Immediate Postsurgical Fitting Of Prostheses For Bilateral Amputations
Robert R. Clark, M.D. Walter A. Hoyt, Jr., M.D. Larry Fitzsimmons, M.D.
Brian C, an eight-year-old child, was in good health until January 3, 1969, when he suffered a sudden onset of nausea, vomiting, diarrhea, lethargy, and purplish spots on the back of his legs. On admission to Trumbull Memorial Hospital in Warren, Ohio, his temperature was recorded as 105 degrees. A lumbar puncture was performed but the smear revealed no identifiable organisms. Initially the administration of Levophed was required to maintain his blood pressure. He was empirically started on Chloromycetin and later switched to ampicillin and Gantrisin in large doses. The tentative diagnosis made at that time was viremia or meningococcemia.
Massive Generalized Purpura
Six days later the child was transferred to the medical service at Akron Children's Hospital. By that time his temperature had decreased to 100 degrees, but he had massive generalized purpura with multiple occurrences of gangrenous skin and denuded areas, especially on the legs, the sacral area, and all digits. Laboratory findings showed a hemoglobin of 13.2, a white blood cell count of 34,200, and a platelet count of 310,000. On two occasions blood cultures failed to grow out any organisms.
Treatment was begun immediately and consisted of Chloromycetin, prednisone, and silver nitrate soaks applied continuously to all affected sloughing areas. From the start physical therapy treatments were administered to the extremities to enhance the range of motion of the affected joints. Surgical debridement of the slough areas and the application of split-thickness grafts were carried out by the surgical service on five separate occasions, with attention directed primarily toward the lower extremities (Fig. 1 ). As the disease progressed, dry gangrenous areas demarcated. These areas included the tips of seven fingers and both feet (Fig. 2 and 3 ). The child's systemic condition improved and corticosteroids were withdrawn gradually as his clinical picture showed progressive improvement. On request the Juvenile Amputee Clinic team provided orthopedic consultation concerning the appropriate site and time of amputation of the gangrenous limbs.
Decision to Amputate
By March 21, 1969, the demarcation of the necrotic (dry gangrene) areas had progressed to a point that a decision on amputation could be made. The grafting procedures of the general surgeons had provided skin coverage of the lower extremities far enough distally to allow below-knee amputations at a level approximately five inches below the knee joint line bilaterally. At this time the medical service felt that the patient was in excellent general condition to allow the use of a general anesthetic and amputation was therefore carried out.
The decision to do immediate postoperative fitting of prostheses was prompted by the strong psychological implications in this case, despite the severe physical deficiencies. Specifically, the presence of very recently healed split-thickness graft skin over the stump sites along with obvious continuance of edema in these areas would seem to preclude this type of approach. However, the psychiatric consultant felt strongly that this child needed more than the routine replacement of his "missing feet." Because our experience with the immediate post-amputation fitting of prostheses on about 40 cases had been quite encouraging, it was elected to attempt this approach in order to minimize the child's adverse psychological reaction to his amputations.
Surgery and Temporary Prostheses
At surgery, the distal phalanges of seven upper-extremity digits, which were totally gangrenous, were removed and the stumps closed per primum. No difficulty was encountered in this procedure. Following re-draping and a second surgical preparation, bilateral below-knee amputations were carried out to provide stumps of approximately five inches below the knee joint which was the maximum length feasible with the existing tissue (Fig. 4 and 5 ). Even at this level, about 20 percent of the muscle tissue encountered was found to be necrotic and had to be debrided. The split-thickness skin flaps were quite edematous, being about three-eighths of an inch thick. A myodesis of the viable muscle tissue was performed following the procedures described by Burgess et al1; and a primary closure of the edematous skin flaps was made.
Immediate temporary prostheses were applied using Orthoflex® elastic plaster bandage. Quick release attachments were incorporated into the plaster for application of metal shafts and SACH feet (Fig. 6 Fig. 7 and 8 ). No technical difficulties were encountered.
Following surgery the patient experienced a minimum of postoperative pain. He was allowed to stand on his temporary prosthetic legs the day after surgery and did so without undue discomfort.
With intensive physical therapy provided by the Amputee Clinic Team, the progress of the patient was most remarkable. On the second postoperative day, he was able to walk a few steps with aid. Within five days, he was ambulating with crutches a distance of about 400 feet without discomfort (Fig. 9 ). Essentially, no psychological repercussions from the amputations were encountered.
On the 12th postoperative day, the patient was given a general anesthetic and the temporary cast pylons were removed. Both stumps were found to have healed completely per primum (Fig. 10 and 11 ). No drainage was evident. No inflammatory tissue was found. The edema present at the time of surgery had reduced essentially to normal. The stitches were removed and a second set of temporary cast sockets was applied. The patient was sent home from the hospital.
Permanent Prostheses Fitted
Two weeks later the patient was readmitted to the hospital for a second change of his temporary plaster sockets. At this change, molds were made for the construction of the permanent prostheses. These limbs were completed in two weeks and since that time the patient has ambulated with them and has not experienced any difficulty. During the time of fabrication, the patient had been ambulatory on his temporary prostheses. No adverse psychological reactions to the amputations have been noted. The child has been extremely happy following his surgery and looks upon his amputations as a blessing. For the three months prior to amputation, he had been entirely bedridden. This procedure enabled him to walk again.
The case presented illustrates a dramatic situation for the use of immediate postoperative prosthetic fitting and typifies the usual response in our experience with this procedure. A more extensive report analyzing our series of about 40 cases will be presented in the near future with an in-depth analysis.
An amputation wound exposed to the immediate fitting modality apparently has greater propensity for healing than one treated by the classical approach. The procedure certainly controls edema more adequately. It provides a psychological boost that is most desirable. And it reduces the period of disability from lower-extremity amputation quite remarkably. It is most interesting to note the lack of severe discomfort experienced by these patients. For these reasons, we are becoming more and more convinced that this technique represents an advancement in surgical-prosthetics management that should be widely adopted.
The case reported underscores these advantages quite strikingly. Split-thickness skin, obviously edematous, with underlying necrotic muscle, can hardly be adjudged an ideal situation for bilateral below-knee immediate postsurgical fittings. The success of the immediate postsurgical fitting technique in this instance dramatically points out the advantages of its use.
®Johnson & Johnson.
Robert R. Clark, M.D., Walter A. Hoyt, Jr., M.D. and Larry Fitzsimmons, M.D. are associated with the Juvenile Amputee Clinic Children's Hospital Akron, Ohio
1. Burgess, E.M.; Traub, J.E.; and Wilson, A.B.: "Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees," Prosthetic and Sensory Aids Service, U.S. Veterans Administration, Washington, D.C., 1967.