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CHAPTER V - Below-Knee Amputations
LONG TIBIAL STUMPS. - An amputation at any point above the ankle and below the knee produces a tibial stump, so termed by the surgical profession, because the tibia or shin bone has partly been saved.

ENLARGED NON-END-BEARING. - Cut E 1 illustrates a stump reaching close to the ankle joint. The extremity, as is usual in long stumps, is poorly protected and incapable of bearing pressure, and, on account of a slight enlargement at the end, an artificial leg must be made so that the stump can be placed in the socket from the front or rear instead of being inserted at the top. Cut E 2 represents an artificial leg especially adapted to stumps of this description; it is shown applied and the wearer seated. It has a socket that incases the rear half of the stump, with a front of leather that can be laced. The rubber foot with spring mattress is constructed as described in Chapter II, and at the top of the socket are steel joints connecting the thigh supporter. The fitting of the leg avoids any weight or pressure on the extremity of the stump or near the end, and no pressure is applied at any point below the junction of the middle and lower thirds. Above this it is graduated to the knee, where the greatest amount of pressure is applied, the interior sloping surface below the knee carrying most of the weight. The anterior prominences of the shin bone and the exterior prominence of the fibula are given ample room, so that no contact is applied; the interior sloping surfaces below the knee carry most of the weight, the supporter above the knee carrying its share.

NO PRESSURE AT THE POPLITEAL SPACE. - It is most important to avoid pressure at the back of the knee in long stumps. The popliteal space is the vascular area of the leg, and any undue pressure will interfere with the circulation and impoverish or strangulate the end of the stump.

The absence of ankle articulation in a leg for a long tibial stump affords an opportunity to give ample space for the end without visibly increasing the external dimensions of the ankle. The rubber foot with spring mattress and yielding heel and toe provides every requisite for easy, lifelike, and noiseless walking without complicated connections. The absence of such connecting parts avoids the necessity of making the leg an inch or two longer than the natural one as is often necessary to obtain space for ankle mechanism used in other systems.

Artificial legs with wooden articulating feet for stumps that reach to any point in the lower third of the leg are impracticable. The ends of long tibial stumps are sensitive, easily irritated, and poorly nourished, and the slightest contact will cause abrasion, frequently necessitating reamputations.

TAPERING STUMPS. - Cuts E 3, E 4, E 5, and E 6 illustrate long tibial stumps. Legs for such amputations must be constructed so there will be ample room for the extremities. In other words, the ends are suspended in space. As these stumps are tapering to the ends they can be inserted from the tops of the sockets. The socket is hollowed out near the bottom of the heel and an abundance of room provided, allowing a wholesome circulation of air; the exterior diameters of the leg are not large enough to be conspicuous. The leg socket and foot core are made of a single piece of wood carved from a naturally curved stick, the grain of which follows the lines of greatest strains. The rubber foot is attached to the core in a substantial way, and the leg is finished so the exudations from the extremity of the stump will not cause damage to the wood.

Cuts E 7 and E 8 show sectional views of a leg for a long tibial stump as described. The lines in the socket and core represent the grains of the wood, which follow the curves of the instep, securing great strength with little material. This method of construction admits of excavating the socket well into the foot so as to provide ample air space. Substantial legs for such stumps cannot be made with ankle articulations, for cords, springs and bolts require space needed by the stumps. As metal becomes corroded by the exudations of the stumps, wood is the only material which will withstand these destructive agencies.

ORDINARY AND SHORT TIBIAL STUMPS. - No difficulties attend the fitting of an artificial leg to a tibial stump reaching to any point between the junction of the middle and lower thirds and the knee, when the knee joint is mobile to not less than two-thirds of the normal range. Cuts E 9 to E 16 are typical below-knee stumps of a variety of lengths and conditions relative to flaps, cicatrices, etc. The location of the cicatrices and the character of the flaps have little importance in non-end-bearing stumps.

ARTIFICIAL LEG FOR TIBIAL STUMP. - A leg suitable for a stump of two inches or more in length, with the knee articulating through a range of 90 degrees or more, is shown in Cut E 17. Cut E 18 shows it applied with the wearer standing. Cut E 19 shows it with the wearer seated. The action of the knee joint is clearly presented.

CONSTRUCTION. - The leg consists of four parts: the foot, the leg, which fills the space between the foot and the knee; the knee joints, and the thigh piece or that part that incases the natural thigh. As the foot has been explained in Chapter II it now remains to describe in detail the other parts.

SOCKET. - The socket that receives the stump is made from willow or basswood, which is excavated to accommodate the stump. Bearings are permitted at places of toleration. No pressure whatever is put on the vascular parts of the stump or on sensitive or prominent bones. The end of the stump is usually required to hang free in space. The exterior of the leg is shaped to as near the natural form as the stump will admit. It is strongly banded and covered with raw hide to obtain strength. The surface is enameled with a waterproof preparation having a soft flesh tint. Knee joints are of the ginglymoid pattern, and as recently improved have very durable wearing surfaces. The thigh piece is made of substantial leather shaped to the contours of the thigh.

KNEE CONNECTION. - Cut E 20 represents the upper section of the leg and lower section of the thigh piece, with the knee joints disconnected at their articulations; aa are the screws that hold the bolts bb in place; cc are the bushings that work on the bolts and receive the wear; a lacing is used to regulate the action of the knee. The mechanical parts of the knee joints are completely illustrated in Cut E 21.

STEEL JOINTS. - Side joints, sometimes called hinge or ginglymoid joints, are used in legs for amputations below the knees. They are more durable and substantial when one of the parts is placed between the lips of the other and the two connected with bolts and screws.

It is unmechanical and not lasting to place one section of a joint by the side of the other, holding them together by a screw, as is done by some manufacturers. Such joints wear irregularly sidewise and have a wabbling motion after limited service. This would not occur if the lateral strains on the upper sections could be kept the same at all times; but lateral pressure, causing unequal wear at the bearings, is brought about by contracting the thigh by lacing, in order to compress an emaciated thigh or distending it to accommodate an enlarged one. These difficulties are only avoided by having one of the elements of the joints work between the lips of the other.

The greatest wear on any joint is on the bolt that holds the parts together, and as the attrition is the greatest when the wearer’s weight is directly over the knee and becomes less as the knee is flexed, the bolt must necessarily wear irregularly. As the wearing surface on the bolt was formerly limited to the thickness of the section that worked on it, the wear was necessarily very rapid.

The object of the improved joint is to increase the wearing surface as much as possible and to make the wearing parts independent and removable. They can then be highly tempered and the non-wearing parts left untempered, so that the supporting parts will not become friable.

The wearing surfaces are increased more than double. They cover the entire surface of the bolt, and the inferior surfaces of the holes in the lips of the lower part. Cut E 21 shows the mechanism very clearly. AA is the upper part; BB the lower part; C is a long bushing which passes through the two lips of the lower part and the one of the upper; the lug D holds the bushing immovably fixed to the upper part. The bolt B passes through the long bushing and becomes immovably fixed to the lower part by means of a stop pin, which is fastened to the hub of the lower part, and fits a recess made in the head of the bolt. The screw A holds the bolt in place and clamps the joint.

A glance at the section, Cut E 22, will show how these parts work together. Every movement of the joint causes the long bushing to revolve about the surface of the bolt and in the lips of the lower part. This mechanism prevents any wear from taking place on either the upper or lower parts, and distributes what does take place over the entire area of the bolt. The bushing and bolt are made very hard, and can be removed and replaced with new ones at any time that may be desirable. Cut E 23 shows a side view of the entire joints and ready to be attached to the leg.

TEST. - A pair of these joints, subjected to a practical test equivalent to that of being worn by a man weighing two hundred pounds, walking an average distance of three miles every day for six consecutive years, failed to develop sufficient wear to cause noise. The joints are made from the most suitable steel, forged from solid material faced and slotted with absolute accuracy, drilled, reamed, and countersunk in templates, the parts being fitted to a nicety and thoroughly tested before being placed on a leg.

THIGH PART. - The thigh part of the leg is made of durable oak-tanned russet leather, formed to the shape of the thigh, and suitably lined inside. There are several methods by which it is made to compress the thigh; buckles and straps are sometimes used; metallic clamps are occasionally preferred; but the greatest number of limb-wearers find the lacing method the most satisfactory, as it permits uniform adjustments and is neat and durable.

LACING METHODS. - Cut E 24 shows the double-eyelet method. A row of eyelets is placed on each front edge, and a strong buckskin lacing passed through them. This method has been in vogue for many years and is still preferred by many wearers.

Cut E 25 shows the lacing system more generally used at the present time. A row of hooks is placed on one edge and a row of eyelets on the other. On removing the leg the loops of the lacing are simply slipped off the hooks, the string remaining in the eyelet holes. When the leg is put on, the loops are put over the hooks and the cord is tightly drawn. Some wearers wish hooks on each edge the same as on shoes. When this is wanted it should be specified in the order.

Cut E 26 shows a device for rapid application. A row of studs is placed on one edge of the thigh piece, and a row of eyelets on the other; a separate piece of leather has also a row of eyelets and a row of studs. This is laced to one side of the thigh piece and buttoned to the other; the lacing can be adjusted once for all. On removing the leg one side is unbuttoned, and the other remains laced, as shown in Cut E 27.

CHECK STRAP. - The lacing at the back of the knee checks the knee action and is regulated by the wearer. It is a very strong leather thong, passing from the thigh piece to the leg part, as in Cut E 20. The more the thong is tightened the less becomes the motion in the knee, and the more weight will be placed on the ball of the foot and less at the heel.

The stump, in all cases, is inserted into the leg socket; the thigh piece is drawn around the thigh and laced tight enough to hold the leg firmly in place. The stump enters the socket comfortably. Bearings are only admitted about the sloping part immediately below the knee; the anterior surface of the tibia is always accommodated by a channel; the bony prominence of the fibula is provided for by a cavity; and the end of the stump hangs free in space, receiving no pressure whatever, either on the sides or at the end, except when conditions will permit.

SENSITIVE STUMPS. - In cases of extreme sensitiveness the weight can be carried entirely above the knee, and the stump is only permitted to perform the function of moving the lower leg forward and backward.

NON-END-BEARING AND END-BEARING. - Weight can rarely be applied to the end of a tibial stump, and only when the end is protected by bone flap or periosteal flap and well covered with muscle tissue. When such favorable conditions exist an end-bearing pad is placed in the socket of the leg, the thickness of which is adjustable, so as to increase or decrease the amount of pressure on the extremity. The made with surprising naturalness. The loss of the natural leg is absolutely concealed, and the substitution by the artificial restores the wearer to his usefulness.

THIGHLESS LEGS. - Artificial legs for tibial stumps are sometimes made without knee joints and thigh pieces, dependence being placed upon the socket when supporting the weight of the wearer, and resisting such lateral strains as may occasionally be brought upon the leg. Such a leg is shown in Cut E 28. From the knee down its construction is much the same as leg E 17. The socket is made of wood excavated to receive the stump properly. The foot is of sponge rubber with spring mattress, and the leg is covered with raw hide and finished in flesh-colored enamel. Straps attached to the leg in the region of the calf are made to pass around the thigh immediately above the knee cap. If these do not hold the leg firmly in place auxiliary straps are attached, to pass over one or both shoulders.

Some manufacturers advocate the use of thighless legs whether the stumps are long or short, and pay little attention to the character of the extremities. They attach more importance to the absence of thigh constriction than they do to the danger of abrasions on the stump or injury to the extremity.

While it is true that there are many cases in which thighless legs are applied and worn with evident satisfaction, it must be clear that the absence of a thigh supporter entails a sacrifice of efficiency and protection. Metal knee joints and thigh supporters perform the very important functions of protecting stumps, avoiding side strains, injuries from concussions, and the tearing of cicatrices. Cut E 29 shows a thighless leg applied, the wearer standing; Cut E 30 the rear view of the same, Cut E 31 the side view, and Cut E 32 the wearer seated. These cuts show the operations of the leg and the action of the suspenders.

DANGERS. - When the wearer is standing with his weight on an artificial leg of the thighless type the stump has to carry all his weight. This usually comes upon the sloping parts immediately below the knee. If the wearer makes a misstep and recovers himself by his artificial leg the stump will receive a strain; if he carries a heavy weight his stump must resist a force that tends to push it further into the socket; and unless the sides of the stump are sufficiently sloping to oppose this there will be danger of injury to the flap and cicatrix.

One of the chief objections to the thighless leg is the difficulty that arises when the stump changes in size, as it so often does. If the stump becomes emaciated the socket of the artificial leg must be filled up to compensate for the loss of flesh, and if the emaciation is not uniform there will be considerable difficulty in padding the inner surfaces of the socket so as to avoid pressure on delicate parts.

One should never experiment with the thighless leg unless the stump has been accustomed to wearing an artificial leg for a considerable length of time, and has become so thoroughly disciplined that further changes are not likely to occur. Those who insist on wearing thighless artificial legs, who have worn them from choice, and who have their stumps sufficiently disciplined will be accommodated in their wishes.

SLIP SOCKETS VERSUS WOOD SOCKETS. - Rival manufacturers have said and published much about the slip or sliding socket and considerable curiosity has been aroused among limb-wearers as to the merits of the idea. As the slip socket applies almost exclusively to artificial legs for tibial stumps, the subject may be introduced and discussed at this time.

We have given the matter much thought and subjected it to a most rigid investigation. We have, moreover, submitted the scheme to many tests and have conferred with several hundred persons who had worn slip sockets. Our investigations were planned to determine whether the scheme had sufficient merit to warrant us in adapting it to our work.

We have long been aware that a well-fitting socket of wood or any smooth hard material will never chafe the stump, even if the stump is permitted to move in it. On the other hand we have known that any socket made of a yielding material like leather will, from the constant pressure and heat of the stump, change in form and cease to be comfortable. Perspiration and other exudations from the stump have deteriorating effect on any material that permits absorption. All exudations from the stump becomes putrid in a very short time and cause offensive odors and bring effete matter in contact with the skin. This almost invariably infects the stump and causes unhealthy conditions. A hard highly polished surface is more pleasant for the stump than any form of soft yielding cushions.

The slip-socket idea is somewhat antiquated. In 1866 the United States Patent Office issued letters patent No. 55,645 to Daniel Gilson, covering the principle of the slip socket, consisting of a leather socket molded on a cast of the stump, then placed inside the artificial leg, and held in place by springs. Its object was to obviate the movement of the stump in the socket and to localize all the motion between the stump socket and the socket of the artificial leg. It was very soon found that the stump socket, being tightly held to the stump at all times, constricted the blood vessels and caused much trouble. The inventor, being conscientious, abandoned the manufacture of legs on that plan.

Quite recently, however, the slip-socket feature has been revived, and some insignificant modifications made on the original Gilson model, mainly in the mode of suspending the inner or slip socket. The idea has been extensively advertised and a considerable number put in use. We have records of many of these cases, and we feel it a duty to the maimed community to disclose the effects a slip socket has had on many stumps.

It must be remembered that in order to carry out the principle of the slip or sliding socket the stump must remain under constant pressure, great enough to avoid any motion or friction between the stump and the socket. All the slipping and sliding due to the intermittent application of weight, as in walking, takes place between the slip socket and the socket of the artificial leg. Few stumps can tolerate this constant pressure without the blood vessels becoming strangulated; we therefore do all we can to dissuade clients from risking such a dangerous experiment.

SLIPPING OF THE STUMP DESIRABLE. - There is nothing so pleasant to a wearer of an artificial limb, no matter what kind of a leg he is wearing, as to be able to lift his stump from its bearings and give it a chance to rest and recover, exactly as one does when standing on natural legs. He throws his weight on one leg for a while and then on the other, and in this way both legs in their turn become rested. Every wearer of a wood-socket limb invariably does this. It is a source of comfort and relief; but it cannot be done with the slip socket, which clings to the stump like a leech.

The socket that is made to fit the stump so that pressure will be uniformly distributed over all its parts, is neither scientific nor tolerable. Every stump has parts that will bear pressure and parts that will not stand any at all. Parts where blood vessels and nerves are clustered, where the bones are close to the surface and poorly protected by tissue, must be prevented from impact. A flexible socket has a tendency to assume the shape of the stump and distribute the pressure uniformly, bringing as much on the forbidden parts as elsewhere. Therefore the flexible socket is a dangerous one to wear.

A socket that fits properly will never chafe the stump, no matter how much it may slip, slide, or move in it. This is a fact ascertained by most careful, thoughtful, and conscientious investigation, and cannot be successfully controverted. We know from very ample experience and inquiry that there is no socket so pleasant to wear, so light, so cool, and so healthful for the stump as the wooden one, when properly and scientifically fitted. No material has ever given such permanently good results as wood.

AN INSTANCE. - Mr. Frank M. Talbot met with a railroad accident in 1890 which crushed his leg. Amputation was made below the knee, leaving a stump four inches in length. He obtained an artificial leg with wooden socket, which he wore for some time with efficiency. His stump, following the usual course, emaciated, and instead of having the leg refitted he was prevailed upon to order a new leg with a slip socket. He wore the leg for a while, but gradually the end of his stump became congested and painful. He went to his slip-socket leg-maker for relief, but was told that his stump was diseased and nothing but medical or surgical treatment would help him. The stump grew worse; he called in a physician, who by medication brought it to a healthy condition, but put him on his back for a while. Shortly after he resumed wearing the slip-socket leg, the trouble recurred. He came to New York, and under the impression that his stump was diseased, consulted several prominent surgeons. All agreed that the stump had been strangulated by the artificial leg, and unless the cause was removed the bone would soon become infected and re-amputation would be necessary.

Mr. Talbot called upon us, and on examination we found the end of the stump swollen and as blue as indigo. An abscess was forming. We told him that his trouble was due to pressure upon the blood vessels, and advised him to abandon the slip socket, and wear a wooden one, so fitted that it would not constrict the blood vessels nor permit any of the tender parts of the stump to take pressure. He yielded to our advice, and we made and applied a leg with wooden socket and our patent rubber foot. It was remarkable how quickly his stump recovered. As soon as the pressure was removed from the vascular parts, circulation was restored and the stump became healthy. This was eleven years ago and the stump at this writing is in a healthy condition, without the slightest indication of a recurrence of his trouble. We can cite hundreds of cases similar to this and will gladly furnish additional data to those desirous of investigating further.

WATERPROOF LEGS. - There are some occupations that require limb-wearers to stand in damp and wet places, exposing their artificial legs to moisture, much to their injury.

Our method of constructing artificial legs with rubber feet, non-articulating at the ankle, enables us to meet every requirement of such cases. The leg and ankle is of natural curved timber, with the grains running on lines of the greatest strains. The foot is of sponge rubber with spring mattress, and the whole is covered with suitable material, coated with a waterproof preparation.

Bridge-builders, oystermen, fishermen, woodsmen, raftsmen, trappers, and hunters find the waterproof style of leg especially adapted to their wants.

BATHING LEGS. - Persons who indulge in aquatic sports can use artificial legs of this kind; with them they can wade, bathe, or swim in salt or fresh water exactly as persons in possession of their natural limbs and without disclosing the fact that their limbs are other than those provided by nature. Cut E 7 is a sectional view on which waterproof legs are constructed. It will be seen that there are no parts, connected by glue, metal, or rivets that can be affected by moisture. The entire lower leg is of one piece, capable of withstanding the severest strains and exposures. The natural-crook feature is covered by letters patent.

SHORTENED THIGH. - Complicated conditions in tibial amputations frequently present themselves and require specifically designed artificial limbs. Cut E 33 illustrates a case in point. The injury to the patient, necessitating the amputation of the leg below the knee, fractured the thigh and dislocated the hip. The femur became lapped and deflected and its head was permanently displaced. This occasioned a shortening of the thigh of several inches. In the artificial leg the shortening of the thigh was compensated for by lengthening below the knee. A leg constructed on the plan of E 17 is suitable for cases of this character. Its thigh piece is made to extend well up to the body and take in the gluteal folds and the entire external surface as far as the crest of the ilium, thus giving the necessary support to the fractured part.

Cut E 34 illustrates a case of shortened thigh of the left leg while the right was amputated. It resulted from a railroad accident which crushed the right foot and ankle and fractured the opposite thigh. The right foot was amputated at the junction of the lower and middle thirds. Despite every effort to bring about the correct union of the fractured femur of the left leg, the boned slipped, resulting in a shortening of the thigh by several inches. An artificial leg constructed on the plan of E 17 was applied. The leg from the knee down was as much shorter than the left as the thigh of the left was shorter than the right.

In both cases the artificial legs necessarily caused a disparity in the lengths of the legs from the knees down, but the differences were not noticeable, even when the wearers were seated, except when closely scrutinized. In other respects there were no inconveniences experienced.

In ordering an artificial leg every peculiarity of the sound leg as well as the partly amputated one should be brought to the attention of the manufacturer. If there is a shortening in either the upper or lower sections of either leg, the manufacturer must be fully informed, so as to be able to construct the artificial leg to meet such conditions.

ECCENTRIC KNEE JOINT. - Occasionally there are circumstances that make it difficult to obtain neat and smooth adjustments of an artificial leg about the knee of a tibial stump. When the leg is made to adjust smoothly while the stump is at full extension, there appears to be a shrinking away of the stump from the socket when flexed. This not only limits the range of knee motion but produces cramping and pinching of the tissues back of the knee. This condition can usually be traced to some peculiarity in the anatomical construction of one or both of the knee-articulating surfaces.

Cut E 35 represents the bones of the natural knee joint at extension; Cut E 36 represents the same at flexion. It will be observed that in passing from one to the other the base of the femur is required to travel over the bearing surface of the tibia. The curvature of the articulating surface of the femur is neither elliptical, parabolic, nor follows any geometric curve. The bearing surface of the tibia should be flat. Sometimes it is slightly curved. When two surfaces roll upon each other there is no point that can be located as the center of motion. The nearer the articulating surfaces of the tibia approach a plane, and the nearer the articulating surfaces of the femur approach an arc of a circle, the more uniform will be the motion of the knee. When the articulating surfaces of the knee of an amputated leg depart from these conditions a modification in the mechanism of the artificial knee joint is required, in order to make the artificial leg articulate more in harmony with the natural knee. The duplex knee joint, which admits of flexion and extension in polycentric curves, has been designed to meet this condition.

DUPLEX KNEE JOINTS. - Cut E 37 represents the conventional type of artificial leg for a tibial stump regardless of eccentricity of the knee motion. The cut shows how the stump, when flexed, is pulled away from the front of the socket, and how the tissues are folded under the knee and pinched, a condition due entirely to the efforts of forcing an eccentric knee to act with a concentric joint. Cut E 38 illustrates the E 17 leg with duplex joints applied to a stump with eccentric knee. The effect, as can be seen, is that the stump is held in its proper place, greater power of genuflection is obtained, the cramping at the back of the knee is obviated, and the stump is caused to remain close to the socket in front; the tibia is pointed directly downward, instead of downward and forward, and is prevented from impinging against the interior-anterior surface of the socket.

The duplex joint has two centers, one well up on the thigh and the other close to the knee; an independent strap connects the two side bars at the rear; an elastic band connected with both side bars passes over the front of the thigh. These straps give firmness to the adjustments, and at the same time admit of sufficient oscillation to permit the stump to remain in its bearings.

CONTRACTED KNEE JOINTS. - Another class of leg stumps are those which are sufficiently long to control the knee movements of the artificial leg, but being partly contracted, the extension of the knee is somewhat limited, so that the use of the ordinary type of E 17 leg is impossible, while the contraction is not sufficient to make the knee joint inoperative in controlling the artificial leg.

Knee joints of tibial stumps become contracted either from the results of the injuries that occasioned their amputations, or, more frequently, from neglect in permitting the stumps to remain in semi-flexed positions during the convalescent periods. Cut E 39 illustrates a partially contracted knee of a tibial stump which is capable of full flexion but of limited extension.

An artificial leg on the plan of E 17 with a slight modification of the socket, as shown in Cut E 40, meets the requirements of the case. By referring to Cut E 41 it will be seen that the stump is received in the socket while in a semi-flexed position. The socket is so made as to bring constant and gentle pressure upon the hamstrings every time a step is taken. The object of this is to induce the breaking up of the contraction and eventually restore full knee motion. The artificial leg is provided with a lacing attachment that passes over the rear part of the stump. As the stump improves in extension this lacing strap is tightened and greater pressure brought upon the stump.

Although a stump may be contracted to a considerable angle a leg of this character can be worn and the wearer enabled to get about in an advantageous way, concealing his loss, walking in a graceful manner, and dispensing with the use of crutches.

We know of no more practical method for breaking up the contraction in the hamstrings than wearing an artificial leg of this type. The wearer is permitted to engage in his usual occupations while the work of restoration of the knee motion progresses. When the knee has become corrected and the stump can be extended to a straight line, the socket on the artificial leg can be removed and the regular socket, similar to that shown in Cut E 17, applied at a very slight expense.

Cut E 41 shows the leg applied to a contracted stump and the wearer walking. Cut E 42 shows it with the wearer seated. The contraction of the hamstrings does not interfere with walking, standing, or sitting.

Cut E 43 illustrates a tibial stump with a contraction of the hamstrings considerably greater than in the last case, so great as to prevent the knee from extending beyond a right angle with the thigh. Cut E 44 represents an artificial leg suitable for this case.

A knee-bearing leg might be considered the more suitable, but when the fact is remembered that there is an angular motion in the knee, with the possibility of improvement, it is better to apply a leg that will keep up the action of the knee and bring a constantly increasing tension on the hamstrings. A leg constructed on the plan of that represented in Cut E 44 is made for this purpose.

HYPERTROPHIED TIBIAL STUMP. - Amputations through the tibia are sometimes necessitated by hypertrophy, with induration of the foot and ankle, as in the case of elephantiasis. Such cases usually produce stumps that are much larger at their extremities than above, the extremities incapable of bearing pressure, and the sides able to tolerate only limited compression. Cut E 45 shows a stump of this character. It requires an artificial leg constructed upon the plan of E 46, with the rear open so as to receive the stump, the stump and socket are incased by a sheath holding the parts together. Cut E 46 represents a side view of an artificial leg suitable for such cases. Cut E 47 presents the front view with leg applied.

In all the complicated cases previously described, the method of constructing artificial legs with rubber feet and spring mattress is especially advantageous. Great strength is obtained, durability is secured with minimum weight and bulk about the enlarged extremity.

ANCHYLOSED KNEE TIBIAL STUMPS EXTENDED. - Some tibial stumps are rigid when extended. That is, they cannot be flexed, owing to anchylosis of the knees resulting from the injuries that caused the amputations, impairment of the knee tendons, calcareous deposits in the articulations, and many other causes. If there is an absence of mobility in the knee and the stump is extended, an artificial leg must be constructed so that the artificial knee articulation will be independent of the natural knee and operate on the sides of the stump approximately at the points where the natural articulation takes place. Cuts E 48 and E 49 represent tibial stumps extended, with knee joints anchylosed.

It will be observed that in Cut E 48 the sides of the stump and thigh are approximately parallel, or in other words they do not slope sufficiently to offer any sustaining surfaces. An artificial leg constructed on the plan of Cut E 50 is intended for a stump of this character.

The top part of the thigh piece is annular and permits the stump and thigh to enter until the gluteal folds, the ischium, and the perineum come in contact with the top border of the socket, where the entire weight is applied, the same as if the amputation had been made in the middle of the thigh. Cut E 49 represents a stump the sides of which are tapering sufficiently to offer some opposition, sustaining in part the weight and lessening the amount of pressure on the top border of the socket. An artificial leg constructed on the plan of E 51 will meet the requirements of this case. Both of the above artificial legs are made to articulate at the knees.

The legs from the knees down are constructed practically the same as the E 17. The thigh piece is leather and wood; the rear of wood and the front of leather arranged for lacing, so that the required pressure will be brought upon the thigh to hold it in place. Leg E 50 differs from E 51 in the top of the socket, it being annular with continuous border. It is held securely to the body by the lacing front, assisted by suspenders passing over the shoulders.

The knee joints of these legs are of the hinge style as illustrated in Cut E 21. Articulation at the knee is limited by a check cord connecting the thigh and calf sections. Cut E 52 shows the leg applied, the wearer seated; and Cut E 53 shows it with the wearer standing. It will be seen that the knee articulation approximates very closely the action of the opposite leg and permits the wearer to stand, walk, sit, or kneel.

PEG LEGS. - Peg legs suitable for tibial stumps are of three kinds. The simplest and least expensive is shown in Cut E 54. It consists of two wooden branches, one running up on the outside of the thigh, well up on the body, the other on the inner side reaching nearly to the crotch.

These branches unite below the point of bearing and continue to the ground, terminating in a rubber tip. A padded shelf is placed between the branches on which the knee rests when in a flexed position. The leg is held in place by leather straps passing around the thigh and body.

Cut E 55 shows a peg leg without knee joint or thigh support suitable for a tibial stump. The socket is shaped to receive the stump from the knee down in a comfortable way. The base terminates with a rubber tip, and straps necessary to hold the socket on the leg are connected with the leg and passed around the thigh immediately above the knee cap. When necessary, suspenders are attached to help carry the weight.

Cut E 56 shows a peg leg suitable for a tibial stump constructed practically as E 17, except that there is no rubber foot, a rubber tip is taking its place.

PEG LEGS SHOULD NOT BE USED PERMANENTLY. - Peg legs are worn as temporary expedients, for disciplining stumps, or to bridge over an impecunious period. We know persons, however, of ample means who have reached advanced years, who from childhood have constantly worn peg legs, and doubtless will continue to do so, as long as they live.

It is quite possible to stump around on peg legs and do much hard work with them. They are immeasurably better than crutches, but they are very far from rendering the services that can be obtained from artificial legs with sponge rubber feet. The foot is an essential factor in helpful easy walking, and a means of opposing strains required in carrying heavy weights, ascending or descending stairs or elevations, and in walking long distances.

We disparage the use of peg legs, as we are keenly alive to the fact that they are inadequate to meet the demands that must be put upon them. Any form of peg leg that will keep the knee joint in a flexed position is liable to weaken the tendons of the knee, impair the knee movement, and limit its range of motion. They should, therefore, be used only as expedients.

FERRULES FOR PEG LEGS. - Cut E 57 represents an aluminum peg-leg ferrule and rubber tip. Cut E 58 represents the aluminum ferrule separate, and Cut E 59 represents a pure gum rubber tip separate, which screws into the ferrule. Cuts represent one-quarter size. The ferrule is permanently fastened to the peg leg, and the rubber tip screws into it.

RUBBER TIP. - When the rubber tip wears down so that the metal ferrule touches the ground, it should be removed and a new one put in. The base of the rubber tip is 2 1-2 inches in diameter and the threaded shank is 1 1-2 inches for diameter.

SUSPENDERS. - Suspenders for artificial legs for tibial stumps are of many kinds. Most persons with long and healthy stumps do not use suspenders at all, and a very small number retain them after they have become accustomed to their artificial legs.

As an aid for the beginner, however, we deem it advisable to put suspenders on every leg made for tibial amputation, whether the stump is long or short.

Cut E 60 shows a double suspender for a tibial stump leg. It consists of two-inch elastic webbing connected with the back of the thigh piece and running well up to the shoulder, where two non-elastic straps, each 1 1-2 inches wide, are attached which branch so as to pass over the shoulder. They are connected with the upper part of the thigh piece in front, and adjusted by clamp buckles with snaps.

Cut E 61 presents a simple yoke suspender preferred by women. It is made to fit the body immediately above and upon the hips. It is seldom necessary to use shoulder straps. Straps running down from the belt connected with the upper part of the thigh piece are usually ample.

Cut E 62 shows a yoke suspender similar to the last, but provided with shoulder straps. Elastic straps buckled into the attachments connected with the thigh piece are used to fasten the yoke to the leg. This method is necessary for small hips and in cases where entire support from the hips or pressure about the loins or over the abdomen cannot be tolerated.

The corset style is frequently preferred by women. It consists of strong elastic straps secured to the lower part of the corset, one in front and one at the back as shown in Cut E 63; they are buckled into straps secured to the upper part of the thigh piece.

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