Bilateral Hip Disarticulation Management
Janet L. Rogers, MS, PTA
C. Dale Pape, MSEd, PT
Richard J. Thiele, CP
ABSTRACT
This article discusses the evaluation, impression, modifications, fabrications and
rehabilitation of a patient with bilateral
hip disarticulations necessitated by severe
decubitus ulcers secondary to a 7th thoracic level (T-7) spinal cord injury. The
care of this patient was a challenge due to
bilateral amputations at such a high level
and the special needs of a patient who has
a spinal cord injury.
Introduction
Hip disarticulation amputations continue to be relatively rare. They are
usually performed when malignant disease of the pelvis, hip joint or upper
thigh cannot be treated by more conservative means. Sometimes they are
performed if osteomyelitis of the pelvis
or proximal femur or certain massive
benign tumors in the pelvic region have
not responded to less radical procedures (1).
In this case study, a 49-year-old T-7
spinal cord-injured male who had bilateral hip disarticulation amputations,
including transection of ischii to the
level of the horizontal ramus of the pubis, was treated prosthetically and rehabilitated. Amputations were secondary to severe decubitus ulcers that developed and did not respond to conservative methods of treatment.
Over the past three years, attempts
at prosthetic fitting failed because of
chronic tissue breakdown over the remaining bony prominences. The patient's decubitus ulcers and inability
to sit upright due to absence of ischii
necessitated that he remain in a prone
position for extended periods of time.
The prolonged prone position resulted
in a 25-degree lumbar lordosis and
a weeping decubitus ulcer over the
right anterior superior illiac spine
(ASIS).
The rarity of this type of amputation,
coupled with alterations in bony landmarks of this particular patient, made
prosthetic fabrication an interesting
challenge. The prosthesis had to provide sitting support, ambulation opportunities with crutches, cosmesis, intimate fit and increased usage without
risk of breakdown. Physical therapy
concentrated on strengthening exercises, monitoring pressure points, and
transfer and gait training.
Evaluation and Impression
The prosthetist took an impression
with the patient suspended between
parallel bars with the thorax encased in
cotton stockinette. The majority of the
weight was distributed to the residuum
to expose bony prominences while a portion of the weight was borne by the forarms. Alignment lines were established prior to impression removal.
Modifications
The positive mold was modified to distribute weight primarily to the shelf
created by the spinal lordosis and posterior thorax region. Selected soft tissue weightbearing was achieved by natural distortion of the tissue during the
weightbearing impression method. Reliefs were provided over bony prominences via plaster build-ups on the
mold.
Fabrication and Fitting
A 9-mm AliplastTM pad was formed
over the distal mold, and a Durr-Plex?
diagnostic socket was blister formed.1,2
The diagnostic socket was evaluated
for fit in sitting, standing and prone
positions. Reliefs were provided to the
bony prominences, and a port was provided to allow passage of the patient's
catheter (see Figure 1
). Proximal trimlines were located at the axilla level
with the medial and lateral aspects lowered sufficiently to prevent impingement during upper-extremity motion
such as flexion and extension of the
glenohumeral joint and lateral trunk
bending.
A hinged anterior section allowed
donning and doffing. An anterior trimline was placed at the level of the ASIS
to allow adjustments to these pressure sensitive areas. Lateral trimlines were
located at the socket midlines. The lateral edges of the anterior shell were
reduced 2 cm and leather tongues were
applied. VelcroŽ straps were also applied so the subject could adjust the
amount of weight borne between the
thorax and the residuum.
Lower appendages were attached using Canadian-style hip joints, Otto
Bock 3P4 manual locking knees and
SACH feet.3,4,5 While a modular approach would have provided weight reductions, the components and covering
would not withstand the stress and
forces encountered when the patient
enters and exits his wheelchair.
Static alignment of the prosthesis
was performed, as recommended by
Foort and Radcliffe (2). The hip joints
were spaced with a 25-cm dimension
between outside edges and positioned
to provide five-degree adduction of the
thigh segments to achieve a support
base of 12.7 cm. The overall length of
the prosthesis is 76 cm from hip joints
to floor, and knee center is located at
47 cm. During dynamic alignment, the
hip bumpers were reduced to accommodate the excessive lordosis.
The definitive prosthesis was laminated with perlon tricot, carbon fibers
and acrylic resin.6,7,8 The Aliplast pad
affixed to the socket provided a 6-mm
air chamber to further equalize pressures to the distal residual limb. Ventilation holes over the entire thorax region allowed for air circulation, which
was further enhanced by using a three-ply acrylic/lycra sock.9 The finished
prosthesis, before ventilation, is seen
in Figure 2a and Figure 2b
.
Before regular use, the socket was
further modified to provide relief to
the right ASIS and the transverse process of the pubis. The proximal trimlines
were lowered in the axilla region to
allow the subject to reach items on the
floor while sitting in his wheelchair.
Rehabilitation
The patient's rehabilitation goals included ambulating for short distances,
independent standing for specific activities of daily living (ADL) such as
cooking, and independence in all other
ADL when in his wheelchair. The
structural lumbar lordosis presented
socket fitting difficulties but benefited
the patient in transfers and floor activities (3). In addition, the lordotic posture helped maintain the extension moment at the hips necessary to maintain
balance when standing.
Positioning of the Canadian-style hip
joints was dynamically assessed in sitting and standing to provide maximum
balance and stance stability.
The high level of the socket provided
additional trunk stability for wheelchair and sitting balance. Additional
trunk strengthening in all planes can be
performed on the floor, with assistance
for distal stabilization or when the
prosthesis is donned. Exercises may include planar and diagonal sit-ups in supine, and upper trunk extension in
prone and supine positions. All activities incorporate compensatory movement patterns at the scapula to enhance functional abilities. Trunk support through the socket may also provide increased intra-abdominal pressure to assist in respiration (4).
Long-sitting (sitting on the floor with prosthetic legs extended) progresses
from sitting with bilateral upper exremity propping to unilateral arm
propping and brief independent sitting.
When in long-sitting with forward
weight shift, downward pressure on the
up joint caused an undesirable upward
kick of the foot, affecting balance in
such forward activities as locking the
knee before standing. This pressure
was corrected during fitting by increasing the height of the hip joints and
rounding the distal socket to match the
contour of the wheelchair seat while
sitting. The rounded socket also enhanced lateral trunk motion. The posterior thigh sections were flattened to
achieve a level base while long-sitting
on the floor.
Upright balance activities must be
performed while wearing the prosthesis due to the removal of the ischii.
According to Decker, standing is an
appropriate functional goal for individuals with spinal cord injuries between
T3 and T1l (5). Rehabilitation for
standing is initiated in parallel bars,
progressing from bilateral upper-extremity support to independent standing. Balance is challenged by movement of arms, head and eventually the
trunk. Maintaining the pelvis anterior
to the shoulders, critical for balanced
standing, is facilitated by positioning
the hip joint and, for this patient, the
lumbar lordosis.
Progression to ambulation also begins in the parallel bars and progresses
to forearm crutches. Ambulation by
This patient was achieved with distances regulated by his energy expenditure. He progressed to ambulation
with forearm crutches for distances of
up to 50 feet indoors and short distances outside as well as standing for
ADL.
Impaired skin sensation secondary
to the mid-thoracic spinal cord injury
makes monitoring pressure points from
the prosthesis of utmost importance.
Throughout the various aspects of rehabilitation, pressure points are monitored. Patient education is important
in regards to which activities pose the
greatest risk to skin integrity and the
specific pressure areas to monitor.
Conclusion
Functional goals of this patient were
met through the careful fitting and dynamic modification of the prosthesis in
response to rehabilitation and skin integrity needs. He is able to live independently and is seen in the clinic for
follow-up care.
Janet L. Rogers, MS, PTA, is an assistant professor in the physical therapist assistant program at Southern Illinois University, Clinical Center, Carbondale, IL 62901; (618) 453-2361.
C. Dale Pape, MSEd, PT, is coordinator of the physical therapist assistant program at Southern Illinois University, Clinical Center, Carbondale, IL 62901; (618) 453-2361.
Richard J. Thiele, CP, is manager of the Carbondale Prosthetic Lab, Route 6, Box 160a1, Carbondale, IL 62901; (618) 457-4629.
References:
- Sanders G. Lower-Limb Amputations:
A Guide to Rehabilitation. FA. Davis,
Philadelphia, PA, 1986; 298.
- Foort J, Radcliffe C. The Canadian-type
hip disarticulation prosthesis. Prosthetic
devices Research Project, Institute of Engineering Research, University of California Berkeley, March 1956; 32-6.
- Somers M. Spinal Cord Injury Functional Rehabilitation. Appleton & Lange, 1992;
139.
- Palmer M, Toms J. Manual for Functional Training. F.A. Davis, 1992.
- Decker M. Exercise for spinal cord injured patients. Therapeutic Exercise. Des:
- Basmajian J, Wolf SL, 1990; 177-205.
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