Experiences In Fitting Lower-Extremity Prostheses To Patients With Skin Deficits
E. Reese Owens, M.D.
Prosthetic training is generally considered to be untenable unless the stump skin is in satisfactory condition. Hence skin loss with subsequent graft replacement presents a particular challenge to the physician, the physiotherapist, and the prosthetist. In our clinic we have prepared split-thickness skin grafts for prosthetic wear by the usual physiotherapeutic procedures. This is necessarily a slow process, and in two instances psychological problems have forced us to institute training while graft healing was incomplete. Persistent use of the prostheses for frequent short periods produced occasional breakdown in tis sue, but ultimately it succeeded in toughening the skin and in shaping the stump. Training was continued uninterruptedly after we found that short rest periods resulted in stump swelling and hemorrhages beneath the scar when activity was resumed. A discussion of these two problem cases follows :
(A Complication of Chickenpox)
R.F. was born March 28, 1961, and contracted chickenpox when he was two years of age. During convalescence, skin discoloration about the perineum progressed to gangrene of the right lower quadrant of the abdomen and the lower extremities. The condition was diagnosed as purpura fulminans, and right above-knee and left below-knee amputations were performed (Fig. 1 Fig. 2 ) A skin deficit overlying the right lower quadrant of the abdomen, the right and left thighs, and the left lower leg were covered with split-thickness grafts.
The child was referred to our clinic and was admitted to the Home for Crippled Children with stumps covered by scar tissue. The right leg was held in flexion, abduction, and external rotation at the hip. The left leg was in mild flexion and external rotation at the hip and flexed at the knee. The extreme sensitivity of the stumps and the contractures were successfully overcome by physiotherapy and exercises.
This boy became withdrawn and negativistic toward treatment. Therefore, as an incentive, prostheses were ordered prior to complete healing of the limbs. He was fitted with a right above-knee and a left below-knee prosthesis with a pelvic band. A night splint maintained the position of the legs when the child was at rest.
Today R.F. walks alone with little gait deviation (Fig. 3 ). Overgrowth of the left proximal tibia has produced skin ulceration over the end of the bone. This condition was treated by simple resection and primary closure of the scar tissue. We felt that the value of the knee joint, with the added control it affords a bilateral amputee, precluded revision of the left below-knee amputation.
C.T. suffered third-degree burns of the lower extremities, extending from the toes to the proximal quarter of the thighs. Emergency care and the initial below-knee amputations were followed by definitive above-knee revisions at the supracondylar level (Fig. 4 and 5 ). The skin deficit was satisfied by split-thickness grafts.
The patient was referred to our clinic for prostheses and training. Our preparations for prosthetic fitting were curtailed by an impending emotional crisis, manifested by threatened suicide and deterioration of personality. Conventional prostheses with pelvic band were ordered for the patient (Fig. 6 and 7 ), although the stumps were edematous and small ulcerations were evident at the >contiguous margins of the grafts. However, during gait training these areas closed, and today, in the sixth postoperative month, the stumps tolerate six to eight hours of prosthetic wear daily.
Early ambulation with prostheses may be employed with success in the amputee with a special skin problem. This parallels the experience of other surgeons with early postoperative prosthetic fitting in above-knee and below-knee amputations.
E. Reese Owens, M.D. is associated with the Child Amputee Clinic Home for Crippled Children Pittsburgh, Pennsylvania