|Year : 2021 | Volume
| Issue : 1 | Page : 78-82
A recent approach of telescopic prosthetic fitment for rehabilitation of a congenital limb deficient child with longitudinal fibular deficiency using Jaipur limb technology: A case study
Achintya Prakash1, Anjali Sharma2
1 Department of Multiple Disabilities and Rehabilitation, Faculty of Special Education, DSMNR University, Lucknow, Uttar Pradesh, India
2 Department of Neuro Rehabilitation, AMRI Hospital, Kolkata, West Bengal, India
|Date of Submission||27-Jun-2020|
|Date of Decision||07-Aug-2020|
|Date of Acceptance||10-Sep-2020|
|Date of Web Publication||2-Feb-2021|
Room No. 108, A2 Block, DSMNR University, Mohaan Road, Lucknow - 226 017, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Rehabilitation of children with congenital lower limb deficiencies is a very confronting task. An 8-year-old boy presented with left lower limb deficiency since birth and inability to perform the activity of daily living as per expectation with his old ortho-prosthesis. The current case study explores a recent telescopic prosthetic design with relatively less engagement over deficient limb but capable to restore maximum function in an economic way.
Keywords: Congenital, Jaipur limb technology, longitudinal fibular deficiency, lower extremity, prosthetic management, rehabilitation
|How to cite this article:|
Prakash A, Sharma A. A recent approach of telescopic prosthetic fitment for rehabilitation of a congenital limb deficient child with longitudinal fibular deficiency using Jaipur limb technology: A case study. Int J Health Allied Sci 2021;10:78-82
|How to cite this URL:|
Prakash A, Sharma A. A recent approach of telescopic prosthetic fitment for rehabilitation of a congenital limb deficient child with longitudinal fibular deficiency using Jaipur limb technology: A case study. Int J Health Allied Sci [serial online] 2021 [cited 2023 Mar 29];10:78-82. Available from: https://www.ijhas.in/text.asp?2021/10/1/78/308583
| Introduction|| |
Children with lower limb deficiencies face a lifetime of utilitarian impediments. Limb deficiencies in children might occur because of congenital disorders or amputation resulting from injury, malignancy, disease, or other pathology. Rather than amputation, congenital anomalies are named being either transverse deficiency, in which all the skeletal elements distal to the level of misfortune are missing as in an acquired amputation or longitudinal deficiency, in which there is a partial or complete absence of elements within the long axis of the extremity, with normal skeletal elements generally present distal to the affected bone. Mcguirk et al. found the general pervasiveness of limb insufficiency among 161,252 newborns to be 0.7 per 1000 births. The evident causes included single mutant genes, familial occurrence and known syndromes (24%); chromosome abnormalities (6%); teratogens (4%); vascular interruption (35%); and obscure reason (32%). All children develop paying little heed to congenital anomalies or amputations. Prosthetic options for congenital anomalies should incorporate measures to keep up comfortable socket fit, arrangement for continuous modifications, oblige unordinary shape (deformity), and keep up balanced limb length. The preschool-age kid may require new prosthesis practically every year. Those in grade school frequently require another prosthesis every 12–18 months, and youngsters grow out of prostheses every 1½–2 years. Another problematic issues that arise with congenital limb deficient child are to maintain legitimate restorative appearance of the prosthesis for psychological acceptance and facilitate the adequate development of the affected limb without trading off for the overall fitting and performance. In the current scenario in India, there is no such prosthetic option to suit children with congenital lower limb insufficiency. This case study presents an unusual telescopic prosthetic fitment for a congenital limb deficient child to facilitate maximum versatility and development with legitimate fit and comfort by utilizing a conventional and financially savvy Jaipur limb technology.
| Case Description|| |
An 8-years-old male child of height 121 cm and body mass index of 16.4 kg/m2 has been reported to our clinic with congenital limb deficiency in the left lower extremity. On examination, we found that he has longitudinal deficiency of fibula total, tarsus partial, and ray 3, 4, and 5 total, according to “ISPO designation system” for the nomenclature of congenital limb deficiency of lower extremities [Figure 1]. The involved limb was additionally moderately shorter (around 13 cm) than the contralateral side but capable to sustain the body weight through the sole of the foot. The status of knee was acceptable with normal movement and general muscle strength. The structure and direction of the foot were seriously disfigured as sole confronting medially (severely supinated) and associated with plantar-flexed ankle (equinovarus). The child was very active and enthusiastic yet somewhat unsatisfied with the performance of his old ortho-prosthesis design extended proximally over the thigh with medial and lateral struts and sidebar joints, using since recent 2 years, which is by all accounts bulky, less agreeable, and somehow hampering his performance during play and comparable outdoor and indoor activities. The child had normal developmental milestones, and he had followed all the commands very well indicating good mental capabilities. He was also able to do some indoor activities without the prosthesis or any other assistive device.
|Figure 1: The anterior view (a), lateral view (b), and medial view (c) of the affected left limb of the child with congenital deficiency|
Click here to view
Thinking about the limitations in the previous prosthesis and to accomplish the goals of the child, we have structured a new telescopic prosthesis [Figure 2] with an inner socket to hold the deficient limb securely and an outer telescopic frame for attaching a prosthetic foot distally. The inner socket was expanded on the idea of patella tendon bearing (PTB) Prosthesis, by creating a patella tendon bar and shaping medial and lateral flare of the tibia to take partial weight and putting the rest of the weight on his sole (distal/end weight-bearing) without upsetting the contour at the lower leg and foot to increase greatest restorative appearance with inevitable weight appropriation (proximally at patellar tendon and distally at the sole). The heel cushion alongside posteriorly and medially confronting sole segment were permitted to take the body weight in an inclined position. The pressure-sensitive areas (bony prominences) were palpated and assuaged from excessive pressure by giving sufficient space and soft padding. All these modifications were done on a positive plaster of Paris (POP) mold [Figure 3] obtained from the negative cast of the affected limb taken from the individual. The forefoot portion of the replica was extended about 15 mm to accommodate for the linear growth of the foot. The circumferential dimensions were additionally kept somewhat free to facilitate the growth of the child. A PTB socket was readied utilizing high-density polyethylene (HDPE) pipe molded over the modified positive replica completely lined with Ethaflex sheet. After evaluating the socket fit, an outer telescopic frame was built over the socket by utilizing the same HDPE pipe to fix the Jaipur foot distally, as the underlying PTB socket had no provision for the attachment of the foot because of its compact distal end. It has been done by further extending the socket distally with POP paste utilized for mold preparation before and getting the desired oval distal shape to take the proximal part of the foot. The distal end of the inner PTB socket was leaved open for perspiration issues. Being a telescopic construct, the outer frame permits the prosthetist to perform linear alterations of few millimeters (about 12 mm) with additional provision for foot interchangeability of various sizes as the child grows. The proximal (top) ankle segment of the Jaipur foot has been removed (cut out) to accommodate the limited distal space. A supracondylar leather cuff suspension was introduced at the top of the socket to hold the prosthesis securely during ambulation.
|Figure 2: Child wearing current telescopic prosthesis consist of an inner Patella Tendon Bearing (PTB) socket (A) and outer telescopic frame (B) separated with cotton stockinette , and Jaipur Foot (C)|
Click here to view
|Figure 3: Modified positive replica showing its medial view (a), lateral view (b), and front view (c)|
Click here to view
The prosthesis has been fitted to the child initially over two cotton stump shocks (adding one by one gradually to confirm socket fit) to accommodate loose fit of the socket as circumferential dimensions of the mold were kept moderately higher to encourage the general development of the deficient limb. The supracondylar cuff suspension has been clasped over femoral condyles, around the distal portion of the thigh. After confirming the alignment and fit, the child has been told to stroll in a parallel bar at first. The additional stump shocks would be removed in response to the growth of the child as the prosthesis become tight.
The child has gained the rhythm of walking rapidly with coordinated knee motion and improved alignment with a reduced base of support [Figure 4], which were the significant limitations in the previous prosthesis. Similarly, the bars extended proximally above the anatomical knee were rubbing the medial condyles of the contralateral side while strolling, in this manner, constraining the child to stroll with a wide base of support. Every similar issue has been settled subsequent to fitting the current prosthesis to the child. The child has been encouraged to report the first follow-up in the following week for a general supervision and modification in fitting and alignment of the prosthesis if necessary. No significant trouble has been in the deficient limb and the prosthesis. He has been told to visit the center following a half year, for fundamental development modification and reassessment of the prosthesis. His parents were never revealed any sort of trouble for the child while using the current prosthesis.
|Figure 4: Improvement in alignment and more normal base of support with the current prosthesis (right) than the old prosthesis (left)|
Click here to view
| Discussion|| |
Each patient with a congenital limb deficiency presents an individual issue among the prosthetic team. The detailed clinical and radiological examination is necessary to assess the capabilities of the insufficient limb, the range of movement of the joints, and the capacity for weight-bearing before prosthetic consideration. In general, if there is sufficient shortening to allow for the fitting of a prosthetic foot, the greater part of these patients can be fitted with extension prosthesis with no surgical intervention, and in many cases, this has given the best functional outcome., In some individuals, surgery to correct flexion or other deformities must be considered before limb fitting is attempted, though in others, an amputation might be indicated. Among some other kinds of congenital deficiency in the lower extremity, the longitudinal deficiency of fibula is the most well-known long bone deficiency., In severe cases, limb deformity is depicted by huge limb shortening, anterior tibial bowing, and foot deformity including tarsal alliance, development of a ball and socket ankle joint, missing rays, and a fixed equinovalgus or rarely equinovarus foot position. The current case is likewise comparative longitudinal deficiency of fibula with critical limb shortening, poorly supinated foot, plantigrade ankle, and absence of various bones in the foot. It was very challenging to contain the whole deformed limb inside the socket, offering appropriate weight transmission, providing space for overall development and looking after cosmesis. To resolve this, a PTB socket configuration was favored having an intimate proximal fit for weight transfer and giving enough space at middle of the socket (from mid-shin to proximal level of the ankle) to encourage wearing and doffing of the severely deformed foot.
Children are commonly very dynamic individuals; therefore, they merit a prosthetic, which must encourage adaption and accessibility to the outer environment according to their expectations, without hampering the motion of normal proximal body parts. Generally, limb deficient children are fitted with extension prosthesis consists of a corset-top caliper with free knee joints mounted on platform prosthesis. Other authors also reported the use of prosthetic design with distal polypropylene ankle–foot orthosis connected with a proximal socket or proximal polypropylene shell extended distally by pylon fitted with prosthetic foot., The approach of the current prosthetic fitment is entirely different. The primary focus of the construction was to create a completely functional prosthesis by minimal engagement of the deficient limb, consequently keeping it at below knee level as opposed to extending and bracing it proximally. This telescopic design was compatible to receive the conventional Jaipur foot distally in extremely limited space. Thus, favoring him for a cost-effective foot option, which is more dynamic and natural than the SACH foot.
The development of componentry for prosthetic management of children has occurred at unpredicted rate over the past few decades. Although the development of lightweight components as energy-storing foot, application of carbon fiber technology in socket and other components, use of silicone-based suspension, and optimization in hydraulic and pneumatic prosthetic components has enhanced the quality of the prosthetic fitment, the majority of limb deficient children are exempted from its benefit due to higher cost. That is why it is quite important to manage such congenital limb deficiencies through conventional technique and material in best possible way.
| Conclusion|| |
The current approach of prosthetic fitment has been found very unique in terms of design, construction, and cosmesis than the other conventional methods. The major advantages experienced were unrestricted knee motion, minimized bulk, easier donning and doffing, and a more symmetrical gait pattern with enhanced cosmetic appearance of the prosthesis. In addition it also facilitates for linear adjustments to accommodate the growth of the child in the future to some extent. The current technique may be utilized for individuals with longitudinal deficiency of fibula and other similar deficiencies in the lower extremity in the future to obtain more successful outcomes. The design can be upgraded in the future by utilizing other materials and components for better results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
This case study is an original work performed at Delhi Bharat Vikas Foundation, New Delhi. We are very thankful to the organization for providing the laboratory, technical support, and subject participated in this study. We are also thankful to Mr. R L Pruthi (Administrative Officer, DBVF), Mr. Reshmi Singh, and Mr. Amit kumar (Technical Staff, DBVF) for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Boonstra AM, Rijnders LJ, Groothoff JW, Eisma WH. Children with congenital deficiencies or acquired amputations of the lower limbs: Functional aspects. Prosthet Orthot Int 2000;24:19-27.
Sener G, Yiğiter K, Bayar K, Erbahçeci F. Effectiveness of prosthetic rehabilitation of children with limb deficiencies present at birth. Prosthet Orthot Int 1999;23:130-4.
McGuirk CK, Westgate MN, Holmes LB. Limb deficiencies in newborn infants. Pediatrics 2001;108:E64.
Blakeslee B, editor. The Limb-Deficient Child. Berkeley, CA: University of California; 1963.
Nelson VS, Flood KM, Bryant PR, Huang ME, Pasquina PF, Roberts TL. Limb deficiency and prosthetic management. 1. Decision making in prosthetic prescription and management. Arch Phys Med Rehabil 2006;87:S3-9.
Foort J. The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria. Artif Limbs 1965;9:4-13.
Mckenzie M, Centre HL. The prosthetic management of congenital deformities of the extremities. J Bone Joint Surg Br 1957;39:233-47.
Hubbard S, Heim W, Giavedoni B. Paediatric prosthetic management. Curr Orthop 1997;11:114-21.
Letts M, Vincent N. Congenital longitudinal deficiency of the fibula (fibular hemimelia). Parental refusal of amputation. Clin Orthop Relat Res 1993;287:160-6.
Froster UG, Baird PA. Congenital defects of lower limbs and associated malformations: A population based study. Am J Med Genet 1993;45:60-4.
Rogala EJ, Wynne-Davies R, Littlejohn A, Gormley J. Congenital limb anomalies: Frequency and aetiological factors. Data from the Edinburgh Register of the Newborn (1964-68). J Med Genet 1974;11:221-33.
Vasudeva A, Sahu S. Rehabilitation challenge in congenital lower limb deficiency: A case report. J Clin Diagnostic Res 2019;13:1-4.
Lenka PK, Chowdhury AR, Kumar R. Design and development of lower extremity paediatric prosthesis, a requirement in developing countries. IJPMR 2008;19:8-12.
Arya AP, Lees A, Nirula HC, Klenerman L. A biomechanical comparison of the SACH, Seattle and Jaipur feet using ground reaction forces. Prosthet Orthot Int 1995;19:37-45.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]