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1407 E. Michigan Ave., Jackson 517-784-1142 770 Riverside Ave., Suite 101, Adrian 517-263-3310
CHAPTER IV - Ankle-Joint Amputations
TIBIO-TARSAL STUMPS. - Amputations through the ankle articulations with or without the maleoli, flaps formed of heel tissues, provide stumps that can be fitted with artificial legs in an advantageous way. Surgeons call these amputations tibio-tarsal or Symes, and if the os-calcis is retained and secured at the extremity of the tibia, it is known as Pirogoff’s.

Usually ankle-joint amputations produce stumps that admit of weight being taken on their extremities. If cicatrices are on the bearing surfaces or nerve complications are present, they become non-end-bearing and artificial limbs must be applied that permit no pressure or contact on the tender extremities.

END-BEARING. - Cuts D 1 to D 6 show end-bearing tibio-tarsal stumps, with flaps favorable for the application of pressure and with cicatrices well away from the bearing surfaces. Cut D 7 illustrates an artificial leg suitable for any of these types; Cut D 8 shows it applied with the wearer seated. Cut D 9 shows a Pirogoff stump with a suitable leg, patterned after style D 7. Cut D 10 shows the leg applied and the foot covered with stocking and shoe. Cut D 11 shows the wearer fully dressed.

In walking his step is graceful, the foot imitates nature, there is no limping, and he is amply equipped to engage in any occupation, even the most laborious.

CONSTRUCTION OF SUITABLE ARTIFICIAL LEG. - The construction of D 7 style is simple. The front, which is the resisting part, and the core of the foot, are cast in aluminum, the interior surface being formed to receive the anterior surface of the leg from the knee down. It is so fitted that pressure will be distributed over the front area, the shin bone and tender parts of the leg being protected and not allowed to bear pressure. The rear part is of leather, shaped to fit the calf and the back of the leg. It is secured at its lower end to the aluminum socket, and when the stump is in place it incases the whole apparatus from the knee down, holding the leg in place with firmness, the pressure being regulated by lacing. The foot is of sponge rubber, re-enforced with spring mattress as explained in Chapter II. Weight is taken by the end of the stump resting on a surface of proper shape, covered by a suitable pad. The strains resulting from rising on the ball of the foot are not permitted to come on the stump; they are distributed over the leg, about the sides of the shin from the knee to the ankle. A stocking and shoe are drawn over the foot, and the apparatus is a counterpart in appearance to the sound leg.

This style of leg for ankle-joint amputation has received the most complimentary comments; it has given great satisfaction to those who have worn it; and it has been quite generally adopted.

Occasionally conditions require the construction of a limb in a manner reverse to that just described, the stump is admitted from the front instead of the rear. In such cases limbs are built on the plan illustrated in Cut D 12. The construction is practically the same as D 7, except that the metal socket is placed at the back and the leather lace in front. The shin bone is protected by a padded loose fly-piece over which the lacing passes. Cut D 13 illustrates the leg applied.

If the end of the stump is small and has no prominences on the side, the socket and core of the foot, which are integrally one piece, are carved from a block of wood the grain of which curves on the line of greatest strains. When the end of the stump is large and it is desired to incase it in a socket of minimum thickness, aluminum must be employed for reasons given.

PARTIALLY END-BEARING. - If only a part of the weight of the wearer can be borne on the end of the stump the top of the socket must be made annular and fitted so that it will impinge against the sloping part of the leg below the knee. Cuts D 14 and D 16 illustrate suitable legs for the same and Cuts D 15 and D 17 show them applied. It is obvious that a stump, being inserted from the top of the socket of either, will not enter further than the top of the socket will permit, and this is just far enough to limit pressure on the end or to avoid it altogether. When pressure can be taken on the end, it is regulated by the thickness of the pad placed in the bottom of the socket on which the end of the stump rests.

A socket that admits the stump from the front, as in Cuts D 12 and D 14, as objectionable when the end of the stump is very large. The material necessary for strength is on the sides of the stump and increases the diameter of the ankle. It also affords but little protection to the sharp or sensitive shin bone. Styles D 7 and D 16 are not open to this objection, but give a smooth, unbroken front, which can be neatly dressed; they are lighter and stronger than D 12 or D 14, because the strain resulting from rising on the ball of the foot is carried forward from the point of contact to a point on line with the front of the leg: and as this point is usually halfway between the ball and the heel the strain is one-half of that applied in D 12, which throws the strain from the ball to the rear of the heel. For this reason the material on the sides of the stump and on the rear of the leg has to be as thick again as the material on the sides and front of the D 7. Hence the difference in weight.

SENSITIVE ENDS. - There are tibio-tarsal stumps that are so sensitive at the extremities that no pressure whatever can be tolerated either on the ends or at the sides of the ends. Notwithstanding this condition, artificial limbs can be applied that will be helpful and comfortable. Cuts D 18, D 19, and D 20 represent stumps of this character.

If the surfaces immediately below the knee are sufficiently sloping to offer resistance, D 14 or D 16 leg can be used, the pressure being placed on the sides of the upper half of the leg immediately below the knee. The stump from calf down hangs in space.

When a leg and stump are nearly uniform in size, the sides being parallel or nearly so, an artificial leg with knee joints and thigh piece must be used. Cut D 21 represents a leg suitable for such a case. Cut D 22 shows the same with knee flexed and sheath unlaced. The lower section is made of wood or aluminum, as the conditions of the stump demand. The rubber foot is attached in the usual way, and the leather sheath passes from the rear to the front, holding the stump in place. The weight of the wearer is supported by side joints connecting the thigh parts with the lower portions.

Cuts D 23 and D 24 illustrate the front and side views of a leg constructed in a similar manner. It is fitted to receive the leg and stump from the front instead of the rear; it contains no important advantage in construction, but is preferred by some persons.

Side joints and thigh supports are essential when stumps cannot be supported on the sloping surfaces just below the knees, and when they are liable to become sensitive and irritable on account of impaired vitality.

PEG LEGS. - Ankle-joint stumps should never use peg legs except when they need disciplining or shrinking. Some stumps with extremely sensitive ends, on which pressure cannot be immediately applied, give promise of improvement in course of time. There are also stumps that are oedematous - made up with soft, flaccid tissue which will pass away in a brief period. In such cases, an inexpensive peg leg can be used to advantage. One may stump about on a peg leg applied to a stump reaching to the ankle joint, much the same as one who uses a peg leg on an upper amputation, but, having no foot, its functions are extremely limited.

Due to the caring craftsmanship and expertise of Ted, the conditions that have caused so much pain in the past are beginning to heal. With the healing the pain is disappearing in my legs. Using the sockets that Ted designed I have been able to do many of the things that I want to but have not been able to since my amputations. Not only is Ted my prosthetist, he is also a very caring and helpful person.

Michael L. Dix

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