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11 REVIEW OF POSTOPERATIVE WOUND INFECTIONS W. A. Altemeier* Infection is one of the salient features of human life, and many infections in patients are of surgical significance. An understanding of this aspect of medicine is, therefore, an essential part of clinical surgery and the supporting professional scientific disciplines which help to provide the surgeon with a safe environment within which to operate and work (l-5). The ubiquity of infectious agents in man's environment, their propensity for in- vading the tissues of the body, their potential for producing significant pathophysiologic effects on the various bodily functions, their remarkable adaptability to circumstance and newer forms of treatment, and the necessity for excluding their presence or controlling their growth sufficiently to permit surgical treatment and effective wound healing, all emphasize the sig- nificance of infection in surgical practice (1,3). Moreover, the expanding horizons of surgery have often been dependent upon the development and appli- cation of special methods of overcoming the hazards of postoperative infec- tions (1,8). It should be remembered also that every operation is an experi- ment in applied and practical bacteriology. History has shown that postoperative and hospital-acquired infections have been problems for as long as there have been hospitals, and attempts to prevent their incidence and spread began hundreds of years ago when separate hospitals were built for patients with communicable diseases. Fever hospitals, smallpox hospitals, tuberculosis sanitoria, and "Pest Houses" were established in an effort to separate infected patients from other patients and the com- munity. It is generally recognized that the introduction of modern antibiotic therapy has had a revolutionary effect on the treatment of many established infections, but clinical experience and experimental bacteriolog- ical studies have shown that its general use for approximately one third of a *Chairman, Department of Surgery, Cincinnati General Hospital. Work reported supported by U.S.P.H.S. Grant 5-P01-GM-15428-08 and U.S. Army Contract DAMD 17-74-C-5018.

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12 W. A. Altemeier century has failed to decrease the overall incidence of postoperative surgical infections (1,2,3,7,8,10). In addition, the widespread use and misuse of antibiotic therapy has undoubtedly increased the problems concerned with their prevention (3,5,8,9,12,15,17,18). Too often its widespread use prophylactical- ly in surgical patients has contributed to the development of an unwarranted overdependence on its effectiveness, a de-emphasis or discredit of the impor- tance of the established surgical principles, a relaxation of the "surgical conscience," a breakdown of isolation procedures, and the establishment of a reservoir of virulent and antibiotic-resistant bacteria concentrated in the hospital environment (1,4,8). These trends have been accentuated by the complexities of modern surgical practice with the concentration of large numbers of patients with established infections in hospitals, the extension of prolonged surgical opera- tions and supportive procedures to a rapidly increasing number of high-risk patients, the increase of the number of individuals with severe trauma, and the growing use of drugs which decrease bodily resistance to infection. Thus, it must be kept in mind that the modern general hospital has become a complex community in which the opportunities for infection are numerous and ever pres- ent. Current hospital practice has resulted in the concentration of many people admitted with a large variety of infections as well as many others who are unusually susceptible to secondary or hospital-acquired infections. The latter have included patients admitted for treatment of recent trauma, persons debilitated by chronic disease, individuals undergoing surgical operations and a multitude of other technical diagnostic procedures, people requiring steroid therapy, and those under treatment for neoplastic diseases. The extension of surgical treatment to aged and debilitated patients, and the widespread use of complicated diagnostic, therapeutic, and anesthetic procedures also have favored the development of hospital-acquired infections. In addition, the urgency associated with the treatment of many patients with life-threatening disease or extensive injuries, the demands of large numbers of patients in a short period of time, and shortages of skilled nursing and other personnel have tended to produce compromises and administrative trends not necessarily in the best interests of infection control (l-3).

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13 Postoperative Wound Infections A particularly important effect of general and indiscriminate antibiotic therapy in hospitals has been the progressive development of re- sistance to penicillin and many of the other antibiotic agents which was acquired by a large variety of important bacteria concentrated in the hospital environment. These virulent microorganisms, both Gram-positive and Gram-nega- tive, have the potential of becoming pathogenic in patients weakened by dis- ease, injury, metabolic conditions, and other debilitating factors as mentioned above (8,10,12,17,18). There are a number of other important factors which have influenced the incidence of postoperative infections at the present time. In a 2 1/2- year collaborative investigation of 15,613 consecutive operative procedures done in five American university centers, an overall infection rate of 7.4 percent for all types of operations was determined under close, energetic, and continuing surveillance. These centers included the University of Pennsyl- vania, Hahnemann Medical Schoo1, the University of California, Los Angeles, George Washington University, and the University of Cincinnati. This project was carried out under the support of the U.S. Public Health Service and the aegis of the National Research Council (13). Many national and international conferences have been held in an effort to bring the various aspects of this situation into proper perspective, to disseminate existing knowledge between countries and scientific disciplines, and to stimulate research for the solution of related problems. One of the first and highly significant meetings of this type was the National Conference on Hospital-Acquired Staphylococcal Disease, held on September 15-17, 1958, in Atlanta, Georgia under the joint sponsorship of the United States Public Health Service and the National Research Council. An International Seminar on Hospital Infections was also held by the Council for International Organiza- tions of Medical Sciences in London, September 24-28, 1962. Delegates from 26 countries and the World Health Organization participated in the discussion, representing a considerable body of resource knowledge and research potential. There were 111 delegates in attendance, each being an expert on some aspect of hospital-acquired infection. Another important example was the International

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A. W. Altemeier Conference on Surgical Infections held by the International Society of Surgery in Moscow on August 2l-28, 1971 (8). These and many other conferences have been helpful, but the fact remains that the problems of postoperative wound and hospital-acquired infec- tions persist, and that considerable confusion exists in the minds of surgeons, physicians, hospital administrators, lay hospital boards, bacteriologists, epidemiologists, sanitary engineers, architectural engineers, attorneys, judges, and others regarding the significant factors actually responsible for these infections. In the meantime, the controversy over the relative importance of the aerial spread and contact spread of infection has continued from the last half of the 19th century to the present (10). Following the discovery and intro- duction of the surgical antisepsis by Lister, Von Bruns and Von Bergmann be- came convinced that contact was the principal method for spread of infection and by their evidence persuaded Lord Lister to abandon his carbolic acid spray of the operating room aerial environment. The use of ultraviolet light, lithium oxide, electrical precipitation of bacterial-laden dust particles, and various types of laminar flow have each been developed and used in an effort to reduce the incidence of postoperative wound infections. Moreover, the increasing costs associated with the care of surgical patients with infections, the progressive threat of malpractice claims, and the growing demands of an informed and often "oversold" public have become important related matters of concern. THE INCIDENCE OF INFECTIONS Currently there is still considerable confusion about the incidence, nature, and causes of infections in surgical practice. There is also much confusion and great divergence of thought regarding the best methods of pre- venting and controlling surgical infections. Consequently, there are no accurate figures in the United States to indicate the incidence of the many types of infection acquired by hospitalized surgical patients, but there is evidence that it is much greater than generally suspected.

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15 V, Postoperative Wound Infections It is generally recognized, however, that from 40 to 65 percent of the patients in general hospitals are usually surgica1, and that approximately 30 percent of hospitalized surgical patients either have established infections at the time of admission or develop some type of infection during their hospi- tal stay. In 1963 it was estimated that approximately 25,000,000 patients had been admitted to hospitals in the United States and that over 1,000,000 of them developed postoperative or hospital-acquired infections. More recent figures made available for the year 1967 have been reported by Altemeier as follows (6,8,10): Table 1. Hospital Infections USA - 1967 Estimated Incidence: Hospital admissions 31,600,000 Surgical operations performed 18,800,000 in the operating room Estimated number of postoperative 1,391,200 wound infections for all types of operations (7.4% of operations) Estimated number of hospital-acquired 2,101,037 infections These estimates are based upon data obtained from 1,118 hospitals in the United States; this number being approximately one-fourth of the total number of hospitals under surveillance of the Joint Commission on Accredita- tion of Hospitals and Blue Cross-Blue Shield. The overall wound infection rate of 7.4 percent used in these estimations was the incidence for all types of operative wounds as determined during a 2 1/2-year collaborative ultraviolet study of 15,613 consecutive operative procedures done in five American university centers under the support of the U.S. Public Health Service and the aegis of the National Research Council. The operative wounds thus studied were composed of clean, clean- contaminated, contaminated, and dirty types. Elective and emergency operations were both included in Tafcle 2 (13).

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16 W. A. Altemeier Table 2. Type of Operative Wound Clean Clean-contaminated Contaminated and dirty Not reported Incidence of Infection No. 11,690 2,589 1,262 72 No. Percent 594 5.1 280 10.8 277 21.9 6 8.3 In the 11,690 clean elective operations in this series, the average wound infection rate was 5.1 percent, but the average rate for all types of operations was 7.4 percent. It also became apparent that the incidence of in- fection varied a great deal with the type of operation (Table .3) • Table 3. Incidence of Infection Following Selected Commonly Performed Operative Procedures (Adapted from Ultraviolet Study) Number of Incidence of times infection performed percent 1,312 1.9 406 2.2 628 6.1 756 6.9 220 10.0 288 10.1 551 11.4 127 17.3 227 18.9 Operative Procedure Herniorrhaphy* Thyrmidectomy Hysterectomy Cholecystectomy Partial Colectomy Subtotal Gastrectomy Appendectomy Nephrectomy Radical Mastectomy *Including inguina1, femoral, and epigastric; excluding incisional and ventral. Noteworthy too was the fact that the incidence of postoperative wound infection was increased three to five fold or more whenever one of the major tracts was transected or resected during a planned elective operation, as compared to elective operations without such procedures.

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17 Postoperative Wound Infections For example, the incidence of infection following hernioplasty was 1.9 percent; whereas it was 6.1 percent for hysterectomy, 6.9 percent for chole- cystectomy, 10.0 percent for partial colectomy, and 10.1 percent for subtotal gastrectomy. It can be seen from the above discussion that hospital-acquired infection is also a problem of considerable monetary magnitude. The average cost per infection has been reported by Swartz at the University of Virginia to vary between $6,000 and $9,000. Using an estimated postoperative wound in- fection cost of approximately $7,000 per patient, on the basis of 1,400,000 postoperative wound infections (as shown in Table 1), the estimated overall cost to society has been estimated to be $9.8 billion (6,8,11). Specific programs are matters for physicians to consider and correct. There appears to be some consensus that a broad-based control program centered around isolation procedures, combined with both formal and informal education, would help to decrease the incidence and cost of infection. Government subsidies would help to defray the cost of infection control and help to insure an optimal output of this public good. Another avenue of possible effective action under consideration is Professional Services Review Organization (PSRO). A review of postoperative wound infections should include a consideration of their classification on the basis of the source or base of in- fection. In this regard, there are three general types: community or home-based infections, operating room-based infections, and hospital-based (other than operating room-based) infections. COMMUNITY OR HOME-BASED INFECTIONS These are infections which develop spontaneously or otherwise in the home or community, being unrelated to the hospital and the hospital reservoir of microorganisms. As many as 30 or 40 percent of patients admitted to a busy surgical service in a general hospital may have infections of this type.

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18 W. A. Altemeier Examples are acute appendicitis, acute cholecystitis, acute diverticulitis with perforation and peritonitis, acute perforated peptic ulcer with peritonitis, etc. Infections in this category are generally not caused by antibiotic resis- tant bacteria, and they do not present at this time new or special problems re- lated to the primary disease. OPERATING ROOM-BASED INFECTIONS These are hospital-based infections which consist primarily of operative wound infections developing postoperatively in relation to surgical procedures performed in the operating room. Because of their importance and the problems which they currently present, they are considered separately from other hospital-acquired infections for purposes of special discussion. The sources of these infections are both endogenous and exogenous. HOSPITAL-BASED INFECTIONS (OTHER THAN OPERATING ROOM) Infections which occur in patients during their hospitalizations are designated as hospital-acquired or nosocomial infections. They are the re- sult of microbial invasion, most often by antibiotic-resistant and virulent microorganisms of the hospital environment. Invasion may follow diagnostic and various therapeutic procedures such as lower urinary tract catheterization or instrumentation, intravenous therapy (especially continuous), tracheostomy, or arteriography. Infection may also be related to the emergence of virulent bacteria during antibiotic therapy and other medications, the decreased host re- sistance by immunosuppression, the impairment of other host defenses, the replace- ment of the normal flora of organisms in the major tracts of the body by virulent or antibiotic-resistant bacteria of the hospital reservoir during prolonged pre- operative hospitalization periods, and the progressive extension of surgical practices in the high-risk, aged, or otherwise debilitated patients. In a review of surgical postoperative infections, their classification by anatomic location and pathologic changes is of interest (Table 4) (11).

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19 Postoperative Wound Infections Table 4. Classification of Surgical Infections By Anatomic Location and Pathologic Changes I. Local Wound Infection A. Cellulitis B. Suppuration or septic liquefaction of tissues C. Abscess D. Septic necrosis E. Local wound, septic thrombophlebitis II. Regional Extension A. Adjacent tissues by direct extension B. Lymphangitis and lymphadenitis C. Thrombophlebitis D. Peritonitis E. Central nervous system infection, including meningitis and brain abscess F. Mediastinitis G. Retroperitoneal cellulitis III. Organ or Visceral Infection IV. Systemic Invasion Based upon clinical and laboratory research on the Surgical Services and the Surgical Research Bacteriology Laboratory of the University of Cincinnati during the past 32 years and a review of pertinent literature, an etiologic classification of surgical infections has been developed (Table 5) (1,11). This emphasizes the large numbers and varieties of bacteria which may produce wound infections.

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20 W. A. Altemeir Table 5. Etiologic Classification of Surgical Wound Infections I. Aerobic Bacterial A. Gram-positive cocci 1. Staphylococcus 2. Streptococcus 3. Pneumococcus B. Gram-negative cocci 1. Neisseria catarrhalis 2. Neisseria gonorrhoeae C. Gram-negative bacillary 1. Escherichia coli 2. Aerobacter aerogenes 3. Klebsiella 4. Pseudomonas aeruginosa 5. Proteus 6. Serratia 7. Paracolgon 8. Alcaligenes faecalis 9. Salmonella 10. Haemophilus influenzae D. Gram-positive bacterial 1. Bacillus anthracis 2. Corynebacterium 3. Diphtheroid 4. Bacillus species 5. Mycobacterium a. Tuberculosis b. Balnei II. Microaerophilic Bacteria A. Gram-positive cocci 1. Streptococcus a. Hemolyticus b. Non-hemolyticus III. Mixed Infections A. Aerobic and Anaerobic B. Gram-positive and Gram-negative C. Synergistic

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21 Postoperative Wound Infections IV. Anaerobic Bacterial A. Gram-positive cocci 1. Peptococcus 2. Peptostreptococcus B. Gram-positive Bacilli 1. Cl. perfringens 2. Cl. novyi 3. Cl. septicum 4. Cl. histolyticum 5. Cl. tetani C. Gram-negative bacilli 1. B. fragilis 2. Bacteroides species 3. B. melaninogenicum V. Non-bacterial Infections A. Fungal 1. Candidiasis (Candida albicans) 2. Actinomycosis (Actinomyces Israelii) 3. Nocardiosis (Nocardia asteroides) 4. Blastomycosis (Blastomvces dermatitides) 5. Coccidioidomycosis (Coccidoides immit.is) 6. Histoplasmosis (Histoplasma capsulatum) 7. Sporotrichosis (Sporotrichum schenckii) 8. Phycomycosis (Mucor sp.) 9. Aspergillosis (Aspergillus niger) B. Viral 1. Herpesvirus 2. Poxvirus (vaccinia) 3. Varicella (Herpes Zoster virus) 4. Cytomegaloviruses 5. Mumps virus (parotitis and pancreatitis) 6. Polovirus 7. Hepatitus virus (infectious and serum) 8. Rabies virus Finally, I would like to point out two other important considerations: first, that there is considerable confusion and controversy as to the definition of a surgical postoperative infection and, secondly, the classification of infec- tions based upon the recognition of different degrees of wound contamination (11).

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337 APPENDIX B PARTICIPANTS WORKSHOP ON CONTROL OF OPERATING ROOM AIRBORNE BACTERIA COMMITTEE ON PROSTHETICS RESEARCH AND DEVELOPMENT COMMITTEE ON PROSTHETIC-ORTHOTIC EDUCATION ASSEMBLY OF LIFE SCIENCES—DIVISION OF MEDICAL SCIENCES NATIONAL ACADEMY OF SCIENCES—NATIONAL RESEARCH COUNCIL ORTHOPAEDIC SURGEONS George T. Aitken, M.D., Chairman 260 Jefferson Avenue, S.E. Grand Rapids, Michigan 49502 Past Chairman - Committee on Prosthe tics Research and Development (CPRD) Past President - American Academy of Orthopaedic Surgeons (AAOS) Harlan C. Amstutz, M.D. University of California Medical Center Los Angeles, California 90024 Professor and Chief, Division of Orthopaedic Surgery - UCLA Member of AAOS Committee on Operating Room Environment & Surgical Asepsis William E. Anspach, Jr., M.D. 648 North U.S. One North Palm Beach, Florida 33408 Member of AAOS Committee on Operating Room Environment & Surgical Asepsis George Bentley, F.R.C.S. University of Oxford Nuffield Orthopaedic Centre Headington, Oxford 0X3 7LD, England Associate Professor Mark B. Coventry, M.D. Mayo Clinic 200 First Street, S.W. Rochester, Minnesota 55901 Professor of Orthopaedic Surgery - Mayo Medical School Member of AAOS Committee on Operating Room Environment & Surgical Asepsis Lt. Col. John A. Feagin, Jr. , M.D. Letterman Army Medical Center Presidio of San Francisco, California 94129 Assistant Chief, Orthopaedic Service Director, Joint Replacement Service Robert H. Fitzgerald, Jr., M.D. Mayo Clinic 200 First Street, S.W. Rochester, Minnesota 55901 Instructor in Orthopaedics - Mayo Medical School

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338 J. Leonard Goldner, M.D. Duke University Medical Center Durham, North Carolina 27710 Professor and Chairman, Division of Orthopaedic Surgery - Duke University Medical Center Howard P. Hogshead, M.D. 333 East Ashley Street Jacksonville, Florida 32202 Director of Rehabilitation - Cathedral Health and Rehabilitation Center Member of AAOS Committee on Operating Room Environment & Surgical Asepsis J. Drennan Lowell, M.D. Peter Bent Brigham Hospital 721 Huntington Avenue Boston, Massachusetts 02115 Director, Orthopaedic Clinical Services - Peter Bent Brigham Hospital Assistant Professor of Orthopaedic Surgery - Harvard Medical School Jo Miller, M.D., F.R.C.S., F.A.C.S. Montreal General Hospital 1650 Cedar Avenue, Room 646 Montreal 109, Quebec, Canada Orthopaedic Surgeon-in-Chief, Montreal General Hospital Member of AAOS Committee on Operating Room Environment & Surgical Asepsis Associate Professor of Surgery, McGlll University Carl L. Nelson, M.D. University of Arkansas Medical Center Little Rock, Arkansas 72201 Professor and Chairman, Department of Orthopaedic Surgery - University of Arkansas Medical Center Member of AAOS Committee on Operating Room Environment & Surgical Asepsis J. Phillip Nelson, M.D. Orthopaedic Associates, P.C. 1707 East 18th Avenue Denver, Colorado 80218 Instructor, Department of Orthopaedics - University of Colorado Active Staff - St. Luke's Hospital Chairman of AAOS Committee on Operating Room Environment & Surgical Asepsis Merrill A. Rltter, M.D. 1815 North Capitol Avenue Indianapolis, Indiana 46202 Associate Professor of Orthopaedic Surgery - Indiana University School of Medicine Dana M. Street, M.D. Harbor General Hospital 1000 West Carson Street Torrance, California 90509 Professor and Chief, Division of Orthopaedic Surgery - Harbor General Hospital

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339 Robert S. Turner, M.D. Lovelace Clinic 5200 Gibson Boulevard, S.E. Albuquerque, New Mexico 87108 Chairman, Department of Orthopaedic Surgery - Lovelace Bataan Medical Center A. M. Wiley, M.Ch., F.R.C.S. 25 Leonard Avenue Suite 101 Toronto, Ontario M5T 2R2, Canada Assistant Professor of Surgery - University of Toronto John C. Wilson, Jr., M.D. 2010 Wilshire Boulevard #803 Los Angeles, California 90057 President - AAOS Philip D. Wilson, Jr., M.D. Hospital for Special Surgery 535 East 70th Street New York, New York 10021 Surgeon-in-Chief - Hospital for Special Surgery Professor of Orthopaedic Surgery - Cornell University Medical College Past President - AAOS GENERAL SURGEONS William A. Altemeier, M.D. Cincinnati General Hospital Cincinnati, Ohio 45229 Chairman, Department of Surgery - Cincinnati General Hospital Professor of Surgery - University of Cincinnati Medical College William C. Beck, M.D., F.A.C.S. Donald Guthrie Foundation for Medical Research Guthrie Square Sayre, Pennsylvania 18840 Chairman, Committee on Operating Room Environment - American College of Surgeons John F. Burke, M.D. Massachusetts General Hospital Boston, Massachusetts 02114 Chief of Staff - Shriners Burns Institute Visiting Surgeon - Massachusetts General Hospital Associate Professor of Surgery - Harvard Medical School Richard E. Clark, M.D. 4960 Audubon Avenue St. Louis, Missouri 63110 Cardiothoracic Surgeon - Barnes General Hospital Associate Professor of Surgery - Washington University School of Medicine

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340 Peter Dineen, M. D. New York Hospital Cornell Medical Center 525 East 68th Street New York, New York 10021 Professor of Surgery - Cornell Medical Center Edward 0. Goodrich, Jr., M.D. , F.A.C.S. Coronado Building Santa Fe, New Mexico 87501 Chairman, Subcommittee on Air Environment of the Committee on Operating Room Environment - American College of Surgeons Col. Gerald Klebanoff , M.D. Headquarters USAF/SGPC Washington, D.C. 20314 Consultant in Surgery Harold Laufman, M.D. , Ph.D. Montefiore Hospital and Medical Center 111 East 210th Street Bronx, New York 10467 Director, Institute of Surgical Studies Past Chairman, Committee on Operating Room Environment - American College of Surgeons MICROS IOLOGISTS Lewis L. Coriell, M.D. , Ph.D. Institute for Medical Research Copewood Street Camden, New Jersey 08103 Director - Institute for Medical Research Bacteriologist Ruth B. Kundsin, Sc.D. Peter Bent Brigham Hospital 721 Huntington Avenue Boston, Massachusetts 02115 Hospital Epidemiologist - Peter Bent Brigham Hospital Director, Surgical Bacteriology Laboratory - Environmental Sepsis Labora tory - Peter Bent Brigham Hospital Principal Research Associate - Harvard Medical School Dick K. Riemensnider Bureau of Health Resources Administration Division of Facilities Utilization, Room 1233 5600 Fishers Lane Rockville, Maryland 20852 Environmental Microbiologist, Bureau of Health Resources Administration Department of Health, Education, and Welfare

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341 John A. Ulrich, M.D. University of New Mexico Medical School 915 Stanford Albuquerque, New Mexico 87131 Chief, Microbiology Service Michael D. Wardie, M.S. Jet Propulsion Laboratory California Institute of Technology 4800 Oak Grove Drive Pasadena, California 91103 Senior Microbiologist J.C.N. Westwood, M.B., B.Chir. University of Ottawa 275 Nicholas Street Ottawa, Ontario KIN 6N5, Canada Professor and Head, Department of Microbiology and Immunology - Faculty of Medicine - University of Ottawa William Whyte, M.D. Building Services Research Unit Department of Mechanical Engineering University of Glasgow 3 Lilybank Gardens Glasgow G12 8RZ, Scotland Bacteriologist ENGINEERS Kenneth L. Credle, P.E. 14317 Woodcrest Drive Rockville, Maryland 20853 General Engineer, Public Assistance Division - Federal Disaster Assistance Administration, Department of Housing and Urban Development Consultant to American Hospital Association Owen M. Lidwell, Ph.D. Central Public Health Laboratory Colindale Avenue London NW9 5HT, England External Scientific Staff - Medical Research Council Deputy Director - Cross Infection Reference Laboratory George F. Mallison Bureau of Epidemiology Center for Disease Control Atlanta, Georgia 30333 Assistant Director, Bacterial Diseases Division - Center for Disease Control

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342 R. Claude Marsh Envirco, Inc. Subsidiary of Bio-dynamics 6701 Jefferson, N.E. P.O. Box 6468 Albuquerque, New Mexico 87107 Health Physicist Director of Research and Development - Envirco, Inc. Norman Petersen, S.M. Phoenix Laboratories Center for Disease Control 4402 North 7th Street Phoenix, Arizona 85014 Sanitary Engineer Director - Phoenix Laboratories J. Clyde Sell, P.E. Office of Architecture and Engineering Bureau of Health Resources Development Division of Facilities Utilization Department of Health, Education, and Welfare Rockville, Maryland 20852 Mechanical Engineer Willis J. Whitfield, Ph.D. Sandia Laboratories Albuquerque, New Mexico 87115 Division Supervisor, Biosystems Research Department - Sandia Laboratories Walter E. Williams Baltimore City Hospital 4940 Eastern Avenue Baltimore, Maryland 21224 Hospital Engineer Director of Hospital Services - Baltimore City Hospital OTHERS E. E. Harris, M.R.C.S. Committee on Prosthetics Research and Development National Academy of Sciences-National Research Council 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Staff Surgeon - CPRD Charles V. Heck, M.D. Executive Director American Academy of Orthopaedic Surgeons 430 N. Michigan Avenue Chicago, Illinois 60611

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343 Eugene F. Murphy, Ph.D. Director, Research Center for Prosthetics Veterans Administration 252 Seventh Avenue New York, New York 10001 A. Bennett Wilson, Jr. Executive Director Committee on Prosthetics Research and Development National Academy of Sciences-National Research Council 2101 Constitution Avenue, N.W. Washington, D.C. 20418

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COMMITTEE ON PROSTHETICS RESEARCH AND DEVELOPMENT ASSEMBLY OF LIFE SCIENCES-NATIONAL RESrAKCM COUNCIL FRANK W. CLIPPINGER, JR., M.D. Acting Chairman Professor of Orthopaedic Surgery Duke University Medical Center DUDLEY S. CHILDRESS, Ph.D. Director Prosthetics Research Laboratory Northwestern University Medical School MARY DORSCH, C.P.O. President Dorsch-United Proothetics-Orthotics, Inc. ROBERT E. FANNIN, C.O. Hanger-Goldsby, Mobile, Ala. SIDNEY FISHMAK, Ph.D. Coordinator, Prosthetics and Orthotics New York University Post-Graduate Medical School VICTOR li. FRANKEL, M.D. Professor, Orthopaedic Surgery and Biomedical Engineering Case Western Reserve University RICHARD M. HERMAN, M.D. Director of Research Krusen Center for Research and Engineering Moss Rehabilitation Hospital RICHARD E. HOOVER, M.D. Department of Ophthalmology The Johns Hopkins University LEON K. KRUGER, M.D. Depcrtraent of Orthopedics Wesson Memorial Hospital, Springfield, Mass. JAMES M. MORRIS, M.D. Associate Professor of Orthopaedic Surgery University of California Medical Center at San Francisco COMMITTEE ON PROSfHETIC-ORTHOTIC EDUCATION ASSEMBLY OF LIFE SCIENCES-NATIONAL RESEARCH COUNCIL HER3ERT E. PEDERSEN, M.D., Chairman Professor and Chairman Peparti"snt of Orthopedic Surgery Wayne State University School of Medicine HARLAN C. AM5TUTZ, M.D. Professor and Chairman Division cf Orthopaedic Surgery University of: California School of Medicine at Los Angeles FRANK W. CLIPPINGER, JR., M.D. Professor of Orthopaedic Surgery Duke University Medical School CLINTON L. COMPERE, M.D. Director, Rehabilitation Engineerins Program Northwestern University Medical School DOROTHY J. HICKS Director Rehabilitation Nursing Program University of Washington School of Nursing DOUGLAS A. I10BSON, P. Eng. Technical Director Rehabilitation Engineering Program Crippled Children's Hospital School Memphis, Tenn. BELLA J. >!AY, Ed.D. Associate Professor and Chairman Department of Physical Therrpy School of Allied Health Professions Medical College of Georgia J. WARREN PERRY, Ph.D. Dean, School of Health Related Professions State University of New York at Buffalo JACQUELI>: PERRY, M.D. Chief, Research and Development Group Kinesiology Service Ranoho Lcs Amigos Hospital, Inc. ALLEN S. RUSSEK, M.D. Director, Amputee-Prosthetic Service New York University Medical Center AUGUSTO SARMIENTO, M.D. Professor and Chairman Department of Orthopaedics and Rehabilitation University of Miami School of Medicine ROY SNELSON, C.P.O., Project Director Amputee and Problem Fracture Service Rancho Los Araigos Hospital, Inc. WALTER A. L. THOMPSON, M.D. Professor and Chairman Department of Orthopedic Surgery New York University School of Medicine STAFF: A. Bennett Wilson, Jr., Executive Director Hector W. Kay, Aosistcrr.- Zxesutiva Director E. E. Harris, Sdiff S'trcson Gustav F. Haas, Staff Vxginesr Peter J. Nelson, Staff Engineer Michael J. Quiglcy, Staff Prosthetist/Orthotist G. E. Sharpies, Staff Officer

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