Schultea, Fanny MSEd, CSCS; O’Brien, Erin CPO, LPO

A new patient was referred to our clinic for prosthetic evaluation and fitting after an interscapulothoracic amputation. She was initially seen by a local physical medicine and rehabilitation physician and prescribed with a cosmetic shoulder cap prosthesis, with the possibility of pursuing a hybrid prosthesis at a later date. The patient was a 63-year-old female (5 ft 3 in, 263 lb) whose amputation occurred on November 23, 2013 as a result of an aggressive infection, necessitating the removal of her entire right arm, scapula, and a portion of her clavicle.

This case provided an excellent example of how each patient with complicated high-level amputations presents his or her individual set of confines and challenges that force us to explore different design concepts. Our patient was receptive to collaborating with us in developing an alternative to fit her unique needs. The patient provided written consent acknowledging the preparation and publication of this case study presentation.

At the time of her initial evaluation, her skin was well healed despite significant scarring and pain associated with light pressure around the cut end of her clavicle (Figure 1). She was employed as a junior high and high school teacher and had been placed on temporary disability since her amputation. She lived at home with her husband, their 32-year-old son, and their 13-year-old granddaughter. During our interview, she expressed concern with the cosmetic appearance of her amputation and was most focused on restoring the shape of her shoulder under her clothing so that she could wear her previous wardrobe without having it altered. Before the amputation, the patient was right-hand dominant. She stated feeling moderately limited with work and regular daily activities and did not feel her amputation interfered with normal social activities.

METHODS

Figure 1

CASTING

The patient was instructed on the time frame for fitting, basic socket design, and harnessing principles, and then scheduled to return for casting pending insurance approval for a passive shoulder cap prosthesis. She was seen again for measurement and casting, at which time a circumferential plaster cast of her torso and right amputation site were taken to begin the process of creating a comfortable cosmetic prosthesis.

FIRST FITTING

We fabricated a right interscapulothoracic socket from polypropylene lined with Pelite along with a lightweight cosmetic foam shoulder restoration and chest harness (Figure 2). The anterior and posterior trimlines extended approximately to midline and to the border of the neck superiorly. During the fitting, the patient expressed concern that the superior border of the prosthesis could be seen extending beyond the collar of her shirt. Because of the shape of her residuum, that portion of her body was important for suspension because it was the only horizontal area available to support the weight of the prosthesis. However, at the patient’s insistence, the superior trimline was lowered to improve the cosmesis under her clothes. The foam shoulder was shaped to the patient’s liking, and she felt comfortable and satisfied with the outcome. She was sent home with the prosthesis that day, with the understanding that follow-up appointments for fit and shape adjustment would be likely to improve the comfort and cosmesis of the prosthesis.

Immediately after the patient left the appointment, she called expressing concerns with the prosthesis. She reported a great deal of shifting on her torso when sitting in the car, specifically when reaching across her body and trying to fasten her seatbelt. Over the next few days, she began wearing the prosthesis a few hours per day for her activities of daily living and still continued to experience shifting. She reported that the rigid frame of the prosthesis would shift upwards and press on the sensitive portion of her clavicle. She requested that we try something slightly less rigid and lighter weight to improve comfort and reduce movement.

Figure 2

SECOND FITTING

The same plaster model of the patient was remodified to fabricate the frame portion of a Compliant Force Distribution Socket (Martin Bionics Innovations; Figure 3). A Vivack check frame was pulled to be used with a Lycra material as an interface against the patient’s skin. After the check frame was fit to the patient with no excessive areas of pressure or discomfort, the material was stretched between the borders of the frame with enough tension to suspend the frame just slightly away from the patient’s skin (Figure 4). On the contralateral side, we continued to use a chest harness for suspension. The anterior attachment point was moved to experiment with what location would provide the least movement. The patient again reported comfort with the socket and harness during the fitting and agreed to take the temporary setup home without additional shoulder shaping to test suspension and comfort over several days of use.

After the appointment, she called to report disappointment in the amount of shifting of the prosthesis on her body. She commented that despite this version of the shoulder cap being more comfortable, it was still unsatisfactory for long-term wear.

Figure 3

Figure 4

We knew after our unsuccessful attempts at lightweight traditional and alternative suspension designs for the shoulder cap that we needed to explore a different option.^1,2 At this juncture, the patient absolutely was no longer open to the idea of any frame type and refused to wear anything rigid, expressing associated pain, shifting, and general discomfort. The next attempt would therefore necessitate compliance, comfort, and ease of donning and doffing while being cosmetically inconspicuous. We conceived of a highly compliant and breathable garment that would contain a removable custom foam cosmetic shoulder cap prosthesis mirrored from the patients’ contralateral sound side.

TEST DESIGN

Before approaching the patient with the idea, we explored the available literature to find potential alternative designs used that may have satisfied our criteria. Unfortunately, because of the patient’s fragile skin, scarring, sensitive clavicle, and neuromas, an adhesive suspension mechanism was not appropriate.³ We discussed the idea with the patient and proposed developing a prototype to wear for 2 weeks to determine whether or not the design would be a good option for her. If the design was successful, we would move forward with a definitive design.

To create the prototype, we acquired a lightweight polyurethane foam block from which we carved a shape to approximate the patient’s sound side. Measurements were taken, and a pattern was drafted to create the suspension garment. Our goals for the test fitting were to mitigate some of the major issues that came along with the rigid designs, including the following: providing the patient with a soft, comfortable, breathable garment; allowing independent donning and doffing; and eliminating pain on clavicular protrusion, neuromas, and scar tissue. In addition, we sought to create an intimate compressive fit, improving comfort while resolving the shifting of the shoulder cap over the course of a full day of wear or while seated. The fitting was a success; we sent the patient home with the prototype and scheduled her to return in 2 weeks for a follow-up and design evaluation.

The patient returned reporting satisfaction with the design and a wear schedule of 8 to 10 hours a day. She expressed that it allowed her to continue to wear her clothes and that it was extremely comfortable, easy to wash, did not shift, and caused her no discomfort or pain. However, she did express concerns regarding the concavity over her bust area as a result of the amputation, hoping to fill out her clothes beyond the shoulder area. We discussed the changes we would make, and the patient decided to move forward with a definitive design that we would create in duplicate to provide her with a back up to facilitate washing.

DEFINITIVE DESIGN

We took a scan of the patient’s torso, and using CAD (Insignia), we mirrored a version of her sound side and carved two models using CAM (Omega, Willow Wood, Mount Sterling, OH) from which to create her shoulder cap. We thermoformed a polyethylene shell over the mirrored model, then aligned it over the actual model to create the negative mold of the shoulder (Figure 5). We then poured a lightweight urethane flex-foam (Smooth-On; Smooth-On Inc, Macungie, PA) into the negative mold and painted the foam with flesh-tone prosthetic skin (SuperSkin; Otto Bock, Austin, TX) to create a more durable and congruent cosmetic shoulder (Figure 6). We used nude colored 4-way stretch Nylon/Spandex Power Mesh (Sportek) to sew the shirts from the custom patterns we created (Figure 7). The garments were full length for easy donning and doffing, had no exposed seams to reduce irritation, and featured an easy snap-in pouch for the shoulder and an incorporated adjustable elastic bust band to control compression (Figures 7 and 8).

Because the contours of the foam shoulder were matched exactly from the scan and suspended firmly with broad distribution through compression from the garment, the patient reported that the shoulder felt extremely lightweight. The patient was able to don, doff, and change out the foam shoulder independently without having to alter any of her wardrobe. Along with having a lifelike feel, the cosmesis allowed the patient to wear her clothes with confidence while filling out the shoulder, sleeve, and proximal bustline (Figure 9). She was comfortable throughout the day and less self-conscious returning to work at school with her students and coworkers. The patient reported wearing the shoulder cap shirt without discomfort every day at work and anytime she left the house.

Figure 5

Figure 6

Figure 7

Figure 8

DISCUSSION

Figure 9

This case was an excellent example of how each patient with complicated high-level amputations presents his or her individual set of confines and challenges that force us to explore different design concepts. Despite having rejected the shoulder cap and prosthetic frame designs of the first two fittings, our patient was receptive to collaborating with us in developing an alternative to fit her unique needs. We provided her with the opportunity to take ownership in the design and empowered her to think creatively about the limitations and opportunities she faced with her new amputation. It was also important for her to begin the process of acclimating to the weight and compression of a shoulder cap in the event she wanted to progress to a hybrid or oppositional prosthesis in the future. As a result of the successful outcome of our design (Figure 9), the patient became more optimistic and receptive to the idea of exploring the use a full prosthetic system as she continues in her recovery.

REFERENCES

KEY INDEXING TERMS: interscapulothoracic; prosthesis; cosmetic prosthesis; alternative design; shoulder restoration; cosmesis; shoulder cap