The design of the rigid outer frame included a void to ensure proper continuity of fit with all three patients involved in this study. This void was created using custom-fabricated high-density Plastazote (Zotefoams Inc., Walton, KY) filler formed to precisely match the shape of the positive mold.
To determine the filler thickness, minimum deflation and maximum inflation of the air cells must be calculated. The minimum deflation of the ROHO low-profile air cells is approximately 0.5 inches and the maximum inflation of the air cells is 2 inches. It was discovered through trial and error that the recommended filler thickness ranged between 1 and 1.25 inches. Once the Plastazote filler has been completed, the 0.25-inch high-density polyethylene is draped or blister-formed over the Plastazote filler and positive mold using a vertical blister form stand and vacuum (Figure 9). The “bucket-type” prosthesis that includes an anterior access panel is then assembled. This finished prosthesis is given to the ROHO Group and is used as their primary pattern for the three custom 2-inch ROHO low-profile cell configurations. The configurations are connected with 2-inch Velcro and secured into the prosthetic bucket, also with 2-inch Velcro.
Before the patient dons the system, he slips on a full-body sock (Knitrite Inc., Kansas City, KS; Figure 10). This custom body sock features a Cool Max (Knitrite, Inc.) fabric, which has been used successfully on transtibial and transfemoral amputees to wick perspiration and moisture away from the skin and has an approximate thickness of a two-ply sock. It is an important first line of protection against skin abrasion and works extremely well to contain or organize any loose tissue because of its diminished friction.
The patient can easily don and doff the prosthesis in the supine position with use of the fully adjustable anterior access panel. By using a torso lift, the patient is able to slide into the posterior aspect of the interface (Figure 11).10 The adjustability of the anterior access panel accommodates minor volume fluctuation. Once the Velcro straps are properly adjusted (Figure 12), the cells can be inflated. It is important that the proximal trimlines are free from impinging the axilla. The patient must also be able to sit fully erect with hands flat on the table and elbows slightly flexed (Figure 13). This will ensure easier transfers and comfortable mobility.
The patient’s urinary and defecation collection bags or urine drainage tubes are easily accessed or threaded through the cushions and base of support (Figure 14). It is important to ensure the accuracy in properly locating the stoma sites so that the collection bags will drain properly and prevent herniation of the soft tissue.
The alignment of the hemicorporectomy prosthesis is angled approximately 5° to 7° of extension with respect to vertical or relative to being perpendicular to the floor (Figure 15). This alignment is directly proportional to the circular base of support attached under the rigid outer frame. The alignment is also dependent on the amount of stability achieved on a flat surface or in the patient’s wheelchair. The alignment angulation is easily changed by removing or adding firm-density Pelite (Knitrite, Inc.) in a wedge-shaped pattern.
The hemicorporectomy prosthesis is independent of the wheelchair and is self-suspending during transfers. It is suspended by off-the-shelf carpenter suspenders converted to over-the-shoulder suspenders (Figure 16). By incorporating the proper suspension, the hemicorporectomy patient has the ability to transfer to any given surface for increased independence and to a wheelchair for immediate mobility.
The Xsensor Pressure Mapping System (Crown Therapeutic, Belleville, IL; Figure 17) was used to measure weight distribution. We also used visual observations to monitor the skin and to ensure the absence of abnormal pressure.
Interviews with the three participants were conducted (two by telephone and one in person) after prosthesis use for periods ranging from 1 month to more than 1 year. The interviewer read from a fully written, prepared script and recorded the answers verbatim from the respondents. The Prosthetic Evaluation Questionnaire11 measured the following: ease of application in donning and doffing, heat dissipation, improved sitting posture and balance, comfort, even weight distribution, prosthesis function (skin health, usefulness, sounds, and appearance), regular hours of daily use, and mobility with wheelchair function. Scoring was accomplished using a linear analog scale, with poor responses rated at 0 and excellent responses rated at 100.
Prosthesis function scores were the highest (skin health, 100, with no skin breakdown from wearing the prosthesis; usefulness, 97.6; sounds, 97.3; appearance, 82.3). Mobility (transfers) with wheelchair function was equally high (transfers, 97; wheelchair function, 90). Ease in application in donning and doffing and even weight distribution scores were the same at 88.3. Comfort level scored 86.7, whereas heat dissipation scores were the lowest at 80. Improved sitting posture and balance score was 92.5 and overall well-being and satisfaction of the patients averaged 99.5. The overall wearing time ranged from 5 to 10 hours on a regular daily basis.
The first patient was our prototype, and significant improvements were made to the second and third hemicorporectomy prostheses as our method evolved, resulting in our percentage scores being higher for the second and third patients. The first patient was interviewed 16 months after he received his prosthesis and reported his wearing time at 5 to 8 hours per day. His weekly activities included mowing his own yard with a zero turning radius, hand-controlled riding lawn mower. He would also go fishing and hunting on an all-terrain vehicle with his nephew. He reported that his future plans include obtaining his driver’s license and having hand controls installed in his van.
The second patient was interviewed 12 months after he received his prosthesis, and his wearing time was 9 to 10 hours on a daily basis. His activities of daily living included living in complete independence at home, driving his van that included hand controls and a ramp, grocery shopping, taking his dog for a 1- to 2-hour walk in the morning, and photography. This patient drove to see the third patient before and after the third patient’s hemicorporectomy surgery. He has also taken several road trips. His future plans include maintaining his independent and active lifestyle.
The third patient was interviewed 1 month after he received his prosthesis, and his wearing time was 8 to 9 hours on a regular daily basis. This patient increased the comfort level and increased heat dissipation by reinflating his cells every 4 to 5 hours. His activities of daily living included weight lifting to improve his upper body strength, independent transfers in which he was able to lift his entire weight with the prosthesis, and regular Veterans Administration outings. This patient’s future plans mirror those of the other two.
It is important to note these patients have endured severe hardships and face significant health complications. Before being fit with their prostheses, the patients spent between 5 and 14 months healing from the hemicorporectomy surgery. When these patients finally received their prosthesis and were able to sit up for the first time and regain their mobility, a sense of renewal and hope was observed. J. Bradley Aust, who performed the first successful translumbar amputation in 1961, said it best: “Freed of the nonfunctioning lower half, the patient is released from the dead weight holding him down, relieved of his chronic infection and/or cancer, and experiences a new mobility, sense of well-being, and renewed enthusiasm for life.”1,3
Like with any prosthetic fitting, the primary factor to a successful rehabilitation of a hemicorporectomy amputee is if the patients possess a high degree of determination, motivation, and compliance. These patients will succeed regardless of the difficulties involved. All three patients in this study were highly motivated. After these three patients were fit with a hemicorporectomy prosthesis that included the three custom 2-inch ROHO low-profile cell configurations with drainage holes lining an adult polymer “bucket-type” prosthesis with an anterior panel for ease in donning and doffing, they succeeded in regaining their mobility and independence. The cushions were highly effective in ease of application in donning and doffing, heat dissipation, improved sitting posture and balance, comfort, even weight distribution, prosthesis function (skin health, usefulness, sounds, and appearance), 5 to 10 hours of daily use, and mobility (transfers) with wheelchair function. Based on the information collected thus far, the new design has met with positive results.
The author thanks Dr. Margaret Stacey Albin-Wilson and Jim Weber, CEO of Prosthetic and Orthotic Care, Inc., for their assistance with editing this article. Special thanks to the ROHO Group whose permission made this report possible.
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Keywords:© 2004 American Academy of Orthotists & Prosthetists
compression therapy; dry floatation; hemicorporectomy; ROHO low-profile therapeutic cushion