Summary of Responses - No Femur

Summary of Responses - No Femur

Taavy Miller

1/11/2012

Hello All,

I would like to share what we ended up doing with the case. I also have the
responses and suggestions from everyone else pasted at the end of the
email.
*Original question:*

I have a 51 y/o male patient who presents functionally as a hip
disarticulation, where as he has no right femur, but they left the muscle
and tissue from his previous transfemoral amputation. He was an AK, got an
infection which resulted in the doctors deciding to remove the femur only
while leaving the length. He says he has all of his pelvis. The patient has
a prosthesis currently but says it doesn't work well for him. He has a
laminated socket with a hip joint and pelvic band, a TPE liner with a KISS
suspension, a hydrualic knee and luxon max foot. He lives in Venezuela,
where it is hot and he doesn't want to compromise comfort but a liner is
hot for him. Complains his socket still rotates on him and the pelvic band
is uncomfortable.



Does anyone have any experience with a similar case? How did you approach
the socket design? It is difficult to control his tissue. He has a
realistic goal of walking with a cane in a comfortable socket.




We went the route of compressing all the tissue up as much as possible. The
pt was able to tolerate end weight bearing, skin fit and he can use socks
if necessary. We attempted using only a suspension belt but finally the pt
understood that the hip joint really did give him more support so we added
the pelvic band and hip joint. He was able to ambulate better with a cane
and the hip joint for stability. I will find out how it works or if it did
for him when he returns to the country next month.


*LIST RESPONSES:*

*
*

I think he will have to fit as a hip disarticulation while accomidating the
redundant tissue. Just a little footnote. The other day I spoke with a PT
and she claims that she is treating a young man that had bone cancer in his
femur. The doctors removed the entire femur and replaced it with an
artificial one and he walk just fine. This type of replacement would be
good for this patient. Then he could be fit as an AK.



Amazingly I had the same situation - TWICE. Both times I had the surgeons
revise the thighs and remove the musculature to a normal hip
disarticulation. All those muscles are useless without a bone to move.



I had a similar patient who had no femur, but about a 4 in. limb length of
tissue. I actually did not become aware of this until I did the evaluation.
The patient said he forgot to mention it.



I actually applied a tension band around the ischial level to increase
suspension. I did this by taking the impression under tension using a
compression garment and pulling the patient into it with a cotton sock. I
suspended the garment from the ceiling as I do with hip disarticulation.
When I measured circumferences, I measured them a little tighter. I did
load the ischium and pressed laterally as I would do for a transfemoral
patient, but wrapped higher with a hip spica over the opposite leg. In
modification I applied greater tension at the ischial level using a the
width of my SureForm rasp as a guideline. I did include the ischial-ramal
angle. In fitting I left the lateral wall higher and used a strap type
Silesian belt.

I was surprised how good the suspension was actually. The patient could
bear weight on the limb very easily as well.



I have a similar patient. We put velcro in the socket to prevent rotation
and used a proflex flexible inner with no silicone (a bit more tacky). Has
he tried an antiperspirant on his limb for the sweating?



I have long thought about the use of RGO type hip joint set up in above
knee. Your patient sounds like a perfect candidate.

As he has a hip joint already it wouldn't be much more to add. You may be
able to get away with just pelvic band but it may require a lower thoracic
band and side uprights as well.

My thinking is as he has no femur to drive the prosthesis but tissue to
fill it.

If you fit RGO hip joint to it, a pelvic band and a hip joint on the sound
side with thigh cuff (or 2 bands due to heat) then the power of the other
limb and forward and backward leaning and forward momentum will be used to
flex and extend the hip on the amp side through the RGO cables. Without a
femur there may be an issue with the socket wanting to gap at the proximal
lateral area which may affect the hip joint function so good bony lock on
the IT would be essential I would think. Good food for thought for you. I
would love to see someone do it. I have not had an appropriate candidate
yet to trial this setup.



*Do you know what a Kipshaft prosthesis is for this level of amputation?*

* *

At first glance, not having a femur but all the muscle and other tissue
sounds strange. But for suspension it sounds pretty smart. So few people
accept hip disartic prostheses. If he wears his limb you are fortunate. We
are in a very warm humid area. We fit a large number of Ossur TF liners
with KISS straps. People do complain the liners make them sweaty, but the
joy of standing and walking again seems to reduce their complaint. Good luck



First off a tough patient to hand to a resident, no offense but this one
could give an experienced prosthetist difficulties. That said a lot
depends upon the nature of the remaining soft tissue. If the length is
reasonable and the muscles have some tone he may be able to function quite
well as a transfemoral amputee. Elongate the tissues when casting and use
a lanyard or conventional suction for suspension so the tissues are drawn
down to their full length in the socket. Fit needs to be tight so the soft
tissues firm up by the sausage skin effect. Trim line need to be a bit
high and some ROM may need to be compromised, especially abduction. Do not
scrimp on ischial containment as that is your only skeletal stability. A
MAS socket would be excellent. I would suggest an auxiliary waist belt
suspension of some type but would hope that the hip joint and pelvic band
would be overkill. If he cannot accept the heat of wearing this sort of
prosthesis then I would suggest that crutches are his best alternative.



If the soft tissue is short and flabby then fit with the hip joint and
pelvic band and train him to walk with crutches using a hip disarticulation
type gait. Or again he may prefer crutches alone.


THANKS EVERYONE, ALL VERY HELPFUL!

--
Taavy Miller, MSPO

Prosthetic Resident,
ABC Prosthetics & Orthotics
Orlando, FL