Case Study-PFFD with Symes Amputation
JEAN G. KOHN, M.D., AND LYNN DUNBAR, C.P.
First seen at Children's Hospital at Stanford in March, 1986 at five days of age. Recommendation for surgical removal (Syme's amputation) of right foot was accepted by the parents and completed January 9, 1987 at age 10 months. Xrays in October, 1986 read as PFFD, Type B.
By February, 1987 at 11 months, child was pulling to stand and crawling rapidly. He was fitted with a Symes type prosthesis ending at the knee joint with total end-bearing. This was unsatisfactory due to knee joint motion and hip instability. It was replaced in August, 1987 with a modified prosthesis including a pelvic band and strap.
By October, 1987, at 19 months he was walking with a walker and taking independent steps, and in November, at 20 months, he walked alone. By June, 1988, at two years, three months, he was at age level in all activities, including climbing and descending stairs. A new prosthesis was delivered December, 1988, an exoskeletal style with supra malleoli suspension and SACH foot.
October 2, 1989 surgery consisted of open reduction and internal fixation of right proximal femoral nonunion of head and neck. The pin was removed January, 1990. By March there was solid fusion on fluoroscopy.
A new prosthesis was delivered in June, 1990. This was a patella tendon bearing type of prosthesis and he used his residual knee to increase mobility in walking. Quadriceps strength was good. Hip was clinically stable.
QUESTION: The next step would be R knee fusion with ultimate plan to fit a knee disarticulation type prosthesis, possible also with stapling on the left side to equalize upper leg lengths. Family are wondering if knee fusion is a good idea since he is so functional, at four years. Question of lengthening upper segments on right would need consideration, as well as reducing growth on left. What does the ACPOC group recommend?
Children's Hospital at Stanford, Rehab. Engineering Center, 520 Sand Hill Road, Palo Alto, CA 94304