Immediate Postsurgical Fitting Of Prostheses In Children
Frank W. Clippinger, M.D.
Recently the concept of fitting lower-extremity amputees with prostheses immediately after amputation has received much attention. Emphasis has been on the promotion of early ambulation and rapid stump maturation, especially in the geriatric group.
The Duke University Orthopaedic Amputee Clinics have participated in a cooperative study of this technique since 1964. We have followed the procedures described by Burgess.
Burgess, Ernest M., M.D. "Immediate Postsurgical Prosthetic Fitting," a paper presented at the 33rd Annual Meeting of the American Academy of Orthopedic Surgeons, January 1966, Chicago, Illinois.
These procedures involve a closed amputation stump, proper drainage with or without suction, and the application of a padded plaster-of-Paris cast, to which is fitted a pylon shin and a SACH foot. The patient is allowed out of bed the day following the amputation and, under close supervision, increasingly bears weight as it can be tolerated over the ensuing days. The cast is changed at intervals to permit stump inspection and to insure the maintenance of adequate fit. When the wound has healed, a removable or "permanent" prosthesis is made.
The problems encountered in the older age group have been the usual ones associated with vascular amputees: generalized vascular insufficiency involving claudication, delayed healing, wound infection, poor balance, senility, and weakness. In general, however, the results have been sufficiently positive to indicate that immediate postsurgical fitting of prostheses has definite practical applications.
In our clinic, 32 patients, including five children, one of whom was a bilateral amputee, have been treated with immediate postsurgical prostheses.
The surgical procedures and casting techniques used on the children were the same as those applied to the older patients. Where possible, myodesis (reattachment of muscle to bone under slight tension) was performed, but in the child the muscle was sutured to the periosteum rather than attached through drill holes in the bone. In the fibular hemimelias where the muscle was hypoplastic, little muscle function was expected. Myodesis was not attempted with the Syme's amputation. Our experiences with the five children in this series are presented below:
Case #1. Male, Age 4 Years
Diagnosis. Congenital paraxial hemimelia, fibular, right (Fig. 1 ).
Previous prosthesis. A pylon, using the anomalous limb as the stump (Fig. 2 ). Fitting was difficult and alignment unsatisfactory because of the lateral offset of the foot. A cosmetic foot could not be applied.
Amputation. Below knee through the distal third of the tibia. Myodesis was performed, attaching the anterior tibial and triceps surae muscles to, but not over, the end of the tibia. A padded, long-leg plaster socket was made and the shin-foot unit attached (Fig. 3 ).
Weight bearing. Was started on first postoperative day, and full weight was tolerated on the second day. No attempt was made to limit weight bearing in these children, although this has been our practice with adults, at least until the time of the first cast change.
First cast change. Was made on the 12th postoperative day; the wound was found to be healed, and the sutures were removed (Fig. 4 ).
Removable prosthesis. Was made the 22nd postoperative day. This prosthesis was a hard socket patellar- tendon-bearing temporary limb (Fig. 5 ), which was worn for six weeks, and then converted to a permanent prosthesis, using the same socket.
Follow-up. At nine months the patient is using the initial hard socket with a three-ply stump sock.
Case #2. Female, Age 4
Diagnosis. Bilateral congenital anomaly: resistant clubfoot, left, which could not be corrected by surgery because of wound infection and bone distortion; and congenital paraxial hemimelia, fibular, right.
Previous prosthesis. A pylon on the right, using the foot as a stump, as in Case #1; clubfoot boot and elastic twister on the left.
Amputation. Conventional Syme's, left; below knee through distal third of tibia, right; with myodesis of anterior tibial and triceps surae muscles.
Weight bearing. Partial weight bearing was started the first postoperative day in parallel bars.
Cast change. Was made the fourth day on the right and the seventh day on the left because both became loose. The casts were changed again on the 10th day, at which time the sutures were removed. A third set of casts was applied on the 22nd day.
Removable prostheses. Were made on the 47th postoperative day, with a modified side-opening plastic Syme's prosthesis fitted on the left, and a hard socket patellar-tendon-bearing prosthesis with waist belt on the right. Permanent prostheses were made four months postoperatively. The initial sockets could not be used because of shrinkage.
Complications. None; good wound healing. The development of independent gait was slow because of (1) bilateral amputations, and (2) ante-version of both femoral necks to a degree that derotational osteotomy was contemplated for a time. In addition, the leverage afforded by the prosthetic forefeet made control of rotation difficult in the early weeks.
Follow-up. A stable, cosmetic gait was observed at ten months. A five-ply stump sock was worn on the right, and a one-ply on the left.
Case #3. Female, Age 5 Years
Diagnosis. Hemangiolymphangioma, left lower extremity, with a prior below-knee amputation at the level of the tibial tubercle and a prominent unstable fibular head fragment which had been irritated by the socket. The child could not keep her stump in the socket.
Amputation. Revision of the stump, with removal of the fibular head and hemangiomatous soft tissue.
Weight bearing. First postoperative day.
Cast change. Was made on the 16th postoperative day, with suture removal.
Removable prosthesis. A permanent prosthesis was made on the 42nd postoperative day and was identical to the preoperative limb.
Complications. None; good wound healing. The child walks with a moderate bent-knee gait, due partially to the short stump and partially to habit.
Follow-up. At nine months, one five-ply stump sock was worn with no stump irritation. The stump does not slip out of the socket.
Case #4. Female, Age 11 Years
Diagnosis. Transverse hemimelia at knee, right. The femoral condyles had rotated to an anteroposterior orientation; hence the stump was narrow mediolaterally but bulbous anteroposteriorly (Fig. 6 ).
Previous prosthesis. Was a conventional knee disarticulation limb, with a leather laced socket and outside knee joints.
Amputation. Revision of the stump, with shortening of the femur to the supracondylar level. Myodesis of the rectus femoris and hamstring tendons was performed with attachment to the distal femur. A plaster, above-knee socket was fitted, a hip spica for retention applied, and a knee-shin-foot unit attached.
Socket change. Was made on the 11th postoperative day. The wound was found to be healed, and the sutures were removed.
Removable prosthesis. Was made on the 41st postoperative day and consisted of a side-opening total-contact plastic socket with pelvic band, a standard knee, and a SACH foot.
Complications. None; with good wound healing. The patient had difficulty during the first two weeks in adjusting to the hospital and became withdrawn and uncooperative. This withdrawal prolonged her hospital stay, but did not otherwise influence the outcome of treatment.
Follow-up. At ten months one five-ply stump sock was being worn. Her gait was better than with the previously worn prosthesis because of a more comfortable socket and accurate knee placement.
Case #5. Female, Age 2 Years
Diagnosis. This girl was run over by a car, sustaining a compound crush injury of the left lower leg and foot (Fig. 7 ).
Amputation. A below-knee amputation at the juncture of the proximal and middle thirds was performed about two hours after the accident occurred. The operation included myodesis of the anterior tibial, peroneal, and triceps surae muscles with attachment to the tibial periosteum, A plaster socket with a shin-foot unit was applied in the operating room. This is the only patient for whom immediate postsurgical fitting of a prosthesis has been undertaken following amputation for acute trauma.
Weight bearing. Was started on the first postoperative day, with full weight bearing tolerated on the third day.
Socket changes. The first change was made on the 12th postoperative day, when the sutures were removed, The socket was again changed on the 22nd day and a third time on the 34th day.
Removable prosthesis. A conventional patellar-tendon-bearing limb with a hard socket and a waist belt was made on the 49th day.
Complications. Fever was evident on the second day after surgery, but subsided after a furuncle on the patient's hand was drained. At the first cast change, a 1 cm area of skin slough along the lateral margin of the wound was noted. This slough was responsible for the prolonged time spent in a plaster socket. In retrospect, the removable prosthesis could have been made on the 22nd day.
Follow-up. At eight months this girl wears a three-ply stump sock and walks without any appreciable limp. She has never used crutches.
All patients were allowed to stand the day after surgery, and progressive increase in weight bearing was allowed in accordance with the patient's tolerance. Considerable variation in the rate of progress of these children was noted. This variability appeared to be a function of (1) discomfort, (2) changes in the mechanics of gait from the preoperative state, and (3) accommodation to hospital surroundings. In the case of the two fibular hemimelias, the children had not previously walked with any approximation of normal foot leverage.
Except for those patients undergoing revision of a previous surgical amputation, we found it advantageous to sedate the child heavily at the time of the first cast change. Psychologically, this seemed to be the first time that the child became fully aware of what had actually happened with regard to the amputation. The smaller children had a tendency to revert for a few days following this first change, and refused to bear full weight during this period.
When the stump was healed, a hard socket patellar-tendon-bearing or total-contact above-knee prosthesis was applied, fitted on a pylon knee-shin or shin-foot unit, and used until the stump had matured. Provision of the permanent prosthesis occurred later in the children than in adults, partially because of gait abnormalities secondary to the congenital deformity and partially because we were in no hurry to get the patient off the removable temporary limb.
Children appear to be good candidates for the immediate postsurgical fitting of prostheses. Their motivation is good, and generalized circulatory complications are rare. Those children with congenital deformities who have never walked normally present some special considerations with respect to gait training, while application of immediate postsurgical fitting procedures to the very immature child has both advantages and disadvantages. In a pilot series as small as the one presented in this report, all of the pitfalls cannot be encountered. A much larger sample of patients will be necessary before all of the criteria, indications, contraindications and complications of the immediate postsurgical fitting procedures can be fully assessed.
Frank W. Clippinger, M.D. is Associate Professor Orthopaedic Surgery and Associate Chief, Duke Orthopaedic Amputee Clinics University Medical Center, Durham, N.C.