PROSTHETIC MANAGEMENT OF CHILDREN WITH UNILATERAL CONGENITAL TRANSVERSE DEFICIENCIES OF THE FOREARM
Lisa V. Wagner, OTRIL; Jon R. Davids, M.D.; Leslie C. Meyer, M.D.; Dawn W. Blackhurst, M.S.; Shriners Hospitals for Children
Considerable controversy exists surrounding the prosthetic management of children with unilateral congenital transverse deficiency of the forearm (UCTDF). The purpose of this study was to answer the following questions:
- What is the best age to begin fitting patient w ith prosthesis?
- Should we admit each patient with UCTDF for training of a new functional prosthesis?
- What is the best prosthetic design for the patient with UCTDF?
We established a database of 228 children with UCTDF. General demographics showed the mode of treatment was primarily an aggressive early fit. By 12 months of age, 65% of these patients had their first visit and 57% received their first prosthesis. The philosophies in regard to training varied with 32% (71 patients) admitted for training at the time of their first functional prosthesis.
In an attempt to review the various prosthetic designs, we divided the patients into four groups based upon prosthetic fitting practices:
- Body powered (BP) 21% or 47 patients
- Myoelectric (MYO) 21% or 48 patients
- Passive (PAS) 13% or 28 patients
- Combination (COM) 43% or 99 patients
The combination group consisted of a patient wearing various prosthesis over time such as myoelectric, body powered, and passive. With this data, we performed a survival analysis for the whole group, with stratification by age at first fit, admission for fit/ training, and prosthetic design. We used the Kaplan-Meier product-limit method and differences in survival curves were assessed with use of the log-rank test. Survival was defined as continuing to attend clinic and parent/child claims to ongoing use of the prosthesis. Failure was defined as parent/ child rejection of the prosthesis or LTF status.
Mean age at first prosthetic fitting was 2.1 with a standard deviation of +/- 2.8 years (range 2 months to 14.5 years). Median survival for the entire group was 10.9 years with 49% of the children LTF or rejecting their prosthesis. Children fit less than or equal to 36 months of age exhibited a median survival of 11.9 years, while those fit greater than 36 months of age exhibited a median survival of 7.5 years.
This difference in median survival was statistically significantly different (p = 0.001). Looking closer at the less then 36 months of age, there was no statistical difference in survival time between 0 to 12 months and 13 to 36 months. Children admitted for fit and training had a median survival of 13.5 years, compared to 10 years for those children not admitted. This difference in median survival was not statistically significantly different (p = 0.056); however, there was a trend appreciated improving median survival in the admission group by 3 ½ years. Due to our large numbers and significant time span, we were able to compare the survival rate with the various prosthetic options. Median survival for children in MYO group was 9.5 years, in the BP group was 5.8 years, and in the PAS group 2.8 years. Median survival for the MYO group was statistically significantly greater than the BP and PAS groups (p = 0.043; p = O.0001). No statistically significant difference was appreciated between the BP and PAS groups. We then combined the MYO, BP, and PAS group and compared it to those patients fit with a combination of prosthetic options. Median survival for the single prosthetic design group was 7.7 years, while that for the COM group was 16 years. This difference in median survival was statistically significantly different (p = 0.0001).
After thorough data analysis, we can say that at our clinic:
- Fitting prior to 36 months is better than fitting at an older age with respect to median survival. We could not demonstrate any advantage to fitting prior to walking age.
- Admission to the hospital for initial fit and training did not statistically improve survival. However, there is a trend favoring admission.
- Providing a variety of prosthetic designs greatly increased survival, reflecting the fact that individuals with UCTDF have changing needs throughout childhood and adolescence.