Modern research and the forgotten prosthetic history of the Vietnam war

Abstract

Clinicians and researchers have become aware that achieving normal anatomical adduction of the femoral remnant is an important objective in transfemoral amputation surgery [1-3]. Achieving anatomical adduction has also been a long-established design goal of the transfemoral prosthetic limb [4-11]. The rationale for attaining normal anatomic adduction in the transfemoral amputee is to provide pelvic stabilization [4-6], provide efficient rest-length action of the abductor muscle group [4,8], and reduce the lateral motion of the center of mass of the body, thus producing a smoother and more energy-efficient gait [3]. The degree to which the prosthetic socket can influence the position of the femoral remnant has been disputed. The promotion of surgical stabilization of the through myodesis has been presented on the basis that the prosthesis does little to influence adduction [1-3]. * In 1989, the concept that socket shape and alignment do not affect the position of the femoral remnant in transfemoral amputations was introduced into the body of prosthetic thought. In their research article, Does socket configuration influence the position of the in above-knee amputation? Gottschalk et al. concluded from observations of 50 weight-bearing X-rays of transfemoral prosthetic sockets that no amount of lateral pressure can change the position of the femur and stated the belief that proper anatomical adduction is achieved through specific applied surgical techniques [1]. The sockets X-rayed in Gottschalk et al.'s study comprised both quadrilateral and ischial containment socket designs, and measurements revealed a reported average of 2[degrees] of abduction for all sockets surveyed. In 1989, the contention that socket shape and alignment do not influence the position of the femoral remnant was hotly debated at presentations at the annual meetings of the American Academy of Orthopaedic Surgeons (AAOS) and American Orthotic and Prosthetic Association (AOPA) [1,12,13 (p. 2)]. As of 2009, with numerous meeting presentations having been given and accepting literature having been published [14-15], the debate has cooled considerably. * Two publications from the 1970s, which resulted from an checkout protocol adopted by Fitzsimons Army Medical Center (FAMC) (Figure 1) after the end of America's military involvement in Vietnam, suggest that Gottschalk et al.'s conclusion is incomplete. The publications, as they exist, can be arguably dismissed and were not cited in Gottschalk et al.'s 1989 research. They comprise a two-page technical note in a 1975 prosthetics journal [9] and an abstract published in 1977 [16]. Combined, the publications are slightly more than 1,000 words. However, they serve as provenance for a collection of recently recovered documents related to FAMC's checkout of the transfemoral limb. These previously unpublished documents indicate that femoral adduction was improved, as per clinical practice, with intervention during prosthetic limb manufacture. These documents, gathered from private collections and presented in a special section of the Orthotics and Prosthetics Virtual Library, the FAMC Institutional Memory Preservation Project (http://www.oandplibrary.org/famc/), suggest that our understanding of the relationship between alignment, socket design, and femoral adduction requires further research. [FIGURE 1 OMITTED] The first published reference to FAMC's use of roentgenograms occurs in the second sentence of Long's Allowing normal adduction of in above-knee amputations, which appeared in the December 1975 issue of Orthotics and Prosthetics. Long wrote, X-ray studies carried out at Fitzsimons Army Hospital since March 1974 show that very few above-knee prostheses built in the United States today achieve proper adduction of the femoral stump [9]. It is of interest that the data from Gottschalk et al.'s research support that observation; the divergence and controversy emerge from the conclusion from that data. …