Lower-Limb Overhaul: A VA Case Study
October 2010 Issue
On April 22, 1968, the year of the Tet Offensive, the U.S. Army's First Infantry Division, Second Battalion, conducted a search-and-destroy mission near Cau Dinh, South Vietnam. Upon hearing the helicopters' sudden approach, the insurgents—the Viet Cong (VC)—did not have time to make a run for it, so they dug in for a do-or-die encounter.
Shortly after clearing the jungle landing zone of the large Huey helicopters that had transported them, the Army 16th Infantry Headquarters company found itself under a hail of machine gun, mortar, and AK-47 fire. Private First Class (PFC) Donald DeWindt, the company's assistant machine gunner, became among the first of many casualties. A rocket-propelled grenade, aimed at his position, successfully found its target. The explosion took most of DeWindt's right leg, as well as the life of DeWindt's partner, who was operating the weapon next to him.
During the controlled chaos that ensued, DeWindt grabbed the first M-16 he found and laid down cover fire for his comrades. Despite fighting both the insurgents and massive blood loss, DeWindt's focus and determination were unwavering—adrenalin masked his pain and even the knowledge that part of him was missing. Due to his well-placed cover fire, he saved the lives of several soldiers within the company's headquarters.
Medics and other support units soon arrived on the scene to rid the killing field of its antagonists. It was then that DeWindt realized he couldn't move about as he could before. He and other casualties were whisked off to the Army's 93rd Evacuation Hospital located near the banks of the Mekong River at Long Binh, just east of what is now Ho Chi Minh City. Some have received the Silver Star medal for less grit in the face of war, and few others the Congressional Medal of Honor. The director of the Secretary of the Army awarded DeWindt the Army Commendation Medal with "V" (valor) and the Purple Heart Medal for his courage in action.
At this point, the record of what happened to DeWindt becomes sketchy. He underwent a transfemoral amputation soon afterward, either at the 93rd Evacuation Hospital or at the U.S. Navy Medical Center in Yokosuka, Japan. Some months later, during the summer of 1968, a picture clearly shows former President Lyndon B. Johnson shaking DeWindt's hand while DeWindt lay in a hospital bed in a barracks-type ward at Walter Reed Army Medical Center (WRAMC) in Washington DC, where he received further medical treatment and some physical therapy.
DeWindt was honorably discharged from the military on October 23, 1968, six months after the ambush.
From State-of-the-Art to Mail Order
Over the next 40 years, DeWindt received five transfemoral prostheses, the first two from the Veterans Administration (VA) Prosthetic Treatment Center in New York, New York. His first prosthesis was as good as one could get at the time: it was a polyester-laminated, quadrilateral socket with an ischial brim and a Scarpa's triangle modification for weight bearing. It also included, among other features, an anterio-medial proximal modification for the relief of a prominent tendon for the adductor longus muscle, a modification developed in 1953 by James Foort and C.W. Radcliff at the University of California, Berkeley. Before that time, ambiguously shaped, wooden, "plug" transfemoral prosthetic sockets had been used for amputee casualties of World War II and the Korean conflict. DeWindt's first prosthetic leg also included a solid ankle and a cushioned heel (SACH) foot—a technological wonder over its solid-wood predecessor. It was exoskeletal in composition; the polyester laminate was applied over willow wood.
In February 2009, DeWindt's primary care physician at the Miami VA Medical Center, Florida, referred him to the prosthetic department for prosthesis repair and to the amputee clinic to further evaluate his prosthetic needs. It was his first visit to the Miami VA Medical Center. (Editor's note: The Miami VA captured DeWindt's story in a video, which is available for viewing below.)<%= GetVideoPlayerById("VID_2010-11-08_01") %>
The prosthesis he walked in with that day was very similar to the one he had first received in 1969, except that it was approximately half the weight of his original device. It was a modular, endoskeletal prosthesis equipped with a safety knee, quadrilateral socket, pelvic band, belt and hip joint suspension, and a SACH foot. A prosthetic vendor that had contracted with the San Juan VA Medical Center, Puerto Rico, had sent it to DeWindt's home in St. Thomas, U.S. Virgin Islands, via the U.S. Postal Service many years previously.
|Raphael Hernandez, LPT, coaches DeWindt during a gait training session.|
The prosthetic socket did not serve him well. What DeWindt gained with weight bearing on the ischial tuberosity, he lost with the socket. It did not contain his residual limb, which is extremely short (less than 2.5 inches) and has a lot of redundant tissue. The pelvic band, belt, and hip joint were being used to control various aspects of dynamic alignment such as abduction-adduction and knee rotation and its tracking through the line of progression. It did little to limit pistoning of the residual limb and sapped DeWindt's energy and strength.
"He had a very circumducted, abducted gait when he came to the Miami VA for prosthetic services," says Tomas Dowell, CPO, LPO, chief of the orthotic-prosthetic lab at the Miami VA. "First we considered using a hip-disarticulation socket with a compact frame and new...hip joint for his replacement prosthesis. Such an extremely short residual limb may be classified as a hip disarticulation. It would provide much better suspension and limit pistoning. Its disadvantage is that it would involve more use of the pelvis to initiate hip flexion. Also, Mr. DeWindt did not like its bulkiness."
The revised approach involved using a pin-suspension locking liner with a narrow M-L, ischial-containment prosthetic socket to further exploit DeWindt's control of the prosthesis and greatly limit its pistoning. It contained his short residual limb, and its higher lateral trimline allowed for better purchase of the trocanter, further aiding its control and suspension.
Dowell and DeWindt selected a rotary hydraulic knee joint as a backup prosthesis. Dowell says that DeWindt felt safer using this than he did using the hydraulic, polycentric modular knee they initially tried.
"[The rotary hydraulic knee joint] creates a dampening effect at the knee's trigger point during stance phase of the gait cycle; it would be less likely to buckle at heel strike or when he walks down slopes," Dowell says.
Good Results Get Even Better
After being fitted with the new prosthesis, DeWindt worked with Raphael A. Hernandez, LPT, on gait training and physical therapy. The results were tremendous. Ninety percent of DeWindt's circumducted gait was eliminated. The narrow M-L socket with pin suspension, locking liner, and ischial containment limited limb pistoning, which served to greatly conserve his strength, stamina, and energy—a significant improvement from his previous prosthesis. A negligible amount of heel whip remains in his gait due to his short femur length and its lack of musculature, tendons, and ligaments.
DeWindt applied the same focus and determination to his physical therapy and gait training that he did to covering his comrades during the height of battle so many years ago. As a result, he progressed swiftly during his physical therapy sessions, and given this quick progress, Dowell and Hernandez decided to see, with a doctor's consult, how much more performance DeWindt could achieve with a prosthesis equipped with a microprocessor knee. The result? DeWindt achieved an even more natural and energy-efficient gait pattern, as well as increased strength and stamina. He can now walk 1,000 feet at a time, nearly triple the distance he was able to walk when he came to the Miami VA in 2009. And this time, his definitive prosthesis was delivered to him personally at the medical center, rather than through the mail.
Gordon Zernich, CP, BOCP, works in the orthotic and prosthetic lab at the Bruce W. Carter Department of Veterans Affairs (VA) Medical Center, Miami, Florida. He has written numerous articles documenting his O&P experiences for professional and health trade journals.