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A Prosthetist's Perspective

by Fritz

Above-knee amputations and their prosthetic devices seen from the point of view of the prosthetist

The most frequent type of amputation is the above-knee, the AK amputation. In this operation the femur, the thigh bone, is usually divided, and remains within the stump. In some cases the whole femur is retained and the amputation is carried out by disarticulating the knee joint. In others the whole femur is removed by disarticulating the hip joint. I shall discuss the effects of the the amputation through the femur, with the retention of a part of this bone.

Having dealt with large numbers of male and female amputees I am aware of the most common problems which can be caused by amputations that do not produce stumps suitable for the fitting of prostheses.

Sometimes it is necessary, in emergency, to amputate as a life-saving procedure and in this case it may not always be possible to construct an ideal stump.

Ideal stumps for the prosthetist are long stumps produced by amputations approximately 4 to 6 inches above the knee. If too long, there is no room to fit the knee apparatus in the artificial limb. If too short there is not enough length to get a good contact between the stump and the socket of the artificial leg, and besides, the work that can be done with a short stump in 'throwing' the limb forward is limited.

The ideal amputation

The ideal amputation (AK) leaves a fresh-looking stump of medium length, with remaining muscular strength and good circulation of the blood. The termination of the stump is not in contact with the bone, and the whole stump can be moved freely and without pain. Ideally the bone should be divided about 2 inches from the end of the stump. People who are very bony, and people who are overweight are likely to have difficulties with their stumps.

Extremely short stumps can be ideal for the patient who does not wear a prosthesis, but from the point of view of appearance I believe that the medium-sized AK is best suited to satisfy all demands.

The amputation in brief

Ideally the level of amputation should be agreed by the surgeon, the prosthetist, and the patient. The operation is carried out by cutting through the tissue, the blood vessels are divided and sutured and two flaps are cut in the skin and underlying muscle. The flaps will be sutured together and will form the end of the stump. They are first tested to determine if they are the right length, and then the sharp edges of the cut bone are smoothed off. In some cases the muscles are attached to the femur, by tying them down and securing the sutures by passing them through holes drilled into the end of the bone. The flaps are them sewn together and a drain is inserted into the stump in the neighbourhood of the stitches.

The first prosthesis

If there was time to prepare for the amputation it may have been decided that a preliminary prosthesis should be fitted as soon as possible after surgery. If this is to take place the newly constructed stump will be covered with several stump socks/liners and a layer of plaster of Paris will be applied as it would be in the plastering of a broken leg. Within this plastering some cables will be attached and on the end of the plastered stump a device into which a pipe can be pushed. The pipe is cut to length and the artificial foot is attached to it.

The advantage is that the patient always has a leg and after a day's rest she will stand up for a few minutes, putting a little weight on the prosthesis. After a few days the patient is able to walk short distances and this causes healing to take place more rapidly than it would without the exercise.

Normal recuperation

The patient must be made aware, as soon as possible after the amputation that she really has only one leg left. Physiotherapy starts immediately with exercise to prevent the muscles from retracting too much. Already, even at this stage, the patient normally suffers relatively little pain.

There are however amputations that make the fitting of a prosthesis almost impossible. People who have lost limbs because of vascular diseases or who have suffered very severe loss of tissue as a result, for example, of burns, and people who have had technically poor quality amputations (bone too long, bone adhering to the muscle etc.) have problems with prostheses. Other who have difficulties include those who gain and lose weight in short intervals, and those who reject prostheses and cannot accept their state of being amputees.

Normally, however, within two or three weeks the patient leaves hospital and consults an appliance manufacturer.

In Germany, unless a post-surgical prosthesis was supplied, the patient will go to an appliance shop to have an artificial leg fitted. This will be done as follows: At the first consultation the appearance of the stump will be examined to determine the pressure that it can withstand. The patient has to be aligned into the normal standing position and a cast is made of the stump. Several measurements of the dimensions of stump and of the sound leg are recorded, and a drawing is made of the sound leg. This concludes the business of the first consultation and the patient is invited to return in a couple of days.

In the meantime the cast will be filled with plaster of Paris, and a mandrel will be inserted into the middle of the plaster, and the model will then be shaped using the measurements and taking account of the shape of the stump and in particular the location of the remaining parts, muscle and bone, capable of withstanding the pressure produced by bearing the patient's weight. Even when standing the wearer of an AK prosthesis practically sits in the the prosthesis if it fits properly. The model is used as a matrix and from the matrix a plastic socket is cast. This socket is placed into a jig in which the foot and artificial knee have already been aligned using the measurements that were previously collected. The parts will be attached together using a binding adhesive, though at this stage the artificial foot and knee will be joined only with a piece of pipe cut to length.

Under normal circumstances a suction socket will be made. To use this the patient wears a 'pulling' sock on the stump. The socket fits snugly and the insertion of the stump displaces air through a valve, and atmospheric pressure holds the socket tightly to the stump. The socket is released by removing the valve allowing the air to rush into the socket, equalising the pressure on the inside and the outside of the socket, allowing the stump to be withdrawn easily. This type of socket is not suitable for some patients. If this is the case the patient will wear a sock on the stump and simply insert the stump into the socket. In this case a hip-belt will hold the prosthesis on to the stump.

Another type of AK prosthesis is made of willow wood, this type of limb is extremely light and pleasant for the wearer to use. As they age the plastic materials used in other sorts of limb eventually start to smell, but the natural wood remains sweet. Often women amputees prefer this type of leg because it gives more freedom, and is easier to wear than other types, and it can be made to fit well by varying the number of stump socks worn as conditions demand.

Normally the artificial foot is made in a single piece of plastic/rubber material. With a foot of this type you can wear only one height of heels.

The patient is fitted with the limb, and afterwards the stump will be examined, and the leg tried again. If everything is satisfactory the first steps, between parallel bars will be taken and in a week the patient should be able to walk fairly well.

The troubles of amputees

Even if the stump is ideal, even if the prosthesis fits well, and even if the patient is motivated to accept her status, problems are inevitable. Sometimes the stump will swell, other times it will shrink, sometimes it will feel as though the prosthesis doesn't fit at all, and sometimes the stump will become sore. These are the times when amputees may prefer to, or have to use crutches. These are the most likely reasons why some amputees never, or only very seldom wear a leg. The most frequent cause for this is either a badly fitting limb, or a stump that is not well fitted by the normal forms of prosthesis. Surprisingly often the patient has been supplied with a badly fitting prosthesis and has adjusted to using it as well as possible, and has become used its deficiencies. It is a wonderful experience to help a patient to walk with a properly fitting leg, perhaps after many years of struggling with an inadequate one. If the old bad habits acquired through the use of the badly fitting limb can be eradicated the patient's gait can be greatly improved, to the point where it is almost normal.

However, many amputees are not inclined to practice to obtain the best possible gait, but are satisfied with a less natural looking but adequate one.

Women amputees often ask if they will be able to wear high heels again. If the stump is normal and of a normal length, and if she is will to commit herself to a considerable amount of exercise, she will be able to wear as high a heel as she can wear on the sound leg. However, she will need a specially designed prosthesis, made for a particular height of heel, which will be no use for a heel of a different height.

The first steps in public

Within a week of fitting the adjustments to the prosthesis will have been made, and gait training will have begun. The patient will try to walk with the prosthesis at first in private and then in public. Over the next three weeks it will probably be necessary to make some further adjustments to the prosthesis. She finds, perhaps to her surprise, that life can be quite normal for an amputee. She will have to reconcile herself to being unable to do certain things like running fast; but there are consolations like not getting a wet foot in the rain!

The feelings of her circle of friends and acquaintances also adjust to what has happened to her and get used to her handicap. She might also become aware of the existence of devotees and perhaps even of wannabes, though in view of their rarity this is unlikely in the period of rehabilitation.

Most traumatic amputees come to accept or even enjoy some aspects of being an amputee. At first, though, the amputation is seen as a severe handicap resulting in the loss of friends and possibly job as well. It may be much later, that the amputee discovers that a few people exist for whom her amputation is a positive attractant; and some amputees never discover this. It would be ideal, in some ways if the devotee who knows, at least in theory, what being amputee really entails, could meet the amputee by chance, and if compatible, form a committed relationship with her. If she can accept her handicap and welcome his response to it, this can result in a very happy relationship.

Not everybody's experience of these matters is happy, however. I have read of a young woman who stated that she was sick of being the subject of devotees' attentions. She was sick of hearing the word 'stump' and felt that it was only because she has a stump that men ask her for dates. I should like to ask this lady if she would be happier if young men avoided her because of her handicap. I think that she should be pleased and to choose somebody who likes everything about her.

Some cases in brief

Of course there are other types of amputation, and also bilateral amputations. I remember a lady who had a medium size AK, a normal BK, and a right AE stump. She was able to walk with high heels. She was married to her third husband, had six children, and was exactly the type of girl everyone looks for. She knew that she was very attractive and willingly talked about her stumps, and her condition.

Another lady with an AK amputation was teacher. She wore high heels, and would spend hours in a walking room observing her own reflection in a mirror.Hergirlfriend was always with her. She used to show off her leg and the way she walked to the people in the shop.

Another young lady with an AK lost the leg by not accepting the patience required after breaking the leg. She was open on this subject and became an ideal amputee.

I had the opportunity once to talk to a woman with bilateral AK amputations. She lost the legs while attempting to commit suicide on the railway track. She told me that she did not regret what she had done despite the severe handicap. Her only bad experiences were with the doctors and with her relatives after the amputations.

A common desire, especially of young women is to have a BK stump revised to an AK. I had a girlfriend who desired this in order to walk better when she was not wearing her prosthesis. I also knew a woman with an AK amputation who desired her other leg to be amputated so that she could be taller, and because she disliked aspects of the appearance of the sound leg.

It may surprise you, but occasionally I have asked amputees about the way they feel with respect to their handicap. Often the response is that they manage well despite the handicap, and occasionally one says that she likes it, or that she does not miss the limb.

I know of one young man who became the darling of all the girls after he lost his leg.

Most amputees say that they feel easy without the leg just going on crutches. Some amputees admit that they like going on crutches in public: they like the feeling and the attention it attracts. In my experience most amputees leave off their prostheses at home when they are in private, but some female amputees say that they feel incomplete without the leg.

The cases I have discussed are the exceptions: very often it is hard to make contact with amputees, who are usually unwilling to talk freely about their situation. In my experience, however, almost every female amputee likes it if you tell her that she looks good with her stump, or that she has a pretty stump. Sometime will admit that she spends time looking in the mirror observing her changed body; and if you get to know the girl well, she may ask you your opinion about her stump, about how she walks, and other matters.

One should find out for oneself if it is just a sexual drive that makes one occasionally desire an amputation or an amputee.

From the age of 13 I have been a devotee and a wannabe in spite of all the problems I know about. For myself I desire an AK amputation and perhaps an arm amputation as well. Once I had the opportunity to obtain an amputation but at the time was not prepared to take it. I held back and made excuses despite the fact that I knew that girls would have loved me even if I was an amputee. I also held back and made excuses when I had the opportunity to marry girl who was an amputee.

I feel that it takes too much time to decide and you cannot find the ways and means to be informed. You hesitate to admit what you like.

Anyway, if you find a girl attractive only because of her handicap forget it! If you find her attractive because of her handicap and because of all the other things, or most of the other things, try to get closer to her. Do not talk about your preferences, do not tell her that you are someone who is especially attracted to girls who are amputees. Talk about all the things in the world, take her out, ignore her handicap.

She will eventually tell you all about it if she wants to get closer to you. She will tell you that, if you hadn't noticed, she walks with a slight limp. She will tell you a long sad story about an accident, or about an illness. She will tell you about other girls with the same handicap and ask you if you have anything against it. Of course you don't. Never ask her to wear high heels unless she asks you. Don't say anything about the prosthesis and don't tell her you would like to look at it.

She will show you how well she can do everything, and you can let her choose what to do when you meet. Don't talk to her about your skill in tennis or athletics, talk about going out to a concert, or about taking her out to a restaurant. Let her feel easy in your presence. She will give you all that you might want if you love her.

She knows herself very well. She knows that most potential partners are not interested in a girl who is an amputee. Therefore it is in her interest to discover if you might be a partner for life, if you can accept her handicap, and if you can cope at a dance, for example, with the fact that your wife doesn't dance because she is an amputee. She will check to see if you can cope with living with her if she has problems with her stump. You too should consider all these matters and if you are prepared to live with the problems go ahead and be happy. If you eventually disclose your secret she will laugh and tell you that she had already noticed and assumed that you liked her amputation.

By the way, stumps are usually very sensitive to touch and the end of the stump is usually especially sensitive. Every amputee likes the stump to be massaged, and every girl that I have known has found some degree of pleasure from having her stump, and especially the end of her stump, massaged.

Some women who are amputees are shocked if you tell them about your preference, and indeed most need some time to come to terms with this and to make up their minds about how to respond to it.

Once I left a letter in the office. In it I explained that I am a devotee and a wannabe. Some of the women talked about it: some wanted to know more about my feelings, some thought I was crazy. The woman working at the next desk told me that she had nothing against people like me, and the idea was sewn in her mind and she developed feelings of devotion, and could imagine herself as an amputee.

What can you do about satisfying your desires?

I feel that you should examine your feelings and decide if you really are a devotee or a wannabe or whether you only have these feelings sometimes. In all cases you should get in touch with the people who share your feelings, with organisations that produce publications dealing with all aspects of your feelings. You should talk freely to other people about your preferences. If you hide your feelings and yourself you will never have the chance of fulfilment. There are too few complementary partners available. Don't waste time! This I say as a person who has had far more opportunities than millions of other men who are not employed in the field of prosthetics. I now regret that I wasted so many opportunities.

If you talk openly about yourself you find that others do the same, you find others share your feelings, others are like you: you are not alone.

You can make contact with groups in other countries if you want to be anonymous.

I feel that prior to getting too close in your relationship with your normal partner, you should talk about your special likings. You may start talking about a former girlfriend who you just met again, who has lost a leg or an arm, and that she manages well despite her handicap. Mention this occasionally again.Your partner will say 'If you like her so much why didn't you marry her?' Then you can explain to her that you love only her, but occasionally you are attracted to women who are amputees. If you are interested in r┘le-playing, now is the time to introduce her to your crutches. You can explain that walking with crutches is also good exercise. Perhaps she will be willing to participate as well. Then is the time to leave about publications dealing with the concerns of devotees and wannabes where she will find them. She will read all this and either accept your feelings or part with you.

If you lose her, it would be much better than getting married to a person who cannot accept your preferences. Your preferences will never diminish: they will always be a part of you, no matter what happens to you, no matter how wealthy or successful you are, no matter how beautiful your wife is.

Only the contact and the support of groups gives you the chance to talk and possibly to fulfil your likings. If we are many we can do this in public. Amputees and devotees and wannabes of both sexes will hear about it and new opportunities will occur.

Why should it not be normal to come out and state that you would like to have an amputation or that you are attracted to women who are amputees? We are not criminals. We have on a special liking and have the right to look for fulfilment, or at least relief.

People with dangerous likings such as mountain climbers, racing drivers, smokers, drinkers, divers, and the like are socially acceptable. Even homosexuals are OK. Now we have to show that we are not a crazy minority. We are quite normal people whose interests do not harm other people in any way

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