Immediate Postsurgical Prosthetic Fitting Of Children And Adolescents Following Lower-Extremity Amputations
Ernest M. Burgess, M.D. Robert L. Romano, M.D.
The concept of fitting patients with prostheses immediately after surgery and initiating ambulation within a day or two seems to have originated with Berlemont(1,2) in the late 1950s. Berlemont's procedure was modified by Weiss(3), who called it to the attention of Americans in a lecture given at the Sixth International Prosthetics Course in Copenhagen, in July 1963. A visit by Weiss to the United States later that year stimulated interest at the University of California Medical School, San Francisco, and at the U.S. Naval Hospital, Oakland, California. Promising results obtained at these institutions prompted the Veterans Administration's Prosthetic and Sensory Aids Service to support an experimental program proposed by the Prosthetics Research Study in Seattle. Other groups, notably Duke University, the University of Oregon, the University of Miami, Marquette University, and a group in New York City centered around the Hospital for Joint Diseases, became interested and embarked on modest experimental programs.
To effect a basis for interchange of information between these groups, the Committee on Prosthetics Research and Development of the National Academy of Sciences sponsored a series of meetings and created an ad hoc committee to coordinate current and future research in this area.
Because no written material or visual aids on the subject existed, each group approached the problem somewhat differently. In November 1964, the Seattle Prosthetics Research Study team was able to visit Dr. Weiss in Poland and observe his then current technique. The team then returned to
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The results obtained at Seattle and at other centers bear out the claims made for immediate postsurgical fitting by the originators -namely, accelerated wound healing and stump maturation, a decrease in postoperative pain, more rapid physical rehabilitation, and improved psychological response to limb loss.
Seattle Program Begins
Our immediate postsurgical prosthetic fitting program in Seattle began when, on May 26, 1964, at the Children's Orthopedic Hospital, a five-year-old girl with bilateral tibial hemimelia (Fig. 1 ), underwent a right knee disarticulation amputation (Fig. 2 ). The wound was closed in layers without drainage, and a rigid quadrilateral-type total-contact socket, fabricated from elastic plaster of Paris bandage and suspended by a pelvic band, was applied.
The day following surgery the patient was allowed to stand with moderate weight-bearing on the temporary limb. Two days postoperative she walked several yards, using crutches and bearing moderate weight on the operated side. Weight-bearing was progressively increased each day. By the tenth postoperative day she was able to walk unsupported, with a brace on the unoperated side and the temporary limb, unaltered since its initial application, on the other.
When the prosthesis was removed for the first time ten days postoperatively, it was found that healing of the operative site had progressed uneventfully. The sutures were removed, a new temporary prosthesis was applied, and the patient resumed full ambulation. Daily walking continued uninterruptedly until the definitive limb was fitted on the 26th postoperative day (Fig. 3 ). The total period of hospitalization following surgery was 28 days.
Our choice of a child to initiate the program was prompted by the high healing potential of children and their typically uneventful postoperative course when conventional techniques are used. We reasoned that these characteristics would provide optimum conditions for success in the experimental immediate postsurgical fitting procedures.
24 Children Treated
By May 26, 1967, three years later to the day from the start of the program, 151 primary lower-extremity amputations, followed by immediate postoperative prosthesis fitting, had been performed in the Prosthetics Research Study. Included among these 151 consecutive cases were 24 patients under the age of 21 years.
Of these 24 children, 11 were female and 13 were male. One was a bilateral amputee; thus a total of 25 amputations were performed. The Table 1 indicates the distribution of cases by age and etiology.
Sufficient clinical experience in immediate postsurgical fitting procedures has now been achieved to enable us to evaluate this plan of management. The present report deals with its specific applications to individuals undergoing amputation during the growth period. As the method has been refined technically, with material and equipment standardized, we consider it the unquestioned method of choice for the growing individual.
Children From One to Five Years of Age
The majority of amputations in the preschool child are for the correction of congenital deformities, burns, tumor, or trauma. As has been pointed out by Aitken in his concise writings on amputation levels in children, epiphyses should be preserved and maximum length retained. In effect, then, most amputations are preferably through or immediately adjacent to joints. In general, these children heal rapidly with conventional management, definitive limbs can be fitted promptly, and gait patterns can be developed naturally if adequate prostheses are provided.
Immediate postsurgical prosthetic fitting is less critical for these young children than for older patients. Its specific values for juveniles lie in the immediate postsurgical degree of comfort it offers; the ease and convenience of management, since no dressings are required prior to removal of the initial cast; and the small amount of postoperative nursing care necessary. In our experience these children feel very little pain and ambulate promptly, often without support. Under normal circumstances one can anticipate rapid healing, prompt maturation of the stump, and early definitive limb fit.
An interesting observation made both by ourselves and others is the occasional unawareness of limb loss on the child's part until the cast and dressings are removed and he can actually see that part of the extremity has been amputated. Hence, fairly heavy sedation, basal anesthesia, or, in unusual circumstances, a light anesthetic may be advisable at the time of the initial cast change, ten to 14 days after surgery.
Children From Six to 14 Years of Age
As with younger children, the preadolescent child amputee has responded remarkably well to immediate postsurgical prosthetic fitting. Postoperative pain and apprehension are slight, activity levels are resumed promptly with the temporary limb, stump healing and maturation proceed uneventfully, and time loss from school and home is minimal. Cast changes are accomplished with analgesics only, and usually on an outpatient basis. The child, and even more specifically the family, seem to benefit psychologically from the early resumption of ambulation and recovery of activities. We have encountered no real problems in gait following conversion from the temporary to the definitive limb.
Children From 14 to 21 Years of Age
Immediate postsurgical prosthetic fitting has its greatest application to the adolescent amputee. Limb loss in this age group generally results from trauma or neoplasm. The catastrophic effect of such loss on both the patient and his family is softened by the relative comfort and immediate postsurgical mobility provided by the technique.
In the case of malignant neoplasm, no lingering doubt remains in the youth's mind as to whether or not he is going to be fitted with a limb or will have to wait "to see how things come out." His limb is fitted upon completion of surgery, and his rehabilitation begins at once.
The difficult, questioning days following amputation for osteogenic sarcoma are made easier for all when the patient is up and about walking, wearing a limb, and planning for the future. Some of the teenagers in this program have been back participating in sports a few weeks after an above-knee amputation for malignancy. Even though life expectancy may be but a question of months, these postamputation days are easier with an artificial limb and the attendant rapid progression to tolerated activity levels.
As with other reconstructive surgery in children, an amputation must anticipate growth and adult life. Expected growth must be calculated as accurately as, for example, in surgery for unequal leg length. A strong, stable stump must be achieved if normal activity levels are to be approached, In our experience, muscle stabilization (myoplasty and/or myodesis) is particularly effective in retaining dynamic muscle function. Proprioception seems to be enhanced when stump muscles are active under physiological tension. Scientific documentation of this clinical observation is not yet fully established. Nevertheless, clinical evaluation substantiates, particularly in the growing individual, the proprioceptive value of stump muscle activity.
Tibiofibular stabilization in the below-knee amputee is also of particular value in the young person. While tibiofibular synostosis is not applicable to all children requiring below-knee amputations, its use under appropriate circumstances will increase the stability, strength, and weight tolerance of the stump. In our series tibiofibular synostosis has been performed in three cases where amputation was carried out through the diaphyses of the long bones. We have not yet precisely defined the preferred surgical technique, but at this time suggest side transfer of the distal fibula into the distal tibia rather than bone graft bridge or periosteal sleeve.
There were no operative deaths in our series. However, of two children with osteogenic sarcoma, one died six months postsurgery and the other nine months postsurgery.
Secondary procedures or revisions were necessary in two cases, one 18 days postoperatively due to inadequate blood supply at the level of amputation. The second patient was amputated at a higher level 17 months following the initial surgery, which had been of an emergency nature with revision planned later for more desirable limb fit.
Representative Case Histories
From the series of more than 20 children fitted with prostheses immediately following surgery in the Seattle study, six cases are briefly described. These cases exemplify some of the etiologies and the age and amputation levels involved.
The right side amputation of Case 1 (bilateral anomalies) was described earlier. Throughout the 11 months following fitting of the permanent prosthesis, the patient did extremely well on the prosthetic side. However, the left leg became progressively worse, and in the last month the patient's activities became severely restricted by the continuing displacement of the lower leg.
On April 27, 1965, the patient underwent a knee disarticulation of the left leg. Because the quadriceps was functional, the patellar tendon was sutured to the cruciate ligaments under some tension with the patella intact.
The patient's postoperative course was uneventful, with full weight-bearing by the fourth postoperative day, suture removal on the 14th postoperative day, and fitting and delivery of the permanent, plastic, end-bearing prosthesis on the 22nd postoperative day (Fig. 4 ).
Gait training in bilateral end-bearing prostheses with free knee joints progressed smoothly, and the patient was discharged from the training program on the 31st postoperative day, walking quite well without external aid.
Congenital Absence of Tibia
Case 14 was a two-year-old white male who underwent a right knee disarticulation on September 2, 1964, for congenital absence of the tibia. Especially in the young, one must consider the fabrication of an end organ, both motor and sensory, for the reception of a functional terminal device. Advances in prosthetic design, fabrication, and materials have enhanced amputee rehabilitation in a spectacular manner. The surgeon can do no less than maintain and preserve to the maximum the dynamic components in the amputation stump, particularly those concerned with muscle activity and proprioception. In this way, the prosthetist is presented with a full opportunity to incorporate into the limb substitute all biomechanical improvements now available or possibly available in the future.
The team then returned to the United States to develop procedures that, hopefully, combined the best features of those that had evolved more or less independently on both sides of the Atlantic.*
The procedures developed and used by the Prosthetics Research Study group in Seattle have recently been described in the handbook, "Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees," by Ernest M. Burgess, M.D., Joseph E. Traub, C.P.O., and A. Bennett Wilson, Jr., U.S. Government Printing Office, 1967.
Ernest M. Burgess, M.D. and Robert L. Romano, M.D. are associated with the Children's Orthopedic Hospital Seattle, Washington
1. Berlemont, M., "Notre Expérience de l'Appareillage Précoce des Amputés des Membres Inférieurs aux Etablissements Hélio-Marins de Berck," An-nales de Médicine Physique, IV, 4, Oct.-Nov.-Dec. 1961.
2. Berlemont, M., "L'Appareillage des Amputés des Membres Inférieurs sur la Table d'Opérations," paper given at the International Congress of Physical Medicine, Paris, 1964.
3. Weiss, Marian, "The Prosthesis on the Operating Table From the Neurophysiological Point of View," Report of Workshop Panel on Lower Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, Feb. 1966.