Consultant in Rehabilitation Medicine at the Specialist Mobility Rehabilitation Centre, Dr Fergus Jepson, leads a prosthetics workshop at Meningitis Research Foundation's Pushing the Boundaries - Life beyond limb loss day in October 2014

1. Dr F Jepson

2. Introduction
 Dr Fergus Jepson
 Consultant and clinical lead for the Specialist Mobility
Rehabilitation Centre, Preston
 2000 Amputees, 70 children attending, 10 due to
meningitis
 Aim of next 10 minutes
 Discuss the different levels of prosthetic centre in England
 Discuss the number and location of the centres
 Discuss changes in commissioning in the future
 Discuss what the letter of the law from NHS England states
and how you work with it.

3. Different levels of service
1. Tertiary Centre
ALL levels of amputation and limb loss (including upper limb, congenital andmultiple limb loss)
 The multidisciplinary team must be led by a suitably experienced consultant in rehabilitation (specialises in
prosthetics: minimum of 5 or more weekly sessions in amputee rehabilitation)
 These centres should have access to socket manufacture and limb assembly on‐site.
 It is recommended
 Close links and access to psychologist and counselling services, podiatry and orthotic services, or preferably to have them
as part of the team.
 MDT members must have specialist experience and the appropriate training in
 Management of children with acquired or congenital limb loss
 Upper limb prosthetics and amputees with complex needs
 Technologically advanced components.
 The centre should have access to inpatient rehabilitation beds for complex cases.
 All services providing paediatric services are required to provide appropriate separate facilities.
 The centres should hold combined clinics including but not limited to, Surgeons and Paediatricians etc. for:
 Congenital limb deficiency
 Pain management
 Limb Surgery including revision and reconstruction
 Tertiary centres must be further developed to ensure specialist expertise in the future, both for rare and expensive
conditions and for innovation, research and development.
 These centres also play a key coordinating and educating role whilst supporting standard centres ensuring high quality
standards are maintained.

4. 2. Standard Centre
 Smaller multidisciplinary team and should have close links and access to a
tertiary centre.
 The team should include an experienced rehabilitation consultant or other
suitably qualified medical practitioner, prosthetists and specialist therapists.
 Other expertise including medical, psychological and engineering input can be
provided through local services or a tertiary centre.
 All standard lower limb services and should have established links and referral
pathways with a tertiary centre for complex cases and additional services.
 Some standard upper limb amputees and congenital limb deficient patients
may be managed provided there are appropriately trained and experienced
staff.
 The standard centre will deliver the core services for most patients in the
relevant local area with some expected variations depending upon local
agreements.
 These centres should have access to socket manufacture and limb assembly
on‐site.

5. 3. Satellite
 Smaller multidisciplinary team and should be affiliated to a
tertiary or standard centre.
 The team includes experienced prosthetists and therapists.
Other expertise including medical, psychological and
engineering input can be provided through the affiliated
tertiary or standard centre.
 These centres should have access to workshop facilities for
minor adjustments and repairs.
4. Visiting Clinic
 A visiting clinic is where a specialist team from a tertiary or
standard centre visits an acute setting, to assess patients
with limb loss together with the acute team and take over
their rehabilitation programme. They generally do not have
any access to workshop facilities.

6. Number of centres currently
 35 in England
 Tertiary centres – 28
 Secondary centres – 5
 Satellite clinics – 2
 Visiting clinics – unknown but do not usually involve
paediatric patients
 Of the 28 tertiary centres 9 have enhanced prosthetic
veteran status, this means increased infrastructure at
those centres – gym etc

7. Changes in commissioning in the
future
 You choose where you want to go, if your not happy
with your centre and you’ve discussed why and they
have not responded then look for a second opinion
 No stipulation on number of limbs but local policy
varies widely
 No stipulation on High definition cosmesis
 No stipulation on types of prosthesis
 NHS England does not support running limbs however
they do no stipulate that you can’t have one if doubles
up, Ie if duel purpose.

8. The future
 Tariffs coming in 2015 for shadowing and 2016 for good
 Tariff will follow the patient
 Increasing cost of prosthetic components
 Awaiting subgroups on
 High definition cosmesis
 Micro processor controlled knee units
 Multigrip hand prosthetics

9. Day to day prosthetics
 The SMRC policy is
 An everyday walking limb
 A secondary limb that can function as a spare limb and may
be a running limb or high definition limb
 A water activity limb if not above
 Problems with children’s Prosthetics
 Limited choices
 Little in the way of energy return
 Heavy relative to the weight of the patient
 Function of the strength required of the components used and
needed to provide safe walking jumping etc
 MOVE TO ADULT PROSTHETICS AS SOON AS SIZE
ALLOWS

10. Blisters and sores
 Blisters form as a result of pressure and friction
 Due to
 Loose fitting socket leading to too much movement
 To tight in the region of the sore this can be due to
growth, increase in weight , changing shape of the
stump, in meningitis – growth plate abnormalities can
lead to changing shape of the bone.
 Bone spur formation
 Poor soft tissue coverage – scar tissue
 Poor alignment of the prosthesis
 Poor socket fit

11. Blisters and sores
 Solutions
 Allow skin to heal by avoiding pressure
 Stop using limbs or decrease use as much as possible
 Review of limb by team to assess best way of off loading
this
 Blowing out socket
 Lining socket, adding sockets
 New socket
 Change in suspension method
 Adding additional components such as shock absorbers etc to
change the profile of loading – but increase the weight

12. What has worked well?
 Dependent on the child and their needs
 http://www.youtube.com/watch?feature=player_embe
dded&v=-omgzTMLHRk