Post Amputation, Early & Extended
Prosthetic Management of Pediatric
Transtibial & Transfemoral
Amputees
Robert N. Brown, Sr., CPO, FAAOP
Lower-Limb Pediatric Prosthetics:
General Considerations and Philosophy
(Cummings & Kapp, JPO > 1992 Vol. 4, Num 4 pp. 196 – 206)
• Causes of Pediatric Amputation
– Emergencies or Trauma
– Congenital Limb Deficiencies
– Elective Amputations
This Presentation Will Focus on:
• Early prosthetic intervention
• Pre-fabricated prosthetic systems
– Immediate
– Early Training
– Preparatory
– Long-term pre-custom definitive
• Transverse and disarticulation amputations
Early Prosthetic Intervention
for Children
Is Not Necessary!
• Kids are resilient – they don’t need anything
special
• Surgeons are reluctant to cover the wound
• Kids heal so fast
• Kids can hop around until they are ready for a
prosthesis
The Real Needs of Children
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Pre-surgical
Surgical
Post surgical
Prosthetic
Physical Medicine & Rehabilitation
Education
Clinical application
Emotional
Social
Pre Surgical Concerns
• Prognosis
• Family support
• Child (or family) is motivated understands
what is being done and why
Pre Surgical Concerns Continued
• Child (or family) realize there may
or could be some delay or
restrictions post-surgically
• Self Esteem
• Child dreams of a life style they
wish to pursue
Surgical Concerns & Solutions
• Transverse amputations
• Exostosis (terminal boney over growth)
– “Good results; original Ertl procedure with
Myoplasty (distal muscle attachment secured
over boney bridge) allows muscles to elongate
without the bone perforating the skin.”
– (Jan Ertl, Md. 2004, children 5 yo to 12 yo)
Surgical Concerns & Solutions
• Disarticulations
– Preserve epiphyses; if possible
• Knee Disarticulation preferred over Above Knee
• Symes over Below Knee
– Lower level Transverse amputation always
preferred to a higher level disarticulation
Post Operative Concerns
• Health; first & foremost
– Skin grafts
– Burns
– Revisions
• All can be successfully managed with prefabricated prostheses
Post Operative Concerns
• Emotional health
– Body image - Self esteem
– Aspirations
• Socialization
• When to begin prosthetics
Pre-fabricated Prosthetic Designs
• Simple
– Advance from protective socket, to rehab prosthesis, to
preparatory prosthesis without the need to re-cast
• Accessible
– Wound is accessible
– Prosthetists will spend less time involved in stand by & fitting
• Versatile
– Will fit a variety of shapes and sizes
• Economic
– Proven to save on long-term rehabilitation costs
Physical Medicine & Rehabilitation
• Initiate programs that help children achieve
their aspirations
– Plan component requests around these goals
• Limit physical activity only as health requires
• Involve family, friends and classmates
Education
• Overwhelm the family with information
– Provide sources for credible information
• It’s what they want
• Bring in successful peers
– Be wary of accidental contacts
• mentoring is a special skill
• Expand the education process to include
friends & classmates
Clinical Application
• Understanding the components selected
and the rehabilitation program is key to
success
• Start slowly but be ready for rapid
progress
– Limit ambulatory progress if physically
necessary
Emotional Concerns
• Children will scrutinize body image
– Will I be accepted; as I am now
– Is “Dance” beyond my dreams
• Just want to be “One of The Gang”
• Self esteem
– Children will question their ability to
achieve their dreams
• Is their an acceptable alternative?
Socialization
• Include friends (peers) and family in daily
programs: whenever, as soon and as often
as possible
• Invite entire class in for a day of education
& to view prosthetic training or facilities
How Can Prosthetists Help?
• Help to foster and encourage a team
approach
• Be aware of the child’s: prognosis, medical
limitations and aspirations
– Offer alternatives if appropriate
• Design prosthetic systems and component
features that meet these findings
How Can Prosthetists Help?
• Use pre-fabricated early inter-active prosthetic
systems; which allow medical staff to examine
& care for wound and offer daily joint therapy
• Assist in the process of component education
based upon prognosis and aspirations
• Be available to assist the therapist early in the
ambulation process
Children Can’t Possibly Benefit
from Traditional or Pre-fabricated
IPOP Systems!
• The proven benefits of IPOP technologies:
– Cost effective
– Traditional prosthetic concepts
– Applied as soon as possible
– Early weight bearing
• prevents edema
• Promotes healing
Pre-Fabricated IPOP features
• Provide early protection as well as weight
bearing without recasting
• Interconnect with pylon and foot to facilitate
ambulation
• Adapt to extended ambulation via rapid
conversion to preparatory and long-term
pre-custom definitive prosthesis
Pre-fabricated Systems Continued
• Minimize Prosthetists stand-by time
• Custom modifications to stock sockets &
systems
– Liners
– Pads
– Heat & relieve
• Custom sockets & systems
Secondary Benefits of Early
Prosthetic Intervention
• Minimize negative medical effects of
delayed treatment
• Rebuild positive body image
• Maintain or rebuild social confidence
• Rejuvenate or maintain self esteem
Pre-fabricated
Sockets & Systems
• Aircast Air-Limb™ --
• APOPPS-TF™ & APOPPS™ by
FLO-TECH® ------
More Pre-fabricated Postoperative
Systems & Sockets
• Danforth – D-PASS -------
• Fillauer POP & POP-PY -----------------
• TEC ------------------------
Other Available Techniques
& Pre-fabricated Systems
• Orthomedics PAL-Guard™ ---------------
• Removable Rigid Dressing
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– RRD
– PSRD
The Michigan Limb
Hosmer PP-AM
USMC Prep TT/TF
BB-d by FLO-TECH
Ossur ----------------------------------------
PEDIATRIC APOPPS™,
APOPPS-TF™ & BB-d;
by FLO-TECH®
– ONLY PRE-FABRICATED
SYSTEMS AVAILABLE FOR
TODDLER TO
YOUNG ADULT
APOPPS™ & APOPPS-TF™
Design Features
• Adjustable, controlled & even compression
• Flexibility of system to promote healing
• Maximize alignment options
• Protocols and Consumer Guide
• Reticulated pad available upon request for
operating room applications
Custom Orders
• Unusual shapes & sizes:
– Length
– Left or Right
– Circumferences
– If order received by noon,
expect same day shipping
• Example: 17" MPT to distal end
compared to stock 7", FLO-TECHTOR
Stock BB-d™ Long-term
Pre-custom definitive Prosthesis
• Adjusts circumferentially at
all levels
• AP adjustability at all levels
• ML conforms to patient at
all levels
• 5 stock sizes
• 2” carved distal end pad
• Custom systems available
One Program for Complete
Prosthetic Rehabilitation
• Protection, early & extended wear
for non-ambulators:
– The FLO-TECH-TOR -------------
• Prevent flexion contractures
OR
– The VCSPS™ -----------------------
• As an RRD or PSRD
One Program for Complete
Prosthetic Rehabilitation
• Supervised Immediate or Early
training ambulation
– The Rehab System -----------
•FLO-TECH-TOR & UFOS 
–48 hrs to 4 weeks post-op
 Pylon
& foot components available
but not included
One Program for Complete
Prosthetic Rehabilitation
• Independent ambulation
– The Preparatory System ----
•VCSPS™ & UFOS™
– 48 hours to 6 months post-op
 Pylon
& foot components available
but not included
One Program for Complete
Prosthetic Rehabilitation
• The BB-d™ -------------
pre-custom definitive
prosthesis
– Patient fluctuates chronically
– Patient needs definitive
durability but is still changing
– Pylon & foot components available
but not included
INTERPRETATION
• Practitioners recognize the benefits of
pre-fabricated postoperative prosthetic
systems. These same benefits are
available for children Transtibial,
Transfemoral, Knee Disarticulation, and
Symes amputations.
OPINION
• Saving money appropriate surgical
procedures and prosthetic component
choices, at the expense of children
suffering revision after revision or
failing to reach their goals, has more
devastating long-term consequences to
the child and to society as a whole.