The nuts and bolts of building a limb
- Friday, May 14, 2010
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By John Brecher Wed Mar 24, 2010 9:55 AM EDT
Prosthetist Gil Mejia from Richmond, Va., makes a cast of the residual limb of earthquake victim Emmanuele Lundy, from Port-au-Prince. The cast is the first step in the process of creating a custom fit prosthetic leg. Here Mejia presses his thumbs into the fiberglass to make indentations around the big tendon just below the kneecap to create extra snugness in a spot where the amputee's limb can carry more weight.
After removing the cast, technicians fill it with plaster and insert a metal rod, visible in foreground. Once the plaster dries, it can be handled by the rod as the fiberglass cast is cut away, as Dubreille Elinor, left, is doing here. The resulting plaster shapes, several of which are visible at right beyond Elinor, are models of the individual amputees' stumps. Custom prosthetics are then built to fit these models.
Prosthetist Jay Tew applies a dense foam wrapper to the plaster model, shaping the first layer of the "socket," the part of the prosthetic that holds the residual limb. This foam layer acts like the inner sole of a shoe -- a firmly cushioned lining in the eventual prosthetic.
After the socket receives its foam wrapper, Alix Paul, left, uses plaster to attach a metal mounting plate where the socket will connect to its post and foot. Next comes a carbon fiber wrapper and layers of fiberglass, all of which are bonded with epoxy. Behind Paul, Randy Roberson, of Birmingham Ala., works with Mark Pierre, Joel Charles, and Herold St. Louis to apply flesh-colored epoxy resin to another prosthetic. After hardening, it will be attached to a metal post and a foot matched to size of the amputee's remaining foot.
The last step in assembly, fitting, means first steps for Christela Eliance, who tries out a new prosthetic leg with help from Jay Tew and her sister Marie Yolaine. At this final stage, the prosthetic expert will make any adjustments needed to ease pain or improve fit.
By JoNel Aleccia
As Christela Eliance takes her first shaky steps on a new prosthetic leg at a clinic in rural Haiti, she's following in the path of hundreds of thousands of Americans.
The limb crafted for the 20-year-old Port-au-Prince woman who lost her left leg in the Jan. 12 earthquake is the same kind used in the U.S.: basic, durable and, best of all, fast to make, said Kevin Carroll, vice president of prosthetics for Hanger Orthopedic Group, the company leading the Haitian Amputee Coalition, with a clinic in Deschapelles.
Since late February, the clinic has provided more than 85 plastic and laminate limbs -- including arms, lower legs and full legs with knee joints to patients like Eliance, who says the possibility of walking again has helped her cope with the trauma of amputation.
"Sometimes you think about what happened and it's hard," she said through a translator. "I'm glad I have people and my family to help me."
But the outreach effort also has renewed an ongoing debate in the international prosthetics community: What's the right kind of limb to use in developing countries?
But the outreach effort also has renewed an ongoing debate in the international prosthetics community: What's the right kind of limb to use in developing countries?
If you ask Colleen O'Connell, a board member with Healing Hands for Haiti, the primary prosthetic group in Haiti before the quake, the answer is a rugged, all-plastic limb manufactured according to standards set by the International Committee of the Red Cross, which typically provides prosthetics in war zones.
A below-the-knee ICRC limb can be built for about $300, said O'Connell. Plus, it's easy to train technicians to repair and maintain. Hanger's limbs don't hew to those suggested standards, costing about $5,000 to produce in the U.S., and about $2,000 in Haiti.
That raises questions among some in the international community and even some who've worked at the new clinic site.
Mike Landry, a physical therapist who is also an assistant professor at the University of Toronto, just finished two weeks of helping amputees adjust to new limbs in Deschapelles. A veteran volunteer who has worked in Bosnia, Kosovo, Sri Lanka and Rwanda, he praises the project and says it has made more progress than any other similar effort in the developing world.
He praises the project and says it has made more progress than any other similar effort in the developing world. But he worries that it may be difficult to sustain such momentum for the long haul, perhaps doing a disservice to amputees fitted with limbs now.
"For-profit firms can come in quickly and leave just as quickly," he said. "This could be a problem."
In addition, Robert Kistenberg, president of the U.S. chapter of the International Society for Prosthetics and Orthotics, says the Seattle foot, a type of prosthetic model used by Hanger, isn't particularly durable in places like Haiti.
"They perform well until exposed to heat, humidity and moisture, hello rainy season, and then the foam rapidly disintegrates," he said. "I'd give it six to nine months."
Carroll, the Hanger executive, disagrees. He said this type of foot has been used extensively in Louisiana and other hot, humid places, with great success.
"The Seattle foot has been around a long, long time," he said of the device invented in the mid-1980s. "It's not something that came out last week."
Jay Tew, the prosthetics expert who set up the clinic, says he fully expects the project to continue for years. He said it could be possible in the future to add ICRC limbs and training, but it was important to get started.
"That's the key: sustainability," he said.
In these early days of earthquake recovery, it's important not to miss the larger goal of providing help, education and training quickly, said Al Ingersoll, a Healing Hands for Haiti board member recently hired as a prosthetics adviser for the country. Hanger is not required to use ICRC technology, which is not allowed in the U.S. because of liability concerns, he noted.
And they're not just making limbs, they're also training Haitian workers as technicians to help patients and to produce and repair prosthetics.
The new lab in Deschapelles is on track to fill a gaping hole in rehabilitation services in rural northern Haiti, says Ingersoll, a prosthetics expert from Minneapolis.
On a recent Tuesday, the crew manufactured 17 limbs in a single day.
"Hanger states that they are here for the long term and after seeing what they are setting up, I believe them," he said.
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