Bilateral Absence Of The Lower Extremities: Prosthetic Restoration
Eric Viel, C.P.T., R.P.T.
In recent years we have been greatly impressed with the free flow of prosthetic information within countries and across international borders. This interchange has manifestly contributed to the improved treatment of amputees throughout the world. Our report concerns one severely handicapped patient whose status was significantly enhanced by the application of modern limb-fitting concepts.
This young boy was seven and one-half years of age at the time of first contact, one year ago. He suffered from congenital deficiencies of the lower extremities (Fig. 1 ), the conditions being recorded 1 as follows :
On the right he had meromelia, terminal transverse femoral M, similar to an above-knee amputation, middle one-third. The length of the stump (from pubis to end) was 5.6 inches (14 cm), and the stump condition was good. No hip flexion contracture was present. The stump was fleshy and fairly well muscled, with no tenderness and with normal sensation.
On the left he had amelia, similar to a hip disarticulation amputation. Stump condition was good, and the stump was fleshy and pain-free.
In addition, he had poor vision, corrected by prescription eyeglasses.
The patient came to us with carefully made prostheses (Fig. 2 and 3 ). However, the design left much to be desired. The body jacket and legs were connected by means of mechanical hip joints. These components permitted no lateral motion of the pelvis and were kept locked when the child stood. The knee joints were of the French (or Bale) type, locked when the child was upright. The feet were of wood, with ankle joints and soft bumpers. The ambulation pattern was that of a swing-through of the "paraplegic" type.
However, the prostheses failed to take advantage of the functioning hip joint on the right side. The artificial limbs were built like a brace for a paraplegic patient, with feet added. Energy output was considerable, even for ambulation over very short distances.
In view of the child's muscle potential and intelligence, and the realistic attitude of his parents, it was decided to consider a more sophisticated type of prosthetic fitting. The goal was to restore a near-normal ambulation pattern and to use the remaining right hip joint. A pair of artificial limbs was fitted, incorporating the following features (Fig. 4 ):
The right prosthesis included a quadrilateral plastic suction socket, total contact, ischial weight-bearing; a constant friction knee with optional locking device; and wood feet with soft bumpers.
The artificial limb was built for a pubis-to-ground length of 24 inches (60 cm). Since the stump is 5.6 inches, the length ratio is 4.3 to 1, which is considered very favorable at the present time.
The ratio of stump-to-artificial-limb length (one-quarter of the total length today), is likely to change for the worse. Burgess2 leads us to believe that retention of the proximal epiphysis, associated with an excellent blood supply and the tone of the stump, should insure its continued growth, although not as much, of course, as if both epiphyses were present.
On the other hand, according to Hall3 there is a risk of bone overgrowth, with resultant surgical interventions and reduction in overall stump length. The need to increase the length of the prostheses to keep the boy's height comparable with his contemporaries will also affect the prosthesis-to-stump ratio adversely.
On the left, a Canadian hip disarticulation prosthesis was fitted according to standard techniques4. An anterior kick-strap was added to strengthen passive extension for a bilateral amputee. The knee was a constant friction type, and the foot was wood, with a soft bumper.
The child can make use of all the mechanical joints provided and walks with a four-point gait. Two elbow crutches add to his stability. Balance is good, even without canes ([popup4] ). The right knee can be locked when the child wants more security.
The child is light, weighing about 33 pounds (60 kg). The original limbs weighed 4,450 grams, compared with 3,300 grams for the new ones. The weight saving is meaningful in terms of percentage of total body weight, since a child so small cannot possibly acquire much strength. However, it was the lack of joint motion (including lateral motion of the pelvis), rather than the weight, which made it so hard for the child to ambulate with the old limbs.
The change affected by the application of modern prosthetic principles has been very beneficial to this patient in terms of improved gait and increased independence.
Grateful acknowledgement is made to Andre Thiery, C.P.O., whose advice and skill were invaluable.
Eric Viel, C.P.T., R.P.T. is the Associate Director of Graduate Studies Ecole de Cadres de Kinesitherapie Paris, France
1. "Nomenclature for Congenital Skeletal Limb Deficiencies, a Revision of the Frantz and O'Rahilly Classification," Artificial Limbs, 10:24-35, Spring 1966.
2. Burgess, E.M., "Sites of Amputation Elections According to Modern Practice," Clin. Orthop., 37:17-21, 1964.
3. Hall, C.B., "Recent Concepts in Treatment of the Limb-Deficient Child," Artificial Limbs, 10:36-51, Spring 1966.
4. Foort, J., "Construction and Fitting of the Canadian-Type Hip Disarticulation Prosthesis," Artificial Limbs, 4:22-28, Autumn 1967.