This retrospective series covered the period from 1954 to 1999 evaluating 260 children with unilateral congenital below elbow deficiencies for their use of a prosthesis. A successful prosthetic outcome was essentially defined as a child and parents who continued to attend the Limb Deficiency Clinic and who claimed at the most recent follow-up that the prosthesis was worn for any period of time. An unsuccessful outcome of prosthetic management was defined as a child and parents who failed to return to Limb Deficiency or who claimed at the time of the most recent follow-up that the child never wore the prosthesis. The mean length of follow-up was approximately 12 years. Ninety eight children (38%) were determined to be active cases (i.e., currently attending Clinic), 105 children (40%) had been lost to follow-up, 39 children (15%) had their case closed because of age (i.e., attended the clinic until 18 years of age), and 18 children (7%) had transferred their care to another hospital.
The actual graduation rate from the authors program was 30%. The mean age at the time of the first prosthetic fitting for the entire group was 2 years and 3 months. A total of 127 children (49%) were either lost to follow-up or reported rejection of the prosthesis. For children fit with the prosthesis before the age of 3 years, the median duration of survival was 6 years and 10 months. For children initially fitted after 3 years of age, the median duration of survival was 1 year and 7 months.
Eighty-three children (32%) were admitted to the hospital for intensive training at the time of the fitting of the first active terminal device. The remaining 177 children, (68%) received home-based training under parental supervision. For children who were admitted for training, the median duration of survival was 9 years and 4 months compared to 4 years and 4 months for children who were not admitted, which was statistically significant. Children fitted with a body-powered prosthesis had a median duration of survival of 3 years and 1 month, compared to children fitted with a myo-electric prosthesis had a median duration of survival of 6 years and 6 months compared to children fitted with a passive hand prosthesis had a median duration of survival of 1 year and 2 months. The difference in the survival curve between children with a body-powered prosthesis and those with a myoelectric prosthesis was not significant.
This study revealed improved prosthetic outcomes when the child was initially fitted before 3 years of age, but showed no statistical benefit if the child was fitted prior to a year of age drawing into question the classic teaching of “fit when they sit”. Intensive monitoring and training particularly by the therapist and the prosthetist were shown to significantly affect overall utilization when implemented aggressively at prosthetic fitting. In addition, the optimal outcome with respect to prosthetic design was noted for the group that was fitted with a combination of prosthesis over time, supporting a prosthetic management strategy that provides a variety of prosthetic designs to children with unilateral congenital below elbow deficiency throughout their years of growth and development. The authors current algorithm based on this study for prosthetic management of children with unilateral congenital below elbow deficiency is provided.
Prosthesis, Prosthetic, Below, Elbow, Limb, Deficiency, Children
J of Bone & Joint Surg