides stronger and more efficient movement control than the shorter conventional mid-femoral section.41

Despite evident progress in the 1980s,The International Society for Prosthetics and Orthotics complained many improved techniques were still woefully lacking in even sophisticated surgical circles, as Murdoch and Wilson explained in 1996:

"... most of the amputations are done by surgeons as a life-saving measure, who see only a few patients a year, have little contact with prosthetists and do not realize the importance of the stump as an organ of locomotion and its relation to the ability of the amputee to obtain maximum use of the prosthesis."41

Despite these comments, supraspecialisation continues to flourish, and it is likely more amputations in the future will be conducted by surgeons trained in the biomechanics of prosthetic design. Further, academic research by biomedical engineers employing gait analysis, load measurements and computer-aided design have contributed new concepts and more-efficient prostheses, whilst amputees themselves are more informed and capable of pressing for personal solutions to particular problems. Growing involvement of the disabled in sports activities and particularly the stimulus of the Para-Olympic Games have created active, competitive amputees who participate in athletic events, seeking the most efficient prosthesis available for successful competition. Today, microprocessors in the Otto Bock 'C' Leg can monitor and control artificial knee movements 50 times a second, enabling the stability and swing action to adapt in response to weight-bearing activity (Fig. 13.15). Amputee sprinters have achieved remarkable times with such prostheses specifically adapted for running (Fig. 13.14) but need another prosthesis for normal walking activity and yet another adaptation for cycling. With respect to hand prostheses, sensory feedback has always proved elusive but ongoing research, in various centres, expresses hope of achieving a robotic hand with sensors stimulating nerves in the stump to elicit sensory motor control of the prosthesis.

Fig. 13.15. Otto Bock leg mechanism. (Copyright Otto Bock UK.)

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Responses

  • Esmeralda
    How did 20th century prosthetic arms close hands?
    1 year ago
  • Alistair McKenzie
    How were prosthetics developed in america during the 20th century?
    11 months ago

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