The Immediate Postsurgical Prosthetic Fitting Technique Applied to Child Amputees
Robert L. Romano, M.D. Ernest M. Burgess, M.D.
This study is supported by the Veterans Administration under Contract #V5261 P-438.
Between May 1964 and December 1969, 33 children underwent lower-extremity amputations and application of the Prosthetics Research Study technique of immediate postsurgical prosthetic fitting. The majority of these children were treated at the Children's Orthopaedic Hospital in Seattle, but some were seen at other hospitals in the area.
The details of the Prosthetics Research Study technique have been described in previous ICIB articles1,2 and in numerous other publications. In the recent past the technique, as applied to various levels of amputation, has been further modified and improved. These applications have been described in a recently published technical manual, "The Management of Lower-Extremity Amputations," by Burgess, Romano, and Zettl3 which is now available through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. Extensively illustrated, this manual presents step-by-step procedures for amputation surgery and immediate postsurgical prosthetic fitting. The method is not technically difficult but it does require care and precise attention to detail. Understanding and correct application of each stage of care is essential if the full potential of the technique for improved amputee rehabilitation is to be realized.
All children treated in the PRS program accepted the procedures well. Although revisions were required in six cases, 73.5 per cent of the children were fitted with definitive prostheses in less than 30 days from the date of surgery and 97 per cent were fitted in less than 60 days. Individual case histories with follow-up data are presented (Table 1 ). In the notations on follow-up status, the functional classification of Kohn and Gordon4 has been used. A statistical summary of the data is presented in Table 2 .
The 33 children included in the Seattle study of the immediate postsurgical fitting technique ranged in age from 2 1/2 to 18 years. The amputations performed were related to a wide range of causes including congenital, traumatic, and malignancy factors. Bilateral amputations (knee-disarticulation) were done on one child.
In those cases where stump revision was necessary, post-revision healing was rapid and uneventful. In all cases on whom follow-up data were available the outcomes were considered to be satisfactory, despite the fact that in children amputated for osteosarcoma, one died six months postoperatively and another at 13 months, while a third has recurrent metastases at 19 months postoperatively.
Postsurgical experience with these patients has led to the formulation of some definite opinions concerning the effectiveness of this form of management in the younger age groups. The research team considers the immediate postsurgical fitting technique to be the unquestioned method of choice for the growing individual. Conclusions concerning the various age groups which have been expressed in earlier reports1,3 have been reaffirmed as additional children have been treated.
Children from 1 to 5 years of age
The majority of amputations in the pre-school child occur as a result of congenital deformities, burns, tumor or trauma (Fig. 1 ). As stressed by Aitken,5 epiphyses should be preserved wherever possible and maximum length retained when amputating on children. In effect, amputations should preferably be performed through or immediately adjacent to joints. In general, children in this youngest age group heal rapidly with conventional management. Definitive limbs can be fitted promptly and natural gait patterns can be developed without intensive training if adequate prostheses are provided.
Immediate postsurgical prosthetic fitting is less critical for these young children than for older patients. Its specific values lie in:
the immediate postsurgical degree of comfort afforded
the ease and convenience of management since no dressings are required prior to removal of the initial cast
the small amount of postoperative 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 by both ourselves and others is the occasional lack of awareness of limb loss on the child's part until the cast and dressings are removed and he can actually see that part of one of his limbs is missing. To combat the distress arising from this discovery, fairly heavy sedation, basal anaesthesia, or in unusual circumstances, a light anaesthetic may be advisable at the time of initial cast change 10 to 14 days after surgery.
Children from 6 to 14 years of age
It has been our experience with these children that:
postoperative pain and apprehension are slight
activity levels are resumed promptly with a temporary limb
stump healing and maturation proceed uneventfully
time loss from school and home is minimal
Cast changes are accomplished with analgesics only and usually are done with the child on an out-patient basis. The patients, and even more noticeably the families, seem to derive psychological benefit from the early resumption of ambulation and preamputation activity levels. We have encountered no real gait problems when the patient is changed from the temporary to the definitive limb.
Children from 14 to 21 years of age
It is for this group of adolescent and postadolescent amputees that immediate postsurgical prosthetic fitting has perhaps its greatest value.
The loss of a limb in this age range is generally the result of trauma or malignancy and in the latter instance primarily affects the lower extremity. The shattering effect of such a loss on both the patient and his family is ameliorated by the relative postoperative comfort and immediate mobility provided by the technique (Fig. 4 ).
In the case of malignant neoplasm, there is no doubt in the youth's mind that he will walk again and not have to wait "to see how things come out." The fitting of his limb upon completion of surgery marks the immediate beginning of his rehabilitation.
The difficult, uncertain days following amputation for osteogenic sarcoma are made easier when the patient can wear a limb, be up and about, walk, and make plans for the future. Some of the teen-agers in the immediate postsurgical fitting program returned to participation in sports a few weeks after above-knee amputation for malignancy. Although postoperative life expectancy may be uncertain, the time, whether it be long or short, is enhanced by the early provision of an artificial limb and the resumption of normal activities to the limit of the youth's tolerance.
As with other reconstructive surgery in children, plans for amputation must anticipate growth and adult life particularly with respect to the ultimate length of the stump and the possibility of bony overgrowth if transection of the long bones is necessary. In our experience muscle stabilization in the young amputee (myoplasty or myodesis) is particularly effective in maintaining dynamic muscle function. Although not yet supported by scientific documentation, clinical evaluations suggest that proprioception is enhanced when stump muscles are active under physiological tension, particularly in the growing individual.
In the young person, tibio-fibular stabilization of the below-knee amputation stump is also of particular value. While this surgical procedure is not applicable to all children requiring below-knee amputations, its use under appropriate circumstances enhances the stability, strength, and weight tolerance of the stump. In the Seattle series, tibio-fibular synostosis was performed in three cases where amputation was carried out through the diaphyses of the long bones. The preferred surgical technique has not yet been precisely defined, although it is suggested at this time that side transfer of the distal fibula into the distal tibia is preferable to the bone-graft bridge or periosteal sleeve procedures. Care must be taken to avoid bony projections and stump irregularities in attempting to obtain a synostosis.
Robert L. Romano, M.D., and Ernest M. Burgess, M.D. are associated with the Prosthetics Research Study, Seattle, Washington
1. Burgess, E. M., and R. R. Romano, "Immediate postsurgical prosthetic fitting of children and adolescents following lower-extremity amputations," Inter-Clinic Information Bull., 7:3:1-10, Dec. 1967.
2. Burgess, E. M., "The below-knee amputation," Inter-Clinic Information Bull., 8:4, Jan.1969.
3. Burgess, E. M., R. R. Romano, and J. H. Zettl, "The management of lower-extremity amputations," Prosthetic and Sensory Aids Service, Veterans Administration, Wash., D.C., Aug. 1969.
4. Kohn, K. H., and E. E. Gordon, "Functional rating scales for lower-extremity amputees," Arch, of Phys. Med. and Rehab., 46:427-432, Jun. 1965.
5. Aitken, George T., "Surgical amputation in children," J. Bone and Joint Surg. (American), 45-A:1735-1741, Dec. 1963.