HIP TO BE COOL: My first experience with a hip disarticulation: Amputee Case Study

Title

HIP TO BE COOL: My first experience with a hip disarticulation

Abstract

This case presentation is my first experience with a client with a hip dis-articulation. I have included her course of treatment from her surgery to walking out the door on her new prosthesis. A total of 5 months in the making. It was a long and difficult journey and she struggled with pain, immobility, and grief for the loss of her limb, but in the end she is now walking and much happier.

Key Words

hip dis-articulation, phantom pain, osteosarcoma, grief

Client Characteristics

Jane Doe is a 61-year-old female who was diagnosed with osteosarcoma in her right leg in October of 2014. As a result, she underwent a hip dis-articulation Jan 23/2015. 
 Jane is otherwise very healthy with no other co-morbidities. She is a retired janitor. She is married and has 2 adult children. She is extremely active and her passion is running. Jane typically ran 10 km 3x/week. 
The loss of her limb was VERY traumatic for her and she was devastated by this gross change in her mobility. 


After her amputation she was transferred to a rehab center in a hospital 160 km away from her home community. She did her pre-prosthetic training there and was discharged home to wait for her wound to heal Feb 24/15. 
Jane returned to the amputee clinic to check the healing of her wound and assess her readiness for prosthetic training and she was casted for her limb March 19/15
She had her first fitting April 14/15 and her second fitting was April 23/15
She started prosthetic training May 25/15 as an inpatient at the same hospital rehab unit that did her pre-prosthetic training.

She successfully walked out of the rehab unit July 3/15 with her new prothesis.

Examination Findings

• Pathology - Jane was diagnosed with osteosarcoma by MRI and biopsy
• Body function and structure (impairments) - Jane's left leg and core were weak. She had decreased muscle endurance. She had decreased mobility and standing balance. She was suffering with stump, incision and phantom pain. She was also depressed about her situation.
• Activities (limitation - During her pre-prosthetic admission, due to pain, Jane's bed mobility and general mobility was impaired. She had difficulty using stairs. Washing and dressing were very time consuming. She was not able to do any meal preparation. On her second admission Jane was only mildly weak. Her mobility was better but not what she was happy with. Washing and dressing were now good. She was now doing some meal preparation
• Participation (restrictions - for both admissions, Jane was not able to do any of her IADL's - cleaning, laundry, groceries. Also she was unable to run, which was her passion.
• Contextual factors (environmental and personal) - She does have a full Multi-disciplinary team to work with at the rehab center. She also has a loving and very supportive spouse and family
  

Clinical Hypothesis

Jane's main problems on her pre-prosthetic admission were pain, weakness, poor mobility and balance, decreased function/ADL's and grief for her lost limb. On her second admission for prosthetic training her main problems were mild weakness, decreased mobility, no previous knowledge or understanding of how to use a prosthesis, and a sense of being a burden to her family/ how would she put meaning back into her life?

Intervention

• On Jane's first admission I taught her how to use a mechanical vibrator to help relieve her phantom pain. She was also prescribed drugs to help with pain. She was encouraged to massage/touch her stump as well as to friction her incision once the staples were out.
• 
I taught Jane bed mobility, transfers, use of a 2 wheeled walker, wheelchair and crutches. I taught her to negotiate stairs using a crutch and a railing. I taught her how to get up/down from the floor using and chair and a 2-wheeled walker. I taught her to get in/out of her vehicle. Jane was given strengthening exercises for left leg and core.
• OT showed Jane how to better dress, bath and to cook/clean from her walker.
• The prosthetist, social worker and I spent time with Jane and her family providing emotional support and information about the grieving process and the next steps in her journey to getting a prosthesis.
• On her second visit to the center Jane and her family were educated about the components of the prosthesis, how to don/doff the prosthesis and how to care for it. Her leg and core exercises were progressed and she started fitness training on the leg/arm ergometer. She was given weight bearing activities, knee control and walking drills in the parallel bars. She then progressed to walking with a 2-wheeled walker, and then to a 4 wheeled walker and lastly 2 canes. She was taught to negotiate stairs with her limb, ascend/ descend hills, negotiate uneven ground, get up/down from the floor
  

Outcome

• Jane is now able to don/doff her limb independently.
• She is walking with 2 canes or sometimes just one cane indoors and a 4-wheeled walker outdoors.
• She is able to negotiate many different terrains including interlocking brick, pavement, grass and hills.
• She is able to negotiate stairs with one railing and a cane.
• Jane has started driving again with her left foot. 

• She is able to do all her IADL's - cooking, cleaning, laundry using her limb and her walker or cane
She is starting to work out at a local gym to continue her strengthening and fitness training. 

• All Jane’s manual muscle tests are improved to grade 5
Her L-test June 19/15 was 1:03 minutes using a 4 wheeled walker.
• Her L-test July 2/15 was 1:10 minutes using 2 canes.Her 2 minutes walk test (3) was 65 m using 2 canes. I will retest her L-test and 2 minute walk test when she returns to amputee clinic in Aug 2015
  

Discussion

In relation to my typical caseload Jane would be considered "high level rehabilitation". Simply because most of my clients are older and have many co-morbidities that limit their prosthetic outcomes. Jane luckily is only 61 and had no other illnesses. I was able to attain grade 5 for manual muscle testing on the left leg. She was also able to do advanced core stability training, which helped her better control the hip and knee joint on her prosthesis. For myself this was the first time I had the opportunity to work with a client that had a hip dis-articulation. The socket is actually a "bucket" that completely encases the pelvis. Very different from TF amputees. The limb has a Otto Bock components HIP: 7E7/ KNEE: 3R60 EBS and FOOT: Triton LP 1C63. Jane is also looking into switching to the C leg, which is a computerized knee down the road. The training we did for this prosthesis was fascinating. There is a great deal of pelvic tilt needed for getting the hip to release after midstance. Also loading of the toe leaver is critical to gain enough knee flexion to swing through well without vaulting. Luckily Jane has good kinesthetic sense and picked up on the necessary pelvic and trunk movements to control the hip and knee quite easily. Keeping up with her and managing to challenge her was fun. A fantastic learning experience for me.