Patellar-Tendon-Supracondylar Prostheses for a Bilateral Below-Knee Amputee
William H. Georgi, M.D. Robert Warner, M.D. Roland H. Daniel, C.P.
The Buffalo Clinic has recently had the opportunity to provide bilateral pa-tellar-tendon-supracondylar prostheses for a young man with bilateral short-below-knee amputations. Since we have not seen any reports of a similar fitting, it seemed worthwhile to detail our experience with this patient.
R.E. is a 13-year-old boy who was run over by a train in June 1969. Both legs were shattered below the knee necessitating bilateral guillotine below-knee amputations. A protruding right fibular head was excised in July 1969; and a very painful fibular head on the left side was removed in September 1969.
When originally seen in the Clinic, the boy had bilateral below-knee stumps which measured a bare two inches from the distal patella to the end of the tibia. The stumps had multiple incisional scars which were very thinly covered by shiny tissue-paper-like skin. The range of motion of the stumps was good, however (Fig. 1 and Fig. 2 ).
The original intention of the Clinic was to provide this boy with patellar-tendon-bearing sockets with knee joints and thigh lacers. Partly because this boy was intelligent, and partly because he was particularly well-motivated, and not at all overweight, we finally decided to try bilateral patellar-tendon-supracondylar sockets. This was done with the reservation that they might have to be modified by the addition of knee joints and thigh lacers later.
R.E. was fitted in the rough in early October 1969, but brief weight-bearing trials indicated that the skin over the scars was still too thin and tender to tolerate this amount of pressure. We grounded him for another month and then let him wear the prostheses again. Gait training was cautiously initiated on November 16, 1969, and proceeded with gradually increasing periods of wear. Over the next month the boy became able to tolerate the prostheses and evolved into a good independent walker.
He has continued to tolerate the prostheses for the past year with only occasional episodes of skin irritation and breakdown. His gait has shown very little lateral instability although a tendency toward valgus deformity of the right knee has been noted (Fig. 3 ). For a double amputee, he walks with a remarkably narrow base. The supracondylar suspension has been very secure both during ambulation and when the boy was seated with his knees flexed.
We feel strongly that, had he been provided with standard prostheses with knee joints and thigh lacers, a major problem might have arisen with displacement of the stumps in the sockets, especially when the knees were flexed.
This young man has grown in the last year, and now shows quite a bit of disproportion between the upper and lower halves of his body. Therefore, we are faced with the problem of lengthening the prostheses. This increase in height and his general body-weight increase may present new difficulties in stump-skin tolerance and knee stability. If these problems should develop, we will consider increasing the amount of lateral support at the knee by adding an external polycentric joint attached to a short thigh cuff, but without sacrificing the supracondylar flares of the socket.
Family and School
Our efforts to provide physical restoration for this young man were aided by the fact that he was a bright boy with a remarkably understanding and highly supportive family. However, despite his generally excellent emotional adjustment, he did show natural anxiety as to what the future would hold for him as a bilateral amputee. When first seen, the patient had already lost several months of school, and it was felt that the first priority in his treatment was to return him as quickly as possible to his peer group at school. In order not to intensify his feelings of being lost and without direction, this was regarded as imperative. Therefore, arrangements were made to have him go temporarily to a school for the physically handicapped, in a wheelchair, while the prosthetic details were being worked out. This procedure enabled him to complete grammar school successfully. He then went on to regular high school after his prostheses were finished. During the year in grammar school, he received above-average grades, and was also elected president of his graduating class.
Extent of Handicap
We believe that it is important for a child or youth not to delay his return to school and his peer group until he is fully rehabilitated, even if this means going on crutches or in a wheelchair. There are two reasons for this belief: 1) it is important for the child to get back among his friends while he is still adjusting to being a handicapped person; 2) the child is able to start from a more handicapped condition and progress to a less handicapped state with the help of the prosthesis. Our experience has shown that this procedure is far better for the child than to wait and stay away from peers until the prosthesis is ready for use. Many patients, however, do express a preference for waiting until this time to return, and many schools attempt to defer readmission until the child has his prosthesis. However, we feel very strongly that, although in both instances he returns to school as a handicapped person, in the former case he returns more handicapped, and therefore makes a great forward stride with the provision of the prosthesis, thus becoming less handicapped in the presence of his peers.
Our educational-vocational staff feels that the boy now has a chance to adjust to his disabilities, and form a better picture of his present self. They consider that he is now ready to proceed with counselling to aid him in selecting a realistic vocation in keeping with his handicap and his remaining abilities.
We feel that we have successfully fitted patellar-tendon-supracondylar below-knee prostheses to a bilateral amputee with stumps which heretofore would normally have been considered too short to be fitted with anything but knee joints and thigh lacers. These prostheses have given adequate lateral stability to the knees so far, and have held the stumps more securely than would be possible with standard prostheses.
We also feel that this case illustrates a successful outcome because all the members of the team worked intelligently and closely together:
- the physician, in making sure that the stumps could tolerate the prostheses;
- the social service case worker, with an exceptionally good family, helping the boy and his family adjust to living with his handicap;
- the educational counsellor and his staff, setting up the early return to school and peer group activities;
- the physical therapists, in providing tactful understanding and gradual, but strictly disciplined, gait training under the watchful eyes of the clinic physicians;
- the vocational counsellor, with his early approach to future vocational planning; and
- the cooperative effort in working together with this boy and his family toward the common goal of giving him a sense of accomplishment and satisfaction in the face of his modified self-image.
While we were accomplishing all this, the prosthetist successfully tried a new or at least unusual prosthetic application for a double amputee with exceptionally short stumps.
Amputee Clinic, Rehabilitation Center Children's Hospital of Buffalo Buffalo. New York