Responses to "Very Short Transfemoral/Shoulder Disarticulation

Responses to "Very Short Transfemoral/Shoulder Disarticulation

Eric Schwelke, C.P.O.

10/16/1999

Thanks for all who responded. We have decided to go forward using a hip dis
design. Referral was molded standing with the hip flexed as much as
possible. An electric treatment table was then raised so that weight
bearing could be achieved. A series of clear test sockets are planned for
optimum socket fit. Componentry is still not finalized; we are considering
the suggestions we received and the final outcome will be posted for the
listserve members. Again, thank you all for your thoughts.

Eric Schwelke, C.P.O.

Here are additional responses to our original posting:
To all:
We are evaluating a new referral w/ the following Hx:
36 yo female s/p traumatic (suicide attempt) Rt. Transfemoral and Rt.
Shoulder Disarticulation. We are only considering lower extremity now. We
have requested films to get a better idea of bone length, but it appears to
be only 1-2 inches. Almost entire aspect of residuum is grafted in a
patchquilt; very lumpy and firm but in good condition. Grafts go as high as
iliac crest. ROM is WNL, and muscle power is good all around. Physically,
there are no other problems. Referral is in a rehab setting, completely
independent, ambulates (hops) with a walker with center handle for 100'-150'
and is highly motivated at this point in time. We are leaning towards
treating as a hip dis, as we don't see how a transfemoral socket can be
functional.
Any ideas, suggestions, or comments on casting techniques, socket design,
and hip/knee components would be greatly appreciated. Replies will be
posted back on the server for all interested.
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Yeah, I would probably think in terms of a hip disartic. also. It really
depends on the contour, and skin integrity (mostly grafts as you say) of the
residual limb). Obviously any sensory, or biomechanical advantages you want
to keep. If the grafts are not full thickness, and are not mobile I would
probably us a custom gel liner, like a TEC, or your own fabrication area of
choice.
In regards to the socket, you might look at the Littig hip components. Also
Littig uses a split flexible ethylene bridge on a hip disartic. I saw of his
once, and this seems like it would offer more volitional liberty with the
residual motion of the hip & Femoral residual limb. Good Luck...also make
sure you know who is treating her mental realities and what medications she
is on. This is very important so that when the both of you go forward
toward an ambulation goal, that you see the same skies as much as possible.
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I think you are right and should treat the pt as a Hip Disartic. I had a pt
with a similar amputation level who did quite well using the Littig hip
joint and a two piece socket that USMC can advise you about. I used a 4 bar
knee but I wonder now if I would opt for something like an Ultimate Knee.
Your pt does not have optimal upper extremity ability, so I think there will
be a problem with stability and balance. The Ultimate knee can be progressed
from locked to weight activated stance control to hydraulic SNS. I think it
will be a considerable accomplishment for you and the pt if she can become
functional. I see the shoulder as the biggest problem for balance and
ability to support while learning to use the LE prosthesis.
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I concur with this conservative, proven approach for the initial prosthesis.
I have done this in similar cases on several occasions. It MAY be possible
later to consider a heroic fitting as a super short TF once the grafts have
matured, but to do so in the beginning usually is an exercise in frustration
for you both.
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I have a few very short transfemoral patients who function as a Trans
femoral quite satisfactorily. One in particular is only 1-2 inches long and
he actually uses a suction socket, without a valve, and is essentially a
plug fit. he functions very well. A couple of others are very short and use
pelvic band and shoulder strap suspension. They all function quite well.
But of course they can all bear weight on their ischial tuberosity, which is
probably the crucial problem you need to consider. Depending on the grafts
and where they are will determine if you can make her a Trans fem user or a
hip disartic. Ideally, as you probably agree, it would be best and most
functional to get her to be a Trans fem. I would discuss with the surgeon
who did the grafts and see if he thinks the grafts will mature enough to
withstand the pressures needed to use a prosthesis. If in doubt I would
adopt a trial and error attitude and discuss it with the client and relevant
staff involved and go for it and try her with a traditional type Trans fem
prosthesis with
pelvic band and shoulder suspension. This would be the most functional
outcome for her. She needs to understand that it may not work and that the
grafts may break down and then you could look at treating her as a hip
disartic but this would only be more successful if the load could be spread
over a larger area. You may want to try some form of gel liner like a TEC
but of course it would have to be custom made and it depends on her funding
arrangements if you can do this. You should probably contact TEC direct and
see what they might suggest can be done with their liner. Good luck and its
solving challenges like this that makes prosthetics such a
rewarding and satisfying career!!
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If you could send a digital picture of residuum only with permission of
amputee, you could get more enlightened responses. What I have read isn't
enough.
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I think you are right and should treat the pt as a Hip Disartic. I had a pt
with a similar amputation level who did quite well using the Littig hip
joint and a two piece socket that USMC can advise you about. I used a 4 bar
knee but I wonder now if I would opt for something like an Ultimate Knee.
Your pt does not have optimal upper extremity ability, so I think there will
be a problem with stability and balance. The Ultimate knee can be progressed
from locked to weight activated stance control to hydraulic SNS. I think it
will be a considerable accomplishment for you and the pt if she can become
functional. I see the shoulder as the biggest problem for balance and
ability to support while learning to use the LE prosthesis.
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Thanks for all who responded. We have decided to go forward using a hip dis
design. Referral was molded standing with the hip flexed as much as
possible. An electric treatment table was then raised so that weight
bearing could be achieved. A series of clear test sockets are planned for
optimum socket fit. Componentry is still not finalized; we are considering
the suggestions we received and the final outcome will be posted for the
listserve members. Again, thank you all for your thoughts.

Eric Schwelke, C.P.O.