There’s More Than One Way To Fit a Patient
By Judith Otto Choosing the right solution for a prosthetic patient is the
practitioner's job--but in exploring the issue with a number of
experienced professionals, we discovered that there is no single
perfect solution, but a variety of different potentially "right
choices" for the same patient.
To illustrate, we developed a description of a hypothetical
patient, and asked a selected panel of prosthetists to consider his
case and recommend appropriate prosthetic componentry. We found
that prosthetists, perhaps partly due to geographic location, age,
gender, and experience, are likely to make very different choices,
each of which will serve their patients well. Consider this case
and see if your prosthetic solution matches our panelists'
choices.
Our hypothetical patient is a 5'10" male, age 66, weighing 190
lbs, recently retired from a professional career. His traumatic
transfemoral amputation, resulting from a motor vehicle accident,
leaves a ten-inch long residual limb. Before his accident, he
enjoyed low-impact recreational activities: camping, hiking, golf,
and playing with his grandchildren.
He has adequate insurance for whatever is medically
necessary.
 Frank Snell, CPO, FAAOP,
president, Snell Prosthetic & Orthotic Laboratory, Little Rock,
Arkansas; board chairman, PrimeCare O&P Network LLC: "After
completion of the healing process, the patient should receive
treatment to reduce the post-surgical swelling by the use of an Ace
elastic bandage or shrinker sock in conjunction with preprosthetic
general conditioning therapy. My recommendations for the initial
prosthesis are:
Socket: Ischial radial containment socket
design with total contact flexible socket in laminated
acrylic/epoxy frame.
Construction: Lightweight endoskeletal design with
alignable componentry.
Suspension: Suspension of the prosthesis
accomplished by roll-on gel liners in conjunction with a distal
locking shuttle device.
Knee: A knee joint featuring a polycentric design
which incorporates pneumatic swing phase control and an extension
assist.
Foot: A lightweight carbon graphite energy-storing
design which allows for multiaxial rotation to compensate for
uneven surfaces."
Robin King, CP, CFI Prosthetics & Orthotics,
Memphis, Tennessee: "Since I assume this is the patient's first
prosthesis, I tend to be on the cautious, conservative side, giving
the patient enough room for improvement and development. I don't
want to load him down too quickly with a lot of features, yet still
want to give him a lot of bells and whistles. So I've chosen a
mix:
Socket: Acrylic lamination with a flexible
inner socket and frame...include total contact as well as begin the
fitting procedure with a test socket.
Construction: Endoskeletal construction with
lightweight titanium components&[with] the choice of either a
one-piece above-knee cover or a two-piece cover.
Suspension: I would first educate the patient
regarding the various suspension types with their pros and cons. We
could try the suction suspension and advise the patient that we
might need to add the Silesian belt for assist, due to the amount
of shrinkage that occurs during the first year of wearing a
definitive prosthesis&
If the patient was reluctant to deal with a suction socket and
volume shrinkage, I would suggest the Silesian belt with stump
socks. I am still perfecting my own technique for a patient to
utilize a suction liner with mechanical shuttle lock system, and
this might be another suspension suggestion&
Knee: The Otto Bock 3R60 Modular Polycentric
EBS (ergonomically balanced stride) knee&our hypothetical
patient is described as low-impact, so I would tend to classify
this patient as a functional level 3, which is a pretty good
activity level for allowing a variety of activities. For a new
amputee, I like the hydraulic swing of the knee, and also the
stance feature built into the knee, which allows stability under
weight-bearing up to 15 degrees worth of knee flexion--great for
camping and golfing.
Foot: I considered several options, but went
with the LuXon Max DP for this new amputee. One of the reasons I
like it is for its shock-absorption capability, as well as the
built-in inversion and eversion and rotation--great for the uneven
terrain he is likely to encounter while camping, hiking, and
golfing&Yet it still has the dynamic response concept to
spring-load him to the next step.
"If the patient progressed well, and it began to appear that
these components were going to hold him back after several years'
worth of experience as an amputee, then the C-Leg might be fun to
consider as an upgrade. We've had good success with fitting the
C-Leg on similar patients--but they all happen to be a bit younger
than 66. This is why I choose to be a little conservative, but
would still select a hydraulic knee.
Jon Batzdorff, CPO, Sierra Orthopedics, Santa Rosa,
California: "Generally the activity level of a patient
with an amputation follows his activity pattern prior to the
amputation, especially for a healthy traumatic amputee. Therefore,
my choices would be:
Socket: Ischial containment.
Construction: Flexible inner socket and rigid
frame.
Suspension: Suction socket.
Knee: C-Leg.
Foot: LuXon Max.
"The socket chosen is pretty much the standard design in use
now, unless there is a really good reason not to use it. Because
this patient has a ten-inch residual limbwhich is a good
length--and he is a traumatic amputee, he should be a good
candidate for a standard suction socket, which has fewer moving
parts, is more durable than alternative sockets, and works well for
an active person. I feel it is better to keep the socket design
simple whenever possible.
I considered a number of knees. I've used several C-legs now,
and patients really like them. I have patients that are very
active, that are enjoying low-impact recreational activities, and I
think the C-Leg is ideal for that situation if the person has
adequate insurance coverage, since it is an expensive knee&
Our job as prosthetists is to help persons who lose a limb to
restore the function as closely as possible to match their previous
level of function with their normal limb. I can't see why anyone
would want anything less than that. Therefore, when I see a knee
that allows varying speeds and has stumble control, as the C-Leg
does, I use it.
Other microprocessor-controlled knees are coming out, but my
experience to date has been with the C-Leg...we have had no
maintenance issues, no problems at all with the C-Leg, and so far,
our patients are very pleased with it. We have seen some of the
other microprocessor knees; we just haven't had enough experience
to know if they are as good or better.
I have tried four or five different types of feet with the
C-leg, and my patients have preferred the LuXon Max&It's
lightweight and seems to have the right combination of flexibility
to help that knee to function and still give patients a comfortable
gait."
Justin Foster, University of
Washington, 2001 P&O graduate and prosthetic resident, Bay
Area, California: "&the first six to twelve months of
prosthetic care should be a time to establish a solid foundation
rooted in the fundamental aspects of wearing and managing a
prosthesis. Why burden your patient, their insurance company, and
yourself with high-cost, high-functioning componentry whose merits
may never be realized? &I would recommend a simple, stable, yet
functional setup to allow this new client to explore the beginning
stages of living with an above-knee amputation& As clear needs
[emerge], components necessary to execute the desired lifestyle can
be integrated into this or future prosthetic designs."
Socket: Narrow ML design for improved
prosthetic control.
Construction: Endoskeletal--modularity for
easy/effective changes.
Suspension: Partial Suction w/ TES Belt--preserves
ability for in-socket modification and addition of sock ply as limb
matures.
Knee: Single-axis constant friction with
weight-activated stance control-- simple, stable, functional, and
inexpensive.
Foot: SAFE II foot--simple, stable, functional,
inexpensive!
"&Strength and balance can be regained (hopefully with PT
assist) and all basic functions can easily be realized with this
design. When the client is ready to regain lost activities&it
is then time to look for solutions to that effect. That old
temporary prosthesis can then become a functional backup for use in
water, dirt, or while the new Jaguar' is in the shop for
repairs!"
So, what's your opinion? Do you agree with the choices of our
prosthetic panel? Or do you have a different prosthetic solution of
your own to offer? Please share your input with us at The O&P
EDGE, and we'll report readers' recommendations: edge@oandp.com.
Table Of Contents - July 2003
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