Surgical Management Of Several Unusual Amputee Problems
Gael R. Frank, M.D.
This paper will present two unusual bone-grafting procedures in upper-extremity amputees and two problems of bone malalignment in below-knee juvenile amputees.
This 39-year-old white male was struck by a rolling semitrailer truck in December, 1959, and sustained a hyperabduction injury to the left shoulder. This traumatic event produced a complete left brachial plexus injury which was associated with a Horner syndrome--due, it was felt, to the avulsion of the roots of the nerves contributing to the brachial plexus. The hyperabduction injury was so violent that a segment of the rib cage on the left side was pulled loose, creating a flail chest. The patient's convalescence from the injury was satisfactory, but he was left with a flail upper extremity, except for those muscles innervated by a source other than the brachial plexus.
On April 15, 1961, a left above-elbow amputation was performed and the left shoulder fused, utilizing a bone-grafting procedure described by Rountree and Rockwood (Fig. 1A and Fig. 1B ). The bone for the peg crossing the shoulder joint was obtained from the amputated left forearm, utilizing a segment of the radius. The subject was first seen in our clinic on August 16, 1964, at which time it was noted that his arm had about 30 degrees of flexion, 20 degrees of extension, and about 30 degrees of abduction. He was fitted with a standard above-elbow prosthesis with elbow lift, a modified figure-of-eight harness, and a 5X terminal device. When last seen in the clinic, he was using the prosthesis satisfactorily.
In 1963 this 50-year-old white female was involved in an automobile accident and sustained fractures of the right hand and arm. These injuries led to an eventual right above-elbow amputation.
Examination in our clinic showed a complete range of motion in the right shoulder, as well as excessive soft tissue distal to the end of the bone. We first considered revising the stump by removing the soft tissue, but felt that with her short humerus, some advantage would be gained by utilizing the soft tissue with a bone graft to provide additional stump length.
On September 27, 1965, a segment of the proximal fibula was inserted into the medullary canal of the humerus to obtain an additional three inches of bony length, thus utilizing the excess soft tissue with the bone graft to effectively lengthen the stump. Her convalescence from this surgery was uncomplicated. On January 1, 1966, a standard above-elbow prosthesis was ordered and she is beginning to use this device satisfactorily (Fig. 2A , Fig. 2B , Fig. 2C ).
We have previously submitted articles from this clinic describing surgical procedures to maintain or increase the effective length of amputation stumps.1 In the present article, the procedures described were applied to adult amputees. However, in one case, our goal was achieved by a shoulder fusion of the type originally devised for situations in which the epiphyses were still open. Dr. Rountree felt that the method involving a bone graft across the center of an epiphysis does not interfere with its growth.
The use of bone graft to add bone length to a stump already containing soft tissue opens up the possibility of planning this type of procedure at the time of the original trauma. If the amount of bone destruction sustained in the original trauma creates a large soft-tissue flap, this soft-tissue pedicle could be saved and a bone graft inserted later. This would probably only be effective in the upper extremity where weight bearing is not a factor. Children would be better candidates than adults for this type of lengthening procedure.
This 16-year-old white male has worn a prosthesis for a right congenital below-knee deficiency since he was three years of age. He was first seen in our Amputee Clinic in 1959, at which time his prosthesis was a standard wood socket with a thigh corset and hip band.
In 1960 he was placed in a patellar- tendon-bearing prosthesis and wore this type of appliance until January, 1966. On June 26, 1963, a spur had developed on the tibia, with skin breakdown and infection, probably as a result of irritation occurring in the early years of life. This spur was removed surgically, and the postoperative course was uncomplicated.
On December 20, 1964, the boy was seen in the emergency room for treatment of an acute dislocation of the patella, which was reduced with no repair to the retinaculum. Following this procedure, the knee was immobilized for three weeks before ambulation was resumed. On January 27, 1966, he slipped on the ice and again dislocated the patella. The patella was easily reduced, and he was kept off weight bearing for two weeks before being returned to his prosthesis. At that time we modified his patellar-tendon-bearing prosthesis by adding a thigh lacer and knee joint. We will consider a Hauser-type procedure to move the patellar tendon insertion medially if the dislocation recurs (Fig. 3A Fig. 3B Fig. 3C ).
This 10-year-old colored male was first seen in 1957 with a right below-knee amputation of traumatic etiology sustained when he was about one year of age. The child wore a below-knee prosthesis with a thigh lacer and shoulder strap until 1961, when he was fitted with a patellar-tendon-bearing prosthesis. In September, 1963, we noted that he was developing genu valgum and overgrowth of the tibia.
He was admitted for resection of the fibula and removal of the tibial spur. At that time the right distal femoral epiphysis was stapled medially to correct the genu valgum. On October 2, 1964, the staples were replaced. At the present time the genu valgum is correcting nicely. Case 4 is the only below-knee juvenile amputee we have had who has required surgical correction of a genu valgum deformity. We plan to place him in a prosthesis with knee hinges and a thigh lacer to prevent any possible recurrence of the valgus strain.
Discussion Cases 3 and 4 illustrate problems of knee instability and osseous changes that have developed in juvenile amputees who have been wearing patellar-tendon-bearing prostheses without knee hinges or thigh lacers. We have fitted this type of prosthesis to a total of 12 patients with open epiphyses and these are the only two cases in our experience that have developed difficulties. It would certainly be unscientific and unfair to blame these on the patellar- tendon-bearing prosthesis, since the condition encountered occurs in otherwise normal children. However, once the complications do appear, it would seem wise to add knee hinges and a thigh lacer to provide the additional support which is apparently needed.
Lambert, Claude N., M.D. "Applicability of the Patellar Tendon Bearing Prosthesis to Skeletally Immature Amputees," Inter-Clinic Information Bulletin, Vol. III, No. 7, May, 1964.
Rountree, C.R., M.D., and Rockwood, C.A., Jr., M.D. "Arthrodesis of the Shoulder in Children Following Infantile Paralysis," S. Medical Journal, 52:861, 1959.
Gael R. Frank, M.D. is Assistant Professor at the Department of Orthopaedic Surgery and Chief at Amputee Clinics University of Oklahoma Medical Center Oklahoma City, Oklahoma
1 "Lower Limb Skin Coverage Problems and Prosthetic Adaptations," Inter-Clinic Information Bulletin, March, 1965.