The APOPPS

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Post Amputation, Early Extended Prosthetic
Management of Pediatric Transtibial
Transfemoral Amputees

• Robert N. Brown, Sr., CPO, FAAOP

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Lower-Limb Pediatric Prosthetics General
Considerations and Philosophy (Cummings Kapp,
JPO gt 1992 Vol. 4, Num 4 pp. 196 206)

• Causes of Pediatric Amputation
• Emergencies or Trauma
• Congenital Limb Deficiencies
• Elective Amputations

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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

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Early Prosthetic Intervention for Children Is
Not Necessary!

• Kids are resilient they dont 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

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The Real Needs of Children

• Pre-surgical
• Surgical
• Post surgical
• Prosthetic
• Physical Medicine Rehabilitation
• Education
• Clinical application
• Emotional
• Social

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Pre Surgical Concerns

• Prognosis
• Family support
• Child (or family) is motivated understands what
  is being done and why

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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

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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)

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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

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Post Operative Concerns

• Health first foremost
• Skin grafts
• Burns
• Revisions
• All can be successfully managed with
  pre-fabricated prostheses

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Post Operative Concerns

• Emotional health
• Body image - Self esteem
• Aspirations
• Socialization
• When to begin prosthetics

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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

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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

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Education

• Overwhelm the family with information
• Provide sources for credible information
• Its 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

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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

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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?

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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

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How Can Prosthetists Help?

• Help to foster and encourage a team approach
• Be aware of the childs prognosis, medical
  limitations and aspirations
• Offer alternatives if appropriate
• Design prosthetic systems and component features
  that meet these findings

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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

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Children Cant 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

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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

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Pre-fabricated Systems Continued

• Minimize Prosthetists stand-by time
• Custom modifications to stock sockets systems
• Liners
• Pads
• Heat relieve
• Custom sockets systems

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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

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Pre-fabricated Sockets Systems

• Aircast Air-Limb --?
• APOPPS-TF APOPPS by FLO-TECH ------?

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More Pre-fabricated Postoperative Systems
Sockets

• Danforth D-PASS -------?
• Fillauer POP POP-PY -----------------?
• TEC ------------------------?

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Other Available Techniques Pre-fabricated
Systems

• Orthomedics PAL-Guard ---------------?
• Removable Rigid Dressing
• RRD
• PSRD
• The Michigan Limb
• Hosmer PP-AM
• USMC Prep TT/TF
• BB-d by FLO-TECH
• Ossur ----------------------------------------?

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PEDIATRIC APOPPS, APOPPS-TF BB-d by
FLO-TECH

• ONLY PRE-FABRICATED SYSTEMS
  AVAILABLE FOR TODDLER TO
  YOUNG ADULT

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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

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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-TECH-TOR?

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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

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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

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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

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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

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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

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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.

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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.