A Leg to Stand on in Vietnam

Dr. Ernest Burgess was, by any measure, a remarkable man. In March 2000, just six months before Dr. Burgess’ death at age 89, Senator Robert Kerrey submitted a resolution commending him for “service to the nation and the international community.”

Senator Kerrey noted, “As a veteran and amputee, I live with the daily reminder of the costs of war. . . . Dr. Burgess pioneered new surgical techniques that allow amputees to move with more comfort and mobility. . . . On a personal note, my passion for running and my ability to ski and play golf and walk these halls could not be a reality without the advances spearheaded by Dr. Burgess.”

Ernest Burgess grew up in rural Utah, profoundly influenced by an aunt who was a practicing physician during an era when women were still struggling for the right to vote. He graduated from Columbia Medical School in 1937 and served in the Pacific theater during World War II. It was this first-hand experience with land mine casualties that kindled his life-long interest in improving the lives of amputees. After a post-war stint as Chief of Surgery at a Honolulu hospital, he settled into an orthopedic surgery practice in Seattle.

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Among other achievements, Dr. Burgess developed new amputation techniques that improved the health of the residual limb. He worked closely with his patients, many of them veterans who wanted to be as active post-amputation as they had been beforehand. “I want to run, I want to climb, I want to do everything I used to do.” Ernest Burgess listened.

Once he had met the need for better surgical techniques, Dr. Burgess turned his attention to improving prosthetics. He told the Mercer Island Reporter in 1999, “Prosthetics were primitive. [There was] no standardization or research. . . . they were cumbersome and very uncomfortable.” In 1964, at the request of the Veterans Administration, he established the Prosthetics Research Study. PRS would become a world-renowned center for postoperative amputee care and the development of lightweight, high-tech artificial limbs. One result of PRS research is a process known as AFMA: automated fabrication of mobility aids. Computer software called Seattle ShapeMaker®, which allows technicians to sculpt artificial limb sockets for a perfect individual fit, is an essential part of the AFMA process. Another PRS design is the Seattle Foot®, the first manufactured one to work like a real foot, thanks to an internal cantilever spring.

The AFMA process begins with a fairly low-tech step: making a plaster cast of the amputee’s stump. Low tech ends there, however. The casting is placed in a three-dimensional digitizer, a device that scans and measures the surface shape and volume of the cast. The digitizer data is then imported into a computer running Seattle ShapeMaker. The prosthetist, who has done a clinical evaluation of the patient before making the plaster cast, modifies the limb socket for a precise individual fit. Next, the modifications are transmitted to a carving machine, which shapes a positive socket mold from a block of plaster. A sheet of 5-mm polypropylene is put into an oven, and a thermoplastic socket is vacuum-formed over the mold. The excess plastic is trimmed off the socket, and then modular limb components – a knee joint if the amputation was above the knee, the shank or pylon, the foot – and a cosmetic cover are added, and the limb is ready to be fitted to the amputee.

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The whole process takes several hours, and the prosthesis will last at least three years. Components such as the foot or knee joint may wear out before then, but those are easily replaced.

In 1989, ready for a new challenge, Dr. Burgess founded the Prosthetics Outreach Foundation (POF), based in Seattle, to provide prosthetic care to amputees in developing countries. Given his years of work with veterans and his humanitarian need to heal more than just physical wounds, Vietnam seemed the obvious place to begin.

Although it’s difficult to get reliable estimates in a country as rural as Vietnam, the most recent data suggest there are more than 100,000 amputees in that country, many of them children and most the victims of motor vehicle accidents or land mines. Rehabilitation services are scarce, and most people can’t afford to pay for them – the average family income in rural areas is between $200 and $300 annually. Bartering is, naturally, a vital aspect of economic life, but acquiring an artificial limb requires cash. Even an inexpensive prosthesis costs $30 to $50, and growing children need a new one at least every 12 to 18 months.

Conventional prostheses aren’t very well suited for a country like Vietnam, with a farm-based economy and a tropical climate. Made from wood and resin, these limbs are stiff and heavy, and while they allow amputees to walk, they don’t provide enough mobility for working in the fields. The life span of these devices is only about 18 months, and they usually require a fair amount of maintenance during that time. And in a developing country, fabrication of conventional limbs may take several days, simply because the work is done manually.

The Prosthetics Outreach Center (POC) in Hanoi opened in 1991. In addition to providing clinical services, prostheses are made on-site, using the AFMA system described above. In its first 18 months, the center produced 1,100 limbs – the same time span saw the production of only 150 conventional limbs. POC provides artificial limbs and rehabilitation services free of charge if families can’t afford to pay for them. According to Raymond Pye, Technical Director of POF in Seattle and a frequent visitor to Vietnam, the biggest problem the foundation has is getting the word out to the more remote villages. Disabled children in these villages may rarely leave their homes. Their parents may not even take them to local clinics when a visiting nurse is available, believing that the cost of care is simply beyond the family’s ability to pay.

The Vietnamese staff of POC makes monthly trips to the rural provinces, from the Chinese border to Da Nang. A prosthetic fitting can be completed in two visits: at the first, the patient is evaluated and a plaster cast of the residual limb is made. After the prosthesis is manufactured in Hanoi, the POC team returns to fit the limb to the patient; adjustments can be made using portable tools. Up to 60 amputees may be fitted during a 2- to 3-day outreach visit. In response to the needs of Vietnamese patients, POF designed a new foot, made from vulcanized rubber, for farmers who work in muddy rice paddies. It’s a very durable item. “Prosthetic feet manufactured in the U.S. or Europe rarely last eighteen months in tropical climates without replacement of some component,” reports Ray. The cost in Vietnam of a foot made in the U.S. ranges from $250 to $400 – and “they don’t last as long as the vulcanized rubber one made in Vietnam” for $3.50.

Since 1998, POF has also helped to underwrite a medical manufacturing facility in Ba Vi (a village about 50 km west of Hanoi) that produces, among other things, limb components such as knee joints and adapters. All the products manufactured at Ba Vi are used in rehab devices. One focus of POF’s work at Ba Vi is to use local resources as much as possible, in an effort to eventually make the facility self-sustaining. The factory has been in existence since the early 1970s; during the Cold War, it was funded by the East German government.

Having modernized the design of artificial limbs, POF opened the newly renovated Ba Vi Orthopedic Technology Center in March 1998 and began the work of modernizing the manufacturing processes as well. The Ba Vi machine shop was, of course, a manual shop. “The machines were all hand-me-downs from the Germans,” according to mechanical engineer Alan Aulie. Ray Pye adds, “There hadn’t been any changes in about 25 years.”

Ray knew they needed CNC machines, and at first he thought a knee mill with a relatively inexpensive add-on CNC package might be the way to go. He soon changed his mind. In the course of his research, he asked his friend Alan Aulie, founder and president of Aulie Devices, Inc., for advice. Aulie Devices is an R&D firm that has patented half a dozen varieties of artificial knee and other prosthetic devices, using a Haas VF-0 vertical mill and an HRT 160 rotary table.

Aulie worked with Dr. Burgess for several years before he started his own company, and he has maintained ties with POF – the Ba Vi facility uses an Aulie knee design, modified for Vietnamese use. “I told him they needed a machining center identical to the one used for product design,” says Aulie. “I design right at the machine. I’ve done complex projects that were designed entirely on the Haas control, and then I sent the finished part to a CAD/CAM place to produce the drawings. This is my R&D fast track.” He also knew the Haas control would be easy for the Ba Vi machinists to learn – “there’s a shortcut on the learning curve” – plus “they’re immune to crashes. It’s really hard to break a Haas. You can make a mistake and it won’t hurt the machine.”

The Haas distributors in the U.S. and in Asia have been extremely helpful, according to Ray Pye. The Seattle Haas Factory Outlet, A Division of Selway Machine Tool Company, “spent a fair amount of time” finding POF a couple of Haas machines the foundation could afford. “It was for a really good cause,” said sales engineer Todd Newhouse, “so we went looking for used machines that had low hours and had been taken care of. We found them a VF-0 first,” in November of 1999, and then in early 2000 a good used HL-1 lathe turned up.

Once the machines were shipped to Ba Vi and installed, the Haas distributor in Thailand, Machine Tech Company Ltd. of Bangkok, has provided service. “They have been remarkable,” says Ray. “Incredibly responsive – they’re about an hour and a half away [by air], and they have been really helpful.” The only problems with the machines have been “a couple of little hiccups with the power – the electrical supply in developing countries isn’t very reliable,” Ray observed. The programmer at Ba Vi knew nothing about CNC or computers when the Haas machines arrived. He taught himself to program within a year, using Haas training manuals and some help from the Machine Tech service technician who installed a new control board.

One of the parts cut by the VF-0 at Ba Vi is the prosthetic knee joint. “A knee joint lasts 12 to 18 months,” Ray says. “It’s incredible, the amount of stress we put on our knees. It’s amazing that the ones we’re born with can last 80 years or more! Anyway – we’re working on extending the life span of these things. The bushings wear out; the limiting factor is the material. We’re trying to develop a bushing that will last three years – and keep the cost of the knee component under $20. That’s the tough part.” The Haas machines are also used to cut modular adapters, which connect the pylon or leg shaft to the socket and to the foot.

The factory at Ba Vi provides products for government medical clinics as well, including several hospitals that have orthopedic workshops. The HL-1 is also used for wheelchair parts, and by next year the Haas machines will be making parts for orthotic devices – knee and foot braces for patients with disabilities such as cerebral palsy or drop foot. These products are still in the development stage.

Prosthetics Outreach Foundation, says Alan Aulie, is different from most charitable organizations in that “they don’t just go in and fix something and then go home.” POF provides local jobs, and Vietnamese people with disabilities are being assisted by their fellow citizens, not by foreign aid workers. The goal is to eventually make both the clinic in Hanoi and the factory in Ba Vi self-sustaining.

POF is funded primarily through private donations. The cost of fitting a prosthesis in Vietnam, including components, medical evaluation and follow-up, and administrative expenses, is about $300.