plethysmography and arteriogram revealed marked vascular insufficiency of toes-foot. Amputation of the second and third toes was accomplished on July 8, 1965 (figure 6). Patient continued to have problems and on July 30, 1965, below-knee amputation, 5-inch level was performed and first postoperative rigid dressing extending to midthigh was applied with prosthetic attachment plate to distal aspect (figure 7). An adjustable pylon unit with SACH foot was alined and the patient assisted in progressive weight bearing and ambulation in parallel bars. Patient progressed satisfactorily (figure 8) and by the 15th postoperative day was ambulating in parallel bars several hours per day with minimal difficulty or discomfort. Patient was discharged and continued as an outpatient with usual cast changes; on 26th postoperative day cast was removed and patient measured and fitted with permanent below knee PTB prosthesis (figure 9). Patient resumed gait

training-ambulating with two canes and was discharged on 35th postoperative day (figure 10). Followup examination by Dr. Burgess and Mr. Traub over a 17-month period indicates no problem-patient continues to do well and uses a cane for balance.

Edema, postoperative pain, phantom limb syndrome and neuromata are relatively alleviated with this prosthetic management program. A sensory motor feedback is accomplished through the spindle cell of the muscles and other receptors of the skin, which creates a neurophysiological analogue, greatly enhancing prosthetic rehabilitation. After further investigation of the sensory motor feedback that is accomplished through this adaptive surgical technique, consideration needs to be given to its application to upper extremity prosthesis with external power. The introduction of a powered actuator reduces or even cuts off the sensory motor feedback arising distal to the actuator. This type of adaptive surgery might be a means of enhancing feedback in

the upper extremity amputee fitted with external powered prosthesis. Prosthetics for children basically are components from adults that are scaled down since the major emphasis over the past several decades has been in the technological advances for adults. It is important that this group of young patients be fitted with prostheses early enough for them to form their lives with an engrained pattern of prosthetic use. It is of major importance that the prosthesis be cosmetically acceptable and tolerable over the years in order that the wearer integrate it into his body image. In applying external power to artificial limbs for children, those who are most likely to benefit are the bilateral highlevel amputee. Control systems should be developed which would enable the wearer to manipulate the prosthesis subconsciously; speed, force and excursion of each movement need to be controlled and simultaneous performance of two or more movements is highly desirable.

Since the introduction of a powered actuator reduces or even cuts off sensory feedback arising distal to the actuator, means of sensory feedback need to be sought.

In retrospect, it seems apparent that we have failed to see the dimensions of the entire problem. Amputees and others with orthopedic physical impairments are much better served today than ever before. However, those of us involved in research and development in prosthetics and orthotics have a tendency, through technological and engineering advances, to perfect a particular unit without considering the education or alteration of the patient as a person: he has been relegated a secondary position in the development.

Areas in prosthetics and orthotics in which additional research and investigation are needed fall into the following:

Physiological research in amputation surgery is providing more functional stumps and more comfort to the patient. Clinical in