Summary of Limb Salvage Inquiry, Part 1

Summary of Limb Salvage Inquiry, Part 1

Custom Prosthetic Services Ltd.

8/9/2006

Thank you to all who responded to my question. I have posted the original question, followed by the responses, below:

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I have been contacted by a young man who is considering the prospect of a
high trans femoral amputation, secondary to femoral shaft fractures caused
by his most recent loose endoprosthesis (distal femur osteotomy for
osteosarcoma 10 years ago).

He has informed me that his anticipated femoral length will be only about 2
inches. He has also had his vastus medialis and lateralis muscles removed
due to the tumour, retaining his rectus femorus. He currently ambulates
with difficulty using crutches.

I suspect that if he receives such a short residuum, it will not be
functional for trans femoral prosthetic fitting. I am interested in others
opinions for advice to the surgeon for best overall outcome. Any references
to successful femoral length salvage/reconstruction via bone transplantation
would be appreciated, as well.

Kindest Regards,

Geoffrey Hall, B.Sc., C.P. ( c )
Victoria, BC
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Responses:

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You are correct. Such a femoral remnant would only be a hindrance to prosthetic fitting. At that level he would have to be fitted as a hip disarticulation unless his circumstances were quite unusual.


Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA

www.amputee.com
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I would recommend this patient talk to a surgeon and consider doing the Van
Ness rotation plasty.

I am not too fond of this procedure, it is a pain to fit and make a
prosthesis for this type of procedure, and the outcome is not always that
great, but much better than a really short AK amputation.

I have another idea for this situation, I have not ever discussed it with
any surgeon or anything. I have thought a few times that if I had a child,
or if it was myself going through this and making a decision like this, I
would prefer having a pseudo-Van Ness rotation surgery, but instead of
saving the foot and using the ankle as a knee joint, I would do a symes
amputation on that limb, leaving it about 3 shorter than the natural knee.
Then it would be similar to a knee disartic, having the end bearing
capabilities, but not the length discrepancy as a knee disartic. That would
be much easier to fit with a prosthesis and the function would be maybe
better than the Van Ness. From what I have seen out there, a person with a
knee disartic does better, and is more mobile and pain free than the Van
Ness patient.

Just my thoughts, but that is what I would opt for if it were my child doing
this. Have the tibia and fibula fused to the end of the femur, and do the
symes amputation at the ankle, thus preserving the length and using the good
bone, tissue, etc.

Good luck,

Jim DeWees, CP
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The VASS from otto bock is a good system for a short ak amputee. Jim Smith sales has a vacuum pump, but it runs off a battery pack.
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Geoffrey,

A couple of things spring to mind, the first of which is Van Nes
rotationplasty. Surgically this is fairly involved, but I'm pretty sure
Torode and Gillespie were writing this up in Toronto in the 80s, so I'm
guessing that there is still some experience there. Loss of knee extensors
shouldn't preclude this option, since it's better to set the prosthetic knee
jts anterior to the anatomical jt anyway. The fem shaft fractures MAY be an
issue, but probably not. This would be my first recommendation for function
and comfort.

Beyond this, what about a Symes style knee disarticulation or trans femoral
level amputation? ie Removal of the endo prosthesis and involved bone in
the femur and tibia, and attachment of the residual distal tibia onto the
femur, with a Symes or Boyd disarticulation of the foot.

This gives a distal weight bearing surface with self suspension and rotation
control over the malleolli using a simple split liner. Again this is a
procedure Torode uses effectively for management of PFFD patients unsuitable
or unwilling to proceed to VN. It's not as effective as VN, but much less
involved surgically and prostheticly, and far superior to a short TF
amputation

Regards, Rod

Rod Lawlor
Senior Prosthetist / Orthotist
Hugh Williamson Orthotic and Prosthetic Unit
The Royal Children's Hospital
Melbourne, Australia

Ph (03) 9345 5870
F (03) 9345 5106
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