A Prosthetic Solution: When Orthopaedic Options are Rejected

Brian Giavedoni, MBA, CP, LP

Sean first presented in the Children's Healthcare of Atlanta Limb Deficiency Clinic when he was 12 years old. His family relocated from Florida to the Atlanta area in 1997. While Sean was in the neonatal unit and he had contracted a staph infection from and IV infiltrate resulting in seminated osteomyelitis. This destroyed multiple joints including his temporomandibular joint, both hips, both knees and both ankles. Since that time, Sean had developed a significant leg length discrepancy. The first challenge with Sean was to meet both the physicians and the parent's expectations of a functional outcome.

Sean was historically treated with shoe lifts to accommodate a leg length discrepancy of 8" but the continued use of a shoe lift possibly supported with and AFO was ruled out due to the inherent instability of the affected knee and limb. In order to better handle the stresses of full weight bearing with the eventual goal of ambulating without crutches, the initial recommendation from the team was a rotationplasty. Upon radiographic examination, this route was abandoned. Both parents were also adamant that there would be no amputation in the hope that medical science would have a "cure" in the pursuing years.

The decision was made to create a "prosthosis". Almost all of the body weight would need to be distributed between the ischium and along the PTB area of the knee. Planar foot surface contact is used to control the lower segment with minimal weight bearing. Long-term weight bearing using only a shoe lift may have contributed to the subluxation seen in the knee. Neither knee was a candidate for reconstruction. A full leg cast was taken with emphasis on the ischial area and the knee. Articulation of the knee was challenging due to the posterior subluxation of the tibial segmented resulting in misalignment and a very prominent fibular head.

During the test fitting stage, initial brim and trim lines were established so that knee flexion was not hindered with the side joints or posterior impingement of the proximal and distal segments of the shell. To help protect the knee and prevent any undue pressure over the fibular head, the anterior distal segment was designed to lie anterior to the head. This also facilitated flexion without impingement.

The design incorporated a proximal ischial-bearing brim with and anterior shell to allow donning and doffing. The lower segment was designed with a full anterior PTB section with a soft posterior pad used in the popliteal area. This allowed Sean to adjust the pressure placed over the anterior section of the knee. Sean underwent intensive physical therapy to help gain control over his new device and to build strength and stamina. Sean was fit with his first prosthsosis in 1998 and continues to wear the same design to this day. Sean was assessed for a power scooter during college to handle the very long distances between classes and the time constraints of college life.

He graduated from College in 2008 and then spent the following month traveling Italy. He currently wears his device all day and does depend on one crutch to aid in ambulation (he is kept supplied with crutch tips). He is now training as a chef and maintains that he is relatively pain free and without any limitations.

Children's Healthcare of Atlanta Atlanta, GA