Non-Standard Prosthetic Applications For Juvenile Amputees
Newton C. McCollough, M. D. Ardis Traut, R. P. T. Jack Caldwell, CP.
The prosthetic industry has demonstrated remarkable ingenuity in the fabrication of non-standard sockets, particularly in the use of plastics for this purpose. This ingenuity has permitted the surgeon to adopt a conservative approach in the treatment of certain anomalous limbs in which surgical alteration might be questionable, particularly in cases of the extremely young. Another consideration of significance to commend this attitude of conservatism is that a small amount of pressure provided by a vestigial digit or remnant appropriately fitted might conceivably be used in the control of external power when we have the opportunity to utilize it.
Five positive indications for the utilization of non-standard prostheses can be cited:
When the parents and/or the patient refuse surgical conversion (Case 1).
When conversion is delayed in the hope that growth and stump changes will permit a more acceptable surgical contouring; or where surgical relief may pose as many problems as it solves (Case 2).
Where partial adactylia indicates delay of conversion to a wrist disarticulation in the hope that metacarpal growth will allow satisfactory development of some type of functional pinch. Also in partial adactylia the envelopment of such a broad stump (without conversion) may increase socket stability against rotational displacement; and also provide freedom from scar tissue and hence increased resistance to socket pressures (Case 3).
During the early periods of observation of the intercalary deficiencies, specifically paraxial hemimelia tibia and fibula, and during the surgical correction of these deficiencies, all of which may extend over a period of years (Cases 4, 5, 6).
In the case of an intercalary paraxial hemimelia fibula or tibia, where there are also bilateral upper extremity deficiencies which necessitate that the patient use his feet in daily living activities, particularly at home (Cases 7 and 8).
The procedures utilized in the treatment of eight patients illustrative of these situations are presented in the following case histories:
A. T., male, age 14 - Observations by the Physical Therapist - Intercalary transverse proximal phocomelia (Fig. 1A and Fig. 1B ). The lack of knee flexion in the present prosthesis (Fig. 1E ) has been of no consequence to the patient. He has experienced no difficulties sitting in school all day or in activities with other children, and even engages in some competitive sports. This lack of flexion has disturbed the clinic team more than it has bothered the patient.
Prosthetic Management - The appliance consists of a leather boot in a steel frame with a cosmetically contoured shin-type extension, and a SACH foot. A leather cuff above the calf aids stability. No knee joint is provided. (Fig. 1C , Fig. 1D , and Fig. 1E ). We are now constructing an appliance of a more recent type with a joint to be mounted under the foot to give flexion at the knee joint level. The fitting is complicated by the externally rotated attitude of the stump. A higher cuff may be necessary to control this factor, particularly during swing phase.
Clinical Comments - Neither this patient nor his mother desired surgical revision, which was recommended by our Clinic a few years ago. As we continued to observe the boy, we noted that he could walk quite well without a prosthesis and that our original ideas concerning conversion were wrong. He was presented at the combined Participating Clinic Chief's meeting at the American Academy of Orthopedic Surgery in Miami, in January, 1963, and our conclusions were heartily endorsed by all.
M.B., male, age 14 - Observations by Physical Therapist - Severe scar and contracture due to subcutaneous injection of sclerosing solution in infancy (Fig. 2A and Fig. 2B ). Because of ankylosis at the knee and hip of the affected leg, the patient stands on a low stool to place his foot in the appliance, bending his sound knee to lower himself into the device. By using the stool, he is able to maintain complete independence in applying and removing his prosthesis.
Prosthetic Management - A leather boot is mounted in a steel frame atop a platform built above a SACH foot. Leather was used for the boot instead of plastic because of excessive scarring. However, a plastic half shell lined with lambswool provides anterior stabilization. Lacing was used initially (Fig. 2C ) but because of ankylosis at the knee and hip, the patient was unable to don the appliance by himself. The eyelets and lacing were replaced by suitcase latches, purchased from a luggage shop, and with these he can don and fasten the appliance alone and satisfactorily (Fig. 2D and Fig. 2E ).
Clinical Comments - The patient's cicatrix extends from well above the hip to the foot and the skin is paper thin and fixed to the bone. His knee is ankylosed, and his hip is dislocated and clinically ankylosed by contracture. The original trauma was caused by injection of ether subcutaneously instead of normal saline solution during an infantile enteritis. This situation defies surgical relief and management is entirely dependent upon prosthetic ingenuity.
M.B., - male, age 8 - Observations by Physical Therapist - Left upper terminal transverse adactylia (Complete except that remnants of metacarpals of rays 1, 2, 3, 4 are present) (Fig. 3A and Fig. 3B ). The child was a participant in the Sierra hand study and cosmetic restoration with the glove was very good (Fig. 3C ). The hand and glove are still worn for dress, the glove being cut long enough to cover the non-standard prosthetic openings and lacings.
Prosthetic Management - A modified below elbow prosthesis of flexible laminated plastic was fabricated with eyelets and a shoe lacing provided on the anterior aspect to allow passage of the bulbous stump end through the narrow part of the prosthetic forearm (Fig. 3D ). This was later changed to provide fastening by means of velcro tape (Fig. 3E ). No particular difficulties were encountered.
Clinical Comments - M.B» was not fitted until he was four years old. When he was seen initially we decided to await possible metacarpal growth, but this did not materialize through the years. Since fitting the boy has been a constant, enthusiastic wearer and it is our opinion that a great deal of the stump-socket stability he now has would be lost if he were disarticulated at the wrist.
D.B., male, age 6 - Observations by Physical Therapist - Right terminal longitudinal complete paraxial hemimelia, fibular, with some femoral shortening (Fig. 4A and Fig. 4B ). Although the child has dissimilar knee levels, we did not encounter any gait training problems in the prosthesis he wore prior to his recent surgery. He is an extremely active and agile boy.
Prosthetic Management - D.B.'s pre-surgical prosthesis consisted of semiflex-ible laminated plastic socket, with a longitudinal split anteriorly to allow for passage of the foot into the socket. A velcro strap assisted in socket retention. The fitting was facilitated by the extreme equinous attitude of the foot. The alignment was basic. Cosmesis was reasonably good since the amount of shortening present permitted the application of a SACH foot without difficulty (Fig. 4C and Fig. 4D ). Following the surgery described below we are currently fabricating a new prosthesis of similar type for D.B. It will be endbearing.
Clinical Comments - At the age of six, the patient finally developed so much valgus tilt to the foot, in spite of attempts to hold it in a relatively corrected position, that pressure on the medial aspect of the os calcis and talus became intolerable. In two operative procedures, the os calcis was brought beneath the tibia after removing the talus. The forefoot was removed at the calcaneo-cuboid level. The heel pad is now parallel to the floor and bony ankylosis has been achieved between the osteotomized body of the os calcis and the distal tibia. Because of his femoral shortening we anticipate this patient will eventually be treated pros-thetically as an above-knee amputee, with the advantage of an end bearing stump.
J. K., male, age 5 - Observations by Physical Therapist - Left terminal longitudinal complete paraxial hemimelia, fibular (Fig. 5A ). This boy has always been extremely rough and active and breakage has been our main problem in prosthetic restoration.
Prosthetic Management - The patient could not be fitted without the support of a below-knee knee joint because of increasing knee valgus. The foot would not stay in an ordinary shoe or surgical boot because of the excessive pull of the Achilles' tendon. Many different types of apparatus were tried (Fig. 5B , Fig. 5C , and Fig. 5D ) until, finally, a leather boot on a neoprene lift with an open socket of plastic was chosen. A single (lateral) brace knee joint was used. The upper calf cuff is used to stabilize against the knee valgus tendency (Fig. 5E , Fig. 5F , and Fig. 5G ).
Clinical Comments - J.K. responded well to all fittings, but this most recent one has been very satisfactory. He is a good walker and has voiced no complaints regarding the weight or appearance of the prosthesis. He is now five years of age and will continue wearing his present prosthesis until, at a later date, we modify his foot surgically to a Boyd type amputation with the os calcis arthrodesed to the distal tibial epiphysis. This procedure is dependent upon parental and patient acceptance and there is no hurry.
W. F., male, age 3 - Observations by Physical Therapist - Bilateral lower terminal longitudinal complete paraxial hemimelia, fibula (Fig. 6A and Fig. 6B ). The present prostheses have been used for standing only and gait training has not been attempted. The patient has outgrown his prostheses and we are now in the process of making new prosthetic appliances.
Prosthetic Management - The prostheses worn by W.F. when he was presented to the clinic consisted of oversized plastic sockets with posterior lacers. Short thigh cuffs and side joints, bilateral fork straps, and SACH feet completed the prostheses (Fig. 6C and Fig. 6D ). Now being fabricated are PTB type bilateral prostheses with supracondylar straps and SACH feet. The feet will be in extreme equinus and fitted for total contact.
Clinical Comments - The fibula deficiencies are bilaterally complete, the feet in marked valgus. Eventually, the os calcis and its heel pad will be fused to the distal tibial epiphysis with the plantar surface parallel to the floor. The accompanying photographs demonstrate the extreme "vigah" of us here in the deep South.
D.W., male, age 19 - Observations by Physical Therapist - Right upper terminal transverse amelia. Left upper terminal transverse hemimelia, above-elbow type. Left lower intercalary longitudinal, complete, paraxial hemimelia, fibular (Fig. 7A and Fig. 7B ).
The patient, a sophomore in college, was originally fitted with bilateral upper-extremity prostheses. The right arm was discarded because it was cumbersome and presented a harnessing problem. It could not be applied independently of the left prosthesis.
Now fitted with a left above-elbow arm only, in addition to his lower-extremity non-standard prosthesis (Fig. 7C and Fig. 7D ), D.w. is completely independent in all activities of daily living, and does not encounter any problems in application of the two prostheses nor in their removal. He has unusual drive and ingenuity in the use of both prostheses, being able to apply the left lower using either the right foot or the left upper extremity prosthesis.
Prosthetic Management - The left lower extremity prosthesis consisted of a semiflexible plastic socket mounted on a platform attached to a SACH foot (Fig. 7E and Fig. 7F ). The fitting was complicated by the fact that the lacing had to be arranged so that the patient could manage it with his right foot and left upper-extremity prosthesis. The alignment was quite critical* In spite of these considerations, no insurmountable difficulties were encountered.
Clinical Comments - The patient has experienced no stump difficulties. An extremely active young man, he bears most of his weight on the head of the first metatarsal, the great toe, and the remainder on the plantar surface of the foot. No difficulty has been encountered with callosities. He uses the toes of both feet with almost equal facility in performing activities of daily living.
S.V., male, age 8 - Observations by Physical Therapist - Right upper terminal transverse amelia, left upper terminal transverse amelia (Fig. 8A , Fig. 8B , and Fig. 8C ); right lower intercalary longitudinal incomplete paraxial hemimelia, fibular, with the characteristic tibial and femoral shortening (2-3/4") (Fig. 8D and Fig. 8E ).
Prosthetic Management - A neoprene build-up (approximately 6") was constructed for the foot with a half shell of laminated plastic enclosing the gastrocnemius (Fig. 8F , Fig. 8G , and Fig. 8H ). The prosthesis is attached by velcro straps which the patient must manipulate with the opposite foot because of his bilateral upper extremity amelias. Difficulties - The patient rejected all conventional types of suspension apparatus and accepted only the one depicted with a thong between the toes.
Clinical Comments - S.V. is an extremely intelligent boy with very firm opinions. In the past, we attempted all types of fully-enclosed sockets on this lad and he rejected our every effort because of haat and a burning sensation in his foot. He is extremely happy, however, with the present arrangement. He writes well with both his right hook and his right foot.
Juvenile Amputee Clinic, Florida Crippled Children's Commission, Orlando, Florida