A Young Hemipelvectomy Patient
WILLIAM R. SVETZ, C.P. CYNTHIA WAGNER, L.P.T. MARY WILLIAMS CLARK, M.D.
At the age of eight days, a child named Michael Fraley underwent a right hemipelvectomy for a fibrosarcoma. His prosthetic care and follow-up are discussed in this article, from fitting with a bucket socket for sitting balance to fitting with a standard hemipelvectomy prosthesis. As we reviewed Michael's case, we discovered that if he had been given a knee joint at an earlier age, his progress would have been more rapid.
Underestimation of the ability of young amputees is a mistake that everyone makes at one time or another. After meeting and working with a young man by the name of Michael Fraley, we have changed greatly our evaluations concerning the ability of very young amputees to function with rather involved prosthetic appliances.
Michael was born on January 27, 1972. At birth a fibrosarcoma of the right thigh was present. Biopsy was done on the second day after birth, and at age eight days a right hemipelvectomy was performed at Children's Hospital of Pittsburgh. Michael at this time became the youngest hemipelvectomy amputee that we had seen.
On June 25, 1972, at age six months, Michael was seen at our clinic for the first time. The amputation had healed well, and Michael was crawling with the use of his arms and was able to stand with support. The only problem was that he could not sit and maintain his balance. He compensated for this by creating a tripod-type sitting position with his left leg, a position which we felt might become a problem later in his development because of the extreme external rotation at the hip. The solution for this problem was for us to provide a new ischial support on the right side for proper balance, allowing him to sit in an upright position.
At six months of age, Michael was measured and fitted with a hemipelvectomy socket for sitting ( Figure 1-A ). The device was constructed as a double-wall socket built up on the lateral side to provide the support needed. The cast modifications were made to create lateral and abdominal compression with relief to the noninvolved iliac crest. The proximal trims were just distal to the costal margins and as high at the inguinal fold as possible, extending laterally over the trochanter and posteriorly cupping as much of the gluteal fold as possible. A lateral opening was used with a plastic tongue and Velcro closures. The overall weight of the socket with buildups was approximately one pound. Fabricating materials were acrylic resin and perlon.
Soon, the sitting prosthesis alone was insufficient for Michael's needs as he began pulling himself to stand. When Michael was 10 months of age we added to his existing socket a pylon system consisting of a single-axis hip joint, one-half inch aluminum tubing, and a hand-formed wood and felt foot ( Figure 1-B ). A small aluminum block was incorporated at the hip joint as a hip-extension stop, and to limit the anterior movement of the pylon a small rubber band was attached from the socket to the pylon ( Figure 1-C ). The pylon attachment at the ankle was made adjustable to allow for growth.
With the pylon-like prosthesis Michael began to cruise around furniture at age one year. At fifteen months he outgrew the original socket; the new socket was lined with Aliplast for increased friction to prevent slippage of the socket ( Figure 2-A and Figure 2-B ). In the next two months he progressed to ambulation with moderate assistance or hand-holding of two hands, but during the following eight to ten months Michael showed no progress and still could not ambulate independently. He was thus, at age two years four months, admitted to Children's Hospital of Pittsburgh for intensive physical therapy. Michael had little difficulty coming to a standing position and cruising with the limb, but he required approximately seven days of instruction before he would initiate ambulation. At discharge, Michael required hand-holding of one hand and utilized a pivot swing-to type of gait. Because he lacked a knee joint, he was also circumducting the limb.
At a clinic visit four months later, at age two years eight months, Michael was not wearing the limb for long periods of time, and he needed two hands for support. Mother complained that the limb was getting in Michael's way because of its length and the lack of a knee joint. Also, Michael had outgrown the socket, and a new prosthesis was prescribed. The new prosthesis had an acrylic socket with single-axis hip joint, single-axis knee joint using arm hinges, SACH-type foot, and an extension bias or stride-length limiting strap ( Figure 3 ).
Michael was hospitalized once again for ambulation training. He learned to advance the limb and achieve knee flexion and heel strike. After three and one-half weeks Michael was progressed from ambulation with a walkerette to independent ambulation on flat surfaces, and he could negotiate stairs with a hand rail. At discharge it was suggested that Michael use the walker for a few weeks until he was adjusted once again to his home environment. Here again, the clinical staff had underestimated the determination of a very young man to overcome a disability that many older patients would have balked at.
Michael went home with the walker, and that is about all he did with it-take it home. Only a few days after being at home, he was walking independently of the walker and was negotiating stairs on his own. Roughhousing with his brother and zipping from room to room on his bike became a common sight in Michael's home ( Figure 4 ).
In retrospect, Michael began to regress at about age two, and we believe that he would have progressed at a faster rate if we had given his limb a knee joint at that age, instead of waiting nine more months.
Needless to say, everyone was extremely pleased with Michael's rapid progress. His case may be only one of many, but working directly with him has been a rewarding experience for our clinic team and has made us more aware of the abilities of the young amputee.