(PDF) Prosthetic Rehabilitation After Hip Disarticulation

Added on - 05 Apr 2021

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Evolution of Surgical and Prosthetic Management ofHip Disarticulation PatientsIn the UK in 2006/07 there were 4574 patients referred to a prosthetic service centre. Of this just 1%were hip disarticulation patients[ CITATION NAS09 \l 2057 ].This type of amputation is associatedwith severe increases in energy consumption for walking and is performed today commonly forpatients with severe vascular problems or for patients who suffered severe trauma. However themost common indication for a hip disarticulation amputation is as a result of a tumour. During the1960s – 1970s there were a lot of these amputation performed due to osteo-sarcomas and the beliefat that time that it was better to remove the entire affected bone. Today the vast majority of lowerlimb osteo-sarcoma patients are treatable using other methods with those unable to keep their limbhaving trans-femoral amputations[ CITATION PSu01 \l 2057 ].The hip-disarticulation amputation is not favoured and is considered to be a poor choice withpatients having severely affected gait and vastly increased energy expenditure with some figuresputting the energy increase as high as 200% for patients[ CITATION Ger01 \l 2057 ].The hip disarticulation amputation was first performed successfully in 1774 by Perault. However inthis era of pre-anaesthetic it was associated with a very high mortality rate and so was rarelyundertaken usually as a last resort[ CITATION SWa04 \l 2057 ]. It was namely done to militarypatients who had been shot or had blast wounds from explosions. In the civilian realms this type ofamputationwas at that time mostly performed as a result of infection and to a lesser extenttumours[ CITATION HLo57 \l 2057 ].Since that time there have been vast improvements in medical care with the discovery ofanaesthetics and the use of blood transfusions helping to vastly improve the survival rates ofpatients. Initially mortality rates were as high as 91%. One of the main reasons for this was due tohemorrhagic shock. This was very problematic to treat as the femur contains a major blood supplywith several branches making it difficult to control blood loss. A tourniquet is also difficult to fit, sothere have been several, perhaps radical, methods designed. One such innovative method wasWyeth’s system which used pins to hold rubber tubing in place. Other radical ideas for minimisingblood loss included the suppression of the aorta[ CITATION HLo57 \l 2057 ].Nowadays a modifiedversion of Harold Boyd’s dis-articulation amputation is used by many surgeons as it utilises racketshaped incision on the anterior portion of the leg to help the surgeon access the blood vessels and tohelp prevent blood loss. Boyd also tried to minimise this blood loss by cutting the muscles at eithertheir origin or their insertion. This racket shaped incision also leaves a large posterior flap which thenin turn allows for an anterior scar which can help isolate any pressure sensitive areas[ CITATIONHBo47 \l 2057 ]. There is also another form of incision known as the semi-oval incision which isperhaps preferred due to the decrease risk of causing a pressure point under the prosthesis that canoccur with the racket shape if the shape is too long[ CITATION RTo01 \l 2057 ].There have also been drastic changes to the shaping of the stump since the original amputations twocenturies ago. During the early history of hip-disarticulation surgery, leaving a large soft tissue stumpwas quite popular amongst surgeons. Another version of this was devised by Lyons in 1859 whichleft some periosteal tissue. However this procedure was difficult to perform although it did have
some merits, with some surgeons claiming that this procedure allowed the residual tissue to beflexed, extended, adducted and abducted powerfully.One of the main pitfalls with this operation was that it was quite common for undesirable growths tooccur with bony spurs. It was also the case that this operation could not be performed for patientswith malignancies. Today the stump shape tends to be a compact one where soft tissues areremoved wherever possible[ CITATION HLo57 \l 2057 ].Ever since the first successful hip disarticulation surgery there has been a need for prostheses forpatients. However even today a lot of patients choose to use crutches or a wheelchair rather thantry and use a prosthesis. There have been a few different types of sockets designed for hipdisarticulation patients. One of the first of these was the “tilting table prosthesis”, this was quite aheavy prosthesis and utilised a leather socket and was attached by a belt around the pelvis. Thisprosthesis then had metal bars attached to the lateral side. This was then attached to thecomponents of the prosthetic leg. This socket type often had a semi-automatic lock which affordedthe patient some control and stability during stance phase[ CITATION CMc57 \l 2057 ].Figure 1 Tilting table prosthesis[ CITATION CMc57 \l 2057 ]Fig.2 US Navy HydraulicProsthesis[ CITATION CMc57 \l 2057 ]This socket type was, however, quite cumbersome and so difficult for patients to utilise effectivelyand efficiently. The tilting table prosthesis also required the patient to thrust their pelvis quiteforcefully to propel it forward, thus vaulting was quite a common occurrence amongst tilting tableusers.The tilting table prosthesis was quite common until around 1954 when the “Canadian” socket typewas introduced. There were however other socket designs that existed at this time, such as the U.SNavy hydraulic prosthesis which was developed at the close of the Second World War. This used amanually controlled valve and hydraulic piston about the knee which gave the patient some shockabsorption as well as the patient having the ability to lock the valve in any position. The valve alsohad some automation, for instance if there was fast movement around the hip the valve would closegiving the patient knee stability. This prosthesis design was lighter and relatively cost effective whencompared with the tilting table due to its use of an aluminium alloy as a base material. Howeverthere were problems with the technology involved such as the noise of the pistons and itsmaintenance[ CITATION CMc57 \l 2057 ].
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