Review Article
Principles of Amputation Surgery, Prosthetics, and
Rehabilitation in Children
Craig Ray Louer, Jr, MD
Phoebe Scott-Wyard, DO
Rebecca Hernandez, CPO,
LPO
Anna Dimitriovna Vergun,
MD
From the Department of Orthopedic Surgery,
Vanderbilt University, Nashville TN (Louer), the
Department of Physical Medicine and
Rehabilitation, Rady Children’s Hospital,
University of California—San Diego, San Diego,
CA (Scott-Wyard), the Department of Orthotics
and Prosthetics, Children’s Healthcare of Atlanta,
Atlanta GA (Hernandez), and the Department of
Orthopedic Surgery, University of North Carolina
School of Medicine, Chapel Hill, NC (Vergun).
None of the following authors or any immediate
family member has received anything of value
from or has stock or stock options held in a
commercial company or institution related
directly or indirectly to the subject of this article:
Louer, Scott-Wyard, Hernandez, and Vergun.
J Am Acad Orthop Surg 2021;29:e702-e713
DOI: 10.5435/JAAOS-D-20-01283
Copyright 2021 by the American Academy of
Orthopaedic Surgeons.
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ABSTRACT
Pediatric patients may benefit from extremity amputations with
potential prosthetic fitting when addressing limb deficiencies, trauma,
infection, limb ischemia, or other pathologies. The performance of a
quality amputation is a fundamental skill to an orthopaedic surgeon, yet
avoidance of pitfalls can be elusive in children. The need for surgical
precision and sound decision-making is amplified in pediatric
amputations, where the skeleton is dynamic and growing, anatomy
can be miniscule and (in the case of congenital anomalies) variable. The
principles that guide amputation level and technical approach are
unique in children. Despite this, descriptions of these procedures as
they should be applied to a growing or congenitally deficient skeleton
are lacking. Furthermore, surgeons must also understand the unique
prosthetic and psychosocial considerations for children. A
collaborative approach between the surgeons, rehabilitation
physicians, prosthetists, therapists, and families is essential to ensuring
optimal results.
T
he differences between children and adult amputees are numerous
and important. The most obvious differences relate to a child’s
physiology: a still-growing skeleton with rapid variations in length,
girth, motor development, and a propensity for terminal bone overgrowth.
There are also differences in etiology with most of children’s amputations
resulting from the lack of formation, whereas adult amputations typically
result from acquired conditions such as trauma or peripheral vascular dis-
ease.1 Because of these differences in etiology, children typically have
improved healing potential and rarely experience phantom pain, but they
may also have aberrant anatomy and are more likely to have multiple
extremity involvement. Child amputees are more likely to have comorbid
physiologic, cognitive, and/or behavioral challenges because of the associated
conditions. Despite these challenges, the physical demands of a child are
generally higher than those of an adult. Finally, the psychological impact of a
limb difference on both the child and the family must be understood.2,3
In light of these challenges, pediatric limb deficiencies are best managed by a
multidisciplinary team including therapists, prosthetists, physical medicine
and rehabilitation physicians, and orthopaedic surgeons with experience
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treating these conditions.4 This collaboration is essential
for guiding treatment decisions (such as the role of
surgery) to obtain optimal outcomes. To this end, the
Association of Children’s Prosthetic-Orthotic Clinics
was founded in 1980 with the goal of advancing
knowledge about the treatment of children with limb
differences. The purpose of this article was to cover the
breadth of these important differences and offer re-
sources for in-depth exploration.
Surgical Principles
Of note, the term “stump” is still commonly used among
surgeons, although it carries stigma within the amputee
community. Terms such as “residuum” and “residual
limb” are preferred. The overall goal of surgical
amputation and prosthetic reconstruction is to optimize
function. The child’s current and eventual adult stature
must both be considered. A broad set of surgical prin-
ciples should be observed.
1. Preserve length and growth plates:
In general, a longer residuum results in improved
function.5-7 The longer lever arm improves power
and improves distribution of contact forces within
the prosthetic socket. For nonambulatory ampu-
tees, longer lower limbs improve seated balance.
Consider this classic example where growth is not
considered: An amputation just proximal to the
distal femoral physis will initially appear the
appropriate length in an infant; however, because
71% of femoral growth is from the distal physis,
the residuum will only grow slightly longer and, at
maturity, the child will function as a hip dis-
articulation amputee.
A residual limb can also become too long. The
space needed to accommodate a prosthetic joint
can range from 5 to 20 cm. With prosthetist
input, a properly timed epiphysiodesis can be done
to provide enough room for high-functioning
prosthetic joints at maturity.
2. Disarticulation is favored over transosseous
amputation:
Terminal bony overgrowth can occur in nearly
50% of transosseous amputations and results in
morbidity and multiple reoperations.8 When
necessary, an osteochondral capping procedure
should also be done, which can successfully pre-
vent overgrowth in 90% of cases.9,10
Consider muscle or skin grafting when necessary
to achieve a more distal amputation or disarticu-
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Craig Ray Louer Jr, MD, et al
Review Article
lation level. Success will vary with the extent and
health of the graft. When faced with the choice
between shortening and grafting, there is evidence
to support successful use of split-thickness skin
grafting in the residuum without a notable
increase in prosthetic complications.11
3. Preserve joint function (especially in the knee):
Gait efficiency and energy expenditure (as mea-
sured by oxygen consumption) is improved when
native joints can be preserved12 and amputations
are as distal as possible.5,13,14 Sports and physical
functioning outcomes scores are markedly worse
when the knee is amputated. A graded decline is
observed in physical function as the amputation
level ascends.7
This is the logic of the rotationplasty procedure: a
patient’s ankle joint can serve as a substitute for a
knee that is not salvageable or length-compatible,
with the benefits of proprioception, stability, and
strength of the original joint.12
Short segments (ie, short tibia) should not lead to
proximal joint sacrifice in a growing child. If the
epiphyseal plate is preserved, the segment will
lengthen. Surgical lengthening or prosthetic ac-
commodations are also possible.
4. Stabilize/normalize proximal portion of limbs
In limb deficiency syndromes, hip and knee
instability may be coincident. Addressing these
proximal concerns can allow for optimal control
and function of a more distal prosthesis.
In more severe congenital femoral focal deficiency
syndromes (Aitken C/D, where the tibia functions
as a femur), the native knee should be fused in full
extension at the time of rotationplasty or foot
ablation. This improves function by increasing
muscle force at the hip and aligning the limb in the
sagittal plane of the trunk.
5. Prepare to address other concerns:
a) Genetic concerns, syndromes:
Lack-of-formation deficiencies were previously
believed to be sporadic events without an
inheritable pattern. Recent work has described
variable modes of inheritance for numerous
skeletal deficiencies, including congenital fem-
oral deficiency, fibular deficiency, tibial defi-
ciency, and split hand or foot deformity.15
Because of the rapid evolution of this information,
a geneticist can be a valuable member of the team.
b) Upper extremity amputations:
Because upper limbs are not weight-bearing, the
necessary structural elements for optimal
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Principles of Amputations in Children
function are much more variable than in the
lower extremity (stable joints, equal lengths,
etc.). Surgery is infrequently indicated. Residual
anatomic differences, such as nubbins, often
have a functional benefit, such as sensation or
touchscreen use, and should not be removed.
A child with upper extremity limb differences can
perform most activities of daily living by using the
unaffected side (if unilateral) or their lower limbs.
Because prosthesis use decreases native sensation
and may hinder function in some cases, not all
children will choose to wear a prosthesis. A meta-
analysis of studies since 1980 shows a 20%
nonwear rate because of varied causes.16,17 An
upper extremity prosthesis can facilitate some
motor milestones (ie,: crawling), bimanual tasks,
and sports. We recommend engaging in shared-
decision making about the use of upper extremity
prostheses.
c) Multiple limb deficiencies:
In the setting of multiple limbs with differences,
the overall function of the child must be con-
sidered, instead of simply “replacing” the
missing parts. Multidisciplinary teams includ-
ing therapists should be consulted before any
surgical treatment. When more than two limbs
are affected or missing, surgery and/or multiple
prostheses are more cumbersome than helpful.
Treatment typically focuses on assistive devices.
Surgical Techniques for Pediatric
Amputations
Ankle amputations (Syme18 and Boyd19 procedures)
Indications and preoperative considerations:
The Syme disarticulation and Boyd amputation
procedures are both used for foot ablation because of
deficiency, instability, infection, trauma, or other.
Advantages of these amputations over a transtibial
amputation in children include avoiding overgrowth,
allowing prosthesis self-suspension, rotational con-
trol, and the ability to end-bear more comfortably
on a broad metaphyseal bony surface and tough heel
pad. The oft-cited drawback to these procedures in
adults (residuum too long) is not applicable in most
children as the limb is already congenitally short or
can altered with an epiphysiodesis.
Syme: This is a tibiotalar disarticulation proce-
dure. The advantages of a Syme are technically
ease, decreased acute postoperative wound com-
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plications, and a quick recovery. The major dis-
advantage reported is the risk of heel pad
migration posteriorly, which can lead to less reli-
able weight-bearing in some cases.20 Heel pad
migration may be unavoidable in severe fibular
hemimelia. In many instances, a posterior heel pad
seems to have minimal effect on function in a
prosthesis.21 Revision should only be attempted if
clearly symptomatic.
Boyd: This procedure is foot amputation with a
talar resection and fusion of the calcaneus to the
distal tibia. This allows the heel pad more stability
because it remains attached to the native calcaneus.
The residuum length at maturity can be modulated
by resection of the distal tibial physis. Disadvantages
of the Boyd amputation include increased technical
difficulty, higher risk of postoperative wound
complications, and longer immobilization before
prosthetic fitting. The residuum is longer than in a
Syme amputation because of calcaneus retention. A
painful nonunion may require revision.19
It is the preference of these authors to perform
Boyd amputations in most cases, which increases
the risk of early postoperative complications but
decreases the risk of later heel pad migration. A
Syme amputation is suitable in limb deformities
where a Boyd is not advisable: for instance, in
calcaneus deformity or migration, many traumatic
etiologies, older patients where nonunion risk is
higher, or if additional length difference is needed
relative to the other limb (prosthesis typically re-
quires 15 to 20 cm of difference at maturity).
Surgical setup and steps:
Syme: The technique is well-described elsewhere,22
but a few modifications are noteworthy in a pediatric
population:
The dissection plane used between the calcaneus and
the heel pad can vary depending on the report.
Historical reports discuss that a subperiosteal dis-
section is key to maintaining heel pad integrity
because disruption of the plantar aponeurosis allows
the fat, which acts as a hydraulic buffer, to escape
the fibrous septae.18 There are, however, reports
that unintentional ossification of this plantar flap
causes prosthetic irritation, causing some to advo-
cate for an extraperiosteal dissection plane.22
The authors’ preference is to perform subperi-
osteal dissection in most cases, positioning the
periosteum over the distal tibia with soft-tissue
tension and suture techniques. The eventual ossi-
fication of this sleeve allows this to function like a
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 Craig Ray Louer Jr, MD, et al

Boyd procedure because the heel pad is more
robustly secured. In some cases (as in more severe
fibular deficiencies), it will not be possible to
position this sleeve under the tibia because of
proximal migration of the native calcaneus. In
these cases, we prefer extraperiosteal dissection to
prevent the formation of heterotopic ossification
in the posterior leg, which can interfere with
the socket fit. Malleoli need not be resected in
children.
Boyd’s amputation (Figure 1):
Setup: patient supine with extremity prepped and
draped free with a thigh tourniquet.
Anterior incision is just distal to the tibiotalar
joint, with plantar incision being as distal as the
metatarsal heads.
The initial anterior exposure, capsulotomy, and
preservation of posterior neurovascular bundle
proceed much like the Syme procedure, except
after the posterior talus is freed, the subtalar
joint is entered and becomes the amputation
plane. The calcaneus is preserved with the large
plantar flap, but the talus and the rest of the foot
are removed.
Approximately one-third of the superior surface of
the calcaneus is removed with a saw cut that is
parallel to the plantar aspect of heel pad. Be aware
Review Article
that a true joint may not exist if a tarsal coalition is
present (as is the case in fibular longitudinal
deficiencies).
The distal tibial osteotomy is done perpendicular
to the mechanical axis through the ossific nucleus
of the epiphysis or the metaphysis, pending the
desired length of the residuum at maturity.
If the distal fibula is present, the distal 4 cm can be
resected, or an epiphysiodesis can be done.
The calcaneus is then opposed to the cut edge of
the tibia, with the anterior edges of each segment
aligned. This can be fixed with percutaneous pins,
suture through bone, or staples.
Postoperative care and prosthetic considerations
Figure 2 shows generalized postoperative time
course. Syme procedure can begin prosthetic fitting
around 2 to 4 weeks, whereas Boyd may require pin
removal at 6 weeks before prosthetic fitting.
Although patients can weight-bear directly on
their residual limb without a prosthesis, this is
done less frequently as patients age. It is more
important to ensure enough discrepancy so the
limb can accommodate a prosthesis.23 A clearance
between 15 and 20 cm allows for multiple com-
ponent options, although the ideal discrepancy
depends on the available technology and should be
discussed with the prosthetist.

Figure 1

Diagram showing Boyd’s amputation. A, Radiograph, clinical photograph, and representative line drawing of a 6-month-old patient with
split foot deformity (with typically developing contralateral leg). Structures outlined in black are ossified, whereas those outlined in gray
represent cartilaginous structures not visible on radiographs. A Boyd amputation was chosen to ablate the non-functional foot (red
dashed line indicates amputation plane). B, After tibiotalar disarticulation, partial amputation of the dysmorphic foot was done, leaving
in place the Achilles tendon, calcaneus (“Ca”), and the lateral ray (“Lat. Ray”). The distal tibia and fibula were cut above their physes,
whereas the calcaneus was cut parallel to the plantar heel surface (red solid lines). C, Using the posterior soft tissue as a hinge, the cut
calcaneus was closed to the cut distal tibia and secured with suture. D, Radiographs and clinical appearance at conclusion of
procedure.

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Principles of Amputations in Children
Figure 2
Diagram showing general recovery timelines. General recovery timelines for amputation healing and prosthetic fitting for both soft-
tissue and bony procedures. Timelines subject to patient-specific considerations, including tissue stability, compliance, and relative
benefit of early fit/mobilization protocols. Young patients may use compressive ACE wraps if a shrinker of appropriate size is not
available.
Outcomes:
Midterm results comparing limb reconstruction
versus amputation for fibular hemimelia demon-
strate no notable functional or psychological dif-
ferences with high satisfaction for both methods.24
Midterm to long-term results comparing ampu-
tation versus extension prosthesis (with foot re-
tained) for fibular hemimelia show improved
function and less pain when amputation was
used.25
“Capping” (ie, “stump capping”) procedure
Indications and preoperative considerations:
This procedure should be considered primarily
when a transosseous amputation is unavoidable or
secondarily when an amputation has been com-
plicated by overgrowth.
Many strategies have been developed to address
overgrowth, including excision, use of prosthetic
caps of varying materials, modifications of the Ertl
tibiofibular osteomyoplasty technique (which
should not be done in young children; Figure 3),
and various other grafted tissues. However, the
use of autologous osteochondral grafts has
become standard after recognizing the success of
disarticulation procedures.10
Grafts can include any healthy cartilage surface
within the body or discarded limb able to be
sacrificed, including metacarpal heads and shafts,
distal or proximal fibula, iliac crest, or tarsal bones
of appropriate size.
Our preferred technique for tibial capping involves
the use of the proximal portion of the fibula, as
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described in a large series of 50 procedures by
Fedorak et al.9
Pearls and pitfalls:
If the proximal fibula is relatively large (or tibia is
small), the fibula segment can be “slotted” lon-
gitudinally and deformed to reduce diameter and
allow proper fit.
Some prosthetists argue that fibular head loss
decreases torsional stability of socket—use dis-
carded parts if available (Figure 4).
Outcomes:
For patients who have already demonstrated the
complication of overgrowth, the success rate of
this procedure was 90%.9
There was no varus instability of the knee postoper
atively despite disruption of the LCL insertion on
the proximal fibula.
Transtibial amputations
Indications, techniques, and outcomes are well-
documented in previous reports.
Pearls and pitfalls specific to children
Primary osteochondral capping should be done in
all children under 12 years to avoid complications
from overgrowth. It can be considered in older
children to improve end-bearing capability.
Early reports of compressive osseointegration fixa-
tion of prosthesis have been shown to decrease
terminal bone overgrowth in a case series of
pediatric transtibial amputation patients.26
Through-knee amputation
Indications:
The primary indication for a knee disarticulation
procedure is a congenital deficiency syndrome
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 Craig Ray Louer Jr, MD, et al

Review Article
Figure 3

Radiograph showing cautionary tale for the Ertl procedure. A, Male patient with amniotic band sequence and congenital transtibial
amputation with tibiofibular synostosis. Despite a revision procedure, the synostosis persisted. B, Because of variable growth between
the proximal tibia and fibular physes, the proximal fibula overgrew the tibia causing prominence and varus deformity. This was partially
addressed with guided growth and fibular osteotomy. C, However, at age 16 years, the patient still has varus and prominence. He is
functional in his prosthesis, yet still reports of irritation laterally with prolonged manual labor. Although the synostosis was not
deliberate, this case demonstrates the negative effects of performing intentional tibiofibular synostosis osteomyoplasty (Ertl procedure)
in growing children, although it is a reasonable option in adults.

where the knee is dysfunctional and reconstruction
is not an option or an acquired etiology where the
knee is not salvageable. Disarticulation is pre-
ferred over transfemoral amputation because risks
of overgrowth are obviated, length is preserved,
and less muscle transection is needed.
Surgical setup and steps (Figure 5):
It is helpful to have access to both anterior and
posterior aspects of the knee using a lateral posi-
tion and native hip motion but can be done supine
as well. A sterile thigh tourniquet is used.
Although most adult techniques discuss using a
posterior flap (vascularized by the sural arteries)
because of less robust circulation anteriorly, in con-
genital pediatric cases, the circulatory advantages are
insignificant. We believe the advantage of improved
prosthetic wear with a posterior scar and prepatellar
skin covering the terminal end make an anterior flap
the optimal choice in these instances.
A posterior facing fish-mouth incision is preferred.
Incise skin circumferentially and undermine full-
thickness flaps once to level of fascia. The patellar
tendon, anterior knee capsule, and cruciate liga-
ments are transected. The authors recommend
removal of patella to avoid future patellofemoral
pain. The pes anserine, iliotibial band, and biceps
femoris insertions can all be identified and released.
Next, extend the arthrotomy circumferentially.

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Principles of Amputations in Children

Figure 4

Radiograph showing osteochondral capping in congenital pseudarthrosis of tibia. This case demonstrates many salient principles of
pediatric amputation, including Boyd amputations, risk of stump overgrowth, and primary capping using parts destined for discard. A,
AP and lateral tibia radiographs for 4-year old girl with neurofibromatosis type 1 and a congenital pseudarthrosis of the tibia (CPT),
status after failed reconstruction attempts. She had a Boyd amputation within the past year along with another attempted CPT
correction and grafting, now with persistent nonunion and progressive deformity. B, This patient underwent transtibial amputation
(above the level of pseudarthrosis) with the simultaneous capping procedure using distal fibula. It is the authors’ experience that a
pseudarthrosis site can still experience overgrowth. Because of poor healing potential, however, it is not the ideal site to perform
capping. C, 4-month follow-up demonstrating progressive healing and integration of the cap. Patient is now 8 years old and functions at
a high level without prosthetic complaints or concern for overgrowth.

Note that in tibial deficiency, many of the structures
about the knee will be aberrant or nonexistent.
The popliteus neurovascular bundle is identified
between the gastrocnemius heads and ligated.
Release the gastrocnemius heads from their origin.
The patellar tendon and hamstrings can be sutured
to the cruciate stump and/or knee capsule for a
myodesis. A full capsular closure often cannot be
achieved, but it is the authors’ experience that this
is inconsequential.
Post-operative care and Prosthetic considerations:
Patient placed in compressive soft dressing for 2
weeks, replaced by stump shrinker with plan to
mold socket at 2-4 weeks post-operatively.
Pearls & Pitfalls:
In tibial deficiency, many of the structures about
the knee will be aberrant or non-existent. For
instance: in the case described in Figure 5, medial
hamstrings, lateral hamstrings, extensor mech-
anism & patella, femoral notch, and cruciate lig-
aments were absent.
In tibial deficiency, the posterior dissection may be
hindered by the knee flexion contracture. In these
cases, it may be advantageous to primarily strip
the gastrocnemius origin to allow extension, then
isolate and ligate the neurovascular bundle.
Trans-femoral amputation
Indications, techniques, and outcomes are well-
documented in prior reports.
Pearls & Pitfalls:
If there are no distal parts to use, stump capping
can be performed by utilizing iliac crest autograft.
Prosthetics in Children
Children with limb deficiencies require ongoing lifelong
prosthetic care. Prosthetic treatment should allow chil-
dren to reach age-appropriate developmental milestones
and participate in activities with their families and able-
bodied peers. A prosthesis should ideally last a child 12 to
18 months. The prosthetist must take into consideration
many factors to include the following: longitudinal and
circumferential growth of the residual limb, space limi-
tations for components such as feet and knees, indepen-
dence in donning/doffing, and strength and durability of

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 Craig Ray Louer Jr, MD, et al

Review Article
Figure 5

Diagram showing knee disarticulation. A, Radiographs and clinical photograph of a 9-month-old male child with Jones type 1a tibial
deficiency with the absence of entire tibia and extensor mechanism. It was decided to proceed with amputation before walking age. B,
Patient was positioned lateral with the apex of fish-mouth incision at joint-line with a larger anterior flap. After anterior dissection and
arthrotomy, dissection was continued medial and lateral. There were no medial hamstring tendons or extensor mechanism
encountered anteriorly, although the iliotibial (IT) band required division laterally (black arrowhead). Dissection then continued
posteriorly, where the popliteus neurovascular structures were isolated before ligation. In tibial deficiency, the posterior dissection may
be hindered by the knee flexion contracture. In these cases, it may be advantageous to primarily strip the gastrocnemius origin to allow
extension, then isolate, and ligate the neurovascular bundle. C, Amputated part and residual limb (note dysmorphic distal femur with
single condyle—white arrowhead—void of notch or cruciate ligaments). D, Final closure with anterior skin flap (posterior flap was
trimmed to eliminate redundancy) and clinical photograph showing prosthesis use at 6 weeks postoperative.

the prosthesis. The follow-up should occur at 3-month
intervals to ensure that the prosthesis is fitting appro-
priately, and growth is accommodated. The design of the
socket and components used vary with age, activity level,
and functional requirements. Activity or sports-specific
devices are used when children can no longer adequately
reach their goals with their daily device, such as a running
leg for competition or a specific terminal device to play a
musical instrument. When possible, prosthetists should
be provided with relevant clinical and radiographic de-
tails. For example, a child with proximal femoral focal
deficiency may need an ischial/gluteal weight-bearing
socket design to address hip instability, or a child with a
fibular deficiency may require a supracondylar socket
design to provide adequate knee stability.27
All prostheses have common structure, including
proximal components to interface with the patient
(socket, interface, suspension, etc.) and distal compo-
nents, such as feet, knees, elbows, hands, or other ter-
minal devices, depending on the level of deficiency. The
socket is custom made from a cast or digital scan to
ensure a proper fit that allow reliefs for bony prom-
inences and loading of tolerant areas. The interface may
consist of socks, gel or silicone liners, or varying dur-
ometers of foams. The suspension maintains the pros-
thesis on the residuum and is often anatomical in nature
in children, suspending over malleoli or condyles.
Sleeves, belts, and liners with locking pins or lanyards are
commonly used for suspension. Suction and vacuum are
infrequently used in children because of the continuous
growth and physiological changes throughout the life-
span of a prosthesis. Advances in materials and tech-
nology are improving prosthetic componentry such as
microprocessor-controlled knees, carbon or fiberglass
composite feet, and multidigit articulating hands. How-
ever, the most important factor in the success of a pros-
thetic device is the socket because it is the connection
between body and prosthesis. If the socket is ill-fitting or
causing discomfort, even the most sophisticated terminal
component is rendered useless. Redundant tissue should
be avoided because this can cause fit and stability chal-
lenges in the socket.28

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Principles of Amputations in Children

Table 1. Troubleshooting Prosthetic Complaints

Pain/Complaints Possible Causes
Distal end pain Terminal overgrowth, excessive distal end-bearing (too few
socks = bottoming out)
Tightness Growth, too many socks, weight gain
Anterior distal tibia pain Excessive pressure (too many or too few socks), change in heel
height in shoe
Burning/prickly sensation/itching when prosthesis is removed Fungal infection
accompanied by rash
Electrical/shocking pain on palpation Neuroma
Localized pain with drainage Folliculitis/boil
Stabbing pain over bony area Callusing
Pulling/tightness Scarring/ adhesions
Rubbing/blistering Pistoning in socket

During the lifespan of a prosthesis, a child may
experience pain or discomfort. The care team must
determine whether the cause is from a physiological
source (ie, neuroma, bony overgrowth, or referred pain),
or if it is from a socket or alignment problem. A careful
skin examination and trying to reproduce the pain or
discomfort with the prosthesis off can provide valuable
insight, especially in the young child who cannot describe
the pain. Table 1 includes some common complaints.
Timing of prosthetic use is an important consideration.
As mentioned, upper extremity prosthetic use is contro-
versial. If desired, an infant with a congenital deficiency
can be fit with a passive upper extremity prosthesis when
Figure 6
they begin to sit so that they can use it for stabilizing ob-
jects and balance in sitting and crawling. An active ter-
minal device may be added around 2 years of age.
Alternatively, children can be fit with a tool for specific
activities (holding a sport apparatus, controlling a bicycle
handlebar, or cosmetic prosthesis for special occasions).
The ideal time to fit an infant with a lower limb prosthesis
for a congenital deficiency is when they pull to stand,
generally between 10 and 12 months. Recent research
indicates that a functioning mechanical knee with the first
prosthesis encourages symmetry in patterns of movement
such as crawling, tall kneeling, and pulling to stand in
select patients.29 Anecdotally, when a bilateral lower

Case demonstrating why collaborative efforts are key. This is a 17-year-old male patient who is a transtibial amputee after severe injury
sustained as a pedestrian struck by a vehicle. He is a K4 (high-functioning) ambulator but needs to use crutches because he cannot
wear a prosthesis. He suffers from skin breakdown because of severe tibial deformity and adherent scars. The orthopaedic surgeon’s
initial plan was a corrective osteotomy to improve length and decrease medial prominence. After discussion with an experienced
prosthetist, the plan was changed for a simple tibia resection (dashed line) with fibula trimming to decrease prominent areas yet
continue to allow distal weight-bearing on the cortical bone at the distal stump which has a broad surface for distributing weight,
thereby protecting the skin. A thigh cuff can be added for improved knee kinematics.

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 Craig Ray Louer Jr, MD, et al

extremity amputee is present, consider nonarticulated
blades rather than prosthetic knees.
If a child has had surgical intervention, postoperative
care is important to ensure timely fitting of their pros-
thesis. With more robust healing capacity of children,
prosthesis fitting can often be accelerated beyond the
recommended timelines to promote psychological bene-
fit. Physical and occupational therapy is critical to iden-
tifying limitations and maximizing a patient’s function
within their environment. Therapy may be episodic in
nature, with more frequent use during initiation of
prosthetic wear or when facing challenges.
Communication between team members is of utmost
importance to allow for seamless care. When deciding
whether to change the limb or prosthesis, it is essential to
consult the prosthetist, so an appropriate decision can be
made (Figure 6). A surgery will often result in the need for a
new socket, and it is important to be sensitive to the family’s
investment (time and financial) when planning surgery.
Review Article
Psychological Considerations: Caring for
the Whole Child (and Family)
Many parents discover their child’s limb deficiency at birth,
although there is increasing frequency of antenatal diagnoses
because of improvements in prenatal ultrasonography.30
The child and family should be offered psychological sup-
port, starting with the initial consultation, including intro-
ducing them to other families of children with similar limb
deficiencies. The extreme benefit of group interactions can-
not be understated (introduction to patient/family resources
can be found in Table 2). Families faced with surgical
intervention for a child with a limb deficiency often struggle
with the idea of “removing” part of a limb. Parents should
be encouraged to journal their feelings regarding the surgery
and to take photographs and “footprints,” if appropriate, to
help with coping. These memories can even be shared with
the child later, when developmentally appropriate. In
addition, involving a child life specialist in the perioperative

Table 2. Resources for Professionals and Families

Resources for Professionals
Association of Children’s Prosthetic-Orthotic Clinics Professional organization that supports and educates s
www.acpoc.org orthotic and prosthetic devices
American Congress of Rehabilitation Medicine Interprofessional organization with mission to improve the lives
www.acrm.org of people with a disability
The Orthotics & Prosthetics virtual library Collection of digital resources, including online access to atlas
www.oandplibrary.org of limb prosthetics: surgical, prosthetic, and rehabilitation
principles (second edition) with permission from AAOS
Resources for Patients/Families
See above professional resources as ACPOC and ACRM both have family resources available
No limits foundation National camps for children with limb deficiencies and their
www.nolimitsfoundation.org families
Lucky fin project International organization that connects families with children
www.luckyfinproject.org who have upper limb differences
Amputee coalition National organization that provides support for amputees of all
www.amputee-coalition.org ages
Challenged athletes foundation Nonprofit organization that provides funding support of various
www.challengedathletes.org types for individuals with disabilities, including sport-specific
prostheses
Team PossAbilities Nonprofit organization managed by Loma Linda University
teampossabilities.org Health that promotes adaptive sport opportunities for people
with disabilities
AmpSurf Nonprofit organization that offers learn to surf opportunities for
Ampsurf.org people with disabilities
Limbs for life Global nonprofit organization dedicated to providing prosthetic
limbsforlife.org care for individuals who cannot otherwise afford it and raising
awareness of the challenges facing amputees

ACPOC, Association of Children’s Prosthetic-Orthotic Clinic

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Principles of Amputations in Children
Figure 7
Photograph showing extension prosthesis. An experienced
and creative prosthetics team can fit a prosthesis around
most any lower limb difference to facilitate ambulation,
regardless of past or future surgical plans.
period can be beneficial.31 Some have recommended al-
lowing parents to see the child in the PACU before awak-
ening from anesthesia, providing an opportunity to
acclimate to the amputated limb before the child waking
up.32,33 In the case of the congenital amputee, parents may
not be prepared to make a decision regarding surgical
intervention. A savvy prosthetist can fit an extension pros-
thesis around almost any lower limb difference to facilitate
ambulation, regardless of surgical intervention (Figure 7).
Once the child becomes more independent because of their
prosthesis, an amputation to make the prosthesis fit better
becomes a more acceptable and logical next step for the
family, often easing their decision for surgery.
In patients with an acquired amputation, they often have
increased levels of depression and disturbance in body
image and social shame postoperatively.34 Depression and
anxiety rates are increased in upper versus lower extremity
acquired amputations, with dominant hand amputations
having the most profound effect.35 Often, oncologic
causes of acquired amputation occur at a time in ado-
lescence when the sense of self is being formed, triggering a
powerful effect on the child’s development. Most patients
will ultimately accept their amputation if parents are
optimistic and encourage them to find positive meaning in
the loss.36 Twenty-plus year follow-up comparing patients
with limb salvage versus amputation for cancer demon-
strated no differences in education, employment, marital
status of survivors, although patients with amputations
required more assistance with walking.37 Amputations
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
can be of benefit even in children with limited life
expectancy (metastatic cancer) through improved mobility
and emotional/psychological well-being.38
Patients and families may have preconceived notions
of what disability means, such as an individual who is
dependent, unattractive, and pitiful. These negative
stereotypes can be discouraged through connection with
other patients who have triumphed over similar chal-
lenges. In studies investigating factors affecting self-
esteem in children with congenital or acquired limb
deficiency, the child’s classmate, parent, teacher, and
friend support network all were notable predictors of
self-esteem and also negatively correlated with depres-
sive symptomatology.39,40 The authors postulated that
low self-esteem should be targeted with interventions
that address the areas that are deficient, such as social
skills training, family therapy, or improved school
supports with an individualized education plan.
Overall, it is important that the team assist the family
and patient in processing their grief, including providing
them with appropriate education and preparation for
outcomes of any intervention (or lack thereof, should
surgery not be indicated), addressing any fears they may
have, and facilitating contact with a support network of
other families and team members.
Summary
Children who require amputations for congenital or
acquired conditions are best served by a multidisciplinary
team with specific experience in pediatric limb differ-
ences. A broad set of principles can be referenced to guide
surgical decision-making. These principles and surgical
techniques are unique to the growing skeleton. Prosthetic
and psychological considerations vary markedly from
the adult amputee; experts in these areas are essential for
optimal outcome of these children.
Acknowledgements
The authors would like to thank Brian Giavedoni, MBA,
CP, LP, from Children’s Healthcare of Atlanta for his
expertise and contributions to this article.
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