it is part 2 of the tibial deficiency discusses the management.

1. Tibial deficiency treatment &
Prosthetic management (part 2)
Abhishek Tripathi
Lecturer, Prosthetics, NILD, Kolkata
abhsihekpo2013@gmail.com
Ref: AAOS Atlas of Ampuatations and limb deficiencies

2. Objectives
• Treatment options based on Jones and Kalamchi Classification
• Detailed Prosthetic management in different treatment.
• Pre-requisite: to have understanding of the classification of Tibial
deficiency as taught in the previous class for achieving objective of
this class.

3. Treatment
• Goal of treatment is to achieve functional outcome of the affected
side at par the sound side for the child’s development.
• Focus should be limb shortening, abnormalities of knee ankle and
foot.
• It is necessary to assess patient as a whole together with part
evaluation as that may affect the plan of treatment.
• Also to minimize iatrogenic morbidity full body assessment is
required

4. Complete tibial deficiency and absent of knee/extensor power (Jones
type 1a or Kalamchi I)
• Knee Disarticulation is indicated with in first year of child life.
• Post-operatively, the child is discharged the next day, after rigid
dressing and soft compressive dressing or plaster.
• He is followed after 5 to 7 days for surgical site examination and
suture is removed approx. 2 weeks later.
• Elastic bandage and later shrinker are used for controlling edema for
2 to 3 weeks.
• Prosthesis fitment is start from 4 to 6 weeks post-operatively so that
the child can stand at normal milestone with the help of proper above
knee prosthesis

5. Complete absence of the tibia with good
extensor (Jones 1b or Kalamchi I)
• Surgical Fibular centralization technique with ablation of deformed foot
during or in later stage was popularized by Dr. Brown.
• Brown’s -Technique creates a femoral-fibular articulation without fusion
• Patient fitted with long transtibial stump design Below knee prosthesis
• Advantage:
• Preservation of knee function (ROM)
• Good leg length possible
• Disadvantage:
• Recurrent and progressive knee flexion contracture
• Varus-valgus abnormalities and hence patient selection was crucial.

6. Proximal tibia absent, distal tibia present (Jones
type 3)
• Proximal tibia is cartilaginous while distal tibia is present
• Has got active extensor function of the knee
• Surgery is done to remove the non functional foot for easy donning
and doffing of the below knee type of prosthesis

7. Proximal tibia present with distal diastasis (Jones type 4
or Kalamchi type III)
• Knee well formed with active quad function
• Foot also relatively well formed but the distal tibia is hypo plastic and
ankle deformed so that significant LLD presence.
• Limb lengthening surgery with the ankle reconstruction or Syme
procedure depending upon LLD severity.

8. Partial tibia present (Jones 2 or kalamchi type II)
• Condition as present:
• Proximal tibia presence
• Good quad function
• Foot and ankle abnormal
• Surgical intervention
• Removal of abnormal foot and ankle by Symes procedure, prosthesis
can be fabricated for use
• Synostosis of fibula to the proximal tibial segment in later surgery when
the proximal tibia is sufficiently developed
• In case of Jone type 2 or kalamchi type II, where tibia is sufficiently
developed proximally, both ablation of non-functional foot and
synostosis are done simultaneously.
• It is important to neutralize the knee alignment at the time of synostosis
to prevent laxity.
• The prominent fibular head due to synostosis is problematic to limb
fitment and hence it can be corrected at the time of surgery

9. Prosthetic management

10. Prosthetic Management: Unilateral Knee
Disarticulation in Tibial deficient side
• Factors affecting the prosthetic management
• Type of deformity involved
• Surgical revision performed, if any
• In case of complete absence of tibia (Jones type 1), where through knee
prosthesis can be considered, following should be features and components:
• The Socket design:
• As the residual stump is femur in this case, which has got normally developed hip with relatively
less bulbous or tapered distal femoral condyle, hence
• In case of bulbous distal end, anatomical suspension just above the distal end, with medial
window cut without ischial bearing can be made.
• In case of less developed distal end of femur, Botta Socket design with split soft insert
(segmented socket design) is easy to don and doff for your child
• In case when there is no bulbous end (flavy stump), suction socket with inner silicone linercan be
prescribled

11. Prosthetic management
• Socket design:
• In case of tapered stump end, Silicone with shuttle lock or distal pull through strap
(lanyard suspension) is also used in pediatric amputee, with the liner thickness of
these silicone liner can be 3mm, 6mm and 9mm.
• Rotational control is created by gripping proximal thigh with in socket in quad socket
fashion
• Cotton socks ply can be used in combination with silicone for growth
accommodation.
• Suspension (auxillary):
• Silesian and more better is TES suspension can be used in infants and toddlers
• TES is more useful, as it gives better stabilizes the hip and control socket rotation in
infant and toddler with associated hip abnormalities
• In adolescent and adult, as the anatomical suspension above the medial femoral
condyle is easily possible, the belt suspension i.e. Silesian or TES can be removed

12. Prosthetic management
• Prosthetic knee:
• Traditionally, the prosthetic articulated knee were fitted by the age of 3 to 6 years of
age for child knee develops by this age.
• Wilk and associates, however advocated to use the articulated knee as early as age
of 17 months
• Giavedoni and associates advocate to use the knee as early as 10 months or when
the child begin to pull to stand or can do kneeling and squatting on the floor.
• Advantage of early articulated knee
• Achievement of normal milestone crawling, pulling to stand, early ambulation
• Prevention of unfavorable compensatory gait pattern
• Even external hinges can be useful in absence of pediatric knee joints.
• Child quickly learns to use hip extensor to control his artificial knee
• Modular polycentric knee joint are preferred choice but in case of exoskeleton design
external free hinges are the choice

13. Prosthetic management
• Shin component:
• In the modular component pylon are preferred as there is adjustment possibility
• In the case of exoskeleton design laminated plastic shell are used
• The Prosthetic foot components:
• If modular foot are available then Dynamic Response feet are preferred over SACH
feet
• In case of non-avaibility of Prosthetic foot, biomechanical design with consideration
of three foot rockers can be made with wood and rubber material
• The arch of the foot-rocker should be with radius measured from knee center.
• The hind foot and forefoot of the foot-rocker should be cushioned for simulated
plantarflexion and toe-break respectively

14. Prosthetic management
• Bilateral Knee Disarticulation:
• In case of bilateral involvement, if both are at the knee disarticulation level,
stubbies was utilized earliar.
• However, with available proper size pediatric Prosthetic knee, full length
prosthesis with overall height shorter than normal are used now a days with
SACH feet, as the child quickly learn to balance.

15. Prosthetic management
• In case of bilateral involvement where both the sides have different
level of tibial deficiency,
• The more deficient side can be made into KD surgically, so that it will be more
stable side with a artificial knee component.
• And the less deficient side is converted into Syme and is most likely to have
knee laxity and is therefore less stable compared to more deficient side.

16. Thank you