Re: Progression of Bilateral Transfemoral
John Warren
Description
Collection
Title:
Re: Progression of Bilateral Transfemoral
Creator:
John Warren
Date:
6/29/2008
Text:
Original post:
Dear List Members, I'd like to know the opinions of the list concerns bilateral transfemoral pts. Let's assume young and very capable with unlimited funding and resources. How you manage them. Start with shorties perhaps and then where? Do you increase the height of the shorties, if so why, when and how much? When do you start with knees? What feet and knees would you use given the above parameters? I'll compile and post. Thanks to everyone in advance, John Warren CP
The Replies:
Hi JohnBesides starting with shorties, I am a fan of Mauch knees for the following reasons. 1. They can be locked in extension for extra early stability. 2. The user can use the flexion resistance to sit slowly into a chair and not have to freefall in the usual locked or free scenario, this can also be used to go down stairs leg over leg. 4. They accommodate variable speed gait. 5. They can be switched to free mode for exircise such as cycling, rowing machine etc. 6. They are cost affective as they can take the user through the whole specrtum of learning to walk.Other options would be the micro-processor controlled options. Allan OatesCPOSouth Africa
John,
I had a similar patient as you described. We started out with shorties by attaching feet to the distal sockets. As she improved, we gradually increased length by using various tubes. At the point she could independently transfer from sit to stand and walk without assistance we introduced locking knees. When the time was appropriate for proceeding with her definitive prostheses we used locking liners, C-legs, with Axtion feet.
Her case was a bit more complicated as she was also missing both upper extremities as well. With her definitive prostheses she was able to independently get from sit to stand using a special platform attached to her kitchen counter and ambulate with a modified walker around the house.
Joel Kempfer CP FAAOP
At BAMC, we started them on shorties with no knees. When they could walkfrom PT to Prosthetics with no assistive devices, we raised them up, butstill without knees. When they could again walk to Prosthetics with noassistive devices we added knees. The key to raising their height is to keepthem as low as you can for as long as you can to keep their CG low andincrease stability. I think that height is the main deterrent to successfulbilateral transfemoral ambulation.David Gerecke
This is Stuart Marquette, C.O., vice president DAW Industries...... I have a lot of experience with this type of patient personally and for 20 years have advised other practitioners on this issue.
The standard that I and a lot of other practitioners us is this,
Stubies are great, almost all of my bilat. have a pair and use them all the time, especially at home, fast and stable, they love them, but do not give them stubies in the beginning alone, always with a full set of legs. The reason for this is psychological more than anything, they need to keep looking for the goal of normal ambulation. Stubies alone often lead to stubbies and a wheelchair........ not the goal I assume......... as far as knees go, these patient do best on polycentric five bars, or at least four bars. The knee on the weakest or shortest limb should be locking at first with the capability of being unlocked. Five bar on the other side with adjustable stability.......... start them locked and really stable........ then adjust in two week increments, then start unlocking the locked knee during PT............ they gain confidence quickly using this protocol.............. do not use total knees on bilat. they cannot sit down safely........... I have really good knees for these issues, but am not here to sell.
Thanks
Stuart
Shorties are a great way to start. I prefer starting with a female pyramid connector on the bottom of the socket and seattle feet. That way you can progress the client very quickly and easily as they get used to taking weight and shifting their center of mass over the foot.
By “young” I’m going to assume you mean “paediatric.” So as the child gets comfortable with the shorties, he will begin to find them limiting. That would be a good time to raise him up to about half his correct height (wingspan). Locking knees are a good way to start, since you’ll want him wearing the devices in sitting as well. When he starts to find the locking knees irritating, and his weight shifting is correct (an experienced PT is a huge help here) then you might switch him out to knees with good stance stability. Total Knee Juniors are good, and Fillauer has a new paediatric auto-unlocking knee called the MiniMac that’s worth a look (a wink to those who saw this presented at CAPO). If you’re using non-locking knees, the Truper is a good choice for the foot.
Bottom line is there are no rules on any of this. It all occurs when the child is ready to switch to more demanding components, and sometimes that takes some encouragement. Your good judgment is required as to when to push and when to let the amputee practice a little longer. Either way, the situation you propose requires aggressive management and vigilance to give the child the best chance of being a good, confident walker.
Best of luck to you and your client!
Bryan Steinnagel CP
I'd say some interesting ideas out there. I agree there is no hard and fast, i.e. when to raise them up and by how much. In my experience, it will be obvious is you have done too much too soon. These pt tend to be their own control. I'd like to thank everyone for there contribution on this.
Sincerely,
John Warren CP
Dear List Members, I'd like to know the opinions of the list concerns bilateral transfemoral pts. Let's assume young and very capable with unlimited funding and resources. How you manage them. Start with shorties perhaps and then where? Do you increase the height of the shorties, if so why, when and how much? When do you start with knees? What feet and knees would you use given the above parameters? I'll compile and post. Thanks to everyone in advance, John Warren CP
The Replies:
Hi JohnBesides starting with shorties, I am a fan of Mauch knees for the following reasons. 1. They can be locked in extension for extra early stability. 2. The user can use the flexion resistance to sit slowly into a chair and not have to freefall in the usual locked or free scenario, this can also be used to go down stairs leg over leg. 4. They accommodate variable speed gait. 5. They can be switched to free mode for exircise such as cycling, rowing machine etc. 6. They are cost affective as they can take the user through the whole specrtum of learning to walk.Other options would be the micro-processor controlled options. Allan OatesCPOSouth Africa
John,
I had a similar patient as you described. We started out with shorties by attaching feet to the distal sockets. As she improved, we gradually increased length by using various tubes. At the point she could independently transfer from sit to stand and walk without assistance we introduced locking knees. When the time was appropriate for proceeding with her definitive prostheses we used locking liners, C-legs, with Axtion feet.
Her case was a bit more complicated as she was also missing both upper extremities as well. With her definitive prostheses she was able to independently get from sit to stand using a special platform attached to her kitchen counter and ambulate with a modified walker around the house.
Joel Kempfer CP FAAOP
At BAMC, we started them on shorties with no knees. When they could walkfrom PT to Prosthetics with no assistive devices, we raised them up, butstill without knees. When they could again walk to Prosthetics with noassistive devices we added knees. The key to raising their height is to keepthem as low as you can for as long as you can to keep their CG low andincrease stability. I think that height is the main deterrent to successfulbilateral transfemoral ambulation.David Gerecke
This is Stuart Marquette, C.O., vice president DAW Industries...... I have a lot of experience with this type of patient personally and for 20 years have advised other practitioners on this issue.
The standard that I and a lot of other practitioners us is this,
Stubies are great, almost all of my bilat. have a pair and use them all the time, especially at home, fast and stable, they love them, but do not give them stubies in the beginning alone, always with a full set of legs. The reason for this is psychological more than anything, they need to keep looking for the goal of normal ambulation. Stubies alone often lead to stubbies and a wheelchair........ not the goal I assume......... as far as knees go, these patient do best on polycentric five bars, or at least four bars. The knee on the weakest or shortest limb should be locking at first with the capability of being unlocked. Five bar on the other side with adjustable stability.......... start them locked and really stable........ then adjust in two week increments, then start unlocking the locked knee during PT............ they gain confidence quickly using this protocol.............. do not use total knees on bilat. they cannot sit down safely........... I have really good knees for these issues, but am not here to sell.
Thanks
Stuart
Shorties are a great way to start. I prefer starting with a female pyramid connector on the bottom of the socket and seattle feet. That way you can progress the client very quickly and easily as they get used to taking weight and shifting their center of mass over the foot.
By “young” I’m going to assume you mean “paediatric.” So as the child gets comfortable with the shorties, he will begin to find them limiting. That would be a good time to raise him up to about half his correct height (wingspan). Locking knees are a good way to start, since you’ll want him wearing the devices in sitting as well. When he starts to find the locking knees irritating, and his weight shifting is correct (an experienced PT is a huge help here) then you might switch him out to knees with good stance stability. Total Knee Juniors are good, and Fillauer has a new paediatric auto-unlocking knee called the MiniMac that’s worth a look (a wink to those who saw this presented at CAPO). If you’re using non-locking knees, the Truper is a good choice for the foot.
Bottom line is there are no rules on any of this. It all occurs when the child is ready to switch to more demanding components, and sometimes that takes some encouragement. Your good judgment is required as to when to push and when to let the amputee practice a little longer. Either way, the situation you propose requires aggressive management and vigilance to give the child the best chance of being a good, confident walker.
Best of luck to you and your client!
Bryan Steinnagel CP
I'd say some interesting ideas out there. I agree there is no hard and fast, i.e. when to raise them up and by how much. In my experience, it will be obvious is you have done too much too soon. These pt tend to be their own control. I'd like to thank everyone for there contribution on this.
Sincerely,
John Warren CP
Citation
John Warren, “Re: Progression of Bilateral Transfemoral,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/229435.
