This document discusses prosthetic and orthotic management for femoral deficiency and prosthetics (LDFP/PFFD). It covers general factors affecting management, conservative non-surgical options like AFOs and KAFOs, surgical options like Syme ankle disarticulation and rotationplasty, and prosthetic designs for various management approaches. Key points include different prosthesis designs for different Aitken types of femoral deficiency, interface design principles, surgical procedures like Syme and rotationplasty and their associated prosthesis designs, and gait considerations for individuals with LDFP. Bilateral involvement is also briefly discussed.

1. Femoral deficiency and
Prosthetic and Orthotic
management (part 2)
Abhishek Tripathi
Lecturer, Prosthetics
abhishekpo2013@gmail.com

2. Main and specific objectives
The main objective of the session to understand the different Prosthetics management in case of LDFP/PFFD
Specific objectives to learn are:
A. General factors affecting P&O management in LDFP
B. Management in LDFP :
1. Conservative management (No surgery)
i. AFO extension Prosthesis (below knee extension) and principle of interface design
ii. KAFO Extension Prosthesis (above knee extension) and principle of interface design
2. Surgical management followed by Prosthetic management
i. Syme Ankle Disarticulation
ii. Syme ankle disarticulation with knee fusion and principle of interface design
iii. Rotation-plasty
3. Bilateral involvement
C. Gait in LDFP
References: 1. AAOS, Atlas of Amputations and Limb Deficiencies, 3rd ed.

3. A. General factors affecting P&O management
of LDFP
• Factors (physical condition) which complicates the
management of LDFP:
• A significant limb length discrepancy
• Hip joint involvement: instability and position of hip
abduction, flexion and internal/external rotation
• Soft tissue contractures (funnel shape thigh
musculature) are common
• Knee is often unstable and position in flexion. Also it
may be difficult to palpate within the short, fleshy thigh
tissues
• The affected side appears apparently shorter than actual
due to flexed position of the hip and knee
• Other complication: compensatory deformity of the
sound side foot and knee

4. B. Management in LDFP

5. 1. Conservative management (No surgery)
• Treatment depends on total length of
femur compared to sound side and
presence of any associated anomalies
• Most simple design mostly in case of
the young child Shoe buildups
indicated in Aitken A.
• When there is significant deficiency in
the femoral length, a Prosthosis is
desired.
• A Prosthosis is so named because it
include principles and components of
both Prosthesis and Orthosis. Also
known as Extension Prosthesis

6. (i) Below knee Prosthosis (Extension
Prosthesis)
• Indicated in Aitken A, in the unilateral LDFP.
• Prosthosis design
• Most common is, AFO (foot plantigrade) with distal pylon and
pyramid adapter (or shell extension in exo) connected to SACH
foot (the design is preferred in child cases)
• AFO with foot in equinus with pylon and Prosthetic foot: preferred
in grown-up child (due to its better cosmesis).
• Note that the equinus design is indicated if the patient can maintain natural
equinus while standing and walking.
• The chances of developing ankle planter flexor contracture can be better
controlled in grown-up as they could be taught how to stretch regularly.

7. Below knee Prosthosis (Extension Prosthesis)
AFO (FRO design) with exoskeleton
extension and SACH foot
Prosthosis with Equinus design AFO
with Exoskeleton Extn & Jaipur foot

8. Principle of interface design
• Casting and measurement are done either in equinus/plantigrade position of the ankle and foot with
partial weight bearing on the compensatory foot blocks beneath the affected side while standing on
the sound side so that ASIS remain levelled in a standing-wall frame/parallel bar.
• Meticulous capturing of planter surface including arch and heel ball is required in case of equinus
design AFO with pylon and foot prosthosis.
• Its an anatomical suspension design catching around heel and dorsum of the foot.
• Advantages:
• Reduced compensation
• Cosmetically better
• More freedom of activity
• Note: In case of associated fibular deficiency, the Primary function of AFO is to control ankle and
foot deformity and hence foot may be kept in plantigrade rather than equinus.

9. (ii) Above knee Prosthosis (without mechanical
knee)
• Indicated in Aitken B, C and D where patient have
lesser control over hip
• The design catches above the knee around the thigh
up to ischial seat.
• Position of the foot may be kept plantigrade rather
than equinus for better distribution of the weight
over planter-surface but it may depend upon
condition of ankle and foot and patient preferences.
• There isn’t any mechanical knee joint in this simple
prosthosis design hence during seating the foot
points upward with long leg shank without
mechanical knee which may hinder in ADL.
• Hence, this design is not feasible in case of teenage
and adult but in child case only.
KAFO extension without knee prosthosis

10. (iii) Above Knee Prosthosis with mechanical knee
joint
• The design includes prosthetic
knee, which can be an external
knee (KDL) or it can be
endoskeleton Prosthetic knee
placed so that the position of the
mechanical knee be at sound side
knee level.
• Indicated in case of LDFP Aitken
type B,C or D where hip is more
involved.
• Advantage: the leg shank can be flexed from
knee level so that better teen ages and adult.
• Limits: The knee is fixed so that difficult swing
clearance KAFO with KDL knee joint
extension Prosthosis

11. Principle of interface design
• This is accomplished by meticulous casting of the affected leg and pelvis while
maintaining the proper foot rotation
• The casting is done with foot on the compensatory blocks with partial weight bearing.
• For those patient with telescoping hip joints, optimum elongation of the affected hip and
knee (hanging angle) should be done during casting which improves ischial weight
bearing during stance.
• If careful molding is not done to achieve good ischial weight bearing, then posterior-
thigh part may bear the weight, as the thigh is in flexion condition, which may cause
increased pistoning motion during stance and swing of the affected side.
• In the case of very young child, casting should be done in partial weight bearing with
plantigrade foot position.
• In cases of teenager or adult child, it could be molded in equinus that allows good
cosmesis and less compensatory length yet permits distributed weight bearing on the
sole of the foot

12. Socket trial
• Transparent test sockets are invaluable in
evaluating the socket fit and testing if the
socket is having all the features as desired
during the casting phase.
• These test socket can be modified by
heating (being made of thermoplastic
material) so that the final socket become
good fit.
• Finally, these test/trial sockets are refilled
to create final socket.

13. 2. Surgical management
followed by Prosthetic
management

14. (i) Syme’s Ankle Disarticulation
and Prosthetic management
• Indicated in AITKEN type A or when the affected side leg is at least
50% or more to the sound side leg.
• Design: Symes Prosthesis (Symes socket with pylon, adapter and
Prosthetic foot)
• Prosthesis, in general cosmetically appears better and child can walk
better and even can run.
• Drawback:
• The thigh will appear shorter and bulgy on the affected side and
• When child sits, the knee discrepancy and longer leg portion will be cosmetically
unappealing.
• In order to decrease the difference between sound side and affected
side thigh length, sometimes epiphysiodesis of the sound side distal
femur end is done together with syme’s operation on affected side.
Syme’s ankle disarticulation prosthesis

15. If only Syme amputation and Prosthetic
Management Aitken type B, C & D
Low profile design but telescopic knee and
hip action possibility
Less Telescopic knee and hip but still odd
shape of socket proximally and
discomfortable sitting
Syme extn Prosthosis
Unconventional syme extn Prosthosis

16. If the Knee Fusion together with Syme
Procedure is done in Aitken B,C & D
• If only Syme’s procedure is done as
shown in fig A, then the prosthetic
socket design required to catch flexed
and abducted knee proximally resulting
in anterior and lateral deviated socket
during stance shown in fig B.
• If knee fusion (in appropriated knee
extension position) is also performed
together with Syme’s procedure as
shown in fig C & D,
• Then the proximal Prosthetic socket
won’t deviate, resulting in simulated
Transfemoral socket (with Ischial
containment brim) is possible as shown
in fig E.

17. (ii) Prosthetic management in post Syme’s
ankle disarticulation and knee-fusion
• Indicated in AITKEN type B,C and D where lower/limb on LDFP side is less than 50%
compared to sound side
• Typically the Syme surgery leaves the affected side at approximately same level as
the knee on the sound side and this surgery is considered at one year when child
start to walk.
• Fusion of the knee, causes Sartorius muscle to act like hip flexor which together
with hip extensor (by hamstring) help during terminal swing and initial contact.
• The prosthetic knee can be introduced at the age of 2 to 3 years when there is more
space to accommodate the modular knee joint component.
• Suspension of the prosthesis is partly happen by Syme anatomical features and
flexed knee features so that socket is generally self suspended.
• Auxiliary suspension such as Silesian or TES also are used.
• Suction/shuttle and pin lock is not recommended.

18. Principle of socket design for Syme’s
disarticulation and knee fusion
• The socket design is unconventional because of unique shape of the affected side after
the Syme and knee fusion.
• Typically the socket appears as ship’s Funnel shaped in the proximal area.
• Lateral wall can remain high for better M-L control, while the medial wall has to
accommodate rounded shape and externally rotated hip joint.
• Most important goal is to create total contact to supplement end weight bearing
• Ischial containment or partial bearing from the ischial and or gluteal is necessary to
decrease pistoling and lateral lurching but due to unique feature of the thigh, the
anterior wall won’t give counter force as in conventional design.
• Syme procedure may be helpful in some distal end weight bearing capability along with
advantage of knee joint space beneath the stump end. But proximal anterior socket
gapping remain a challenge together with posterior socket wall pinching.
• Knee fusion decreases chance of hip and knee flexion so that reduce pistoning, (reduced
anterior thigh bulk) also provides longer lever like in long transfemoral amputee,

19. Drawback in Syme’s procedure and (knee fusion?)
in Aitken type C or D: may result in more sensitive
distal end

20. (iii) Rotation-plasty
• Primarily, Rotation-plasty was indicated for limb salvage following femoral tumor resection.
• First described in 1930 by Borggreve, who performed rotation through the femur.
• In 1950, Van Nes described the technique, rotating the foot 180 degree, so that the toes
point posteriorly while enabling ankle to act as knee joint with the heel as knee cap.
• The osteotomy is done so that the ankle remain at the same level as sound side knee.
• For optimal function (so that ankle act efficiently as knee) the active ROM of the affected side
ankle and foot should have at least 60 degree arc of motion (including df and pf).
• The ankle planterflexor (gastric-soleus muscle complex) act as extensor of new knee (ankle)
and can therefore restrain prosthetic leg flexion while the ankle dorsiflexor group act as knee
flexors.
• Henceforth a below knee Prosthesis can be fitted after healing of the surgical site.
• Note: There is possibility of gradual derotation with growth hence repeated surgery become
necessary. To solve the problem of derotation, various surgical procedure were described, for
example: one stage tibial rotation-plasty, using section of fibula as graft to maintain the
alignment and stability.

21. Rotationplasty used in distal femoral tumor

22. Rotation-plasty in LDFP
• In cases of LDFP, Rotation-plasty is indicated
if the child’s affected side foot is
approximately at the level knee of the
sound side.
• Rotationplasty are found to be more
successful compared to Symes procedure
and knee fusion
• Picture showing Rotationplasty with
femoral-Ilium arthrodesis (Modified
Rotationplasty)

23. Below knee Prosthesis design in
Rotationplasty
• Bochmann has described the ideal prosthetic design for
Rotationplasty.
• The child bears load through the anteriorly located
planter surface mainly just distal to ball of the heel
of the foot which are enclosed with-in the socket.
• During bench alignment, foot is position in the full
planter-flexion of ankle and provides some space
distally for toes growth.
• A soft socket liner is utmost essential part which
protect the dorsum of the foot
• The socket (foot socket) trim-line anteriorly should
cover upto just below the anterior border of ball of the
heel, mediolaterally it should be just over the malleoli
while posteriorly it should cover maximum dorsum
surface and flared away
• Suspension is self suspended due to anatomy of the
foot and ankle part but thigh corset and side hinges
may also be included to redistribute weight bearing
load over the thigh and ischial tuberosity.
Foot socket
Exoskeleton
below knee
design

24. Prosthesis design in Rotationplasty
• The side hinges and thigh shell
controls
• the mediolateral instability of the
ankle to protect ankle from injury
• The mechanical axis is kept at the
level of anatomical ankle axis, with
mild posterior offset (why?)
• Partial ischial bearing thigh shell is
indicated to prevent pistoning
during initial fitting.
• Overall child can be more active
with strengthening and training
of the muscles around ankle and
hip.

25. Casting principle
• During the casting procedure the patient should be
standing with the limb in a relaxed vertical position and
the foot in the utmost plantar flexion.
• Plaster wrap is applied over a tailored cotton stockinette.
• The wrap covers the up to the level of proximal thigh
(depending upon the condition, partial Ischial bearing
design may be created)
• Meticulous shaping of the foot planter surface and just
distal to the ball of the heel
• When the plaster is set to some extent, foot is
repositioned in platigrade position on a raised platform
with partial bearing and medial-lateral and dorsum
surface is also shaped.
• In the same plantigrade position, the sound side knee axis
level is marked on the plaster (which should be approx. at
ankle level)
• Keeping the same plantigrade positon, frontal alignment
(adduction angle of the hip) and sagittal alignment
(flexion angle of the hip) is marked over the plaster which
helps in finding mandrel position in the positive mold.

26. Final prosthesis design (Below knee
Prosthesis design in Rotationplasty)

27. Case study: Hemant, 5 yrs, Male

28. Case study: Hemant, 5yrs, Male

29. 3. Bilateral involvement
• Bilateral LDFP :
• Found in 15% of LDFP. And belongs to Aitken D.
• One treatment method is simply “no treatment” if patient is
functional
• Can walk without any prosthetic support, if surgery performed
to stabilize the hip with compensation for the discrepancy if
any.
• Also they may use stubbies/stilt-like Prosthesis with foot for
all ADL
• In Bilateral LDFP, full length Prosthesis are not recommended
due to increased energy demand

30. C. Gait in LDFP
• Depending upon the Aitken type, the gait deviation increases from A to D.
Common Gait Deviation are:
• Because of the unique feature of flexed, abducted and externally rotated hip with
flexed knee, the leg is advanced by Sartoirius and Adductor with a pelvic twist, so
that there is uncontrolled swing phase.
• The unique muscular condition around the hip, stabilize other wise unstable hip very
similar what rotator cuff does in Shoulder joint.
• Circumductory gait as the affected side get passively lengthen somewhat during
swing.
• Vaulting on the sound side again due to the same reason as said in just above
• Gluteal Medius Lurch or Trendelenburg positive gait due to abductor weakness
• Stride length discrepancy due to difference in knee level compared to sound side
• Lateral lurching still remain problem as hip joint instability in Rotationplasty

31. Thank you !