The Management Of Several Interesting Cases At The University Of Oklahoma Juvenile Amputee Clinic

William Waldrop, M.D. Gael R. Frank, M.D. Ralph Payne, Jr., M.D.

We have not treated any series of unusual cases at our amputee clinic, but in several individual instances we have attempted unusual solutions to interesting and difficult problems.

Case One

The child depicted in Fig. 1A and Fig. 1B , an eight-year-old boy, underwent bilateral above-knee amputations as the result of a train accident. Before coming to our clinic, his treatment consisted of revision of both amputation stumps, resulting in a very short above-knee amputation with good skin and soft tissue coverage on the right. The length of the left lower limb was maintained as a knee disarticulation but, as can be noted from the photographs, the skin coverage is thin split thickness skin which will not withstand prosthetic wear.

Our first inclination was to shorten the femur and obtain good skin coverage in the shortest time. However, X-rays (Fig. 1A ) indicated that the distal femoral epiphysis was still present and capable of increasing the stump length. Considering the extremely short stump on the right side, this would be most desirable in the later life of the patient.

After consulting with the Plastic Surgery Service, we decided to attempt coverage of the left femur with a tubed pedicle flap to be raised from the abdomen and chest (note outlined flap, Fig. 1B ). This tubed flap will be transferred to the left amputation stump by attaching it initially to the left forearm. When an adequate blood supply is available from the forearm, the flap will be attached to the left knee region.

As can be noted from the photographs, we are a long way from the completion of this ambitious undertaking. However, if and when it is completed, the added length on the left will greatly improve the patient's prosthetic fitting. We hope to report on the outcome of this attempt at a later date.

Case Two

The second case is a three-year-old boy who was first seen in our clinic at the age of eight months for club foot deformity refractory to cast correction. X-rays revealed left paraxial tibial hemimelia. Our initial plan was to place the fibula on the talus distally, and into the inter-condylar notch of the femur proximally. After the surgery to replace the distal fibula on the talus had taken place (Fig. 2A ), we were informed of the excellent results obtained with similar cases by Syme amputation, open reduction at the knee, and fitting with a modified patel-lar-tendon-bearing type prosthesis. We suggested this possibility to the child's mother, but she steadfastly refused to allow us to perform the Syme amputation.

We therefore proceeded with the open reduction of the fibula into the inter-condylar notch (Fig. 2B ), hoping that the mother would consent to the amputation of the foot at a later date.

Fig. 2C (eight months post operative) depicts the widening of the proximal fibula in an attempt to form a proximal tibial configuration. (The clinical result at this point is shown in Fig. 2D .) The patient was fitted with a prosthesis (Fig. 2E ), and we will allow weight bearing to further stimulate growth and remodeling of the fibula, and also to encourage use of the limb.

Eventually, we hope to persuade the mother to allow a Syme amputation at the ankle and fitting with a suitable prosthesis. It is our thought that it might be helpful to show the mother motion pictures of a child treated successfully in this manner. À central library of films of this type would undoubtedly be useful to all of the child amputee centers.

Case Three

Our third patient illustrates another method of handling a case of paraxial hemimelia. This boy was seen initially at 22 months of age for a paraxial fibular hemimelia. Several attempts (both closed and open) were made to obtain satisfactory alignment of the foot elements on the tibia (Fig. 3A ). Note also the absent talus. These attempts were unsuccessful in obtaining a functional alignment, even with brace support.

The forefoot was amputated and the cal-caneous fused to the distal tibia when the child was two-and-one-half years old (Fig. 3B , Fig. 3C ). The boy was fitted with a modified end bearing prosthesis with SACH foot, brace side straps, free knee joint, and leather thigh cuff. The condition of the stump and the stability of the knee will permit weight bearing (Fig. 3D ), It is our plan to ultimately fit the patient with a modified Canadian Syme prosthesis.

University of Oklahoma Hospital Clinic for Amputees, Department of Orthopedic Surgery, Oklahoma City, Oklahoma

1. Brown, F. W., "Construction of a Knee Joint in Total Congenital Absence of the Tibia; A Preliminary Report". Journal of Bone and Joint Surgery, 44-A, 1264-1265, 1962.