In the field of prosthetics, there is no single objective criterion for what constitutes a complex case. Because each patient is multifaceted in his or her physical, psychological, cultural and intellectual make-up, with each one of these facets interconnected, any one of these separately or in combination could make a case complex. To manage a more difficult case, it is essential that a multidisciplinary approach is used to address these individual traits.
There are many reasons people lose a limb or multiple limbs such as trauma, vascular disease, congenital disorders, cancer, etc., and each category can have its own inherent complexities. Moreover, the perception and skills of prosthetists or surgeons are factors. What one prosthetist or surgeon believes to be a challenging case may, in fact, be a simple or routine one for another and vice versa.
In this article, clinicians discuss what they view as a complex prosthetic case versus a more simple, straightforward case, their approach to treating complex cases, the skills the prosthetist or surgeon needs to manage these cases and other related issues.
Defining a complex case
According to Randall Alley, CP, FAAOP, of biodesigns Inc. in Thousand Oaks, Calif., if success is defined as a positive outcome through frequency of use or how well the prosthetic strategy meets the individual’s needs, then the range of what defines a complex case is broad.
“The typical focus is on the physical condition of the individual; however, there are many more aspects to consider,” Alley said. “What may appear to be a relatively straightforward case in terms of the amputation level for example, can often transpire into an extremely difficult challenge due to patient expectations, social integration, self-esteem, etc.”
Alley emphasized that clinicians should be using a more holistic model of care to address the psychological, social and physical needs of all patients.
“Each of the above variables impact one another, as well as the overall complexity level of the case,” he said. “To ignore any one of them is to put the patient’s success in jeopardy.”
According to Walther Bohne, MD, an orthopedic surgeon at the Hospital for Special Surgery, and an associate professor of orthopedics, Weill Cornell Medical College, both in New York City, a complex case, from the surgeon’s perspective, is any case that stretches the knowledge and ability of the person who has to do the amputation.
“Complex cases on the whole are cases that may require more than one operation,” Bohne said. “For instance, many farm yard injuries, of which I see quite a lot, require an amputation and when they do, they are always done as an open amputation. These ultimately need to have a revision to turn the open amputation into a closed amputation.”
Sometimes, strange as it may seem, amputation is actually the more conservative way of dealing with certain clinical problems, Bohne said.
Soldiers as special cases
Most likely, some of the most challenging prosthetic cases are the military personnel returning from Iraq and Afghanistan. There is often multiple limb loss resulting from blasts, burns and puncture wounds from flying debris and shrapnel.
Zach Harvey, CPO, chief prosthetist, at Walter Reed Army Medical Center in Washington D.C., sees many soldiers with a condition called heterotropic ossification, a bone disorder in which bone regrows in the soft tissue where it should not be. It often occurs in soldiers who have experienced high intensity blasts that shred the muscles, tendons and bones. It is believed to be the body’s way of trying to repair itself through growing new bone.
“This condition presents a real challenge when we try and fit a comfortable socket,” Harvey said. “We try to stabilize points critical to the function of the socket, for example, a lateral shaft femur in the case of a transfemoral amputee.”
When heterotropic ossification presents, Harvey and his colleagues do what they can to accommodate it.
A complex case can be defined as someone with a disability who has expectations or requirements above the norm who needs additional time, resources or collaborative effort to satisfy, Harvey added.
Simple turns complex
For Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics of Hanger Prosthetics & Orthotics, sometimes what may appear to be a simple case at the beginning ends up being an extremely challenging case.
“For example, a person may come in with a transfemoral amputation and we assess the situation,” Carroll said. “As we get into the evaluation, we find out it is not simple at all.”
An example would be a case Carroll has now, a woman with an unusual vascular condition called Klippel-Trenaunay-Weber syndrome. Most people with Klippel-Trenaunay-Weber syndrome have asymmetrical limb hypertrophy and the treatment is conservative. In rare cases, however, the limb may become enormous with associated clotting problems. An amputation may be necessary.
When Carroll has a complex case such as this, he must ask many questions to provide effective treatment. He might wonder what the condition is going to do to a person who is wearing a prosthetic socket or how he will control the residual limb and prevent bleeding and swelling.
“If it is poorly managed, the patient could die,” Carroll said. “If we do not understand the complexities behind certain conditions, we could do a lot of harm rather quickly.”
John Lamorte, CP, CPed, Ortho-Pros Inc., Santa Monica, Calif., finds that patient expectations can cause an otherwise textbook case to be difficult.
“I have a patient who is a beautiful woman and you cannot tell she walks with an above-knee prosthesis,” Lamorte said. “Nevertheless, her main concern is cosmesis.”
One of the unique problems with a knee disarticulation prosthesis is when the cosmetic cover is applied over the knee, the cover acts as an extension aid. This creates an unnatural gait and also makes sitting with the prosthesis unnatural. Everything Lamorte and his colleagues have tried has been unsuccessful.
“The only solution is a compromise,” Lamorte said. “We bring the cosmetic skin up just above the knee and sew cosmetic hose from the knee to the top of the thigh.”
One of the most harmful things Alley also sees in some patients is the result of unrealistic expectations.
“Nothing destroys motivation and determination more than the disparity between an unreasonably high expectation and the limited functionality of upper extremity prosthetic technology,” Alley said. “I am grateful for the Internet because patients now have more access to prosthetic information than ever before and as a result, they can form a more realistic picture as to what is available and what to expect.”
Other medical issues
Medical issues unrelated to the amputation also can pose problems as well. For example, one of Lamorte’s patients had a shunt in her arm for dialysis treatments, which became infected. The arm was completely bandaged. Consequently, the woman could only use one hand resulting in an inability to put on or take off her liner.
Complex versus simple case
Clinicians sometimes must define what constitutes a complex case versus a simple case based on individual and variable criteria. But most of them would likely agree with Alley in his view that an important difference between a complex versus a simple case often lies in establishing the appropriate groundwork along with a thorough evaluation and follow-up visits.
“For any case, setting the foundation correctly from the start is key, while creating a dynamic response to issues that arise is what keeps the case on the right course,” he said. “Complex cases differentiate themselves by demanding more preparation and consideration in the assessment phase, as well as more communication and attention to detail in the post-delivery phase.”
Parallel to Alley’s belief, Carroll stresses deliberate contemplation and forethought in all phases of care.
“The difference is to know when to take a few steps back,” Carroll said. “Do not automatically jump into the treatment mode. Consult with other clinicians and use the multidisciplinary team approach.”
Harvey agrees. Complicated cases require more monitoring and attention to detail. What this means at Walter Reed is that the prosthetist often joins the patient in therapy to make sure the prosthesis is fitting and functioning properly. It also may mean requesting a radiograph or 3-D model to understand the underlying bony topography. The advantage of being at Walter Reed is the collaboration across disciplinary treatment teams, said Harvey. A lot more attention is given to complex cases.
Protocol of simple case
From Bohne’s perspective, an uncomplicated amputation will have a schedule of events; e.g., surgery, which includes an immediate postop rigid dressing; getting the patient out of bed the day after surgery and in a chair 2 days post surgery then walking with minimal weight bearing on the amputated leg with a pylon and a prosthetic foot. The rigid dressing is changed at the latest after 2 weeks and the usual plan is to have three rigid dressings before the residual limb has matured to the point where a temporary prosthesis can be applied.
“This protocol has served me well,” Bohne said.
Complex case, more problems
The complicated cases are a bigger problem, he said. For instance, in the farmyard injury after the closure of the open amputation has been achieved, the clinician can do a delayed rigid dressing and sort of hasten the maturation of the residual limb to the point where the non-weight bearing time period of the amputee is extended, Bohne said.
“We can try to shorten that period, but too often that is not possible because there are superficial infections that require the patient to return to the office frequently for dressing changes, incisions and drainages,” Bohne said. “This makes it a much longer post op period until the patient can enter the rehab.”
Approach to complex cases
Clinicians, especially more experienced ones, learn to adopt certain effective strategies for dealing with more complicated cases.
The first thing Harvey and Lamorte do is determine what is the most important thing to the patient and his family.
“Then I try and give them a realistic picture,” Harvey said. “Once I do this, they might understand they are indeed a complex case and it will take some time and patience to heal and move on with their life.”
Harvey also tries to set the stage so the patients are not set up for failure. He does this by maintaining a positive attitude. It is possible to inspire confidence while at the same time paint a realistic picture of what is to come, Harvey said.
“Being excited about what we do as orthotists and prosthetists makes that person feel a sense of trust in that they are dealing with someone who takes pride in his or her work,” he said.
Lamorte asks patients as many questions as possible and encourages them to talk.
“Usually, when they start talking, I find out a lot more information,” he said. “Even if it seems trivial to their family members, it is usually information I can use to help them.”
For Alley, it is essential to not only understand exactly where the critical areas are that may adversely effect the outcome, but it is also vital to identify the appropriate strategies to eliminate or at least alleviate the negative impact of these areas.
Bohne’s fundamental approach is to make sure the patient fully understands his or her role during the entire process.
“An important point is that the patient understands what the outcome will be,” Bohne said. “More importantly, the future amputee needs to understand that he or she is the leader of a team. Without the patient’s leadership, it can become a roaring disaster. The patient has to realize that while we can sort of cheer from the sidelines, he or she has to do the work. It is a team effort of the surgeon, nurses, physical therapist, psychologist and prosthetist, but above all, it requires the patient’s cooperation.”
Most difficult case
Most likely, every practitioner has or will have one or more difficult cases that he or she, for many reasons, will never forget.
Alley worked with a patient with quadrilateral amelia at the shoulder and hip levels who also had severe scoliosis. She was a middle-aged woman who weighed a mere 40 pounds, but was determined to feed herself. According to Alley, the necessary upper extremity technology available at that time weighed about a quarter of her body weight. To realize the patient’s goal, Alley had to approach a manufacturer to create an ultra-light electric hand-wrist-elbow combination that had never been made previously.
“Some of the most satisfying parts of my work are when manufacturers and clinicians come together to provide a solution to a previously unsolved dilemma and ultimately, the general patient community benefits,” he said.
Alley has had a few cases where the people were not really interested in prosthetic success, but rather having access to the most expensive prosthetic technology.
“A ton of resources are brought to bear in order to provide a comprehensive strategy and solution for patients and it pains me to put such a process in motion when it is for all the wrong reasons,” Alley said.
Life or death
One of Bohne’s most complex cases was a woman who had a knee replacement, which was infected with a strain of difficult-to-treat bacteria. It ultimately became a question of life or death whether she kept her lower extremity or not. The question was whether Bohne and his colleagues should do a hip disarticulation or a high transfemoral amputation.
“We did the latter because it is much easier for a person to sit and in this case, it was an older person who needed all the help she could get,” he said.
The woman had been on blood thinners so it was difficult to get adequate hemostasis, Bohne said. Even after closure of the wound, she continued to bleed so she ultimately required three or four blood transfusions. She survived and is now doing fairly well and uses a wheelchair.
One of Harvey’s current patients has an amputation at the lesser trocanter. This patient also has a lot of heterotropic ossification that expanded into the medial part of his thigh. He has a big bony mass on the inside of the groin area, which required a unique socket suspension system.
“We did a cushion liner, flipped it down on itself and used vacuum to hold the leg on in conjunction with a belt,” Harvey said. “This soldier needed a lot of protection over the heterotropic ossification. We had to use a liner to give him that flexibility.”
Another difficult case for Harvey was a woman who has worn a hemipelvectomy prosthesis for 10 years. She tried other sockets but she always returned to her old design. Harvey said the problem was that her prosthesis was wearing out and she had lost weight since it was fabricated. He had to cast her, pulling up a trash bag, then sitting her in her prosthesis. This resulted in capturing her socket shape while tightening things up at the same time.
“I am proud to say it worked,” Harvey said.
For Carroll, the patient with Klippel-Trenaunay-Weber syndrome presented as an extremely difficult case. He figured out a way to prevent the blood from pooling in one area of the socket.
“We had come up with a way to capture the residual limb in a certain manner that compressed the blood and got it back up into the woman’s body versus pooling in the limb,” he said.
Lamorte said he had a patient who was a transfemoral amputee as a result of a gunshot wound. The patient had a lot of invaginations and no matter what Lamonte and his staff did, they could not make the man comfortable. They eventually found out he was walking around on crutches for 6 years without a prosthesis. His paraspinal muscles were knotted up like a rope.
“We sent him to a chiropractor and after about 6 weeks, he was comfortable,” Lamorte said. “We were able to align him just fine.”
In the realm of mental health, complex cases do not necessarily pose more psychological issues, although they can. Most anyone who experiences an amputation will experience the universal feelings of grief, loss and some depression. It depends on many factors.
While the grieving process is normal and necessary for most people who lose a limb, soldiers have unique issues when it comes to grieving.
“A lot of the soldiers I work with regret not being back with their unit,” Harvey said. “It is survival guilt. We encourage them to stay in contact with their units and let them know along the way the stages of their rehab. Even though they are respected as heroes who have sacrificed for their country, they have a certain amount of regret not to be back with their units.”
Depression and suicide
Carroll observes that sometimes, men in particular, put on the “tough guy” act. They refuse to express any emotions they perceive as being “weak,” let alone cry. They then get severely depressed or even suicidal.
“Not expressing the grief is what drives them to suicide,” Carroll said. “We need to identify depression early and hopefully, the psychologist is part of the team.”
Lamorte believes that poor body image after an amputation, especially in women, can cause depression. With these women, what would otherwise be a simple case becomes a complex case, he said.
“The prosthesis may function just fine, but now you are trying to fashion it so it looks perfect, which is impossible,” he said.
Lamorte also finds that some patients would rather have the attention and care they receive from their spouse or family due to their disability than become independent with a prosthesis.
Skills needed by prosthetist
The prosthetist or surgeon needs many skills to manage complex cases. Experience, knowledge of components, surgical skills, compassion, an intense desire to help and interest and commitment are just a few important traits.
“If a prosthetist understands the limitations and capabilities of prosthetic control systems and components, is capable of creating a functionally superior interface that is comfortable and has great patient management skills, the sky is the limit in terms of patient success,” Alley said. “The first quality provides one with a roadmap, the second maximizes the capabilities of the prosthetic systems and the third maximizes the individual’s use and integration of the prosthesis or prostheses into their life.”
Creativity and resourcefulness
Walter Reed is different than most rehabilitation facilities because the patients are expecting more of their prosthesis and generally put their prostheses to the test. Harvey’s goal is not just to get his patients back to achieving functional activities of daily living. His goal is also to return his patients to what they were doing previously.
To accomplish such, he may be called to create rock climbing feet, custom rollerblades, prostheses for scuba diving and ski diving. He tries different things with his patients while thinking outside the box. Creativity and resourcefulness are crucial. It is important to keep the soldiers motivated by having them do real world activities such as skiing, hunting, rock climbing, etc.
“These activities really challenge them to do things they may have never done before,” Harvey said.
Lamorte researches to determine what has been done first before he “reinvents the wheel.”
“You have to be innovative and creative with a positive attitude,” he said. “If the practitioner really wants to help the patient he or she will find a way.”
Commitment is important, according to Carroll. The willingness to take the time needed, ask the right questions and call on colleagues for help is part of that commitment, he said.
“Oftentimes, a rookie practitioner can do a phenomenal job if he or she is committed,” Carroll said.
Interface, the residual limb and technology
The first thing the surgeon needs to know is that there has to be an interface between the remaining limb and the prosthesis, said Bohne. He or she also needs to know how to achieve this interface with the least amount of discomfort to the patient, even in those amputations, which were less than perfect.
“Additionally, the prosthetist needs to have an intimate knowledge of what is available now,” Bohne said. “There are so many new and different technologies that have come up. It seems to take nightly reading to keep up with what is available. The number of feet alone is amazing.”
The residual limb has to fit into a prosthesis, which takes the most skill on the part of the surgeon, said Bohne. The surgeon also has to have a superficial knowledge of what the prosthesis looks like and what is required for the interface.
“Many surgeons do amputations but they are really not interested in what happens afterwards,” Bohne said. “They may write a prescription that says ‘below knee prosthesis,’ but what kind of below knee prosthesis? What is the best prosthesis for an individual patient? Most orthopedists should be conversant with what is available, but often, they are not. The prosthetist is not a surgeon. He or she has to deal with what the surgeon puts into his hands. Once the amputation is over, the general surgeon often treats it more like an appendectomy. When the wound is healed the patient is on his or her own. That is not really what should happen.”
For more information:
- Bone Condition hampers soldier’s recovery. Available at: www.usatoday.com/news/health/2006-02-12-bone-condition_x.htm. Accessed Feb. 2, 2007.
- Klippel-Trenaunay-Weber Syndrome. Available at: www.medicinenet.com/klippel-trenaunay-weber_syndrome/article.htm. Accessed Feb. 2, 2007.
Rachel Kelley is a staff writer for O&P Business News.