Immediate Post-Surgical Prosthetic Fitting In Children
Ernest M. Burgess, M.D. Joseph E. Traub
In July 1963, at the 6th International Prosthetics Course in Copenhagen, a paper on amputee electromyographic studies was presented by Marian A. Weiss, M.D., Director of the Konstancin Rehabilitation Hospital near Warsaw, Poland. In this paper Dr. Weiss introduced the concept of immediate post-surgical prosthetic fitting. The reported results of this unorthodox management procedure were quite spectacular. It was apparent that if Dr. Weiss' report had been interpreted accurately, this revolutionary technique might represent a major advance in the field of amputee rehabilitation.
Dr. Weiss Invited to United States
Accordingly, through the efforts of Mr. A. Bennett Wilson, Executive Director of the Committee on Prosthetics Research and Development, and Mr. Anthony Staros, Director of the Veterans Administration Prosthetics Center, who were faculty members at the International Prosthetics Course, Dr. Weiss was invited to visit the United States, to present his theories on immediate prosthetic fittings at three of the major research centers in this country.
Prosthetics Research Study Organized
Dr. Weiss toured the United States in the fall of 1963 and stimulated much interest in the application of his theories. Accordingly in Seattle, Washington the Prosthetics Research Study was instituted, under the Direction of Dr. Ernest M. Burgess, to investigate the value of immediate post surgical fitting. The project was financed by the Prosthetics and Sensory Aids Division of the Veterans Administration under a private contract to Dr. Burgess. This arrangement made possible the inclusion of any individuals in the study, including children, and avoided restrictions based on patient age, disability or hospitalization.
In May 1964 we began our controlled study of the technique for Immediate Post-Surgical Prosthetic Fitting as outlined by Dr. Weiss. From May through October 1964, our team treated sixteen patients utilizing this procedure.
The patients ranged in age from 2-1/2 years to 78 years, and in etiology from severe vascular disease with open draining infection to congenital deformity. In general, the results of Immediate Post-Surgical Prosthetic Fitting for these sixteen amputees were extremely encouraging. The time from surgery to fitting of the final permanent prosthesis ranged from 21 to 35 post-operative days.
Visit to Poland
During November, 1964, our team, consisting of Dr. Burgess, Dr. Robert L. Romano, and Mr. Traub, journeyed to Warsaw, Poland to consult with Dr. Weiss on his then current technique . This trip was sponsored by the International Activities Division of the Vocational Rehabilitation Administration, which is assisting Dr. Weiss financially in his research. Our visit with Dr. Weiss was extremely informative and pleasant. Copies of our report on this trip to Poland are available on request.
Since our return to Seattle, we have continued our study of Immediate Post-Surgical Prosthetic Fitting with ten additional cases.
Of the 26 patients treated with Immediate Post-Surgical Fitting, seven have been children. In all cases surgery was performed to correct congenital or bony deformities. Case reports on three of these children are included here to provide some insight into the technique as currently applied for the child amputee. Since this is a continuing study our case load is still somewhat limited. Thus the material presented in this report must be construed as descriptive of individual case management only and not as generally recommended procedures. It is anticipated that a fully detailed report of definitive techniques for surgery and Immediate Post-Surgical Prosthetic Fitting will be distributed by our research team in the fall of 1965.
In practically all instances of amputation surgery and prosthetic application, children recover and adapt more quickly than adults. This has also been the finding in our study of Immediate Post-Surgical Prosthetic Fitting. In all cases our results have been gratifying; with children the experience has bordered on the spectacular.
PRS Case #1: On May 26, 1964 the first application of Immediate Post-Surgical Prosthetic Fitting was made at the Children's Orthopedic Hospital in Seattle. The patient was a five year old white female with congenital absence of the tibiae bilaterally. (Fig. 1A ) Both lower extremities had been braced extensively from the time the patient was 15 months old. However, with increase in weight and activities over the years, the right fibula had migrated proximally, making successful bracing of this extremity impossible. Several reconstructive and stabilizing operations had proved inadequate.
On May 26th, disarticulation at the right knee was performed. The suture line to close this amputation was located on the posterior thigh approximately 2-1/2 inches proximal to the bone end, in order to fashion a good end-bearing stump.
After the wound had been closed, one layer of Owens silk surgical dressing was applied directly over the wound and a sterile 5 ply wool stump stocking was placed over the amputation stump. No drains were used. A tensor pressure bandage was then wrapped tightly over the distal stump end to promote additional hemostasis and the patient was removed to the cast room.
After five minutes, and while the patient was still under anesthesia, the tensor bandage was removed and a plaster cast applied to the complete stump surface. The initial plaster wrap was applied with moderate tension using elastic plaster of Paris bandage and the proximal or brim portion was distorted to a quadrilateral shape with a special wooden casting form applied over the wet elastic plaster bandage in the proximal area. As soon as the plaster had set, it was reinforced over the total surface with standard plaster of Paris bandage. A detachable pylon assembly was then attached in the proper flexion-adduction attitude, again using regular plaster of Paris bandage. The patient was then taken to the recovery room.
Immediate Training Program
Standing activities were instituted the next day (Fig. 1B ) with ambulation initiated on the third post-operative day. The cast remained in position on the stump for ten full days during which the patient made good progress with no discomfort. On the tenth post-surgical day, the patient's temperature was 104°, and although it was felt that infected tonsils were causing the temperature elevation, the cast socket was removed to be sure that the wound had not become infected. After examination of the stump, which proved to be healing well, the sutures were removed and the stump was again cast in the manner previously described. That night, the waist belt loosened and the cast came off. To prevent the formationof edema, it was decided to wrap her stump distally with a pressure bandage since she was in isolation for throat infection and could not be moved to the cast room. After four days, the patient was again taken to the cast room and a negative plaster mold of the stump, to be used for the fabrication of her permanent prosthesis, was made. Following this, she was again placed in a plaster cast socket with pylon and returned to her ambulatory activities.
On the 22nd post-operative day, the permanent prosthesis was fitted and gait training with an articulated knee joint commenced. Fig. 1C shows the patient four days later. By the 28th post-surgical day, she was considered fully rehabilitated and was discharged from the hospital.
PRS Case #14: On September 2, 1964 a standard knee disarticulation amputation of the right leg was performed on a 2-1/2 year old white male with complete tibial absence in the right lower extremity (Fig. 2A ). Surgical attempts to center the fibula for articulation with the femur had failed, However on the congenitally deficient left leg, the proximal tibia was intact and fusion of tibial and fibular segments had produced an excellent result.
Since the femoral condyles on the side to be amputated had formed, they were smoothed and the patella was excised. The skin suture line to close this amputation was located approximately 2-1/2 inches proximal to the stump end on the posterior aspect. The tissue over the stump end was soft and pliable.
Following surgical hemostasis and wound closure, four sterile gauze fluffs were placed over the wound and a sterile 2 inch tensor bandage was wrapped tightly over the distal stump to promote additional hemostasis. After five minutes, the tensor bandage was removed and one piece of Owens silk surgical dressing was applied directly over the wound.
Because a stump stocking of the proper size was not available, two layers of sterile bias cut surgical stockinette were applied to the stump surface. With firm tension distally, the initial elastic plaster bandage wrap was then applied to the entire stump surface. The plaster was deformed by the prosthetist's hands proximally under the ischial tuberosity and in the Scarpa's triangle area, since it had not been possible to devise a casting fixture small enough. Additional bias cut stockinette was applied to the patient's waist and incorporated into the reinforcing plaster of Paris of the socket for suspension. (Fig. 2B ) The patient was then removed to the recovery room.
During the late morning of the first postoperative day, the patient pulled the cast socket off his stump. The resident surgeon attempted to push the cast back on the stump but Was only able to get it 75% on. The prosthetist was called and the patient recast in exactly the same manner as previously. However, on this occasion, the plaster was continued from the cast socket around the waist, thereby preventing any hip motion but making it impossible for the patient to remove the cast.
Although it had been intended to attach a pylon to the cast socket on this first post-operative day, this patient was so young and active it was decided not to attach the extension until the fifth post-operative day.
During the following four post-operative days, the patient was happy and very active in his crib with no apparent problems.
On the 6th post-operative day, the cast socket was removed and the wound inspected. This examination revealed that the wound was healing well. No edema or abrasions were evident but the stump end was slightly bruised as a result of the "pounding" the child had given it in ambulation, etc. The stump was immediately recast in the same manner except that in addition to the Owens silk surgical dressing, three sterile fluffs were located over the stump end to protect it from impact damage. The pylon was attached with reinforcing standard plaster of Paris bandage and the hips were again immobilized by inclusion in the suspension cast. (Fig. 2C )
The patient progressed extremely well and was in excellent spirits for the next eight days. On the 14th post-operative day, the cast socket was again removed for inspection of the wound and continued healing was evident. (Fig. 2D ) There were still no abrasions or edema. The sutures were removed and a mold impression taken for the permanent prosthetic socket. The stump and hip were then recast with the pylon extension attached.
During the next nine days, the patient did extremely well, his spirits continued to be excellent and there were no medical complications. However, on the 22nd post-operative day it was noticed that the cast socket was loose and rotating somewhat on the stump. Since the permanent prosthesis was to be fitted on the 23rd post-operative day, it was decided to discontinue ambulation activities for one day.
Permanent Prosthesis Fitted
On the 23rd post-operative day, the cast socket was removed and the stump inspected. The stump was excellently shaped and completely healed. The permanent prosthesis which had a plastic total contact (end-bearing) quadrilateral socket with outside knee joints, Silesian bandage suspension, elastic knee extension aid, and SACH foot, was fitted. (Fig. 2E ) This prosthesis was considered to be an excellent fit and was accepted without modification. Gait training was commenced with an articulated knee joint.
This patient learned to handle the permanent prosthesis quite well in the initial three days of training and was considered to be rehabilitated with his permanent prosthesis 26 days post-surgery. His progress and future prosthetic care will be continued through the Amputee Clinic at Children's Orthopedic Hospital in Seattle.
PRS Case #15: This patient was a 7 year old white male. On October 7, 1964 Dr. Burgess performed a standard Syme amputation of the right lower extremity. The child had suffered a gunshot wound which had destroyed the distal tibial epiphysis of the right leg three years previously. (Fig. 3A ) A 2-1/2 inch shortening of the right leg and awkward ambulation prompted the decision to amputate. It was felt that elective surgical amputation of the foot and good continuing prosthetic care would produce maximum rehabilitation.
Surgery and Immediate Post-Surgical Prosthetic Fitting
A classical Syme skin incision was made extending from a point just inferior to the medial malleolus anteriorly to the joint margin, laterally and posteriorly to the lateral malleolus and then vertically to the sole of the foot and around the base to the opposite side. The removal of the distal foot was accomplished in a normal manner with the tendons pulled and cut at their base and allowed to retract proximally. Nerves were cleanly divided and allowed to retract. The distal ends of the tibia and fibula were then exposed and cut transversely to the line of the leg. The transection was approximately 1 cm. above joint level with the concavity of the distal tibia eliminated. The edges of the bone ends were rounded and filed smooth. (Fig. 3B ) The heel was approximated in the center of the weight bearing area. Redundant skin anteriorly and laterally was carefully excised, some redundancy of the heel skin being left to avoid compromising the circulation.
The skin was then closed, a small Penrose drain was inserted through and through at the apex of the incision One piece of Owens silk surgical dressing was loosely applied directly over the distal stump and a 5 ply wood stump stocking was pulled snugly over the stump to the level of the knee. Two strips of 1/4" medium hard felt, the length of the tibia from the anterior tibial tubercle to within one inch proximal to the suture line anteriorly, were fashioned and taped to the stump stocking on either side of the tibial crest to protect this bony prominence from abnormal pressure.
The stump was then encased in a cast of elastic plaster of Paris bandage to attain uniform pressure. This cast extended proximally to the level of the anterior tibial tubercle and medium tension was applied throughout with the cast suspended by its contour only. (Fig. 3C ) The patient was then taken to the recovery room.
Because of the distal redundant tissue and the location of the drain, ambulatory activities were considered inadvisable until after the drain had been removed. However, the patient was up in a wheelchair on the first postsurgical day and was quite comfortable.
The cast was taken off on the second post-operative day for drain removal and wound inspection. The wound was healing well and the heel skin was being maintained in excellent weight bearing position. Following removal of the drain the stump was recast in the same man ner. At this time the initial elastic plaster of Paris bandage was reinforced with standard plaster bandage. The plaster was extended 2-1/2 inches distally and a rubber "walking bar" included. (Fig. 3D ). The patient was then returned to his room and allowed up only in his wheelchair for the remainder of the day in order to give the plaster a chance to set completely.
Ambulation on Third Day
On the third post-operative day, standing and limited ambulation were instituted with the patient tolerating the activities very well. Ambulation was initially restricted to 5 minute sessions three times daily in the parallel bars. The duration of these training sessions was gradually increased until at the 14th post-surgical day, the patient was ambulating out of the parallel bars with full weight bearing for 2-1/2 hours a day.
On the 15th post-operative day, the cast socket was again removed. The wound was inspected and found to be dry and well healed. The sutures were removed and the stump immediately recast in the same manner as with the second cast socket. The patient was then discharged from the hospital to his home. The mold for the permanent prosthesis was not taken at this time as the necessary casting technique involved too much time and the possibility of trauma to the wound at this early date made it inadvisable.
On the 22nd post-surgical day, the patient returned for wound inspection and casting for the permanent prosthesis. The wound was dry and well healed and tolerated handling without pain. The cast for the permanent prosthesis was taken at this time and the stump was then recast in exactly the same manner as previously.
Skin Irritation Noted
On the 31st post-surgical day the cast was again removed for fitting of the permanent prosthesis. A slight irritation of the wound was noted with a possible low grade skin infection. The patient was returned to the hospital for whirlpool treatment and washing with pHisohex.
On the 35th post-operative day, the dermatitis had completely cleared and the permanent prosthesis was fitted.
Thus, the total time elapsed from surgery to the permanent prosthesis was 35 days, with dermatitis and deferment of casting accounting for a 12 day delay in his final rehabilitation.
Ernest Burgess is Director, Child Amputee and Congenital Deficiency Clinic, Children's Orthopedic Hospital, Seattle, Washington
Joseph Traub is Director, Prosthetics Research Study, Seattle, Washington