22 y/o female with proximal femoral focal deficiency of right lower-extremity presents with a leg length discrepancy of six inches. Tibial lengths are similar. Has full ROM at both knees & ankle joints. Right hip flexion & extension mildly limited. MMT 5/5 in all extremities. She is an active individual with prosthetic needs beyond basic ambulation and is a competitive hip hop dancer and gymnast. Presents with prosthesis, patellar-tendon-bearing socket design with a large anterior fenestration. The right calcanous, bilateral malleoli, and anterior toe-box are encapsulated within socket and footplate placed in 35° plantarflexion. A second fenestration allows the digits to be open to air. Two straps assist in suspension. An exoskeleton style build up attaches an energy-storing multi-axial foot to prosthesis.
Due to shortening of the lower limb, function/mobility were significantly impacted. Surgery declined. At 3yrs she was placed in a conventional PFFD prosthesis with a quadralateral above-knee socket . This locked out movement at her anatomical knee-joint. As she grew, imaging revealed a functional hip and knee joint. She had several sessions of PT and at 6yrs was tried in a below-knee style prosthesis with anatomical footplate at neutral, however she kept plantar-flexing and had discomfort. Footplate set to 35° plantar-flexion, adjustments made to optimize suspension. Once foot was placed in a comfortable position and hip & knee were given full range, she was able to become very active, joined gymnastics and later began competitive dance enabled by a flex-foot with multi-axial movement.
PFFD has significant impact on function. Treatment should be individualized to the desires of the patient and family and not just follow suggested treatments per classification. Serial imaging should be obtained to evaluate changing morphology as patient grows and treatments adjusted accordingly. A multi-disciplinary team approach to care is also vital for success.
Vinay Vanodia– Chief Resident, Montefiore Medical Center/Albert Einstein College of Medicine
Ratnakar Veeramachaneni– Resident PGY-3, Montefiore medical center
Stephanie Rand– Associate Program Director, Montefiore Medical Center
Francisco Martinez– Certified Prosthetist Orthotist, East Coast Orthotic & Prosthetic Corp.