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1407 E. Michigan Ave., Jackson 517-784-1142 770 Riverside Ave., Suite 101, Adrian 517-263-3310
CHAPTER III - Partial Feet Amputations
SINGLE-TOE AMPUTATIONS. - The loss of a single toe, particularly if it be the great one, may or may not be the cause of inconvenience and discomfort, yet the application of an artificial part is often found necessary, both as an aid in walking and as a protection to the amputated surface.

If one or more of the interplaced toes are removed and the hiatus has been filled up by the union of the adjacent surfaces, there can be no gain whatever in applying artificial ones. If the great toe (see Cut C 1) or the small toe be removed, and the amputated surface is tender and painful to the touch, an appliance similar to that represented in Cut C 2 can be advantageously applied.

This appliance consists of a duplicate of the removed part, made of suitable material and secured to a plate shaped as the sole of the foot. It is held to the foot by an incasement of leather, laced down the front; when applied it is ready for the shoe, as shown in Cut C 3. This simple arrangement protects the amputated surface, assists in walking, fills the shoe, and prevents unsightly wrinkles in the leather.

AMPUTATIONS AT BASE OF TOES. - It is necessary to apply an artificial part when all the toes have been removed, as shown in Cut C 4. It must be so constructed that it can be held in place and avoid pressure on the scarred surface. Shoes stuffed with cotton or with pieces of cork should never be used; such expedients, having no support on the under sides, will eventually encroach on the amputated surfaces and permit the shoe to bend near the ends of the stumps.

An appliance illustrated in Cut C 5 is suitable for such an amputation; it is shown applied in Cut C 6. It can be made of wood or metal as may be required, and shaped to receive the foot in a comfortable manner; tender points are protected by recesses provided for them. Cut C 6 shows this apparatus applied and ready for the shoe. Usually the mate to the shoe worn on the natural foot can be used without alteration; in cases where more room is needed, almost any shoemaker can supply it by ripping off part of the upper and substituting a larger piece.

INSTEP AMPUTATIONS. - These are termed tarso-metatarsal and medio-tarsal by the surgical profession, and are frequently designated by the names of the surgeons who first performed them, as Chopart, Lisfranc, Hays, Hancock, and many others. These amputations are performed with the object of sacrificing as little of the foot as possible, and retaining the heel and a part of the foot as a base on which the patient is supposed to be able to walk or stand. Although a person with the front part of his foot removed may be able to get about with an ordinary shoe, it is not long before he discovers that something is lacking and his locomotion impeded by the absence of the removed part. He may pack the vacancy in his shoe with cotton, cork, or other material, and may re-enforce the sole with a steel plate; but he soon finds that only partial relief has been obtained, and that there is an imperative demand for a substitute for the ball of the foot which will enable him to rise on and elevate his heel from the ground. Something is needed having great strength and that can be firmly secured to the remaining part of foot and leg.

The construction of artificial feet for this class of amputations has taxed the ingenuity of artificial-limb-makers for many years. The absence of space between the bottom of the heel and the floor presented an obstacle to the construction of a helpful and durable appliance until aluminum was employed. It may be useful to review some of the devices used for such cases.

Cut C 7 represents a stump resulting from a partial foot amputation.

ILL-ADVISED PROTHESIS. - Cut C 8 represents the way in which many manufacturers have endeavored to supply the want. The appliance consists of a leather shoe inclosing the stump and part of the ankle, the front of which is made of wood, rubber, or cork with a metal plate at the base, running from heel to toe, calculated to make the sole firm and unyielding at the ball. This apparatus gives a natural appearance to the amputated member, but fails to support the wearer in a helpful or substantial way. The stump will soon crowd forward, coming into unpleasant contact with the appliance; the steel plate will bend or break and the shoe will yield where the stump terminates, creasing the shoe and making it rocker-shaped; consequently it utterly fails in supplying the want, because of the lack of firmness with which it is held to the remaining part; the heel, moreover, will yield to the constantly contracting tendency of the tendo-Achilles and become displaced.

Cut C 9 represents another ill-advised apparatus. It consists of a sheet of metal formed to receive the remaining plantar surface of the foot; bent up on either side, hinged at the ankle to steel straps thus providing a joint for ankle articulation; the steel straps run up the sides of the leg and are held in position by a leather corset, shaped to inclose the leg. The front of the metal sole is secured to a part of a foot. The main objection to this device is the insecurity of the attachment; weight applied to the ball of the foot will cause the ankle to flex and permit the amputated surface of the stump to rub against either the front or the bottom plate, causing abrasions; a heel cord placed at the back connecting the leg section with the foot plate will not be effective in holding the appliance in its proper position at all times and checking the action of the ankle articulation at the proper angle.

OBJECTIONS. - A glance will show that the legs illustrated in Cuts C 8 and C 9 must prove inadequate. When weight is applied to the ball of the foot the heel of the artificial part will remain on the ground, while the heel of the stump will lift away. The wearer will walk flat-footed and will press the delicate cicatrized surface against the attachment. These conditions will not only cause suffering but defeat the object of the artificial foot.

It might appear that an appliance constructed on the plan shown in Cut C 5 could be secured so firmly to the remaining part of a Chopart stump as to enable the wearer to rise on the ball. If this were possible the method of treatment would be greatly simplified; unfortunately, however, the severity of the compression needful to hold the appliance in place when weight is thrown on the ball, will stop the flow of blood in the heel, causing great pain, endangering the health of the entire leg.

It is important to emphasize the fact that it is absolutely useless to apply any form of foot to a partial foot stump unless the artificial part is held so firmly that the wearer may rise on the ball of the foot, and not only support his weight while in that position but carry such additional weight and resist such strains as his habits or occupation demand.

Cut C 10 represents an amputation a little forward of the instep. The wisdom of the application of apparatus C 5 in this case is doubtful. It might prove adequate in the case of a person who does little walking and no lifting, and who places little demand on the front part of the foot; but for a laboring man, who has to lift and carry articles of weight, it would be a disappointment. It will be better considered, therefore, among instep amputations that require the placing and distribution of the strain above the ankle joint.

Cuts C 11, C 12, C 13, and C 14 show instep amputations after the Lisfranc, Hancock, and Chopart methods. Cut C 15 shows an amputation of the instep with all the tarsals removed, a part of the astragalus and the entire os-calcis retained and kept in their normal relations, a very unusual occurrence.

The remaining plantar surfaces of each of these amputations are of a character to permit the application of the weight of the wearer on them.

Cuts C 16 and C 17 show instep amputations in which the heels have retracted slightly, but not so much so as to prohibit the application of weight to the remaining plantar surfaces.

PRACTICAL PROTHESIS. - The only artificial limb that has ever been devised that adequately meets the needs of any of the above instep amputations is illustrated in Cut C 18. A half leg, or front, including the core of the foot, is made of aluminum, without articulation at the ankle. The rear half is made of leather, shaped to incase the leg and the aluminum shell and hold the appliance in place, as shown in Cut C 19. The sole of the foot, including the toes, is made of rubber with a spring mattress as described in Chapter II. Comfortable bearings are provided by proper fittings and suitable linings. The pressure needed to secure firmness is distributed over the entire leg from the ankle to the knee; with this leg the wearer can rise on the ball of the foot without endangering the amputated surfaces or straining the ankle joint. The shinbone is protected by the aluminum shell on the front, and, when dressed, presents an appearance very close to nature. When there is a tendency for the heel to retract, the leather sheath at the back is re-enforced with metal shaped to hold the heel down to its proper place.

This artificial leg can be worn without inconvenience or pain. The wearer walks gracefully, striking the heel first, then rolling on the sole until the ball is reached, and then rising on the ball he receives assistance in walking. Cut C 20 shows the leg applied and the wearer seated. Cut C 21 shows the leg applied with the shoe on and the wearer walking with the weight on the ball of the foot, similar to the position taken by the natural foot when in the act of throwing the body forward.

The method of meeting instep amputations, as just described, possesses many merits aside from those to which attention has been called.

RETRACTED HEELS. - Cuts C 22, C 23, C 24, show amputations in which the heels are retracted so that the amputated surfaces are directly under the legs, where the weight must be applied if the bearings are to be at the ends. These are unfortunate conditions. An artificial leg cannot be applied to a stump under such conditions that will permit any pressure on the scarred extremity; the weight, therefore, must be placed immediately below the knee or about the thigh.

A limb constructed on the plan shown in Cut C 25 is adaptable for some stumps with retracted heels; the rear half is made of metal, the front of leather, capable of being laced. This permits close fittings about the heel and tends to force it back to its proper position. If the sides of the leg are sloping, the fitting can be such as to apply all the weight on the leg immediately below the knee. Cut C 26 shows the leg applied and the wearer seated.

If the sides of a leg do not slope sufficiently to prevent settling into the artificial leg socket, it is necessary to introduce an annular top and possibly knee joints and thigh support. The annular top can be applied to a leg constructed as described; it then has the appearance of Cut C 27. It can also be applied to a leg constructed on the plan of C 25. Knee joints and thigh support can likewise be applied to a leg constructed on the plan of either C 18 or C 25. Cut C 28 shows such additions applied to C 18 leg. When the annular top is employed the support is calculated to be localized immediately below the knee. The leg is opened from the rear and the stump inserted; the annular top is laced firmly and the leather sheath is pulled over the entire apparatus and laced in front. When the knee joint and thigh support are required, as shown in Cut C 28, the lower section of the leg is made of aluminum, with the rear sheath of leather. The thigh part incases the natural thigh and holds it with sufficient firmness to carry the weight above the knee and so prevent the leg from slipping in the socket.

ALUMINUM SOCKETS. - The utilization of aluminum in the construction of artificial legs for instep amputations is especially advantageous. It can be worked to a very slight thickness, thus adding but little to the diameters of the large stump that it incases. A wood socket would require a thickness of at least half an inch on each side, thus making the leg conspicuously bulky and objectionable.

During the past few years we have made many experiments looking to the general application of aluminum in the construction of artificial limbs for upper amputations, but have met with disappointment except in ankle-joint and partial-foot amputations. The characteristics of aluminum are low specific gravity and comparative strength. Its weight is the least of all metals (one-quarter that of silver). Its strength is comparable with that of copper. It will not corrode when exposed to fresh water or to a moist atmosphere.

We desire to correct the prevalent impression often expressed in the remark that aluminum is “lighter than cork and stronger than steel.” As a matter of fact aluminum will sink in water, whereas cork or wood will float; it is therefore heavier and although aluminum is strong, it has but a fractional part of the strength of straight-grained wood. Its use in artificial legs is, therefore, narrowed down to sockets for long and large stumps, where the minimizing of bulk is an important feature.

We hold United States patents on artificial limbs with aluminum sockets, and if we could make satisfactory use of that metal for general purposes we would unhesitatingly do so.

Comment from follow-up survey
My Orthotics fit great and my heel pain is almost nil because of them. I was told not to go to you by someone else. It was another company in competion with you. But because of insurance I had to go to you. Well it was a blessing in disguise. I was never happier with you and your staff and expertise. I am glad now the other didn’t accept my insurance and I tell everyone the story. Thank you very much for your time, caring and the welcoming feeling I got from your business.