RESPONSES TO VAN NESS INQUIRY

RESPONSES TO VAN NESS INQUIRY

Barry Steineman, CPO

Dear Colleagues and other list members:
    On 3/24/00 I posted the following message:
Dear Colleagues:
     I've been referred a 9 year old patient who has recently undergone a Van
Ness Rotation Osteotomy procedure subsequent to a resection of a distal
femoral tumor. She is two days post-op, neurologically intact, tibial
fixation to remnant femur with plate and screws, no other health problems. I
have not yet had an opportunity to fit anyone with this type of amputation
and would welcome any input from experienced individuals regarding fitting
options.
     We expect to begin prosthetic care within 6 weeks. Please reply to me
directly; anyone interested in responses I receive may request forwarding.
Thank you,
Barry Steineman, CPO

I received numerous requests to post responses, so, here goes........
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I fit a twelve year old with a Van Ness procedure. It is an incredibly
practical amputation level. He can run, jump, everything. Remember that a
nine year old girl is hitting some major growth spurts for the next three -
five years. Endo will help prevent a new leg every couple months, although
she may be active enough to need something pretty durable. I like the
Seattle lite foot which has lengthening shims. Springlite also has growth
componentry, but be aware that if she gains enough weight, she'll be too
heavy for the foot. (I made that mistake on a client; I'll try not to
again) The fitting of the socket is really straight forward; it's
basically a TT socket with joints and corset. I have heard of people using
a silicone suction system and not crossing the knee (ankle?) at all. My
experience was with a very active individual who had been in joints and
corset for several years. I was wary of compromising stability in a child
who must have some serious atrophy of inverters/everters. Good luck and
write if you have any questions. (I only take easy questions though)
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I'll be interested...any reason ot to do the summary for the whole list??
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I would appreciate to be forwarded the information and responses you
receive. We have learned a bit about fitting these individuals, but I am
not very experienced in fitting. If you aren't getting much information,
let me know.
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I have done quite a few PFFD prostheses. I will get you more info as soon
as I can put it together. You will more than likely need to work with out
side knee joints on this patient. If you can possibly email me a digital
photo that would help. If you are unable to send one, then I will email as
best a description as I can on Impression and Fabrication procedures.
Be In touch!!!
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We are working with two patients/clients it this time and both are doing very
well. The first thing to remember is to cast them with their foot
plantarflexed as far as possible. If the operation was successful and the
reattachments of the muscle groups have been relocated properly the ankle
will become the knee center. We use joints and thigh corset on both children.
The knee joints must be located the same position as you would place the
joints on the AFO.

This is just a short overview. The Atlas of Prosthetics covers it well.
Please give me a call and we can talk about the socket itself or any other
question that you may have.
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Since this nine year old girl is still 'neurologically intact' you might
consider
giving her care to somone with experience fitting this type amputation. Of
course, since you have no experience, it is fine to experiment and learn on
her. At nine she will never know the difference. But then, if you turned her
care over to someone else with experience instead of using her as a learning
experience you would lose the money to be gained from your continuing
education.

just an amputee
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I have treated a young man following a Van Ness for the past 10
years. I have fabricated 3 prostheses for him as he grew. He has been very,
very functional and has led a quite normal adolescence. I created a socket
with primary weight bearing on the distal calcaneous, much the same as a
PTB. I have used a nickleplast socket insert to allow modifications to the
socket and as a method of filling out abnormal shapes around the foot for
ease of donning. I found that I needed to use knee joints and a thigh lacer
for ML stability and suspension. He does not use a back check or an
extension aid or belt. Balance of prosthesis is endoskeletal with an
appropriate foot. Cosmesis was not an issue with him but may be more of a
challenge with your patient. Note: Be sure to leave enough room around the
toes! Let me know if you would like to discuss.
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Please refer to a chapter dedicated to this amputation in the Prosthetic
Atlas by AAOS publshed by C.V.Mosby&co.
Do write about the prosthetic treatment.
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Why do they keep doing this? Better wt bearing? There was a study done, I
think at Duke about the incidence of suicide of teens with this procedure,
suicide becomes a huge risk because now not only are you an amputee but know
your also a freak. (Not my words but a patient of same said procedure). I
have had 2 pts with Van Ness, one ended up in corset and joints, had
perpetual breakdown of the foot/knee and psychologically couldn't handle it,
she became a functional AK. The second was PFFD and was treated as an AK
with frame socket and outside joints.
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I have fit several a few years back. I am assuming you have the foot at knee
level and it was turned 180 degrees. The foot then becomes a knee. I
learned something fast. You do not need a preparatory when thinking you need
to stretch the foot to full planter flexion. The thigh section may be
another issue (but you can always make another socket later). I recommend
going into a definitive from the start. Fit like a transtibial joint and
lacer. But I always made a CAT-CAM thigh section and attached joints to it.
Anterior section is open.

I do recommend therapy to stretch the foot until you can make the prosthesis.
 Call with questions.
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A Van Ness Procedure is usually performed , in order to view it as a BKA . It
can be designed and fitted as such, using the inferior ridge of the calcanial
bulge as the patella tendon and the bulge itself as the knee . With
sufficient flexion present ( 90 degree would be desireable. ) If this is so ,
the receptacle could be designed with a suprapatellar type encasement, giving
the remnant-or now to be viewed as a below knee rersidual limb a fairly
decent cosmesis as well as function.Should flexin be restricted , and
meedial - lateral instability be present , the task becomes somewhat more
complicated . A receptacle would be fashioned in the same manner as above ,
but would have to be provided with a proximal support structure -------
Polycentric or step up knee joints to facilitate flexion of the lower shank
and terminal device . It would also be important that the procedure was
performed with a prosthetic design in mind ----- that the foot now being used
as a BKA residual limb would be at the same level as the opposite knee .
Therefore the tibial fusion would be high enough on the femur for this to be
a reality .
One would also wonder if in a 9 year old patient the epiphyseal - growth
plates would have been stapled to retard growth so that cosmesis could be
maintained during her
liftime ??
During my 52 years of orthotic and prosthetic activities I had occasions to
design and fit this type of procedure several times with less friendly
materials that are available today, and I know it can be very challenging .
Not only in the beginning of success but satisfying the individual for the
future. Like everything else each case is different .
Hoping this will help in a small way, and I hope you will be receiving more
fitting options from other practitioners, I wish you success
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I have had some experience with this level of amputation.
What I tell every patient is that their ROM is the number one critical factor
for sucess.
If you will look in the Atlas of Limb Prosthetics, second edition, 1992 you
will find some good information on page 896-897.
Good Luck.
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I and my associates have been involved with a series of perhaps 8 clients who
have undergone the Van Ness rotationplasty over the last 10 years. Very
similar scenario that you have described. It will be difficult to carry this
out via internet, and perhaps you might call me to discuss your specific
concerns, and I might be able to more completely inform you through a dialog.
 Very few references exist, but there may be some. These are somewhat
technically challenging, but not so much as the first one appears to be!
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I have fit a number of these while working at Shriners Intermountain
Unit, one for the exact reason you have stated.
E- mail me with what you would like to know, and I will help if I can.
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