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Chapter 22B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Translumbar Amputation (Hemicorporectomy): Prosthetic Considerations

Greg Gruman, C.P. 
John W. Michael, M.Ed., C.P.O. 

OVERVIEW

The translumbar (hemicorporectomy) amputee requires a special degree of care from the entire medical and prosthetic management team since this level of amputation represents a heroic effort to save the patient's life in the face of severe trauma, infection, or cancer. It requires the full cooperation of both the professionals involved and the amputee himself to achieve success.

Prior to performing the operation, the surgeon will ensure that the patient understands both the outcome of the procedure and the potential for rehabilitation.Ideally, the patient will have good support from spouse and family and will have completed a realistic goal-setting process. The purpose of preprosthetic therapy is strengthening of the entire upper part of the body due to primary dependence on the upper limbs for mobility following amputation.

Since translumbar amputation (TLA) has only been performed in recent decades and is therefore rarely encountered in clinical practice. There is a tendency for the prosthetist, therapist, and physician to feel overwhelmed when faced with this challenge (Fig 22B-1.). However, prior experience with paraplegics is very good preparation for working with the TLA survivor. In fact, ambulation may be easier for the translumbar amputee since the weight of modern prosthetic limbs is but a fraction of the weight of the missing portions of the body. Donning, doffing, standing, and sitting techniques are all similar for both paraplegic and translumbar patients. Furthermore, the literature reports numerous cases of successful prosthetic fitting following TLA, including instances of independent household and limited community am-bulation.

The prosthetic management of a translumbar amputee involves several key decisions, including the choice of a static or ambulatory system, componentry options, and suspension techniques. All are important factors in developing a prescription and treatment plan and require close consultation with the prosthetist. One key factor is the amputee's interest in and physical potential for ambulation. As would be expected, depression as well as significant medical complications are commonly encountered; both can preclude ambulation until resolved. Physical barriers to prosthetic fitting can include gross obesity, inability to tolerate an upright posture, and poor upper-limb strength. A semireclined custom seating system may be considered in such cases.

SITTING PROSTHESIS

Most authors advise provision of a static sitting support system prior to consideration of ambulatory prostheses, and many variants have been detailed in the literature. This nonambulatory system is used after primary healing is complete and while the rehabilitation options are being analyzed. The static sitting prosthesis is a good diagnostic tool for assessing amputee tolerance and cooperation. Greater acceptance will occur if the amputee is allowed to fully acclimate to the sitting device prior to the introduction of an ambulatory system.

Initially, the sitting device has a level distal surface to enhance safety and stability (Fig 22B-2.). Once comfort and a few hours' tolerance for sitting upright have been achieved, the distal platform may be altered by adding a rocker bottom to allow smoother forward progression by using the arms for a swing-through gait. The specific contour of the rocker depends upon such factors as body weight, torso height, and arm length and is best determined by dynamic alignment of the prosthesis during hand walking. Dankmeyer and Doshi have suggested that the proper height for the base allows placement of the palms flat on the floor with slight elbow flexion. Ideally it will provide sufficient stability to allow the amputee to pick up small objects without tipping over and yet allow an easy weight shift to initiate ambulation.

Prior to casting for the prosthesis, it is desirable to use a tilt table with various degrees of elevation so that the amputee may develop a tolerance for the casting procedure. It is generally recommended that the amputee be suspended from a casting frame to allow the design of an accurate weight-bearing cast in a vertical position. It is important to place the tissues carefully in the position they will occupy in the final prosthesis. Epoxy resin-based bandage can be used for the cast and reused later as a temporary prosthesis with the tilt table to increase the tolerance for weight bearing.

SOCKET DESIGN

The socket design for the translumbar amputee must precisely identify weight-bearing and relief areas by using multiple transparent test socket procedures. The major weight-bearing area is the thorax assisted by containment of the abdominal tissues. Several areas need pressure relief, including the inferior borders of the scapulae, any prominent spinous processes, the axillae, and the brachial plexus complex. It is desirable to use a proximally adjustable socket to accommodate weight loss or gain and to allow the amputee to partially redistribute the weight-bearing forces to increase comfort. The socket design must also accommodate the ostomy stomas and allow free access to these sites for self-care. The most common design utilizes "mail slots" to allow the collection bags to remain outside the socket, free of the pressures induced by weight bearing. Any openings in the socket must be carefully limited, or the abdominal skin will protrude. In some cases, it is necessary to fashion a latex strap (fastened with Velcro) to cover the "mail slots" and provide gentle pressure to reduce the soft-tissue herniation. With flat drainage bags, it may be possible to omit the colostomy opening, provided that the amputee can defecate daily when not wearing the prosthesis.

Simons et al. have summarized the goals of socket design for the translumbar amputee as follows:

1. Independent transfer in and out of the socket (Fig 22B-3.)
2. Sufficient stability to permit free use of the upper limbs and wheelchair mobility
3. Minimum socket tolerance of two 4-hour periods daily
4. Sufficient weight-bearing pressure distribution to prevent skin necrosis
5. Allowance for adequate respiratory exchange
6. No abdominal pain or nausea from pressure within the socket
7. Prevention of eversion of the colostomy and ileal bladder drainage bags
8. Easy access to drainage bags for self-care
9. Pressure relief over the sternum and distal portion of the spine, even when leaning forward or back in the socket
10. Acceptable cosmesis
11. Ease in cleansing socket areas in contact with the body

Due to the limited surface area available for weight bearing, total contact is the best approach to reduce the pressure per square centimeter. Although earlier reports speculated about the possibility of interfering with respiration, a paper by Grimby and Stener noted only minimal change in vital capacity with a new prosthesis designed to reduce rib contact. It is usually advisable to unweight the prosthesis at frequent intervals by pushing up with the arms, analogous to the advice given paraplegics to avoid skin breakdown. Over a period of weeks or months, the amputee can gradually increase tolerance to an upright posture in the device up to 8 hours or more daily. Several reports of return to gainful employment have been noted in the literature.

AMBULATORY PROSTHESES

Having accomplished this degree of independence, some amputees will request prosthetic legs for cosmetic purposes or to permit limited ambulation. Davis et al. have reported long-term follow-up with two patients who remained ambulatory and gainfully employed for several years following prosthetic fitting and note that "the appearance of body normality appeared to play an important part in motivating them towards seeking a life other than institutionalized hopelessness and helpless invalidism." Williams concurs and reports that "when the patient was fitted with his final prosthesis, his attitude toward life changed dramatically .... Legs, even in a wheelchair, apparently made a difference for which there was no substitute . . . ," Although ambulation with crutches or a walker is feasible, transfers will be more cumbersome with prosthetic legs attached. Rather than encumbering the sitting prosthesis, it may be preferable to prescribe a separate ambulatory prosthesis with a new socket. Dankmeyer and Doshi have reported a clever alternative (illustrated in Fig 22B-6.) whereby the ambulatory prosthesis fastens on top of the sitting device, thus allowing the amputee to leave the legs behind in the chair when transferring.

Goals for dynamic alignment include stability of knees and hips, gentle heel strike, and smooth rollover during stance phase. The gait pattern may be swing-through using forearm crutches or swing-to using a walker. As is the case with paraplegia, it is the upper portion of the body that provides the propulsive force for such ambulation. Success with a reciprocating gait by swiveling the torso has also been reported for both bilateral hip disarticulation and for translumbar amputation, provided that transverse rotation units are incorporated into the prosthesis.

Due to the small number of cases reported, it is not possible to recommend particular components. Each clinic team must therefore make an individual determination based upon their experience and judgement. Successful ambulation has been reported with either free or locking hips joints; polycentric, stance-control, or locking knees; and either articulated or solid-ankle foot mechanisms (Fig 22B-4.).

Although successful exoskeletal fittings have been reported in the past (Fig 22B-5.), most recent cases utilize realignable endoskeletal componentry because of its versatility and light weight. Due to the ease of interchangeable components, endoskeletal designs permit clinical verification of various foot, ankle, knee, and hip joint combinations during gait training (Fig 22B-6.). It is also possible to add components sequentially. Initially, prosthetic feet may be added directly to the socket to create a "stubby" prosthesis similar to the well-known design for bilateral transfemoral (above-knee) amputees. Length can be increased in increments, as the patient's balance and strength permit, with hip and knee joints added as the amputee progresses.

Suspension of the prosthesis is critical if the stresses of swing-through ambulation are to be tolerated. Over-the-shoulder suspenders have proved to be the best option for this type of prosthesis. Care must be taken not to pinch any protruding flesh where the suspenders cross the proximal edge of the socket.

CONCLUSION

The survival period for translumbar amputees may sometimes be limited but has increased steadily as medical care has advanced; survival for more than 20 years has been documented. It is the mission of the clinic team to enhance quality of life during whatever time remains. This is accomplished by providing the greatest possible independence and freedom, including employment and ambulation to whatever degree the amputee is capable. The primary factors in the successful rehabilitation of the translumbar amputee are motivation and compliance: the highly motivated individual will succeed despite the difficulties.

J. Bradley Aust performed the first successful TLA in 1961; the amputee found work in a nursing home and survived until 1980. Aust summarizes his long-term experience with this procedure in a recent paper as follows:

"Freed of the nonfunctioning lower half, the patient is released from the dead weight holding him down, relieved of his chronic infection and/or cancer, and experiences a new mobility, sense of well-being, and renewed enthusiasm for life."

The obvious loss of more than half of the body mass notwithstanding, numerous successful fittings following TLA attest to the potential for rehabilitation of the person faced with this singularly difficult challenge.

References:

1. Aust JB, Page CP: Hemicorporectomy. J Surg Oncol 1985; 30:226-230.
2. Baker TC, Berkowitz T, Lord GB, et al: Hemicorporectomy. Br J Surg 1970; 57:471-476.
3. Dankmeyer CH Jr, Doshi R: Prosthetic management of adult hemicorporectomy and bilateral hip disarticulation amputees. Orthot Prosthet 1981; 35:11-18.
4. Davis SW, Chu DS, Yang CJ: Translumbar amputation for nonneoplastic cause: Rehabilitation and follow-up. Arch Phys Med Rehabil 1975; 56:359-362.
5. DeLateur BJ, et al: Rehabilitation of the patient after hemicorporectomy. Arch Phys Med Rehabil 1969; 50:11-16.
6. Easton JKM, Aust JB, Dawson WJ, et al: Fitting of a prosthesis on a patient after hemicorporectomy. Arch Phys Med Rehabil 1963; 44:335-337.
7. Frieden FH, Gertler M, Tosberg W, et al: Rehabilitation after hemicorporectomy. Arch Phys Med Rehabil 1969; 50:259-291.
8. Friedmann LW, Marin EL, Park YS: Hemicorporectomy for functional rehabilitation. Arch Phys Med Rehabil 1981; 62:83-86.
9. Grimby G, Stener B: Physical performance and cardiorespiratory function after hemicorporectomy. Scand J Rehabil Med 1973: 5:124-129.
10. Leichtentritt KG: Rehabilitation after hemicorporectomy. Am J Proctol 1972; 23:408-413.
11. Mackenzie AR, Miller TR, Randall HT: Translumbar amputation for advanced leiomyosarcoma of the prostate. J Urol 1967; 97:133-136.
12. Miller TR, Mackenzie AR, Karasewich EG: Translumbar amputation for carcinoma of the vagina. Arch Surg 1966; 93:502-506.
13. Miller TR, Mackenzie AR, Randall HT, et al: Hemicorporectomy. Surgery 1966; 59:988-993.
14. Miller TR, Mackenzie AR, Randall HT: Translumbar amputation for advanced cancer: Indications and physiologic alterations in four cases. Ann Surg 1966; 164:514-521.
15. Pearlman SW, McShane RH, Jockimsen PR, et al: Hemicorporectomy for intractable decubitus ulcers. Arch Surg 1976; 111:1139-1143.
16. Simons BC, Lehman JF, Taylor N, et al: Prosthetic management of hemicorporectomy. Orthot Prosthet 1968; 22:63-68.
17. Terz JJ, Schaffner MJ, Goodkin R, et al: Translumbar amputation. Cancer 1990; 65:2668-2675.
18. The most radical procedure. Inter-Clin Info Bull 1966; 5:22-23.
19. Williams RD, Fish JC: Translumbar amputation. Cancer 1968; 23:416-418.

Chapter 22B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

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