Each patient must be treated individually. Their psychological, social, vocational, and avocational needs should be addressed in addition to the physical amputation when determining the appropriate kind of prosthesis.
Contraindications to providing an aesthetic prosthesis include patients without motivation or realistic expectations about what the device can accomplish.
Restoring near-normal appearance improves a patient’s function in a global sense, enabling him to better use what he has in the complex environment of today’s mobile society.
Aesthetic hand prostheses, initially designed and made in the 1950s, were viewed by everyone, including surgeons, physicians, and therapists, as being a beautiful accomplishment but, at the same time, an extravagance that an amputee could permit himself as long as he did not actually use it. Their attitude was that because the prosthesis was inert, insensitive, and nonfunctional, it could be likened only to a mere gadget. In fact, aesthetic hand prostheses fulfill, then and now, not only an aesthetic role, but also provide passive function for professional and social purposes.
Social function can be defined as “that which concerns the members of society, their economic and psychological conditions, and which aims at the improvement of living conditions, especially material conditions, for the members of society.” Thus an aesthetic prosthesis, which in the past may have been considered a gadget with no perceptible use or purpose, proves to be valuable for individuals whose physical integrity has been impaired, and therefore are psychologically affected.
Approximately 50 years have passed since the first prostheses were introduced, and more than 10,000 amputees have been fitted. In the reviews of these patients, it has become clear that the aesthetic prosthesis not only provides a cosmetic improvement but, in many cases, increases function of the involved extremity. To more accurately reflect its dual benefits of aesthetics and function, it is now called the passive functional aesthetic prosthesis.
Because when surgeons and therapists come into contact with the recent amputee they tend to focus on the severely handicapped person’s need for functional help, and they sometimes fail to realize that certain patients also may need an aesthetic aid. However, the futures of such people are difficult to predict. In addition, surgeons and therapists tend to have less experience with patients with agenesis because such patients rarely have the physical injuries that are often the primary reason for most orthopedic and hand therapy care.
Unilateral Distal Amputees
After amputation, the amputee experiences a major functional handicap. She may believe that surgery and a prosthesis can provide a miracle. It is a time of illusions, but progressively the amputee adjusts to reality during the period of healing, prosthetic fitting, reeducation, and vocational rehabilitation. It is also a time mixed with hope and frustration, during which doctors, therapists, and psychologists all have important roles to play.
Some amputees become invalids, never able to accept their amputations. They hide their stumps and refuse to use them. They wear their functional prostheses but do not make use of them, as if the mere presence of the prostheses justifies their behavior. Others accept their amputations too well—they are delighted to be helped and to be treated as children, and their attitude reflects a psychological need.
Such patients represent a small group; the majority of amputees get down to the business of leading a normal life. They reintegrate with their families and society and are able to do so because they have succeeded in making a realistic assessment of their disabilities. In conjunction with the stump, the remaining hand becomes increasingly skillful, to the amazement of not only immediate family members but also the amputee himself.
Thus, for certain amputees, it is the unaesthetic aspect of the stump rather than the functional handicap that is the inhibiting factor and this causes the amputee to blame the amputation for her failures. Such a transfer of blame clearly exists, and most amputees suffer from it. No functional prosthesis is going to eliminate it. Most patients finally grow accustomed to their physical impairments, learning to disregard them and even to forget about the function that has been lost. However, even this group may feel for a long time, and perhaps forever, aesthetic frustration like that experienced by the congenital amputee.
Unilateral Distal Congenital Amputees
In my (JP) experience, unilateral distal congenital amputees almost never ask spontaneously for a functional prosthesis. In the very rare exceptions, it has been relatively easy to discern the influence of parents or family practitioners, both equally misinformed.
When one is treating a congenital amputee, it is common to commit a dual error by considering the patient as a disabled person and by wishing to fit a functional prosthesis. That thinking is wrong concerning such a person. He or she is not a true amputee but rather has an imperfect development because of a congenital deformity. These patients have established their own perception of their bodies, which differs from our perception of them. They see themselves as being complete and normal.
Whatever their ages, congenital unilateral amputees manage all activities of daily living without any prostheses. For each need, they use a technique that differs from ours. Naturally, they experience some frustration from not being able to do certain things, a frustration that varies from one person to another. As among normal people, there are lazy and also clumsy agenetic persons, and giving them insensitive functional prostheses will not make them any more dexterous.
To suggest fitting a functional prosthesis for a patient with unilateral agenesis, however perfect the prosthesis may be, is tantamount to encumbering a normal person with a third hand. In fact, that was the reaction of such a patient when I asked why he did not have a functional prosthesis. “Doctor,” he said, “What would you want with a third hand?”
Unlike the amputee, an agenetic person does not experience the initial emotional shock of losing a hand. Congenital amputees consider themselves from the outset as being normal from a functional point of view, and only gradually do they come to realize that they are not like other people. The congenital amputee has felt the same aesthetic need as the amputee who has had a traumatic or surgical loss.
In some cases the unilateral agenetic amputee insists on having a prosthesis even though it will certainly be uncomfortable and represent a significant loss in function and poor aesthetic results. For instance, out-of-axis digital stumps always result in an ungainly prostheses, and multiple digital prostheses on the same hand reduce its sensitivity and gripping power. Disarticulation of several digits at the metacarpophalangeal (MCP) level requires that the prosthesis cover the hand completely, and trophic problems may make it unbearable. In these cases, we must dissuade the patient from being fitted with such a device unless the psychological indication is more important than the disadvantages posed by the prosthesis. The amputee must learn to accept the fact that a prosthesis is not a panacea.
Physical impairment is so great for the bilateral amputee that it overshadows the aesthetic concern, but such concerns, in fact, are not diminished in these patients. Benefits may be derived in the bilateral amputee by fitting one side with an aesthetic prosthesis; however, the need for sensitivity of a part on at least one side precludes useful bilateral fitting.
For agenetic patients who have made their own functional adaptation, aesthetic prostheses may help them go unnoticed, depending on the case, through more natural gestures. As some patients with acquired traumatic or therapeutic amputations acknowledge their functional impairment, they may feel the necessity of not exposing their mutilation in full view of others. In this instance, the aesthetic prosthesis fully plays its role by allowing them to resume a social life that would seem impossible without it.
A patient, who underwent amputation at the level of her forearms for therapeutic reasons when she was 65 years old and who had been using prostheses for 6 years, told us that she could no longer do without her prostheses, which she wears from morning until night. They allow her to appear before others, especially members of her family, without shocking them. Furthermore, as time goes by, her prostheses are an invaluable aid in taking hold of certain objects and leafing through a book or magazine.
Another patient, whose fingers were all amputated after being burned in an explosion, requested digital prostheses to resume her profession as a teacher. As we explained to her the disadvantages of wearing 10 prostheses, she replied that she might not wear them all at once, but that she would then be in a position to decide which fingers to fit according to her requirements and her activities. Since then, she adapts her prostheses to their use.
Another patient whose right hand and three fingers of her left hand were amputated insisted on having a hand prostheses for her right hand, but preferred to leave her left hand “free” to maintain the best function possible, especially for writing.
In cases of therapeutic amputation, patients are confronted not only with the loss of their limb, but also are dealing with a serious illness and possibly a distressing diagnosis.
Aesthetic Prostheses for Children
The majority of children seen in consultation for prostheses have a congenital abnormality. If the stump does not have a pinch mechanism, fitting of a prosthesis may be carried out at a very early age—usually between 6 and 18 months. Fitting at this age accustoms the child to the presence of the prosthesis and encourages bimanual activity. However, skin-related problems often occur before 18 months.
If the stump has a useful pinch mechanism, the prosthesis is functionally more bothersome than useful in the daily activities of school and play. In these circumstances, it is preferable to postpone fitting until the child is near adolescence, at which time his “self-image” becomes preeminent and he is more motivated to accept the inconveniences of the prosthesis.
A child’s physical appearance at birth is of primary importance to the parents, and it is sometimes necessary to fit a child with a prosthesis if the parents are suffering from psychological trauma. In such cases, it is the parents we are treating through the child. This is a dilemma that can lead to serious consequences. We are dealing with the parents’ wishes, as legitimate as they may seem, and not with a request from the child, who is the person concerned. This is not the conventional approach.
The agenetic child is, above all else, a child who is an evolving person, a fact that should not be overlooked or ignored. Problems arise when parents, the family circle, teachers, and medical teams all focus on the congenital deformity. Our experience has shown us the extent to which it is often difficult to discover the child hidden behind the anguish, the feelings of guilt, and even the disappointment of her parents. Therefore, it is absolutely necessary to allow the parents to express themselves regarding their child’s body and to let them sum up the situation and what they expect for themselves and for the child because, after all, who will undergo the treatment, the parents or the child?
As long as one or both parents do not accept the deformity, any suggestion of surgical reconstruction or prosthetic fitting, or even both, must be considered with the utmost reserve. It may be that the parents, distressed and insistent and unable to admit that their child is “different” from other children, want this image to be erased or masked at any cost. The doctor then becomes responsible for making this deformity vanish, with the unspoken wish that he or she should bring normality to this child who is perceived as abnormal. In many cases, these children are seen as “objects to be repaired.”
Although children with congenital amputations have known since birth that they were dissimilar, during the period of prepuberty and puberty their deformity can act as a catalyst to problems specific to adolescence, especially relational problems. We know that at this time in life, their main concern is to be “identical” to others in order to belong to the group.
Even if in the preceding years their physical disparity was not a cause for major problems, it often takes on a profound importance because relational difficulties for these teenagers whose bodies are different can focus on the upper limb. They feel rejected and start concealing it and hiding themselves, some through withdrawal, some with a depressive condition, and some through massive antagonistic behavior fraught with aggressiveness. All feelings of discomfort are magnified and usually leave parents in a state of confusion.
It is our duty to distinguish between psychological problems specific to adolescence and problems relating to the hand to help patients understand what is happening and allow them to express a coherent request: what is the nature of their current distress? We believe it is crucial, no matter the age of the agenetic patient, that we understand the meaning of the patient’s request, just as it is important that we realize when the time is right to propose surgery or a prosthesis, while always mentioning that to do nothing, at least temporarily, is a perfectly acceptable solution. The mother who refuses a toe transfer or a prosthesis is not a bad mother and she is not abandoning her child to his misfortune. This attitude is preferable to yielding to various pressures from the family or doctors, if the idea of operating or fitting is unacceptable to herself or her child or both.
We know that the body cannot be viewed in its physical dimension alone, allowing for technical gestures. Only the psychological dimension ensures the integration required for improving the agenetic’s performance. Thus there is not one solution to this problem that we may consider at any given time in answer to the amputee’s request, but a series of solutions in agreement with the patient’s wish and evolution.
Prosthetic Considerations According to Level of Amputation
The presence or lack of a pinch mechanism determines if an amputation is distal or proximal ( Box 98-1 ). With a proximal amputation, the stump does not have a functional pinch.
Proximal (stump without functional pinch)
Arm: long stump, short stump
Forearm: long stump, short stump
Distal (stump with a functional pinch)
The Ungual Lesion
Through its specific function and the symbolic part it plays, the nail, whether it is deformed, distorted, or partially or totally lacking, allows for extremely precise and restricted possibilities of ungual prostheses in response to a search for perfection. On a physical level, the functional disability is often major, even when the lesion is of little significance. The smallest wound impairs such an accurate and efficient tool.
Loss of Fingernail
The fingernail has both an aesthetic and a functional role. Functionally, it provides fingernail or tip-to-tip pinch, which is used mainly for prehension of small objects. Some patients are willing to give up this function for aesthetics, by preferring an unusually long fingernail or by wearing a bandage to hide an injured and disfigured fingernail. When injury occurs, the slightest alteration in the beauty of the fingernail may entail important psychological consequences in certain patients. To give a “real” fingernail to these patients is like a salve for them. To make a fingernail is easy; however, to provide secure fixation is essential.
Partial Loss of a Nail
It is possible to form a fingernail with acrylic paste. Composed of powder and liquid, the mixture is applied to the remaining fingernail with small brushes and a spatula. Fixation is perfect because the resin adheres to the fingernail. The resin is well tolerated by the skin. However, the technique is too complex for patients to do themselves. The fingernail must be formed in a specialized salon and requires touching up every 3 weeks, depending on how much the natural fingernail grows.
Total Loss of a Nail
Attachment of a commercially available fingernail to the skin can present some problems. If the glue used to secure the fingernail to the skin is to be effective, it may cause an adverse skin reaction. If the glue is less effective so as not to irritate the skin, fixation does not last.
A custom-made prosthetic fingernail can be inserted into a surgically made rim, after the ungual and matrix residues have been removed. However, it is also necessary to use glue to affix this prosthesis, which often causes cellulitis and skin complications. In addition, the result is short-lived. After a few weeks or months, the surgically made pocket retracts with increased scarring, and the appearance is very poor.
The only method available for secure fixation of a normal-looking fingernail involves covering the entire distal phalanx with a very thin prosthesis like a thimble, but the disadvantages are obvious. Secure fixation remains a problem without a good solution.
Nail Implants and Prostheses
Research is currently under way that may lead to fingernail implants. However, there is a major risk of infection as a result of the fixation and of ulceration resulting from the mobility of the skin. Therefore, nail implants should be applied only on skin that adheres to the bone and that is thin and immobile. The “upkeep” of nail implants is delicate and must be done daily. Our experience in this field is still limited.
Strictly speaking, nail prostheses do not exist as far as we are concerned. They are part of prosthetic fittings in partial or total amputations of the third phalanx. The replacement nail remains a delicate problem to deal with because it is either a matter for the nail boutiques in the simpler cases or for surgery in complex ones. To fulfill its purpose, the digit prosthesis must have well-defined qualities. The particulars of the nail are especially important. The nail is made of a hard and translucent material. It must be integrated into the prosthesis and be like the patient’s other nails in shape, color, length, and dimensions of the lunula ( Fig. 98-1 ). One should be able to paint the nail easily with store-bought nail polish and take it off with an acetone-free remover.