The Jaipur Foot…….From Sobs to Smiles!

The Jaipur Foot…….From Sobs to Smiles!

H.S. is a young man who ekes out a living doing part time jobs. Although his income is meager, a large part of this comes from his ability to climb up trees and gather the fruits. Having lost both his parents to diabetes related complications, he was left at a relatively tender age of 17 years to look after his little sister. H.S., although poor, worked hard enough to look after his sister and at the same time was keeping aside some of his small income for the day when he would be able to marry of his sister in a befitting manner. Unfortunately, at the age of 24 he developed an ulcer on his foot, but living in a remote area, he took the help of some herbal medicines. The infection spread and it was only when his leg was badly swollen and red, did he attend a hospital. Investigations showed him to have diabetes, but in spite of the best efforts possible in the health care setting available to him, the doctors could not save his leg and he had to undergo a below knee amputation. For the type of work he did, this was almost a death sentence. The doctors advised him of the various excellent prosthesis which were available, but each cost what he could earn in 5-7 years! Totally depressed, he even contemplated suicide, but the thought of his sister kept him alive. The problem was that he was alive but what was the future?

And then he met a doctor at a rural health camp who told him a clinic in Jaipur which could help him out and even was kind enough to give him money to go to Jaipur.

The result…….. he was fitted with the Jaipur foot!

Not only did this cost less than 5% of what most other prosthesis cost, but a charitable organization working closely with the clinic paid for the small amount of money also. Not only that, he was trained in the making of the Jaipur foot and moving his sister to the city, he stared working making and fitting these “feet” for others. To day his sister is happily married, and he does not have to climb trees to earn a living, but is still happy to do so for fun!

Fig 1. H.S. showing his skills at climbing trees….this time just for fun!

Another recent story which comes to mind is that of a farmer Y.G. aged 66 years, who having lost his only son to tuberculosis, was left to look after the whole family, including three young children of his deceased son. Y.G. knew he had diabetes and did take care of to the best extent he could. One day he noticed a cut on his foot. Being in the midst of the harvest season and not having any help on the farm, he kept postponing going to the hospital in spite of the pain in his foot increasing and the foot turning red and becoming swollen. But the time, he did seek medical attention, it was too late and he had to undergo an amputation. Again, the future looked dismal. Fortunately, he was being treated in a town close to Jaipur and he was told about the Jaipur foot. Today, he is back at work in his fields!

Fig 2. Y.G. back at work on his farm fun!

There are many such stories where the Jaipur Foot has turned “Sobs” have turned to “Smiles”.

There is no denying the fact that the optimal management for diabetes related foot problems is to prevent them. If one is unable to prevent them, then at the very least, foot problems should be treated at the earliest so that the feet can be salvaged completely. But as has it famously been said, “Stuff happens!” and for whatever be the reason the foot has to be amputated.

It is not that artificial limbs are not available. But the question is…. are they affordable? One has to realize that more than 70% of all people with diabetes come from poor and transitional countries. How many people can afford these costly artificial limbs, many of them costing in the vicinity of 5000 to 8000 U.S. Dollars! In this context one has to realize that in many countries, the average daily per capita income is around one U.S. dollar, and there is no universal health care which especially covers diabetes and diabetes related complications.

Moreover, many of these western style artificial limbs may not be suitable for the lifestyles and habits of people in other countries. The lower limbs are not meant only for locomotion. They serve a number of diverse functions and must be culturally and socially acceptable to people of different ethnicity.

Take India for instance.

The life style of an average Indian demands long times spent in position of squatting, sitting cross legged on floor etc. While squatting the ankles have to dorsiflex fully, the knees have to flex till the soft tissues of the thighs and calf can flatten against each other.

It is this which allows our center of gravity to fall within our point of support to provide a stable equilibrium so that we do not fall backwards. An average Indian would also disapprove of using the street shoes inside the house.

Also, the "shoe" attached to the old artificial limb was made of heavy sponge, making it worthless for any farmer working in the rain or in irrigated paddies, and 72% of India lives, and works, in its villages.

Although one can always say that “beggars cannot be choosers” and that they should use whatever is available, one must also accept the fact that a person with diabetes and a diabetes related amputation is also a human being and must get along with his or her life.

Thus an artificial limb should be cosmetically acceptable as far as possible, allow one to function in a socially and culturally acceptable manner. The artificial limb should not absolutely require the wearing of a shoe, should allow a person to squat at least for a short interval, sit cross legged and should have sufficient flexibility to allow one to walk on uneven ground, and be durable and waterproof to allow work in rough terrain of farm fields, water ditches, mud paths etc. It should also be fabricated out of cheap and easily available materials without requiring very sophisticated machinery and personnel training!

Needless to say, having such artificial limbs available is one thing, but being affordable is all the more important especially to the poor and vulnerable sections of society.

The Jaipur Foot with its modifications which meets many of these requirements.

Many a step has been taken since the Jaipur Foot was first developed way back in 1968.

The People……The inventors were as different as chalk and cheese! Pramod Karan Sethi, was an orthopedic surgeon, a fellow of Britain's Royal College of Surgeons, while his partner was an artisan named Ram Chandra who had studied only up to the 4th standard. But he came from a family of known artisans and his work itself was par excellence!

The Place……the Sawai Man Singh Hospital in Jaipur. There, Sethi was helping his orthopedic patients wobble down the corridor on their crutches, and Chandra was teaching lepers to make handicrafts so that they could earn a living.

The Invention……..Seeing the plight of the patients wobbling around in considerable discomfort, Chandra was convinced that a better and more lifelike artificial limb could be made. He spoke to Sethi who was also enthused about this, possibly with the thought that anything could be better than what they had at that time. In any case, Sethi took pains to explain to Chandra concepts of bone movements within the feet and as importantly the importance of guarding against the pressure points which could lead to significant problems.

For almost a couple of years, they worked fashioning a variety of limbs the out of willow, sponges and other molds, but all these failed to meet their expectations. And then one day whilst riding his bicycle to work, Chandra had a flat tire and when he took the cycle to have the tire repaired, he saw the person re-treading a truck tire with rubber.

After talking to Sethi, Chandra returned to the shop with an amputee patient and a foot cast and asked if he could cast a rubber foot. "He agreed,'' Sethi says, "and refused to accept any money once he found out why we were doing it."

The result was much better than whatever they had made before but the rubber shredded after just a few days. So they made the rubber foot around a hinged wooden ankle wrapping this in flesh coloured lighter rubber and then vulcanizing the whole. The resulting limb took only 45 minutes to build and fit onto the patient and was sturdy enough to last for many years.

In 1971 Sethi felt confident enough about the invention to present it to British orthopedic surgeons at Oxford, who were impressed by the artificial limb's suppleness and durability. But there was a lot of opposition from other doctors, and between 1968 to 1975 only 59 patients were outfitted with the Jaipur foot.

But with the Afghan war which started in the late 1970s, the Jaipur Foot suddenly gained widespread international recognition. Land mines--some diabolically shaped like butterflies to attract curious children--caused thousands of injuries, and the International Committee of the Red Cross discovered that the Jaipur foot was the hardiest limb for the mountainous Afghan terrain. Moreover, the low cost and the use of simple and locally available materials as well as the simplicity of making it, were its major plus points. In Afghanistan craftsmen hammer the foot together out of spent artillery shells. In Cambodia, where roughly 1 out of every 380 people is a war amputee, part of the foot's rubber components are scavenged from truck tires.

The widespread publicity gained by the Jaipur Foot in treating war and accident ravaged subjects masked its use in subjects with other ailments such as polio and importantly diabetes!

In 1991, Pooran et al in a paper published in the West Indian Medical Journal had this to say, “The amputation rate at the Port-of-Spain General Hospital has doubled over the last 10 years from 114 and 102 in 1979 and 1980 to 274 and 225 in 1988 and 1989. The majority of the amputees are not able to work again because of the unavailability of a suitable prosthesis and physical and psychological rehabilitation are severely compromised. In order to overcome this, we decided to carry out a programme of fitting of prostheses. Of 200 amputees who were assessed 92 were fitted with prostheses, 60 (65 percent) above and 32 (35 percent) below the knee. Most were diabetics ranging in age from 18 to 62 years with a M:F ratio of 1.2:1. The Jaipur foot prosthesis was chosen for its light weight (about 2 kg), low cost (US$8 - $18), and good features (waterproof, well ventilated, good grip, shock absorbent, flexible and cosmetic appearance). Four patients returned for minor adjustments to the stump/socket interface and 90 percent expressed extreme satisfaction with their prosthesis. The Jaipur foot prosthesis seems ideal for West Indian amputees and there is a strong case for an on-going well co-ordinated programme involving trained technicians, physiotheraptists and surgeons to address the needs of the large amputee population in Trinidad and Tobago.”

But it is a fact that there very few published papers validating the use of the Jaipur Foot in people with diabetes and there are many so-called “experts” who still refuse to accept that the Jaipur Foot can be of any practical use in people with diabetes, especially for above knee amputations. Whether this reflects a total ignorance of the changes which have been made in the Jaipur foot since its initial invention or is this the power of companies making costlier artificial lower limbs is not for us to say!

Conversely, there are many leading authorities who feel that the Jaipur Foot does indeed have a role to play in managing diabetes amputations especially in the economically handicapped.

The Jaipur Foot of 2007 is different from the Jaipur Foot of 1968!

Today, the foot has basically two parts. The foot piece and the socket which is basically the “Jaipur Foot” and the extensions which are the joints depending on whether the limb needed was Below-Knee or Above-Knee. There is this total misconception that the jaipur Foot can only be used in below knee amputations. This is a total misconception. The Jaipur foot can be used with all levels of amputations starting from partial foot amputation to hip disarticulation with equal efficiency and case.

Although lightweight aluminum shanks crafted by tinsmiths are still available, it is recommended that for people with diabetes, the material used for the sockets is EVA and a polypropylene based material. This is much more user friendly and safer for use in people with diabetes. Moreover, the open ended sockets are a thing of the past and have been replaced by total contact sockets again improving the user friendliness of the artificial foot.

Jaipur Limb is light weight. For a middle sized person the socket with belt and Jaipur Foot, the total weight of a below knee limb varies between 1.3 Kg. to 1.5 Kg. Similarly for a similar kind of person the total weight of the above knee limb varies between 2.25 Kg. to 2.5 Kg whereas, average weight of the whole leg + foot in living human weighing 55 kg. is 3.36 kg so this artificial limb does not place a weight burden on the patient.

Importantly, it allows most of the social, cultural and work related needs discussed above to be met. Importantly, since wearing shoes is not essential, the Jaipur foot user can go to places of worships like Temple, Mosque, Gurudwara etc.

Fig. 3 A man squatting wearing the Jaipur Foot

The one drawback to the wider use of the Jaipur Foot is the requirement for the patient to come to Jaipur for the fitting. For quite a few people the cost of the travel is prohibitive and although there are NGOs which do help out, many people are still left out of the loop. One way out for this would be to set up clinics in different places so that the distance a person has to travel is minimised. The personnel are trained by the Jaipur Foot Clinic and they also help set up the center, examine if local materials are available which can also be used and are available to sort out difficulties. Interestingly the personnel do not have to be highly trained technicians, but even uneducated people and workers such as cobblers, tinsmiths, etc. can be taught to make the artificial feet under the supervision of a doctor who may want to undergo a brief 2 week course at the Clinic.

Today, a good western style lower limb prosthesis which is usually mostly cosmetic, is very costly, and prohibitively so, in many countries especially in the poor sections of society. The SACH foot which is often used as a benchmark costs around U.S. Dollars 8000 ( Indian rupees 340,000). Even cheaper versions for below knee amputation replacements can cost around Indian Rupees 100,000. Compare this to the cost of below knee Jaipur Foot replacement of Indian Rs. 3000 ( U.S. Dollars 70) and an above knee replacement of around Indian Rs. 6000 ( U.S. Dollars 140-150)!

We intend starting ten such centers all over India over the next few years. In fact, we have been receiving many queries about the Jaipur Foot from other countries and the people at the Jaipur Foot Center are more than willing to show them the facilities and to help in setting up centers in other different countries. It is always possible that modifications and alterations may be made depending on the circumstances, but the basic principle behind the Jaipur Foot “stands”.

It is true that more work needs to be done to validate the longterm usefulness of the Jaipur Foot use in diabetes related amputations, but then the same can easily be said of many so called “preventive” regimens.

Lastly, whilst we argue about the need for more studies and validation etc., let us get out of our academic towers and realize that most of the people want to get along with their lives and are not willing to wait until the “experts” agree.

If you do not believe us, ask the young man H.S. or the farmer Y.G. and many others like them whose sobs have turned to smiles and they will tell you so.

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