There’s More Than One Way To Fit a Patient
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
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.
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
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: firstname.lastname@example.org.