The cineplastic method in upper-extremity amputations.

Observations by the Army Surgeon General's Eunropean Commission on Amputations and Prostheses early in 1946, and the work of the Committee on Journal Artificial Limbs since that time, have resulted in additional knowledge of the cineplastic method. The only cineplastic method still in use is that of Sauerbruch, developed in Germany during and after World War I. Little was known, until early in 1946, of the status of cineplasty in Germany or of the management of arm amputations in general in that country during and since World War II. The cineplastic method was found to be in active use chiefly in two centers, Munich and Berlin. Cineplasty was by no means used to the exclusion of other methods, even in these two centers. Patients were usually given their choice of the three methods generally used,—the cineplastic, the Krukenberg, and the conventional methods requiring no special surgical procedures. Prof. Max Lebsche of Munich introduced the practice of liberating the distal attachment of the canalized muscle in cineplastic operations. This modification seemed to improve the results without unduly complicating the procedure. The surgery of cineplasty was found to be highly developed. It is doubtful if the surgical aspects of the method can be improved appreciably. The principle of the method consists in the use of two muscle motors on the arm; these are constructed by raising a flap of skin on the stump and converting it into a tube, which is placed through a hole in the muscle belly. When the muscle is contracted by the amputee, the tube is moved. A rod through the tube is connected to the prosthesis. Active contraction of the muscle thus governs the action of the prosthesis through the rod. One muscle motor is constructed on the flexor surface of the arm and the other on the extensor surface. The selection of the sites for placement of the muscle motors is of the utmost importance. The muscles should be tunneled at the distal end of the muscle fibers. The excursion of the muscle tunnel is in direct proportion to the length of the muscle through which the tube passes. The strength of the motor is in direct proportion to the width or diameter of the muscle belly. The biceps alone or the biceps and triceps should both be canalized for short stumps below the elbow, and the pectoral motor should be used for short arm stumps above the elbow. The preoperative and postoperative care, consisting chiefly in proper muscle exercises, is highly important. Before operation, all of the muscles are strengthened to the maximum extent, and the patient is taught selective use of those to be tunneled. Following operation, the patient is taught active use of the muscle motors, while the muscles are stretched to their full length. Strength and excursion of the motors are increased by active contraction of the muscle motor against gradually increasing resistance on a rod which passes through the tunnel. The German prosthesis is still essentially the same as that originally developed. It is lacking in cosmetic, mechanical, and functional qualities. It is also very delicate, and the component parts are subject to wear and frequent breakage. At present, no prosthesis is known which is essentially different or better than the German one. Much recent work has been done on the cineplastic method by the Committee on Artificial Limbs. Fundamental research has been carried out on cineplastic amputees, with particular regard to the physiology of the muscle motors in relation to the mechanical needs of the prosthesis. Results of these studies at the University of California have already indicated a definite need for compensatory mechanisms in the prosthesis, to take the place of the natural ones which were lost when amputation was sustained. The incorporation of these and other valuable principles, worked out by the Committee on Artificial Limbs, should improve the future prosthesis appreciably. When this has been done and a better prosthesis has been made available for use in properly organized cineplastic centers, the method may well enjoy more extended use than at present.