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Complications following treatment of disease about the hip may render a limb so nonfunctional that the patient is confined to bed or a wheelchair. Admitting therapeutic defeat and knowing "how and when to quit" may be wise. Four chronically disabled patients released from their confinement and rehabilitated by disarticulation of the hip are described.
A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient with bilateral amputations at the shoulder disarticulation level. Four independently controlled nerve-muscle units were created by surgically anastomosing residual brachial plexus nerves to dissected and divided aspects of the pectoralis major and minor muscles. The musculocutaneous nerve was anastomosed to the upper pectoralis major; the median nerve was transferred to the middle pectoralis major region; the radial nerve was anastomosed to the lower pectoralis major region; and the ulnar nerve was transferred to the pectoralis minor muscle which was moved out to the lateral chest wall. After five months, three nerve-muscle units were successful (the musculocutaneous, median and radial nerves) in that a contraction could be seen, felt and a surface electromyogram (EMG) could be recorded. Sensory reinnervation also occurred on the chest in an area where the subcutaneous fat was removed. The patient was fitted with a new myoelectric prosthesis using the targeted muscle reinnervation. The patient could simultaneously control two degrees-of-freedom with the experimental prosthesis, the elbow and either the terminal device or wrist. Objective testing showed a doubling of blocks moved with a box and blocks test and a 26% increase in speed with a clothes pin moving test. Subjectively the patient clearly preferred the new prosthesis. He reported that it was easier and faster to use, and felt more natural.
The subjective responses and gait patterns of unilateral knee disarticulation amputees wearing prostheses fitted first with the Multiflex foot and then with the Quantum foot were studied. Nine amputees were included in the trial. A questionnaire asked the amputees about their preference for one of the feet. Gait analysis was performed measuring temporal parameters and goniometry of hips, knees and ankles in the sagittal and frontal planes. There was a slight preference for the Quantum foot. Preference seemed not to be related to physical characteristics of the amputees nor to gait parameters. There were no differences in gait as far as the temporal factors were concerned. The main differences in the range of motion of the joints were in the frontal plane: the eversion-inversion movement of the ankle and the adduction-abduction movement of the hip. During walking at comfortable speed with the Multiflex foot the ankle and hip range of motion averaged 2.1 and 3.1 degrees respectively, less than during walking with the Quantum foot.
Equipment and methods used in treating a patient with a traumatic bilateral shoulder disarticulation in order to achieve independence in several daily living skills without the use of prostheses are described in this article. Dressing, bathing, toileting, communication, and hygiene skills are presented.
Interscapulothoracic amputation, disarticulation of the hip and hemipelvectomy were performed relatively seldom in the past. The results in 38 patients demonstrate that the aim to save the extremity at all events at the beginning of treatment will often lead to incurable conditions later on. Radical surgery of sarcomas of the extremities is the only chance for cure.
The authors describe a modified technique for knee joint disarticulation surgery. Their approach provides two flaps, one medial and one lateral, which result in a posterior, longitudinal scar that remains outside the contact areas of the prosthesis. They abrade the lateral and posterior aspect of each condyle, peeling out the articular cartilage and re-covering the condyles with the joint capsule. This technique allows a satisfactory stability in prosthetic rotation, and improves the appearance of the artificial limb. For post-operative rehabilitation the authors use a tridimensional alignment jig and a prosthetic ankle with three degrees of freedom: flexion-extension, lateral-medial motion and rotation, making easier the swing phase while maintaining the obvious advantages of a pilon-type prosthesis.
A special sitting orthosis was designed and fitted for a 59-year-old patient with right-side hemiplegia and expressive aphasia who underwent bilateral hip disarticulation due to peripheral vascular disease involving both lower extremities. The orthosis prevented the patient from sliding down in the wheelchair and allowed him to sit comfortably and safely with even weight distribution that prevented formation of pressure sores. Without the orthosis, the patient was unable to sit in a wheelchair without hazardous sliding. It also helped him sitting in bed. The orthosis, strapped to the back of an amputee wheelchair equipped with an antitipping extension aid, permitted the patient to sit safely upright in a relaxed position, wheel himself more easily, use a desk arm if desired to feed himself, read, or perform other activities. The patient, when secured in the orthosis, also could be lifted easily and placed into any chair, bed, or even on the floor.
A 24-year-old man, who was late attaining developmental milestones and tested in the severely mentally retarded range, had incurred third- and fourth-degree burns at 2.5 years that resulted in a deformed, anesthetic, and useless distal left upper limb. Following wrist disarticulation, he was fitted with a cosmetic prosthesis that he accepted enthusiastically. It permitted him to use his left upper limb as an effective assister. Attempts to wear and use a functional prosthesis were not successful because the bulbous stump was covered with abnormal skin that ulcerated whenever he wore the prosthesis. At present, he resides at home with his mother and has all self-care skills. He attends a day treatment program and helps his mother with household chores as well as neighborhood errands. The prognosis for continued functional improvement is good, even though he remains severely mentally retarded.
An otherwise healthy 17-year-old young man developed bilateral heel pad necrosis due to meningococcemia, adult respiratory distress syndrome, and disseminated intravascular coagulation. Bilateral ankle disarticulation amputations were salvaged by use of a dorsally based local flap on one residual limb and a free muscle transfer to reconstruct the weight-bearing surface of the contralateral residual limb. The case report illustrates two methods of unusual salvage of the end-bearing, weight-bearing surface of the residual limbs in a bilateral end-bearing amputation.
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