Child Amputee Clinic Chiefs Hold Conference

A Conference of Child Amputee Clinic Chiefs was held, under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development, at the National Academy of Sciences, Washington, D.C., on June 13 and 14, 1968. Some 82 persons attended the conference. Dr. George T. Aitken, Chairman of the Subcommittee on Child Prosthetics Problems, presided.

A major feature of the conference was a Symposium on Proximal Femoral Focal Deficiency, at which presentations were made by Dr. Aitken, Medical Co-Director of the Area Child Amputee Center; Dr. Harlan C, Amstutz, Hospital for Special Surgery, New York, N.Y.; Dr. John E. Hall, Ontario Crippled Children's Centre, Toronto, Ont.; Dr. Richard E. King, Georgia Juvenile Amputee Clinic, Atlanta, Ga.; and Dr. G. Wilbur Westin, Los Angeles, Calif. All of the presentations were extensively illustrated with projection slides and motion pictures. The papers presented will be published as a National Academy of Sciences monograph.

In opening his presentation, Dr. Aitken said that the nomenclature for congenital deficiencies proposed by Dr. Charles H. Frantz and Dr. Ronan O'Rahilly does not provide a specific descriptive term for the not uncommon anomaly referred to as "proximal femoral focal deficiency." Thirty-five patients with this anomaly had been treated at the Child Amputee Clinic in Grand Rapids, Mich. Dr. Aitken showed pictures and roentgenograms illustrating proximal femoral focal deficiencies which he divided into four categories. He pointed out that, since there usually were numerous associated skeletal deficiencies, the patients were frequently very severely handicapped. Dr. Aitken described types of prosthetic fittings that had been employed in the care of the patients both with and without surgery.

Dr. Amstutz presented a classification of proximal femoral focal deficiencies which differed slightly from Dr. Aitken's. Dr. Amstutz said that his classification was based upon analyses of the records of 60 patients. He said that certain morphological criteria were used in the classification to provide the basis for a more accurate prediction of later developments, particularly the prediction of inequality of leg length.

Dr. Hall confined his presentation to descriptions of surgical conversions (including the Van Ness procedure) and types of prostheses that had been provided to a number of patients with proximal femoral focal deficiencies at the Ontario Crippled Children's Centre. It was essential, he said, to make a radical differentiation between unilateral and bilateral cases. He also felt that early surgical procedures (including rotation osteotomies) and early prosthetic fittings were desirable so that the patients could become accustomed to use of their prostheses.

Dr. King said that the proximal femoral focal deficiency could be definitely recognized as an entity. He then reviewed its embryology and histology, identifying four types of the deficiency. In unilateral cases, he advocated early surgical conversion to obtain a prosthetic knee joint at the same level as the natural knee joint. Ideally, such surgical conversion would create a single skeletal lever to activate the prosthesis. Reasonable comfort, function, and cosmesis had been achieved for a number of patients through such surgical procedures.

Dr. Westin's presentation was based upon a review of the records of 165 cases treated at 17 Shriners hospitals. He said that the collective experience assembled for the review favored early surgical conversion. The review also showed that in general the rotation osteotomies performed had not been successful.

Dr. Charles H. Epps, Jr., Chief of the Juvenile Amputee Clinic at the District of Columbia General Hospital, then presented six patients undergoing treatment at the D.C. clinic who had proximal femoral focal deficiencies of various types. Roentgenograms were presented for each patient, and each was extensively discussed.

Current Activities

Brief reports were then made on the status of various activities being carried on under the sponsorship of the Subcommittee on Child Prosthetics Problems of CPRD.

Mr. Hector Kay, Assistant Executive Director of the Committee on Prosthetics Research and Development reported that 26 specialized Child Amputee Clinics are now participating in the cooperative research program sponsored by the Subcommittee on Child Prosthetics Problems. A list of these clinics had been distributed with a request that the information pertaining to them be updated by each respective clinic. Mr. Kay also stated that some 12 to 14 additional clinics had indicated an interest in joining the cooperative program. It was anticipated that five or six of these clinics would meet the criteria established by the Subcommittee and affiliate with the program within the next year.

In reporting on the Inter-Clinic Information Bulletin, Mr. Kay stated that this journal is now nearing the end of its seventh year of publication. A regular monthly schedule was being maintained, each issue being of 20-22 pages. For the current (June 1968) issue, 2000 copies had been printed and distributed. Mr. Kay expressed appreciation at the excellent cooperation being given by the clinic chiefs in providing articles for the ICIB- over the past eleven months 18 of 22 scheduled contributors had submitted materials. Mr. Kay emphasized that the current schedule of contributions terminated in September 1968 and that the establishment of a new schedule was necessary for continuance of the Bulletin. By a show of hands the clinic chiefs indicated willingness to accept a further schedule of contributions to the ICIB.

Dr. Sidney Fishman, Coordinator of Prosthetics and Orthotics at New York University, described an ongoing census 1 of the child amputee population being conducted by NYU. Data for the census are obtained from the 26 cooperating clinics affiliated with the cooperative child prosthetics program and from 14 clinics not presently affiliated. In the total census of approximately 4,000 children, 57 percent were males and 43 percent were females. With regard to the various etiologies and levels of amputation, males always outnumbered females, the greatest difference being among unilateral lower-extremity amputees-61 percent males and 39 percent females. Congenital causes outnumbered acquired by a ratio of 2:1. In conclusion, Dr. Fishman said that the child amputee population appeared to be reasonably stable with respect to incidence and types.

At Dr. Fishman's request, Clyde M.E. Dolan, a staff scientist at NYU, reported on studies made of the Michigan feeder arm. Although subject to malfunctions, the arm had considerable merit. However, Dr. Fishman pointed out that the Ontario Crippled Children's Centre coordinated arm is now available and appeared to be superior to the Michigan item.

Dr. Fishman reported that a field study of the porous laminate below-knee prosthesis conducted by NYU showed that the prosthesis provided increased comfort, particularly during hot and humid weather, and a weight reduction of 32 percent. However, the additional labor required for its fabrication had been criticized by some of the clinics. Dr. Fishman suggested that perhaps the next step should be to study ways by which the clinics' objections might be overcome.

Dr. Fishman described a prosthesis evaluation scale developed at NYU, saying that a report on the scale is available and that the scale itself was also available for clinical use. The scale is a questionnaire, and the score achieved by a patient reflects the extent of his satisfaction with his prosthesis.

Dr. Fishman and Mr. Dolan described a study being made of the radiographic diagnosis of socket fit. Mr. Dolan discussed a study of transparent sockets now in progress and showed a film of a patient wearing a transparent socket. Dr. Fishman pointed out that although no relative movement between stump and socket was detectable at the brim, considerable piston action of the distal portion of the stump within the sockets was apparent. Dr. Fishman said NYU would soon publish a fabrication manual on transparent sockets.

Dr. Fishman and Dr. Yoshio Setoguchi of the the University of California at Los Angeles Child Amputee Prosthetics Project showed a number of items developed at UCLA which will be available in the fall for clinical use. Included were elbow units, shoulder joints, and terminal devices for children. In addition, several UCLA electric carts (described in the Autumn 1964 issue of Artificial Limbs) would be available.

Films

The last hour of the session on June 13th was devoted to films of special interest. Dr. Aitken showed a film on sacral agenesis which presented three patients with a complete absence of the lumbral spine and sacrum who had been treated at the Grand Rapids clinic. Mr. A. Bennett Wilson, Jr., Executive Director of the Committee on Prosthetics Research and Development, showed a Polish film dealing with training and fitting of a bilateral above-knee amputee, a boy with exceptional physical strength and coordination. Dr. John E. Hall showed a film dealing with a patient on whom a rotational osteotomy (Van Ness procedure) had been performed.

New Devices

The session on June 14th was devoted to a presentation of new prosthetic devices, consideration of the report of the Ad Hoc Committee on the Planning of Specialized Child Amputee Fitting Centers, and a short executive session of the Subcommittee on Child Prosthetics Problems.

Mr. Colin A. McLaurin, Chairman of the Subcommittee on Design and Development of the Committee on Prosthetics Research and Development, conducted the presentation of new devices. Included were stable (polycentric) knees that were light and cosmetic; and ankle units for the swivel walker.

Externally Powered Devices

Mr. McLaurin briefly reviewed the beginnings of externally powered prostheses in Heidelberg some 20 years ago, pointing out that, through the Otto Bock Company, a complete line of components for carbon dioxide powered devices is now available. He added that at present only prototype components are available for electrically powered devices. At Mr. McLaurin's request, Dr. Maurice Mongeau of the Rehabilitation Institute of Montreal discussed the use of pneumatically powered devices for bilateral upper-extremity amputees. Mr. Bert R. Titus of the Duke University Medical Center demonstrated a three-function AIPR pneumatically powered arm that had been fitted to a child, saying that perhaps the most valuable additional function given to the patient was the wrist rotator. The work of Northern Electric on an elec-trohydraulic mechanism was described. In concluding the presentation of new devices, Mr. McLaurin said that hardware means nothing in itself; the components must be clinically directed and placed on patients to be of value.

Special Fitting Centers

Dr. Aitken said that, although precise figures for the entire United States are not available, it appeared that 25 percent of the child amputee population falls into the severely handicapped category and would greatly benefit from care at specialized prosthetics centers, should such centers be established. For this reason, an Ad Hoc Committee on the Planning of Specialized Child Amputee Fitting Centers had been formed. At Dr. Aitken's request, Mr. McLaurin reported on the recommendations of the ad hoc committee, of which he was chairman.

Dr. Aitken said that the report of the ad hoc committee had been presented for discussion and consideration. He added that specialized prosthetics centers in Canada, Germany, and the United Kingdom caring for thalidomide victims have demonstrated that more sophisticated care can be given to severely handicapped children than is now being given in the United States. A motion was made, and carried unanimously, that the participants in the Conference of Child Amputee Clinic Chiefs accept the philosophy outlined in the report of the ad hoc committee.

References:
1. Munson, Nancy K., and Dolan, Clyde M.E., Patient Census at Child Amputee Clinics-1967, Prosthetics and Orthotics, New York University Post-Graduate Medical School, May 1968.