The flawed assumption in prosthetics
Thomas Cutler
Description
Collection
Title:
The flawed assumption in prosthetics
Creator:
Thomas Cutler
Date:
8/26/2018
Text:
Dear Esteemed Colleagues,
Have you ever been in the midst of an argument only to realize that one of your assumptions was flawed? It changes everything and yet cannot be attributed to a lack of intelligence on the part of the misinformed. A helpful example may be that of a husband and wife. Let’s say he is surreptitiously planning a surprise cruise for their tenth anniversary, yet the wife assumes that his sudden sneaky calls and communications are evidence of infidelity. As things progress, her suspicions based on the single flawed assumption become certain and ingrained. It is not unheard of for infidelities to occur after a decade, thus the assumption isn’t irrational. While all the behaviors fit the context to an extent (“he’s just being extra sweet to me so I won’t suspect he’s cheating with some trollop!”), correcting one simple assumption has a consequence. The consequence isn’t merely that of adjusting what already exists. That occurs when additional information is provided to assumptions that are sound. The consequence of replacing her flawed assumption is that she needs to deconstruct and then re-construct their entire experience ever since the inception of her flawed assumption. Every action and response that she has made to the husband was affected by that flawed assumption. Are you readers now fully digesting what is potentially to follow?
The current assumption: hip abductors are intact for transfemoral amputees.
The proposed assumption: The TFL/IT band provides 30% of hip abduction power and its absence significantly compromises the success of every one of our TF prosthetic patients.
In 2012, I became enthralled with sub-ischial sockets and in the process of fitting one on a gold-medal-winning Paralympian. The more I allowed myself to embrace this approach, the more worthwhile and beneficial it seemed to eliminate the ischial containment portion.
---“The femur flexes and extends 45 degrees in ambulation, but the pelvis doesn’t. This means that the containment section of the ischial containment socket can’t get a bony lock without rubbing the niblets out of the patient’s tender parts. And who want’s callouses there?”
---We can go subischial and get true femoral hip abduction without compromise to power since ‘the hip abductors are intact on TF amputees’…”
Being part of my learning curve, I had to re-do the socket and the patient asked me to put the containment ear back in… and since the gold medal was in archery and he could silently kill me from a distance (or perhaps I knew that I could later trim it off), I reluctantly agreed. I would also consider us to be friends and perhaps that’s why I always remembered him insisting that he needed it. Then I started noticing struggles and unexplained “weakness” in other patients fit with subischial sockets. Their trunk leaning was markedly greater as well…huh... maybe something’s going on after all…
Fast forward to 2014 and dealing with a patient who would be the subject of my 2017 JPO case report. It was my first attempt at a journal article. When I wondered in 2015 where to start the timeline in a prosthetic article, I figured it made sense to start with the surgery, right? So, I read the chapter on transfemoral amputation surgery in the Atlas, which was put out by the AAOS. Mind you, I don’t even know if I paid attention to this during school. Hell, I don’t even know if I ever opened that chapter before, during, or even after school! But now, with the words of a Paralympian ringing in my ears, time slowed to a crawl and I found myself stunned as I read about how one of the primary surgical goals of transfemoral amputation involves avoiding hip abduction contractures by removing the IT band and putting it on the medial thigh. Hip abductors in amputees are removed…
What?... You’re intentionally removing one of the hip abductors? But, I’m thinking I need as much hip abduction as I can get to support body weight in stance. It’s about harnessing hip abduction forces, not removing them. I asked around to other practitioners and inquired whether hip abduction contractures were a major concern… What I found out, from asking a collective CPO experience of 280 years in clinical practice, was that not only was it not even a minor concern for any ambulating TF patient, but we realized during these conversations that Trendelenburg gait and hip abduction contractures are mutually exclusive. The concern has always been with preventing lateral femoral migration through soft tissue within the socket. The 1988 article about sockets controlling femoral adduction angle let something slip out that the principal author never intended… “Hip abduction causes distal femoral pain”, so it must be reduced. Did that slip by you? Can you even walk without hip abduction? Can you see the flawed thinking that seems so irrational? In order for us to rationalize something so obviously ludicrous, we could assume “abduction in a loose socket causes distal femoral pain” and keep reading… but after recently reading the surgical goals in the Atlas, I’m beginning to wonder… What’s this guy thinking? I dig further and he states that knee disarticulation is the only amputation level that doesn’t experience this. Then he alone decides that those patients get femoral adduction control from the medial attachment of the adductor muscles (I will prove this is wrong). Suddenly, I’m no longer working from the assumption that he’s right. Whether you prefer to call it the scales falling from my eyes, the blinders coming off, or simply that I am now being scientifically objective… I’m really starting to wonder and question this guy.
I’ve always thought that KD adduction control comes from the more aggressive contours of the socket. I reached out to the only CPO included in the article, Mac McClellan and we were both in agreement about the obviously likely impact of KD socket shape and wondered why socket shape wouldn’t have been considered. I chided him by saying “you were the prosthetist on that project, didn’t they check with you?” (which they obviously didn’t). I’m grateful that he took the time to answer a few questions during this astonishing journey of mine. Fortunately, I dug deeper and found that they reference Burgess’ chapter on knee disarticulation in Moore and Malone’s text which I have on my shelf. In addition to information about TF surgical procedures, guess what I found on page 133? Perry Rogers, a KD amputee and himself an orthopedic surgeon, directly or indirectly credits socket shape for stability on three occasions with no mention of any role of adductors.
Next step… I reached out to editors of the Atlas. Fortunately, the AAOS was already working on a new edition and I hoped we could have a discussion prior to its publication in order for them to provide an entire generation of new surgeons with the best surgical goals and techniques. Being that they provide the surgical foundation for our profession, I am more than entitled to engage on this topic. My initial conversation was terrific and with an orthopod that has impressed me both with his care and his character. Perhaps that is why I found it so strange that he was not greatly concerned about the importance of the tensor fasciae latae/IT band complex. He is a surgeon, not a biomechanist, so his was the position of one who would naturally rely on the existing body of work of others.
Because I thought he was cool, I did some digging to understand why our views differed. I found it. Now it was time to contact the AAOS, which I did. Please note that I did not make demands. I did not ask for money for research. I didn’t blame anyone. I was very clear that I was asking to have a discussion whereby they could explain the validity of seeking to reduce the magnitude of hip abduction power during the transfemoral amputation surgical technique that they promote. I am ethically obligated to broach this subject and they are ethically obligated to respond to a legitimate inquiry. I was asking to have a conversation so that we could address my concerns with a procedure performed on 0.4% of the 21 million diabetics every year… that’s 84,000 families impacted by this. Surely that’s worth having a chat.
The encounter with these folks didn’t fare as well as the other one. I was told “experience isn’t science” and “remember, in the times of Columbus, intelligent experienced people thought that the earth was flat” (it was lost on him that I was trying to tell HIM that the earth was round…) So, they had a discussion with the guy who designed the surgery, excluded me from that conversation, and told me that they would side with him and that the only next step was for me to partner with a university to publish. Let’s be clear--- I simply looked at their model of the hip and said “hey, your math on this is impossible.” Do I need to publish in a journal just to work through the math? Despite their many years of practicing, it didn’t compare to the 2270 years that we’ve had Archimedes’ Law of the Lever proved by geometric reasoning and responsible for the field of engineering… oh and probably getting us to the moon. You see, since both sides of a lever balance when you multiply the weight times the distance, nothing is allowed to equal zero or the equation falls apart. Ready for this? I said, “Hey, why is that muscle just dangling? Don’t you have to attach it to something for it to pull tension? Otherwise, that muscle side of the teeter totter does nothing…” Well, after 5 email attempts to engage with them, and 8 fruitless attempts to engage with the guy who designed the surgery, I stopped. So, now I’ll assume that they would have said, “the hip abductors attach to the greater trochanter”. Well, mathematically and in reality, this is part of the femur. Unfortunately for their model, the fulcrum of their hip model is also the femur (femoral head). This means that you either violate rules of physics by having two independent manifestations of the femur in a single free body diagram (this is cheating, folks, since you can only have one of each)… or you combine the two and have a distance of zero, violating Archimedes’ Law. And since any force magnitude times zero distance equals… yep… Impossible math.
Is the IT band important?
--I went to Johns Hopkins to get their definitive model of hip joint biomechanics. Surprisingly, in their surgeon resource, aboutjoints.com, they deferred to Friedrich Pauwels’ texts to explain biomechanics.
--1993, Kummer did a modern analysis of Pauwels’ theory. Guess what the last sentence of the pubmed abstract says? In order for the math to pencil out, 30% of hip power in abduction must come through the IT band. Is that what a 25-year-old smoking gun looks like?
--1988, Ryser was publishing at the Mayo clinic… and found that every healthy TF amputee was missing a particular amount of hip abduction torque. 30%, interestingly enough.
Because of their surgical goals, your patients can never get past 70% power... This explains the paltry rehab results in Pauley 2009.
You say, “no way, Tom! The gluteus medius is 94% of muscle volume in the hip abductor group.” Who cares? Volume is highly correlated to functional range and thus irrelevant. A short muscle designed for a short range of motion will have only a small fraction of the volume of a longer range-of-motion muscle. Quads have big volume because they have long muscle bellies… because the knee has a large sagittal plane range. TFL has a 13 degree range with a far greater lever arm. Our bodies would certainly adapt the rest of that long lever structure to a long ligament that has a negligible metabolic cost for walking. It’s only in recent decades that the human race hasn’t struggled to get enough calories. Thus, TFL having the IT band rather than calorie-burning muscle is a far more efficient mechanism for ambulation. In 2016, UCSF confirmed that the adductor myodesis surgical technique does not account for the tremendously long lever arm of the TFL/IT band. In case you don’t believe that surgeons could overlook leverage, please do some research on the tibial tubercle osteotomy procedure. The Maquet and Fulkerson procedures (which are still performed) intentionally reduce the biomechanical leverage of the patella by elevating the tibial tubercle. If we agree that the patella provides leverage, then reducing the leverage but keeping the same magnitude of tension reduces power. Since their surgical goal excludes functional metrics and success comes from “reduced patellofemoral pressure”… well, somebody should have told Maquet back in 1969 that this might not be a good idea. And yes, people who have had this surgery done have personally told me about their lack of power afterward.
You say, “no way, Tom! If you weaken the gluteus medius and minimus, you’re going to get Trendelenburg gait!” Are you sure about that? In 2015, Dr. Michael Pohl did that with a nerve block and found no kinetic nor kinematic changes during gait. Sorry Charlie… the kinematic changes from the prior studies were a result of the painful hypersaline injections used to weaken the glutes in those studies. Switch to the non-hurty-hurty nerve block and see the TFL shine… with no kinematic change. So, I guess that it’s a “Yes way!” oh, and yes, he confirmed that he got a lot of resistance to publishing the truth.
So… The IT band is important. The TFL/IT band is a primary abductor of the hip. The hip abductors are not, in fact, intact for any of our TF amputees… hip power for amputees could theoretically increase by 44%… and the AAOS doesn’t include the IT band in their biomechanical model. Did I cover everything?
One last thing… the difference between valid and sound. Science can be validated based on bad information. Science can only be sound when based on true information. Just because people agree on assumptions doesn’t make those assumptions accurate/true/sound. So, if you say, “Tom, this has been validated!” I would agree. Yes, you validated that surgery/socket/intervention based on flawed assumptions. But… it is obviously unsound. Please don’t be petulant just because you are wrong.
Any challenges? I can show you where Inman made his flawed assumption in 1947… or Denham with his flawed assumptions in 1959… or Radcliffe inserting too many fulcrums in his models in 1955… or Perry’s 1976 oversight in gait… Don’t worry, for me to mention by name any biomechanist still living would be in poor taste. But I certainly have a long and illustrious list…
Folks, the prosthetists aren’t unfaithful spouses… they’ve been trying to book a cruise with the rest of the medical professionals for decades. Do you understand about assumptions having consequences? Perhaps now you are beginning to see… we aren’t the ones who are wrong about biomechanics.
They are.
Have a good week.
Tom
Thomas J. Cutler, CPO, FAAOP
Limb.itless, LLC
PO Box 1508
Visalia, CA 93279
113 N. Church St., Ste. 312
Visalia, CA 93291
p.559.901.8103
f.559.553.8837
ps: if this post finds you wanting to disagree with me, please do yourself a favor and assume that have withheld the other 93% of that which I have discovered. If this post finds you nodding your head as certain things are making more sense, you have already done me a favor and I am both humbled and pleased that you would see it as such. Nothing has harmed our human experience as much as the willful ignorance of those in positions of influence.
“The only true wisdom comes from knowing that we know nothing.” Socrates
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Have you ever been in the midst of an argument only to realize that one of your assumptions was flawed? It changes everything and yet cannot be attributed to a lack of intelligence on the part of the misinformed. A helpful example may be that of a husband and wife. Let’s say he is surreptitiously planning a surprise cruise for their tenth anniversary, yet the wife assumes that his sudden sneaky calls and communications are evidence of infidelity. As things progress, her suspicions based on the single flawed assumption become certain and ingrained. It is not unheard of for infidelities to occur after a decade, thus the assumption isn’t irrational. While all the behaviors fit the context to an extent (“he’s just being extra sweet to me so I won’t suspect he’s cheating with some trollop!”), correcting one simple assumption has a consequence. The consequence isn’t merely that of adjusting what already exists. That occurs when additional information is provided to assumptions that are sound. The consequence of replacing her flawed assumption is that she needs to deconstruct and then re-construct their entire experience ever since the inception of her flawed assumption. Every action and response that she has made to the husband was affected by that flawed assumption. Are you readers now fully digesting what is potentially to follow?
The current assumption: hip abductors are intact for transfemoral amputees.
The proposed assumption: The TFL/IT band provides 30% of hip abduction power and its absence significantly compromises the success of every one of our TF prosthetic patients.
In 2012, I became enthralled with sub-ischial sockets and in the process of fitting one on a gold-medal-winning Paralympian. The more I allowed myself to embrace this approach, the more worthwhile and beneficial it seemed to eliminate the ischial containment portion.
---“The femur flexes and extends 45 degrees in ambulation, but the pelvis doesn’t. This means that the containment section of the ischial containment socket can’t get a bony lock without rubbing the niblets out of the patient’s tender parts. And who want’s callouses there?”
---We can go subischial and get true femoral hip abduction without compromise to power since ‘the hip abductors are intact on TF amputees’…”
Being part of my learning curve, I had to re-do the socket and the patient asked me to put the containment ear back in… and since the gold medal was in archery and he could silently kill me from a distance (or perhaps I knew that I could later trim it off), I reluctantly agreed. I would also consider us to be friends and perhaps that’s why I always remembered him insisting that he needed it. Then I started noticing struggles and unexplained “weakness” in other patients fit with subischial sockets. Their trunk leaning was markedly greater as well…huh... maybe something’s going on after all…
Fast forward to 2014 and dealing with a patient who would be the subject of my 2017 JPO case report. It was my first attempt at a journal article. When I wondered in 2015 where to start the timeline in a prosthetic article, I figured it made sense to start with the surgery, right? So, I read the chapter on transfemoral amputation surgery in the Atlas, which was put out by the AAOS. Mind you, I don’t even know if I paid attention to this during school. Hell, I don’t even know if I ever opened that chapter before, during, or even after school! But now, with the words of a Paralympian ringing in my ears, time slowed to a crawl and I found myself stunned as I read about how one of the primary surgical goals of transfemoral amputation involves avoiding hip abduction contractures by removing the IT band and putting it on the medial thigh. Hip abductors in amputees are removed…
What?... You’re intentionally removing one of the hip abductors? But, I’m thinking I need as much hip abduction as I can get to support body weight in stance. It’s about harnessing hip abduction forces, not removing them. I asked around to other practitioners and inquired whether hip abduction contractures were a major concern… What I found out, from asking a collective CPO experience of 280 years in clinical practice, was that not only was it not even a minor concern for any ambulating TF patient, but we realized during these conversations that Trendelenburg gait and hip abduction contractures are mutually exclusive. The concern has always been with preventing lateral femoral migration through soft tissue within the socket. The 1988 article about sockets controlling femoral adduction angle let something slip out that the principal author never intended… “Hip abduction causes distal femoral pain”, so it must be reduced. Did that slip by you? Can you even walk without hip abduction? Can you see the flawed thinking that seems so irrational? In order for us to rationalize something so obviously ludicrous, we could assume “abduction in a loose socket causes distal femoral pain” and keep reading… but after recently reading the surgical goals in the Atlas, I’m beginning to wonder… What’s this guy thinking? I dig further and he states that knee disarticulation is the only amputation level that doesn’t experience this. Then he alone decides that those patients get femoral adduction control from the medial attachment of the adductor muscles (I will prove this is wrong). Suddenly, I’m no longer working from the assumption that he’s right. Whether you prefer to call it the scales falling from my eyes, the blinders coming off, or simply that I am now being scientifically objective… I’m really starting to wonder and question this guy.
I’ve always thought that KD adduction control comes from the more aggressive contours of the socket. I reached out to the only CPO included in the article, Mac McClellan and we were both in agreement about the obviously likely impact of KD socket shape and wondered why socket shape wouldn’t have been considered. I chided him by saying “you were the prosthetist on that project, didn’t they check with you?” (which they obviously didn’t). I’m grateful that he took the time to answer a few questions during this astonishing journey of mine. Fortunately, I dug deeper and found that they reference Burgess’ chapter on knee disarticulation in Moore and Malone’s text which I have on my shelf. In addition to information about TF surgical procedures, guess what I found on page 133? Perry Rogers, a KD amputee and himself an orthopedic surgeon, directly or indirectly credits socket shape for stability on three occasions with no mention of any role of adductors.
Next step… I reached out to editors of the Atlas. Fortunately, the AAOS was already working on a new edition and I hoped we could have a discussion prior to its publication in order for them to provide an entire generation of new surgeons with the best surgical goals and techniques. Being that they provide the surgical foundation for our profession, I am more than entitled to engage on this topic. My initial conversation was terrific and with an orthopod that has impressed me both with his care and his character. Perhaps that is why I found it so strange that he was not greatly concerned about the importance of the tensor fasciae latae/IT band complex. He is a surgeon, not a biomechanist, so his was the position of one who would naturally rely on the existing body of work of others.
Because I thought he was cool, I did some digging to understand why our views differed. I found it. Now it was time to contact the AAOS, which I did. Please note that I did not make demands. I did not ask for money for research. I didn’t blame anyone. I was very clear that I was asking to have a discussion whereby they could explain the validity of seeking to reduce the magnitude of hip abduction power during the transfemoral amputation surgical technique that they promote. I am ethically obligated to broach this subject and they are ethically obligated to respond to a legitimate inquiry. I was asking to have a conversation so that we could address my concerns with a procedure performed on 0.4% of the 21 million diabetics every year… that’s 84,000 families impacted by this. Surely that’s worth having a chat.
The encounter with these folks didn’t fare as well as the other one. I was told “experience isn’t science” and “remember, in the times of Columbus, intelligent experienced people thought that the earth was flat” (it was lost on him that I was trying to tell HIM that the earth was round…) So, they had a discussion with the guy who designed the surgery, excluded me from that conversation, and told me that they would side with him and that the only next step was for me to partner with a university to publish. Let’s be clear--- I simply looked at their model of the hip and said “hey, your math on this is impossible.” Do I need to publish in a journal just to work through the math? Despite their many years of practicing, it didn’t compare to the 2270 years that we’ve had Archimedes’ Law of the Lever proved by geometric reasoning and responsible for the field of engineering… oh and probably getting us to the moon. You see, since both sides of a lever balance when you multiply the weight times the distance, nothing is allowed to equal zero or the equation falls apart. Ready for this? I said, “Hey, why is that muscle just dangling? Don’t you have to attach it to something for it to pull tension? Otherwise, that muscle side of the teeter totter does nothing…” Well, after 5 email attempts to engage with them, and 8 fruitless attempts to engage with the guy who designed the surgery, I stopped. So, now I’ll assume that they would have said, “the hip abductors attach to the greater trochanter”. Well, mathematically and in reality, this is part of the femur. Unfortunately for their model, the fulcrum of their hip model is also the femur (femoral head). This means that you either violate rules of physics by having two independent manifestations of the femur in a single free body diagram (this is cheating, folks, since you can only have one of each)… or you combine the two and have a distance of zero, violating Archimedes’ Law. And since any force magnitude times zero distance equals… yep… Impossible math.
Is the IT band important?
--I went to Johns Hopkins to get their definitive model of hip joint biomechanics. Surprisingly, in their surgeon resource, aboutjoints.com, they deferred to Friedrich Pauwels’ texts to explain biomechanics.
--1993, Kummer did a modern analysis of Pauwels’ theory. Guess what the last sentence of the pubmed abstract says? In order for the math to pencil out, 30% of hip power in abduction must come through the IT band. Is that what a 25-year-old smoking gun looks like?
--1988, Ryser was publishing at the Mayo clinic… and found that every healthy TF amputee was missing a particular amount of hip abduction torque. 30%, interestingly enough.
Because of their surgical goals, your patients can never get past 70% power... This explains the paltry rehab results in Pauley 2009.
You say, “no way, Tom! The gluteus medius is 94% of muscle volume in the hip abductor group.” Who cares? Volume is highly correlated to functional range and thus irrelevant. A short muscle designed for a short range of motion will have only a small fraction of the volume of a longer range-of-motion muscle. Quads have big volume because they have long muscle bellies… because the knee has a large sagittal plane range. TFL has a 13 degree range with a far greater lever arm. Our bodies would certainly adapt the rest of that long lever structure to a long ligament that has a negligible metabolic cost for walking. It’s only in recent decades that the human race hasn’t struggled to get enough calories. Thus, TFL having the IT band rather than calorie-burning muscle is a far more efficient mechanism for ambulation. In 2016, UCSF confirmed that the adductor myodesis surgical technique does not account for the tremendously long lever arm of the TFL/IT band. In case you don’t believe that surgeons could overlook leverage, please do some research on the tibial tubercle osteotomy procedure. The Maquet and Fulkerson procedures (which are still performed) intentionally reduce the biomechanical leverage of the patella by elevating the tibial tubercle. If we agree that the patella provides leverage, then reducing the leverage but keeping the same magnitude of tension reduces power. Since their surgical goal excludes functional metrics and success comes from “reduced patellofemoral pressure”… well, somebody should have told Maquet back in 1969 that this might not be a good idea. And yes, people who have had this surgery done have personally told me about their lack of power afterward.
You say, “no way, Tom! If you weaken the gluteus medius and minimus, you’re going to get Trendelenburg gait!” Are you sure about that? In 2015, Dr. Michael Pohl did that with a nerve block and found no kinetic nor kinematic changes during gait. Sorry Charlie… the kinematic changes from the prior studies were a result of the painful hypersaline injections used to weaken the glutes in those studies. Switch to the non-hurty-hurty nerve block and see the TFL shine… with no kinematic change. So, I guess that it’s a “Yes way!” oh, and yes, he confirmed that he got a lot of resistance to publishing the truth.
So… The IT band is important. The TFL/IT band is a primary abductor of the hip. The hip abductors are not, in fact, intact for any of our TF amputees… hip power for amputees could theoretically increase by 44%… and the AAOS doesn’t include the IT band in their biomechanical model. Did I cover everything?
One last thing… the difference between valid and sound. Science can be validated based on bad information. Science can only be sound when based on true information. Just because people agree on assumptions doesn’t make those assumptions accurate/true/sound. So, if you say, “Tom, this has been validated!” I would agree. Yes, you validated that surgery/socket/intervention based on flawed assumptions. But… it is obviously unsound. Please don’t be petulant just because you are wrong.
Any challenges? I can show you where Inman made his flawed assumption in 1947… or Denham with his flawed assumptions in 1959… or Radcliffe inserting too many fulcrums in his models in 1955… or Perry’s 1976 oversight in gait… Don’t worry, for me to mention by name any biomechanist still living would be in poor taste. But I certainly have a long and illustrious list…
Folks, the prosthetists aren’t unfaithful spouses… they’ve been trying to book a cruise with the rest of the medical professionals for decades. Do you understand about assumptions having consequences? Perhaps now you are beginning to see… we aren’t the ones who are wrong about biomechanics.
They are.
Have a good week.
Tom
Thomas J. Cutler, CPO, FAAOP
Limb.itless, LLC
PO Box 1508
Visalia, CA 93279
113 N. Church St., Ste. 312
Visalia, CA 93291
p.559.901.8103
f.559.553.8837
ps: if this post finds you wanting to disagree with me, please do yourself a favor and assume that have withheld the other 93% of that which I have discovered. If this post finds you nodding your head as certain things are making more sense, you have already done me a favor and I am both humbled and pleased that you would see it as such. Nothing has harmed our human experience as much as the willful ignorance of those in positions of influence.
“The only true wisdom comes from knowing that we know nothing.” Socrates
Sent from Mail< <URL Redacted>> for Windows 10
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Thomas Cutler, “The flawed assumption in prosthetics,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/209107.
