A Unique Perspective of Prosthetic Fitment to an Amputee with Very Short Transtibial Amputation and Knee Arthrodesis: A Case Study
1,2Department of Physical Medicine and Rehabilitation, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
3,4Department of Multiple Disabilities and Rehabilitation, Dr Shakuntala Mishra National Rehabilitation University, Lucknow, Uttar Pradesh, India
Corresponding Author: Raj Kumar, Department of Physical Medicine and Rehabilitation, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India, Phone: +91 7368064155, e-mail: firstname.lastname@example.org
How to cite this article Kumar R, Prakash A, Gautam SP, et al. A Unique Perspective of Prosthetic Fitment to an Amputee with Very Short Transtibial Amputation and Knee Arthrodesis: A Case Study. Indian J Phys Med Rehab 2020;31(4):101–104.
Source of support: Nil
Conflict of interest: None
This case study introduces a distinctive strategy for rehabilitation of an amputee with a very rare kind of transtibial amputation, leading an extremely short stump in addition to knee joint arthrodesis leading the stump in a fixed extension position, in a very cost-effective way by utilizing the Jaipur prosthesis fabrication technology and material.
Keywords: Jaipur limb technology, Knee arthrodesis, Prosthetic management, Transtibial amputation.
The most incessant reasons for amputation among people are diabetes mellitus, vascular ailment, injury and malignancies, and congenital anomalies. 1 After amputation of extremities, missing body part is falsely subbed by a prosthesis. Fruitful rehabilitation of the amputee necessitates that the prosthesis is adequate regarding a few variables including cosmesis, mass properties of the prosthesis, solace, and capacity. 2 Transtibial or below-knee amputation is the second most performed surgical procedure among various levels of amputation. 3 A transtibial prosthesis consists of various components as prosthetic foot, shank, socket, and suspension assembled together by adapters, nuts, and bolts, contained within a cosmetic cover. The most significant component of the lower extremity transtibial prosthesis is the socket. 4 The socket presents as an interface between the human and the mechanical supportive network. Inadequate socket fit can prompt distress or skin breakdown leading to unacceptance or rejection by the user. Accomplishing and keeping up a comfortable and tissue-tolerant socket fit stays a significant clinical problem. This study reveals the utilization of an unusual way to fabricate prosthesis, explicitly intended for improved solace, fit, function, and cosmesis of an amputee having a very short transtibial amputation and knee joint arthrodesis by using the idea of total surface bearing (TSB) socket, through customary Jaipur foot technology.
MATERIALS AND METHODS
A man of 42 years of age, weighing 60 kg and 168 cm tall, having right transtibial amputation has reported to our Prosthetic and Orthotic Center on May 26, 2018. He met a street auto collision on May 4, 2010, bringing about multiple fractures in the right leg and foot. In the wake of endeavoring seven repetitious medical procedures of the extremity in the following 7 years, specialists, at last, decided to go for amputation and knee arthrodesis as the recuperation was exceptionally moderate, poor, and circumstance became perilous for him. Before amputation, the individual was using calipers for the exercise of day-by-day living. The man got amputated at underneath knee level on August 24, 2017, leaving a very short residual limb of just 6.5 cm from a medial tibial plateau and linear adherent scars on the backside as well as medial and lateral aspects of the stump around the patella as shown in the Figure 1. On assessment, the stump was found to be cylindrical, with firm musculature and good delicate tissue inclusion all around, however, the knee joint was fixed with no movement of the patella. The distal end of the stump was all around padded with no dense projections and neuroma indicating the opportunities for distal weight-bearing. The patient was utilizing a crape bandage on an ordinary premise so there were no signs of edema. Likewise, there was no evidence of cardiovascular disease, diabetes, or any associated excruciating conditions in the proximal joints.
Custom-crafted distinctive prostheses have a lightweight, TSB, and the self-suspended socket has been intended to give the least inclusion and most extreme hold up to the residual limb. The socket was molded with high-density polyethylene (HDPE) pipe through a suction molding procedure, over a modified positive replica (Fig. 2) of the stump obtained from a negative cast taken from the amputee. The socket has vertical projections (struts) of 2″ width medially and laterally extended up to mid-thigh level to give mediolateral solidity and ideal weight-bearing through thigh musculature (Figs 3A to D). At the proximal end of the strut a calfskin belt (proximal ties) was set to hold the strut steadily over the thigh (Fig. 4). The anterior trim-lines of the socket kept were one and a half inches proximal to the superior border of the patella for the formation of the quadriceps bar to accomplish suprapatellar suspension. 5 Another calfskin belt (suprapatellar ties) has been placed circumferentially around the suprapatellar region (Fig. 4). The supracondylar suspension has been constructed by narrowing the medial and lateral struts inward just above the condyles. The proximal and suprapatellar ties hold the thigh cozily with the struts and help to aid in supracondylar-suprapatellar suspension. The anterior trim-line was higher than the posterior to facilitate wearing and removing the prosthesis (Fig. 3C). The medial and lateral struts were made adaptable enough to extend while wearing and doffing, yet in addition sufficiently wide to hold the thigh securely. The shank piece was made of the same HDPE pipe utilized for socket molding, frequently used in Jaipur limb fabrication, and attached with Jaipur foot of respective foot size. 6 The socket and shank were joined together by a metal sidebar joint with a knee drop lock (Fig. 4). The prosthetic knee axis was set, coordinating the anatomical pivot of the knee. The distal part of the socket was very much cushioned inside for shock absorption, comfort, and even weight dissemination by expanding the mold distally around 1″ with ethylene-vinyl acetate (EVA) sheet during the mold preparation process (Fig. 2D), as it was the tertiary of most extreme weight-bearing in stance phase. All prosthetic parts were aligned by normal arrangement technique following weight reference line. The prosthesis was kept slightly shorter than the normal limb to allow unrestricted ground clearance in the swing phase. 7
During introductory fitment, the amputee was first suggested to wear the prosthesis over the stump with a single cotton stockinette by expanding the struts of the socket manually. In the wake of donning, the proximal and distal ends of the struts were attached with the proximal and suprapatellar ties (Fig. 4). The patient was then permitted to stand and stroll for 15 minutes into a parallel bar, after which the indications of excessive pressure like redness, swelling, and skin breakdown on stump territory were inspected. This training cum observation procedure has been performed several times on regular interim followed by sufficient rest throughout the day. After legitimate fitting and alignment check, the individual was discharged with extra shocks and essential guidance of cleanliness care for stump and prosthesis. The first follow-up of the amputee has been scheduled immediately in the next week to observe the fitting, performance, and stump condition.
On introductory preliminary, the patient set aside some effort to be acquainted with the prosthesis, however, bit by bit his certainty level has been raised and he began getting a charge out of it. The relative movement as far as rotation and shear between the stump and socket was negligible with proper fit and solace. The knee joint was effectively accessible while sitting without a lot of manual exertion. After ideal utilization of prosthesis for 7 days, the amputee needed to include extra shocks as the socket became somewhat loose. The patient was especially steady, certain, and content with the prosthesis as it was extremely light, effectively operational, and less cumbersome.
Postoperative utilitarian freedom and forestall idleness of prosthesis can expand the dangers of deep vein thrombosis, pneumonia, deformity, and muscular deconditioning. This case study represents the requirement of a unique approach to deal with, build up a device to improve fitting and function rather than managing it traditionally. The fitting prosthesis has consistently been a difficult errand, which relies upon legitimate assessment, understanding patient desire, and finally clinical decision making. Socket design and fit is constantly prioritized over any other components as it acts as a human prosthesis interface to transmit body weight to the ground through intermediate prosthetic components and ground reaction forces to the proximal body segments. While designing a socket, the consideration of suspension is also essential simultaneously. In 1957, patella tendon bearing (PTB) sockets got well known for transtibial prostheses in which body weight is principally borne on the patellar tendon region and halfway on the lower fringe of the tibial medial condyle. 8 Even though the PTB socket gives a solid match, it has issues of suspension and in some cases gives horrendous weight on the patellar tendon. The constrained weight-bearing territories produce a stretch effect over the delicate tissues and permit piston motion of the stump inside the socket prompting skin abrasions. To overcome these issues, the TSB prosthetic socket, in which weight is borne by the whole surface of the residual limb, was created (Kristinsson, 1993). The purpose of planning a TSB socket is to distribute uniform weight over the whole surface of the residual limb and to omit the piston movement by giving a genuine total contact during strolling. 9 Identical concept has been utilized in our study for socket design and fit as patella tendon pressure cannot be applied because the level of amputation was above tibial tubercle and presence of scar tissue around the popliteal fossa.
Another significant thought while designing a prosthesis is the process by which the prosthesis is held to the residual limb; often known as “suspension”. The possibilities of relative movement between the socket and the residual limb are insignificant if the prosthesis is suspended properly. 10 Here, we have tried to achieve a perfect suspension by narrowing the supracondylar and suprapatellar regions inward at the respective socket walls. This has not only the advantage of preventing the knee from getting out of the socket but also ensures mediolateral stability during locomotion. 5
Before proceeding with a new approach, we have also thought for the two most accepted options, which might have been suitable for the management of such an exceptional case. The prior one consideration was, management through the conventional transtibial prosthetic procedure and the latter one was, by extending the prosthesis proximally to facilitate ischial weight-bearing as in the case of through knee prosthetic fitment. Both the procedures are well accepted and applicable for the management of similar conditions in the recent practice but finally, we decided to proceed with an intermediate approach for various reasons. As suggested in many studies, the vast majority of individuals invest a dominant part of their time in sitting than they do standing or strolling. 10 The main motivation behind designing a mid-thigh level prosthesis was to permit the client to sit in a perfect posture as it has been found constantly difficult for the individuals with a full-length prosthesis because of the outward projected brim at the posterior medial socket corner as in the case of sub-ischial (quadrilateral socket) or Ischial containment socket. Likewise, in the case of a full-length prosthesis, the socket slips distally while sitting which includes further asymmetry in the knee joint situation of normal and prosthetic side. 11 The reason for not fitting a below-knee prosthesis was, the lack of knee control due to knee arthrodesis as patellar tendon insertion has not been preserved, which would lead to deconditioning of the normal health of the fixed knee joint after arthrodesis. Also, there would have been a chance of mediolateral instability due to the abnormal thrust generated from ground reaction forces which could not have been neutralized by insufficient leverage due to very limited socket-stump interface. The current approach was effective in neutralizing the abnormal medial or lateral thrust around the knee as the struts projected to mid-thigh levels add additional leverage to control the medial or lateral deviation of the knee from the mid-sagittal plane as clearly visible during the dynamic alignment procedure.
Since we have utilized Jaipur limb technology, the sidebar drop lock knee joints and conventional Jaipur foot were considered for the fabrication of this ideal prosthesis. Jaipur foot is commonly utilized in India and other developing countries. It is the least expensive prosthetic foot with a restorative appearance and appropriate to oblige the tropical atmospheres, harsh territory, ranch work conditions, mass barefoot strolling, and ideal for low annual income clients, which is locally accessible, durable, water and erosion resistant, equipped for basic and quick reproducible creation by neighborhood staff, lightweight, and psychosocially worthy. 12
The current strategy of prosthetic fitment was acquisition very effective in terms of execution, adequacy, cost, and comfort. Somehow the cosmetic appearance was a little compromised but still acceptable by the prosthetic user. After customary utilization of the prosthesis for the last one and a half years, the patient reported no significant trouble with the exception of minor skin issues basically in summer due to negligence of proper hygiene. The efficacy of the current approach in the management of such unique conditions should be tested on the experimental background. The current design can be further optimized to provide free motion at the knee joint and enhanced cosmetic appearance by using advanced materials and technology.
Dr Shakuntala Misra National Rehabilitation University, Lucknow, India.
2. Zahedi MS, Spence WD, Solomonidis SE, et al. Alignment of lowe-limb prostheses. J Rehabil Res Dev 1986;23(2):2–19.
3. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United Sates. South Med J 2002;95(8):875–883. DOI: 10.1097/00007611-200295080-00019.
4. Hawari Mohd N, Jawaid M, Tahir Md P, et al. Case study: survey of patient satisfaction with prosthesis quality and design among below-knee prosthetic leg socket users. Disabil Rehabil Assist Technol 2017;12(8):868–874. Available from: 10.1080/17483107.2016.1269209.
5. Knapp D. Transtibial prosthetics. In: ed. MM, Lusardi M, Jorge Millee C, Nielsen ed. Orthotics and prosthetics in rehabilitation. 3rd ed., Missouri, USA: Saunders, Elsevier Inc; 2013. pp. 622–651.
8. Yigiter K, Sener G, Bayar K. Comparison of the effects of patellar tendon bearing and total surface bearing sockets on prosthetic fitting and rehabilitation. Prosthetics Orthot Int 2002;26(3):206–212. DOI: 10.1080/03093640208726649.
9. Staats TB, Lundt J. The UCLA total surface bearing suction below-knee prosthesis. Clin Prosthetics Orthot 1987;11(3):118–130.
10. Richard P. Transfemoral prostheses. In: ed. MM, Lusardi M, Jorge Millee C, Nielsen ed. Orthotics and prosthetics in rehabilitation. 3rd ed., Missouri, USA: Saunders, Elsevier Inc; 2013. pp. 652–684.
11. Carroll K. Getting down to basics: improving life with an aboveknee prosthesis. In Motion 2001;11(5):14–15.
12. Laferrier JZ, Groff A, Hale S, et al. A review of commonly used prosthetic feet for developing countries: a call for research and development. J Nov Physiother 2018;8(1):380. DOI: 10.4172/2165-7025.1000380.
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.