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June 2007 • Vol. 3, No. 3
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Advancing Orthotic and Prosthetic
Care Through Knowledge
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Jonathan D. Day, CPO, LPO
Jennifer Block, orthotic resident
Abstract
This case study shows one method to provide convenient, durable, low-cost residual-limb protectors suitable for indoor and limited outdoor ambulation for the bilateral pediatric knee-disarticulation patient. Background: Pediatric amputees are often reluctant to use prostheses within the household environment. In particular, children with bilateral knee disarticulations can ambulate easily on their residual limbs with minimal energy expenditure. The main consideration in this circumstance becomes protecting the skin over the distal ends of the femurs, which can suffer bruising and abrasions from household surfaces such as carpet and tile. Case Study and Methods: A two-year-old child with bilateral knee disarticulations was provided with off-the-shelf gel liners from Össur, Aliso Viejo, California, which were further modified through the application of leather and cork soling over the manufacturer's silicone end caps, for indoor and limited outdoor ambulation. Discussion: The "nub caps" described in this case study are suitable for unlimited indoor use by pediatric amputees with bilateral knee disarticulations. The caps have proven to be durable, easy to don, and well accepted by the patient and family. This system allows for protection of the residual limbs as well as reduced energy expenditure, improved proprioception, and spontaneity in initiating ambulation for the patient when compared to bilateral prostheses. In addition, suspension is easily maintained by the gel liner itself, so the patient is unencumbered by auxiliary suspension.
Background
 - Figure 1
Children with congenital amputations, or those who receive amputations early in life, often find themselves encumbered by prostheses, particularly within the household. Lower-limb prosthetic management for young children is demanding for parents and caregivers. Donning the prostheses can require an interruption in activities, and the prostheses themselves can induce undesirable gait deviations such as circumduction and excessive posterior pelvic tilt.1 Suspension is challenging with young children, as their limbs often lack the size and anatomical maturity which aid in keeping lower-limb prostheses suspended and free from excessive rotation. Feedback from parents of children with bilateral knee disarticulations indicates that there is a need for limb protectors for indoor use that are durable, convenient to use, and affordable.
Case Study
 - Figure 2
This case study outlines the treatment of a two-year-old child who received bilateral knee disarticulation amputations at the age of eight months secondary to complete longitudinal deficiency of both tibias (figure 1). The patient was fit with bilateral prostheses without knees at one year of age (figure 2) after demonstrating the ability to pull up to stand. The patient was capable of ambulating in the prostheses.2 However, within the household, the child was quite adept at ambulating without prostheses, which allowed for spontaneity in initiating ambulation and improved feedback from the environment. As the subject's activity level increased, concern developed over the skin integrity of the residual limbs. An alternative to the prostheses was sought which would be conforming, protective, durable, and easy to manage. The solution also needed to be easily available off-the-shelf at a reasonable cost in case funding issues arose with the insurance provider.
Methods
 - Figure 3
The patient was first provided with Alpha® liners from Ohio Willow Wood, Mt. Sterling, Ohio, with a variety of cork and crepe sole materials affixed to the distal end for reinforcement (figure 3). The patient was able to ambulate in these; however, problems developed after only a few weeks of use. The stock liners were not available in an appropriate size, which led to gapping between the distal end of the limb and the liner (figure 4). This caused undue wear to the liner and increased the likelihood of skin complications for the patient (figure 5). In addition, no secure method of attaching soling material to the fabric cover of the liner was achieved, despite consultation with Ohio Willow Wood. The decision was then made to use Össur's Iceross® Dermo cushion gel liners, which have an integrated endcap made of a resilient silicone material. No modifications were initially made. These liners proved durable enough to withstand three months of indoor use with no appreciable wear. In addition, a second set of liners was provided, which had been modified with a leather cap affixed to the manufacturer's endcap with silicone epoxy. Cork was then adhered to the leather using contact cement to create a sole (figure 6). These liners were provided for limited outdoor use and have also proven to be durable in the three months since they were furnished.
 - Figure 4
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 - Figure 5
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Discussion
 - Figure 6
Complete longitudinal deficiency of the tibia is a rare anomaly, occurring in approximately one in one million live births.3 This condition results in severe equinovarus deformity and is usually treated with amputation at the knee disarticulation level.4 Toddlers with bilateral knee disarticulations are capable of efficient, rapid, and spontaneous ambulation without prostheses, as the base of the femoral condyle is designed for skeletal loading.5 While pediatric bilateral knee disarticulation amputees are a small part of most prosthetists' patient population, their needs are unique and require creative solutions. Typical prostheses, with their accompanying socks, liners, and suspension belts, are cumbersome and often unnecessary in the household environment. The limb protectors described in this study represent an "off-label" use for a widely available stock item and can be easily obtained and modified by most prosthetic facilities.
Residual-limb protectors may be of value to other amputee populations. Many pediatric and adult prosthetic patients enjoy swimming with their friends and family but are concerned about abrading their residual limbs on the pool or surrounding concrete. Others prefer to keep their residual limbs covered in public places. Patients who have suffered a Syme or long end-bearing transtibial amputation may be able to utilize a similar system for swimming and outdoor activities.
References
Wilk B, Karol L, Halliday S, Cummings DR, Haideri N, Stephenson J. Transition to an articulating knee prosthesis in pediatric amputees. J Prosthet Orthot 1999;11:69-74. Cummings DR, Kapp SL. Lower-limb pediatric prosthetics: general considerations and philosophy. J Prosthet Orthot 1992;4:196-206. Fernandez-Palazzi F, Bendahan J, Rivas S. Congenital deficiency of the tibia: a report on 22 cases. J Pediatr Orthop 1998;B7(4):298-302. Suganthy J, Rassau M, Koshi R, Battacharjee S. Bilateral tibial hemimelia I. Clin Anat 2006, Available at: www3.interscience.wiley.com/cgi-bin/...PDFSTART. Accessed Jan 7, 2007. Stark G. Overview of knee disarticulation. J Prosthet Orthot 2004;16:130-137.
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