Initial Fitting of Bilateral Lower-Extremity Prostheses in the Teen-Ager
William H. Georgi, M.D. Bernie P. Davis, M.D. Robert Warner, M.D. Daniel F. Alessi, M.S.
Rehabilitation of a child with bilateral lower-extremity amputations is always a challenge. The problems are compounded when a chronic lower-extremity disability is present throughout childhood but amputations and prosthetic applications are not carried out until the middle teens.
In the past few years the Buffalo clinic team has treated two girls with histories of this type. Their problems of physical restoration and social, educational, and vocational rehabilitation are strikingly similar.
Case No. 1
R.C. was 15-1/2 years old when first seen in our clinic in 1966. She had multiple congenital abnormalities of the lower extremities, including deformed feet, absent tibiae bilaterally, and an extra femur protruding from the right hip. Over the course of the years the extra femur was removed surgically and she had been subjected to multiple orthopedic corrective procedures (about 12). She finally came to our attention after she had had bilateral knee fusions and Syme's-type amputations distally (Fig. 1 ).
At the initial evaluation our clinic group felt that with the limbs as presented this girl could not be successfully fitted with prostheses, primarily because of the potential instability arising from the fusion of the small fibula to the femur; and also because she would have no knee motion. Bilateral supracondylar amputations were done in April 1967 (Fig. 2 ), and she was provided with quadrilateral, suction-socket, above-knee prostheses bilaterally in September of that year. By November 1967 she was able to ambulate independently
with crutches. The patient was quite obese but, supported by intensive counseling, she did lose some weight through dieting and medication. This weight reduction plus her strenuous ambulation activities caused enough stump shrinkage to necessitate replacement of her sockets in January 1969. At present she is ambulating independently with Canadian crutches (Fig. 3 ).
Case No. 2
K.G. was referred to the clinic in 1967 when she was 17 years of age. Born with a meningocele which was repaired in infancy, she had deformities of both feet which were described as clubfeet with complete anesthesia. She also had been subjected to multiple orthopedic procedures 12 prior to bilateral below-knee amputations in March 1967 (Fig. 4 ). Because of urinary incontinence, an ileal-loop urinary-diversion procedure had been carried out at 11 years of age. She weighed 178 pounds.
Muscle testing revealed moderate trunk weakness, marked weakness of the hip extensors and abductors, normal knee extensors, and fair knee flexors. She had loss of sensation over the buttocks and posterior thighs, but adequate sensation in the stumps. Bilateral patellar- tendon- bear ing plastic prostheses were provided in May 1968. After some 60 hours of training she was able to ambulate independently with crutches. Shoulder harnesses had to be substituted for a waist-belt suspension because the belt interfered with her ileal conduit opening (Fig. 5 ). Despite the fact that her stumps were nine inches long, she showed lateral knee instability, and recently knee joints and thigh lacers had to be added to the PTB prostheses.
Both girls had and still have the problem of obesity. Under the stimulus of their desire to walk, both have lost moderate amounts of weight. But even with constant supportive counseling, excess weight continues to be a problem. Associated with obesity, at least in part, has been the problem of personal hygiene, especially of the thighs and stumps; and a strenuous indoctrination program has been necessary to prevent skin infections.
These girls also have similar educational backgrounds. They both have low intelligence quotients, and are incapable of scoring much higher than sixth-grade level in school achievement tests. This retardation can be related to the numerous hospitalizations which necessitated home study programs with only short periods of regular classroom instruction. The "home study" programs leave much to be desired. Children separated from peers tend to have low psychological and achievement scores, to be immature with respect to peer relationships, and to have unrealistic vocational goals.
As a result they present a problem in vocational placement because of their limited education and social immaturity. Long periods of hospitalizations often make these youngsters think of future vocations in some type of hospital work - as doctors, nurses, etc. Their goals are often quite unrealistic. However, this lack of reality may be typical of many teen-agers and it follows that they would select jobs in areas with which they were most familiar.
Vocational training factors for these girls have been their limited education and limited mobility. This approach only emphasizes negative factors and we have, of course, also evaluated their positive personality traits. R.C., for instance, has a cheerful, bubbly personality, an ability to relate to adults, a pleasant voice, and is people-oriented; that is, she apparently feels a need to help people. This girl has been placed as a switchboard operator which offers her a chance to assist people and calls upon the types of strength that she possesses. The other girl is waiting to be evaluated at a local vocational rehabilitation center.
Vocational goals are only one of the many problems for which these girls need counseling. A young lady who has not been able to mix with her own age group or have dates will have fantasies when it comes to sex and marriage.
Certainly all girls go through this process - but with someone who is deprived of "normal sexual learning experiences" these fantasies may continue for a longer period of time. This problem, too, will have to be handled in counseling, but timing is important. If the counselor breaks too many bubbles too fast, the results can be disastrous. In these situations vocational goals have first priority and must be dealt with at once and realistically. Finally, the counselor must decide how realistic it will be to plan on the patients returning to school or seeking "high school equivalency." Age, ability, and motivation have to be carefully considered.
The problems involved in the rehabilitation of two teen-age children who had recent bilateral leg amputations for lower-extremity disabilities present since birth, have been diseussed. It should be emphasized that these patients need more than the usual amount of attention from all members of the amputee clinic team. It must be anticipated that in order to maintain these girls as useful members of society intensive long-term counseling as well as meticulous and frequent reviews of their prosthetic management will be necessary.
William H. Georgi, M.D., Bernie P. Davis, M.D., Robert Warner, M.D., and Daniel F. Alessi, M.S. are associated with the Children's Rehabilitation Center Buffalo, New York