ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report

| Contents | | Photos | | Previous Page | | Next Page |

Papers

LOCAL TECHNOLOGY AND SOCIAL SERVICE OF PROSTHETICS AND ORTHOTICS IN INDONESIA

Handojo Tjandrakusuma

Background Information

Before the second World War prosthetics and orthotics services were not available in Indonesia. After that, during the Indonesian struggle for independence (1945-1950) many Indonesian military personnel and private citizens became amputees due to war injuries.

Observing this situation, the late Prof. Dr. Soeharso started a small prosthetic/orthotic workshop, the first in Indonesia. At that time the demand for prosthetic/orthotic devices was growing. To meet this increasing demand, the late Prof. Dr. Soeharso established the Institute for Prosthetics and Orthotics in 1950. This Institute is managed by the Indonesian Ministry of Health. The polio outbreak, in 1955, happened during this intensive development in orthotics. Until 1973, the Solo Institute for Prosthetics and Orthotics was the only centre of development of prosthetics and orthotics in Indonesia.

In 1973, the Indonesian Ministry of Health started a new national programme in the field of medical rehabilitation, i.e. the establishment of the "Medical Rehabilitation Department" or MRD in government hospitals. The programme started with the setting up of MRDs in provincial referral hospitals. At present, more than 20 Provincial referral hospitals have MRDs. Prosthetic/orthotic services are included in the MRDs of general hospitals. At district-level hospitals, MRDs are also being developed. However, the prosthetic/orthotic services offered in the MRDs are not comprehensive, and in most cases prosthetic/orthotic services are just starting to be developed. In addition to the government prosthetic/orthotic services, the private sector of the prosthetic/orthotic service has also been growing. Therefore, at present, besides the government prosthetic/orthotic workshops, there are also private ones being offered.

Technological Development of Prosthetics/Orthotics in Indonesia

Technological development of prosthetics and orthotics in Indonesia depends on many factors. Among these are:

1. Awareness among the community, especially the clients, of the value of orthotics and prosthetics services
2. Purchasing power of the clients
3. Human resource and professionalism

Awareness among the Community, Especially the Clients, of the Value of Prosthetics and Orthotics Services

Community awareness and client appreciation of prosthetic/orthotic services are still inadequate.

Lacking proper information, and guidance, they consider using prosthetic/orthotic devices a burden. They do not really appreciate the full potential that the devices can offer. Since a client's attitude does create an impact on the development of a particular technology, the situation discussed above does not have a positive influence.

Purchasing power of the clients

The quantity and the level of technology of prosthetic/orthotic services depend on two factors:

1. Human resource
2. Material/component cost

In the last 10 years, economic development in Indonesia has created a strong "middle class" among its citizens. These people expect and can afford a higher quality of prosthetic/orthotic services. In several major Indonesian cities, some private prosthetic/orthotic workshops will be able to provide services with imported technology and materials/components. However, the number of these "middle class" citizens is still small. The purchasing power of the community in general is still too weak to support a market of high-tech prosthetic/orthotic devices.

Human Resource and Professionalism

The development of technology must be supported by human resource armed with a good standard of professionalism. At present, prosthetic/orthotic services in Indonesia are provided mostly by technicians who have been trained for only 6 months. Of these, only a few will get opportunities to receive additional training abroad. Such situations are not conducive to the advancement of professionalism in prosthetics and orthotics.

Professionalism in prosthetics and orthotics can only be developed by providing a formal education of acceptable standard. Unfortunately, this is not available at present. Compared to the development of professionalism in the field of physiotherapy, professionalism in prosthetics and orthotics has far to go. The formal education of a physiotherapist was started in 1964. To qualify as a physiotherapist, a candidate must obtain a high school degree, followed by a successful three-year study in the school of physiotherapy. Currently the number of Physiotherapy Association members in Indonesia is more than 2000. It is obvious that such enthusiasm is very promising in the development of professionalism.

Conclusion

It is difficult to describe the present status of technological development in the fields of prosthetics and orthotics in Indonesia. In some places, technology which was developed some 40 years ago is still in use. In others, new and modern technology is available. Clearly, there needs to be an established standard in order for prosthetic/orthotic services to be effective in Indonesia. To achieve that, one major ingredient is a strong knowledge base which calls for a good formal education system to be in place. It is thus important that the Nation's authority in the field decide on a long-term strategic plan to successfully steer this course of development in the right direction.

ORTHOTICS & PROSTHETICS: LOCAL TECHNOLOGY AND SOCIAL SERVICE IN MALAYSIA

Zaliha Omar

Summary

The development of orthotics and prosthetics has progressed gradually since its first inception in 1937. Rapid industrialisation in recent years has called for excellence in all types of services in Malaysia including orthotic and prosthetic service. The national and international phenomenon of liberalisation of public services has also crept into this service. However, demand for an ideal service to meet the ever-increasing needs of people with disabilities has yet to be met. Local technology is limited to individual ingenuity and is very scarce. A very high proportion of imported technology as well as componentry predominates.

Introduction

Malaysia straddles a total land area of 151,418 sq. km. and has a total population of 19.7 million at the last (1994) census. The one and only sample survey of 1958 revealed a prevalence of disability of 1 % amongst the population. We are now in the midst of a national health and morbidity survey, NHMS II, which includes a section on disability. To date there is no data on the exact demand for orthotic and prosthetic services in the country.

As Malaysians work towards being industrialised by the year 2020 as aspired to by our honourable Prime Minister, our social responsibilities are often questioned by the ever increasing numbers of vocal advocates for services for persons with disabilities. The latter are demanding their basic needs for reasonable quality-of-life, including the provision of up-to-date orthotic and prosthetic service that they see so often in the mass media and through the popularised Internet, etc.

Development of Orthotic and Prosthetic Services in Malaysia

History reveals that orthotic and prosthetic services developed through the realisation of their demand in specific areas. In 1937, Dr. B.D. Molesworth, a British Doctor, initiated the setting up of an orthopaedic appliance workshop in the National Leprosy Control Centre in Sungai Buloh, a small town in the state of Selangor close to the capital Kuala Lumpur. Services were provided by artisans amidst persons with Hansen's Disease for their own counterparts within the settlement as well as for those from throughout the country. Unwanted prostheses, which were donated by veterans' administrations of Britain and Australia, were shipped to then Malaya and later Malaysia. They were then modified and fitted on patients. As leprosy has almost been eradicated, the National Leprosy Control Centre has now made way for a district hospital and the orthotic and prosthetic workshop now provides mainly orthoses and other rehabilitation aids made by occupational therapists and not leprosy patients anymore.

In 1949, a similar workshop was started by Mr. Mellowship in the General Hospital Kuala Lumpur, to meet the needs of orthopaedic patients. He administered it from Penang, some 500 km north of Kuala Lumpur where he was based. In 1951 it was placed under the administration of the General Hospital Kuala Lumpur. Two technicians went on a two-year training programme at the Hangers Orthotic and Prosthetic Company in United Kingdom. In 1969, this little workshop made way for the National Limb Fitting Centre Kuala Lumpur. The latter was recently gazetted as the Rehabilitation Technology Section of the Rehabilitation Medicine Department of Hospital Kuala Lumpur, Ministry of Health. Staff in the centre had mainly on-the-job training as prosthetic/orthotic technicians. One rehabilitation physician and three technicians were trained under the Japanese International Co-operation Agency (JICA) programme. In 1997 it provided 271 orthoses and 33 prostheses mainly to public servants.

In 1967, an orthotic and prosthetic service was started as one of the medical rehabilitation services for orthopaedic patients and other persons with disabilities managed by the University Hospital, Kuala Lumpur (Ministry of Education). At the beginning, artisans were the pillars of the service. In the early 1970s, two of them were funded by the World Rehabilitation Fund and were trained in Prosthetic and Orthotic Technology in Hong Kong. From 1980 to 1982, three were trained together with three social welfare officers from the Department of Welfare by an orthotist and prosthetist from the German Overseas Volunteer Corporation. Between 1987 and 1992, five had the opportunity to train as prosthetic and orthotic technicians under the Japan International Co-operation Agency (JICA) scheme. In the meantime, in the past 10 years, an average of twice yearly updates in orthotics and prosthetics had been organised, aimed at improving knowledge and increasing skills of technicians in the fields of orthotics and prosthetics. Attempts to employ full time orthotists and prosthetists and a rehabilitation engineer to further improve professionalism in the prosthetic and orthotic service failed. Hence, a liberalisation exercise for the provision of orthoses and prostheses in the hospital (now called University of Malaya Medical Centre) was carried out in March 1996. The justifications for the liberalisation exercise were as follows:

1. to increase the efficiency of the prosthetic and orthotic service in particular and the rehabilitation medicine service in general;
2. to produce a high quality service;
3. to increase the prosthetic and orthotic product range in keeping with the demands of patients, people with disabilities and the relevant medical services especially rehabilitation medical and orthopaedic services;
4. to promote education and training programmes in prosthetics and orthotics for technical and health professionals including teachings in the said curriculum for undergraduate and postgraduate doctors;
5. to strengthen community outreach programmes aimed at making prosthetic and orthotic services more accessible;
6. to ensure a marketable service in keeping with the aspirations of our newly corporatised medical centre;
7. to promote and carry out research and development projects aimed at improving prosthetic and orthotic services for the nation.

Since then, the rehabilitation medicine service has been able to focus on the provision of a comprehensive and holistic service instead of worrying over the quality and quantity of orthotic and prosthetic products. Out of about 200,000 patients seen in the Rehabilitation Unit during the year from October 1996 to September 1997, 23 came for prosthetic and 1783 for orthotic services.

The 1970's saw the mushrooming of private enterprise orthotic and prosthetic services in Malaysia. At present there are seven private prosthetic and orthotic companies in Malaysia. Only one is formally associated with a hospital and is hospital-based.

In 1980, the Department of Welfare set up its very own orthotic and prosthetic service aimed at the provision of low cost orthoses and prostheses for people with disabilities. At least eight welfare officers have been trained as prosthetic and orthotic technicians under various programmes including British Overseas Assistance, German Overseas Volunteer and Japan International Co-operation Agency. Orthotic and prosthetic technology was also promoted as another vocational option for vocational trainees under their jurisdiction. At the moment there is one prosthetic and orthotic technical workshop managed by prosthetic and orthotic technicians which provides prosthetic and orthotic services for clients from the Department of Welfare.

Around the same time, the Ministry of Defence sent two officers for training in Australia and later in England. This arose because of their plans to set up an amputee service for the many booby trap victims. However, a workshop was not set up; instead the trained officers were seconded to the Department of Welfare.

JICA had also trained one other prosthetic and orthotic technician from the Ministry of Health and another from Universiti Kebangsaan Malaysia (UKM), both of whom do minimal work in prosthetics and orthotics at the moment.

Range of Prosthetic and Orthotic Items

The types of orthoses and prostheses which are available in Malaysia range from simple off-the-shelf orthotic items to custom-made orthoses and prostheses. Modem technology has also penetrated, giving our patients better and more options for materials as well as aesthetics. Modular systems and thermoplastics are widely used particularly for convenience and speed. Almost all components are imported from the United Kingdom, USA, Australia, Japan, Germany and Taiwan. Except for the rare occasion of individually designed prostheses and orthoses, there has been no local production of components.

Human Resources

The development of health services in general, and particularly the training of human resources, contribute greatly to the development of orthotic and prosthetic services in Malaysia. The rehabilitation medicine curriculum for the training of doctors in the University of Malaya and the rehabilitation, orthotic and prosthetic curriculum in the training of orthopaedic surgeons, sports physicians and rehabilitation physicians have led to a more concerted effort to improve this service. Though the provision of orthoses and prostheses. is possible through all the workshops mentioned above, a comprehensive and holistic service seems to be only possible where it is provided through a rehabilitation medicine service. At the moment there are only three such services in the country, i.e. at the Hospital Kuala Lumpur which is the national referral centre in the country, the Seremban Hospital which is a General Hospital, and the University of Malaya Medical Centre which is one of seven teaching hospitals in the country.

With regard to professionals providing the service, only the University of Malaya Medical Centre has an ideal rehabilitation team including orthotists and prosthetists, rehabilitation physicians, physiotherapists, occupational therapists, medical social workers and others as well as easy referral to orthopaedic surgery, plastic surgery, psychology and others. About three orthotists and prosthetists along with a variable number of technicians provide a mobile private orthotic and prosthetic service throughout the country. The overall supervision of all orthotic and prosthetic service in the country with the exception of the University of Malaya Medical Centre lies in the hands of orthopaedic surgeons in hospitals or rehabilitation workers in the community, most of whom have very limited knowledge in orthotics and prosthetics. In the University of Malaya Medical Centre, rehabilitation physicians are responsible for patients requiring orthoses and prostheses. They work closely with other colleagues including other medical rehabilitation professionals (including orthotists and prosthetists), orthopaedic surgeons and other health professionals.

Problems

Some of the problems which can be identified in the present orthotic and prosthetic service in Malaysia include the following:

1. lack of a database on the epidemiology of persons with disability requiring the service.
2. shortage of trained professionals in providing the service. This includes orthotists, prosthetists, qualified prosthetic and orthotic technicians, rehabilitation physicians and others.
3. non-availability of facilities for training professionals for the service.
4. shortage of services.
5. poor distribution of services, rendering them inaccessible for many. Most services are in the Klang Valley which surrounds the capital city.
6. poor co-operation and co-ordination of existing services.
7. no standardised quality control of orthotic and prosthetic products.
8. lack of price control for orthotic and prosthetic products.
9. no information network system which is easily accessible to most persons with disability.
10. non-existent national agenda for research and development in orthotics and prosthetics.

Possible Solutions

The problems mentioned above need to be addressed to ensure future development of orthotics and prosthetics in Malaysia. The following are some suggestions:

1. the setting up of a database on the epidemiology of persons with disability requiring orthotic and prosthetic services.
2. The database can be used to plan the distribution of services throughout the country as well as for other research and development projects.
3. Establish formal training programmes for orthotic and prosthetic technicians and possibly for prosthetists and orthotists
4. Increase the number of services throughout the country. Every hospital should have a facility and a small one should have access for referral to a higher level.
5. Decentralisation of services.
6. Establish a co-ordinating body which can plan a national agenda, ensure quality control of products, control pricing, etc.
7. Encourage research and development particularly in promoting low cost local technology in the production of prostheses and orthoses.
8. setting up of an information network system which can be easily accessed by persons with disabilities and their carers.

Conclusion

The prosthetic and orthotic services in Malaysia have slowly developed through meeting the needs of patients within hospitals and people with disabilities in the community. A much more dynamic and proactive approach is needed to see progress in the field. The potential for development is enormous.

LOCAL TECHNOLOGY FOR CHEAP LOWER LIMB PROSTHESIS IN SINGAPORE

P Balasubramaniam and S T Lee

This paper describes the use of cane, softwood, rubber, leather and resins for manufacture of different types of lower limb prostheses. These materials have been used to make temporary as well as permanent prostheses. Cane (Calamus rotang) is used traditionally in the manufacture of durable crutches, calipers and walking frames. It is cheap, light, does not splinter and it can be moulded into any shape by heat. All these properties make cane a very suitable material for manufacture of lower limb prosthesis in developing countries.

Temporary Trans-Tibial Prosthesis

Trans-tibial amputation is the commonest major amputation of the lower limb and its successful rehabilitation depends on early fitting of a pylon which must be fabricated easily in a short time by unqualified technicians in developing countries.

The principle of an axillary crutch was used to make a trans-tibial cane pylon. A 40cm long and 4cm thick cane was used as an endoskeleton. It was split into two for about 20cm for riveting each half to the prosthetic socket (Fig 1).

D

If no plastic material is available, the socket can be made from plaster of Paris bandages, reinforced with stockinette impregnated with resins and then riveted to the cane. The lower end of the cane is fixed to a wooden block with a rubber cap. The pylon is harnessed to the thigh with leather straps fixed to the socket. If necessary the pylon can be fitted with a wooden rocker foot and tyre sole. A cane pylon can be assembled in a modular fashion by a technician and fitted without any delay for rehabilitation.

Trans-Tibial Cane Prosthesis

A thick cane is used as the endoskeleton of this prosthesis. A metre of 4cm thick cane costs about USD7.00 and this length of cane can be cut into pieces to make four prostheses. The upper end of a 25cm long piece of the cane is fixed to the socket by wood mounting or a socket base made of two strips of u-shaped steel plates. The mounting is reinforced with plastic resins and the lower end of the cane is bolted to a locally made SACH foot The cane is finally covered by plastazote and stockings to give it a cosmetic appearance (Fig 2).

D

Modified SACH Foot

The imported SACH foot has many disadvantages in developing countries. It needs a shoe and is not suitable for use on rough and wet ground. Under these conditions the rubber of the foot cracks especially where it is bolted to the ankle. Valgus and varus deformities of imported SACH feet were also a problem if the heel was made of very soft sponge rubber. This deformity makes heel strike difficult and unsteady with the prosthesis. A sponge rubber SACH foot wears faster in a wet tropical climate and the amputees come for its replacement within three to four months of its active use.

A modified SACH foot was therefore made locally with materials like soft wood, pelite rubber and leather to overcome the disadvantages of imported SACH foot and also to cut down its cost. Locally available soft wood was used for the solid ankle and two layers of belting material were stapled to its front to form the toe piece of the foot. Two layers of 3mm thick leather were glued beneath this framework to form the deeper layer of the sole. A wedge of six laminations of pelite rubber were glued beneath it to form the cushioned heel. A second layer of two strips of leather were then glued to it to form the superficial layer of the sole. The top of the wooden frame and the toe piece were glued with layers of pelite rubber in a papier mache fashion to complete the foot (Fig 3). The foot was finally shaped to the correct size by shaving off the excess rubber to fit the shoe of the patient. The gluing of the layers of rubber has to be done carefully without leaving any air pockets between them, otherwise the layers separate easily. This locally designed SACH foot can be made for USD10 and it can be made easily by an orthopaedic appliance maker.

D

Trans-Femoral Cane Pylon

A trans-femoral pylon can be quickly fabricated without a knee joint from one long piece of cane and a socket. If a knee joint is desired, two pieces of 4cm thick cane measuring about 15cm for the thigh and 25cm for the leg are necessary. The knee joint for the pylon is a simple hinge made of a steel axle and bush fixed to the lower end of the cane for the thigh. The ends of the cane forming the knee joint are slotted into tight fitting brass sleeves. The axle of the knee joint is joined to two 10cm long stainless steel plates bolted to the sides of the brass sleeve on the leg piece of cane. The lower end of cane for the thigh has two 5cm long stainless steel plates bolted to it in a similar manner. The two pairs of stainless steel plates are fashioned in the manner of a knee joint for an above knee caliper to provide locking in full extension. Elastic rubber belting is fixed across the knee to function as an extension spring (Fig 4). The socket for the thigh is wood mounted as in the case of the trans-tibial prosthesis.

D

Trans-Femoral Cane Prosthesis

For a trans-femoral cane prosthesis it is only necessary to cover the cane pylon with plastazote and stockings to improve the cosmetic appearance. The knee alignment is tested in a jig for every prosthesis.

Discussion

Cane prostheses have been made in the National Artificial Limb Centre at Tan Tock Seng Hospital, Singapore since 1983. So. far, 484 lower limb cane prostheses have been made and the majority of them are for trans-tibial amputations which are the commonest major amputations of the lower limb in our population. A temporary trans-tibial cane pylon can be fabricated cheaply, easily and quickly in a modular fashion by any unqualified technician. Even if plastic materials to make a socket are not available it can be made with plaster of Paris bandages and reinforced with layers of stockinette impregnated with resins. The lining for this type of socket can also be made with stockinette. Once a stump has shrunk and the patient has learnt to walk with the cane pylon he or she can switch to a permanent prosthesis made of cane and fitted with a locally made SACH foot. Squatting is possible with a trans-tibial cane prosthesis. Loosening one of the harness straps of the prosthesis during squatting makes it comfortable.

Though most of our amputees using the cane leg are elderly, young active adults have also found it light, functional and cosmetically acceptable and they have no difficulty in climbing hills with the locally made SACH foot.

This SACH foot, made from wood, rubber and leather, is slightly stiff when compared to the soft imported ones, but after a few months of use the leather sole becomes less stiff and it continues to prevent cracks in the foot when it is used under wet conditions. The leather sole of the locally made SACH foot and its rubber top make it ideal for wet conditions and the prostheses can therefore be worn by ladies while washing clothes on the floor. This SACH foot does not soak under water nor become soggy and crack like an imported SACH foot, made of sponge rubber, in wet conditions.

Pelite rubber, unlike sponge rubber, is solid and sheets of it can be moulded and glued together around the wooden skeleton of the foot in the fashion of making a papier mache toy. It is soft enough to cushion the heel but stiff enough not to deform and it can be used without a shoe.

Elderly patients with trans-femoral amputation seem to prefer a temporary cane pylon without a knee joint for it is light and stable to start their walking training. Once they get used to walking they do not mind switching to one with a knee joint. The knee joint mechanism described for this prosthesis can be made by any blacksmith and the locking device which is similar to that of an above-knee caliper makes the prosthesis steady on extension.

There was one failure in this series of cane prostheses. It was not due to a failure of the cane as a material, but do to an error during its manufacture. The cane broke at the site where it was slotted into a square brass sleeve to connect it to the SACH foot. To make a square peg, the strong outer covering of the cane was shaved off by a technician. The strength of cane as a material not only depends on its fibres, but also on its strong outer covering. When the strong outer covering of cane is shaved off it becomes weak and fractures easily. It is important that its outer covering is not shaved off when a prosthesis is made with cane.

Cheap, light and durable lower limb prostheses can be made by unqualified technicians with locally available materials like soft wood, cane and rubber.

LOCAL TECHNOLOGY AND SOCIAL SERVICE OF PROSTHETICS AND ORTHOTICS IN THAILAND

Therdchai Jivacate

Thailand is a developing country with the population of 60 millions. The majority of the population consists of farmers working in agriculture. The number of the physically disabled persons was about 122,440 in 1992 and the number of amputees is not exactly known. Before the law for the disabled was implemented in 1996, persons with physical disabilities had to help themselves in getting prostheses and orthoses. Some have to make their own, some get prostheses and orthoses from private organisations. Five years ago the Prostheses Foundation was founded by the King's Mother to provide prostheses free of charge to the poor. Now the disabled can get prostheses and orthoses from the government service.

In Thailand we can provide nearly every kind of prosthesis and orthosis, using old technology, which still function well are not so expensive.

For upper extremity amputees, we can make trans-radial and trans-humeral prostheses. Terminal devices used are the hook and functional hand which have to be imported. The elbow unit is of the single axis type with manual lock and is locally made. We can make all kinds of lower limb prostheses such as trans-tibial prosthesis with PTB socket, knee disarticulation prosthesis and trans-femoral prosthesis with single axis knee or safety knee according to indication. The single axis knee, SACH foot and single axis foot can be locally made, as well as the hip joint for hip disarticulation prosthesis.

All kinds of orthosis can be made locally such as plastic AFO, short leg brace, long leg brace, hand and finger splints and the Knight, Taylor, Jewette, Boston and SOMI braces.

LOCAL TECHNOLOGY AND SOCIAL SERVICE OF PROSTHETICS AND ORTHOTICS IN VIETNAM

Ha Anh

The Vietnam Orthopaedics and Prosthetics Branch was founded in 1947 during the war against the French colonists in order to service the Vietnamese army. After peace in the north of Vietnam in 1954 prostheses and orthoses have been provided for disabled people. Before 1975 Vietnam was divided into two parts:

• Almost all techniques used in the north of Vietnam were derived from China
• In the south of Vietnam, America helped the orthopaedic workshops

After 1975 Vietnam Orthopaedics and Prosthetics Branch grew and orthotic techniques unproved. Since 1981, West Germany has helped Vietnam to train orthopaedic workers and all orthopaedics and rehabilitation centres in Vietnam have been using West German techniques. From 1990 the "Open door" policy of the Vietnam Government has allowed technology from all over the world to be applied in Vietnam by NGOs and government offices.

Techniques Used for Prosthetic Limbs in Vietnam

1. The old technique.
This technique uses wood to make prostheses. There is one orthopaedic factory specialising in making components from wood for all orthopaedics centres in Vietnam. Making a prosthetic socket from wood is very time consuming. Now wood sockets are not used in Vietnam because they are heavy and not cosmetic.

2. Plastic prostheses.
In almost all orthopaedic centres, prostheses are made of plastic. Prosthetic sockets are made from polyester resin laminate. Feet and knees are produced at the Ba Vi component factory. The knee is a single-axis constant friction design and the feet are like the exposed-keel SACH foot. Polypropylene (PP) feet are produced at HCM centre and Jaipur feet are produced at Tarn Diep. The socket type for the trans-tibial amputee is the PTB with cuff suspension or knee joints and thigh lacer. Trans-femoral amputees receive a quadrilateral socket with either pelvic belt suspension or Silesian suspension. Suspension straps are popularly used in Vietnam. Resin sockets are good for Vietnamese amputees. They are light, cosmetic and durable.

3. The polypropylene (PP) technique.
Since 1991 CICR has helped HCM orthopaedics and rehabilitation centre in making prostheses and orthoses from PP. Up to. now about 10,000 prostheses and over 1,000 orthoses have been provided for disabled people. The PP prosthesis is light, water-resistant and environmentally friendly. The components can be produced right at the orthopaedic centre. The PP technology is now used in many developing countries but has not yet been adopted by all centres in Vietnam because it has some problems. This technology requires special equipment and local repairs are difficult. The amputees have difficulty when their artificial limbs fail and they cannot repair them at home. Vietnam does not yet manufacture PP; we must buy PP from other countries. Vietnam is hot and humid so most of the amputees in the north of Vietnam or in the mountains and rural areas do not like to wear the PP limb.

4. Aluminium prostheses
In Vietnam some prosthetic limbs still incorporate an aluminium shank and leather socket. Orthotic production uses standard aluminium and leather techniques. The Tam Diep centre specialises in making aluminium prostheses. Since 1994 Tarn Diep has been making the aluminium Jaipur limb. Aluminium prostheses can be used for peasants in the fields, and people living in the mountains like using aluminium prostheses more than other systems because they are light and simple and can be repaired easily by themselves. People living in the high mountains and far from cities and towns cannot come to the orthopaedic centre for repairs to their artificial limbs so they like the simple limbs.

5. Modular artificial limbs
In 1989, a prosthetic outreach centre (POC) was founded in Hanoi to manufacture prostheses using a CAD-CAM system. It was assisted by the Prosthetic Outreach Foundation (POF) in Seattle, USA. Plastic components were produced by M+IND factory in Seattle, USA. These prostheses have been quickly accepted by the amputees in Vietnam. Nearly 7,000 amputees in Vietnam have been fitted with automatic fabrication mobility aids (AFMA) limbs. This prosthetic system is light, durable, stable, cosmetic and suitable for office work and for amputees living in Vietnam. Almost all components for this kind of prostheses are imported. At present, we have a project helped by POF to design and manufacture these kinds of components at Vietnam.

Techniques for Orthoses

In Vietnam there are fewer orthoses than prosthetics limbs. Most of the orthoses are provided for children with polio. Disabled people are very poor so they do not have enough money to buy artificial limbs or orthoses. They receive prostheses free of charge, helped by the Government or NGOs. At present there is help from Terre de Homme in the south. From 1998 World vision has been helping four centres in the middle of Vietnam to make orthoses for disabled people.