Trans-USA Hip Disarticulation/Transpelvic Prostheses Tour:Part Three = Suwanee, Georgia
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Our second visit was to Stephen Schulte's facility in Suwanee, Georgia.
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As noted in prior Corners, I spent two solid weeks this summer criss-crossing the United States with a colleague from England, Steve Taylor. The purpose of our travels was to meet with a convenience sample of US prosthetists who had a special interest in high-level amputations to share information and learn from their collective experience.
The second stop on our whirlwind tour was in a small town outside Atlanta, Georgia to visit Stephen Schulte CP and his staff. Stephen and I have exchanged ideas and discussed difficult cases via telephone or email for many years, so I knew he had a number of active patients in his practice who had hip disarticulation and higher level fittings. He extended that gracious hospitality that the South is noted for, and welcomed us into his busy facility.
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Steve Taylor prefers to use elastic webbing straps to better define key anatomical landmarks, including the ascending ischiopubic ramus.
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Stephen had even contacted for a patient who was due for a replacement prosthesis who was interested in meeting with us. With the patient's permission, Steve Taylor conducted a clinical evaluation of her existing prosthesis and discussed the benefits and limitations of a number of prosthetic options based on his European experience. Since her present prosthesis no longer fitted due to changes in her residual limb contours, he also volunteered to take the plaster impression and rectify the positive model that would be used to form the initial test socket. This would allow Steve to demonstrate some of the details of his technique in more detail, while Stephen Schulte would still make the final decisions about the fitting since the test socket procedure and dynamic alignment trials were scheduled for the following week. With the patient's permission, that is precisely what transpired.
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Steve's impression method works best with an assistant, and is similar to other European techniques for casting transfemoral amputees.
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Steve emphasizes full containment of the ascending ischiopubic ramus, particular for patients with a mature residual limb. His experience parallels mine, which is that this approach seems to improve rotary stability of the residual limb within the socket and to offer the patient better control of the limb in the sagittal plane. It is possible that this contour results in a more energy efficient gait, and that it might account for the improvement in the PCI index that Steve's research has consistently demonstrated when IC is added to the design of an HD socket.
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Modified positive model demonstrating complete encasement of the ascending ischiopubic ramus. The region surrounding the distal pelvis will be reinforced internally with a rigid acrylic lamination while the shaded region will gradually transition to a completely flexible laminated mini-socket. The anterior lace closure will permit the amputee to "cinch" the socket snugly so that most of it can be laminated only with fabric-reinforced flexible silicone elastomer.
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Stephen Schulte later emailed me a note reporting that the test socket fit quite well, and would be suitable for a definitive socket after some selective remolding to improve patient comfort. Most patients who transition to a flexible silicone socket from a more rigid thermoplastic or laminated design report increased comfort, particularly when sitting. Lacing the socket snugly has a "girdle-like" effect that some patients report makes the socket seem less bulky under clothing. Hopefully this young lady will experience similar benefits from her new prosthesis, which will include a micro-hydraulic knee and dynamic response foot.
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Ante: Dynamic test socket proved comfortable, offered excellent control of the prosthesis, and fully contained the medial pelvis to the midline.
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Post: Dynamic test socket proved comfortable, offered excellent control of the prosthesis, and fully contained the medial pelvis to the midline.
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