Trans-USA Hip Disarticulation/Transpelvic Prostheses Tour: Part Six = Texas Scottish Rite Hospital for Children
From California, Steve Taylor and I flew into Dallas, Texas to meet with Don Cummings, CP, who is the head of the prosthetic department at this outstanding pediatric specialty hospital. TSRHC is an exceptionally nice facility that is geared exclusively to the treatment of children and young adults. The generosity of the donors who support its operation is evident from the cheerful colors that adorn the ample exam rooms and waiting areas in this ultramodern but very "homey" facility. Steve was very impressed with how "kid friendly" the entire operation was and took several pictures to share with the hospital staff back in the United Kingdom.
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Although we had a chance to meet a couple of patients at the clinic who used transfemoral prostheses, it happened that no one with a high level amputation was scheduled for the day we were there. Instead, we met with Don in his office and he gave a PowerPoint presentation that summarized the typical treatment protocols used at TSRHC to manage patients with hip disarticulation and transpelvic levels of loss or congenital absence, from infancy until they become adults. There are very few people in the United States with the depth and breadth of experience that Don has in treating all ages of such patients, so this was a particularly valuable perspective to share with Steve.
Don recommends fitting even high-level unilateral amputees as infants, ideally providing the initial prosthesis just before they are developmentally ready to pull-to-stand so they can develop their ambulation skills at the same pace as any other children. The infant prosthesis is typically very simple biomechanically with only an articulated hip joint. The knee and ankle are generally solid and a basic SACH or flexible keel foot provides simple stability. The socket is often made from a thermoplastic material, and accommodates the child's diapers; the free hip joint makes it simple to sit but does not impede crawling.
The decision to articulate the knee and/or ankle is a clinical judgment based on an assessment of the child's strength, balance, and developmental ability to control a free knee. Although it was traditionally believed that very young children could not be expected to master a freely bending prosthetic knee, recent research has shed doubt on the accuracy of this assumption for those with a transfemoral residuum. Most clinics first transition to a locked knee that can be unlocked for sitting and then offer a free knee later.
The current approach at TSRHC is to offer a polycentric knee when the child with unilateral involvement is approximately 2-3 years old. The timing is more variable for children with bilateral lower limb loss, but is typically a year or two later.
There is general agreement among most pediatric rehabilitation clinics that the biomechanical complexity and technological sophistication of the components should gradually increase as the children enter school and eventually become teenagers, so that by the time they are skeletally mature they have smoothly transitioned to sophisticated adult prostheses. TSRHC follows the same prescription pattern.
With permission, I am posting a short summary of Don's clinical preferences for different age groups with unilateral hip disarticulation or similar levels of absence:
Toddlers:
Flexible thermoplastic socket and frame with pediatric hip joint, no knee, and a solid ankle foot; cast and fit over diaper.
Child 2-8 Years Old:
Flexible thermoplastic socket and frame with ischial containment; add polycentric knee and ankle-foot component consistent with patients activity level.
Adolescent 10-15 Years Old:
Flexible thermoplastic socket and frame with ischial containment; fluid controlled knee for variable cadence; dynamic response foot; consider shock pylon, torque absorber, and Littig Strut hip joint if patient activities justify the added weight.
Young Adult 16-21 Years Old:
Same as the Adolescent configuration but consider microprocessor-controlled hydraulic knee for maximum stability and cadence response.
Don can be reached at Don.Cummings@tsrh.org.
