Key Concepts

• With enhanced emergency medicine, many soldiers are coming home from war with grievous injuries instead of being killed.
• Innovation in arm and hand prostheses has been slow because the market for the devices is small and development costs are high.
• The Open Prosthetics Project (OPP) has applied the “open source” model—long used in developing “community-based” software—to the design of inexpensive prosthetic hands and arms that a small demand can still support. The designs are free for anyone to use.

Before Jonathan Kuniholm, a marine re­­serv­­ist, was shipped off to the war in Iraq, he and three friends formed a research and development firm they called Tackle Design. The four men had worked together in an industrial engineering class at North Carolina State University (N.C.S.U.), and, filled with youthful enthusiasm, they hoped their fledgling company could survive on jobs that were interesting and beneficial rather than simply moneymaking. They worked with inventors—making prototypes for a plastic lock to keep shoestrings tied and a fishing lure with an embedded LED—as well as with medical engineers from their alma mater, who were developing tools for minimally invasive robotic surgery.

Then, before business had a chance to get off the ground, Kuniholm was deployed. A few months later, on New Year’s Day 2005, he and about 35 other marines were ambushed near the Hadithah Dam along the Euphrates River northwest of Baghdad. His platoon had been looking for insurgents who had fired at a Swift boat patrolling around the dam a few hours earlier. As the marines closed in on the suspected hotspot, an IED—improvised explosive device—hidden in a can of olive oil exploded. Shrapnel ripped through the platoon, and Kuniholm was blasted off his feet. Moments later, when he came to his senses, he discovered his M16 rifle had been blown in half and his right arm was nearly severed just below the elbow. Caught in a raging firefight, Kuniholm pulled himself out of harm’s way. His fellow marines called for air evacuation, and soon surgeons at a hospital near Baghdad were amputating his ravaged arm.

After returning to North Carolina, Kuniholm underwent multiple surgeries at the Duke University Medical Center. Then, following his convalescence, he visited Walter Reed Army Medical Center in Washington, D.C., where doctors outfitted him with two kinds of artificial replacement for his hand and lower arm. One was a conventional split-hook device, essentially two hooks aligned with each other, which the user can spread apart or close up via a harness and cable system activated by the shoulder or arm. The second was a more advanced “myoelectric” prosthesis, which picks up nerve signals produced by the slightest muscle tension and translates the signals into movement. Flexing the upper arm muscle causes the pincers of a prosthetic “hand” to grip; relaxing the muscles causes the pincers to release.

The two prostheses from Walter Reed were state-of-the-art, the latest in prosthetic design. But back in North Carolina, Kuniholm and his partners at Tackle Design were shocked at the lack of innovation in arm and hand prostheses. They were sure they could do better. And that is how the small North Carolina design firm got into the prosthetics business. More, Kuniholm and his partners have created a clearinghouse for prosthetic designs, an online consortium they call the Open Prosthetics Project (OPP), whose goal is to nurture useful ideas for innovations and then freely give the designs away. The idea is to benefit not only people such as Kuniholm, who already have the resources that come from living in a first-world economy, but also amputees all over the world.

Innovation Stagnation
Ironically, one of the reasons a group such as the OPP can get on the public radar at all is the high human cost of the wars in Iraq and Afghanistan. Because of tremendous advances in emergency medicine, as well as the use of such armor as Kevlar vests, the fighting has resulted in a far lower fatality rate among injured soldiers than it has in past wars. That’s the good news. The bad news is that many veterans whose wounds would have killed them in the past come home today with grievous injuries.

Still, in absolute terms, the number of upper-limb amputees is small, and the prosthetics market is hard to crack. As Kuniholm and his partners did their research about the prosthetics industry, it became evident that the main reason for the lack of innovation was a lack of financial incentive. According to the Amputee Coalition of America, 1.7 million Americans have lost a limb because of illness or trauma, but relatively few of them need a replacement arm or hand. The typical amputee is older than 50 and has lost a leg or a foot to diabetes or some other disease. Upper-extremity amputees—those who have lost an arm or a hand—number about 100,000 people, or some 6 percent of the total. Fewer still are wounded veterans. As of the end of 2007, about 700 veterans of the wars in Iraq and Afghanistan are amputees, and of those about 150 have lost a hand or an arm (or, in some cases, both arms).