Hello, everyone. My name is Kevin Osment, and I'm a PGY-3 at Northwestern Shirley Ryan Ability Lab, and today I'll be presenting a very interesting and unique case report titled Rehabilitation Following a Hemicorporectomy and Right Elbow Disarticulation. So this case begins with an 18-year-old male who was involved in a traumatic construction work zone accident where he suffered a massive forklift crush injury to the pelvis with right arm disarticulation at the elbow, resulting in an emergent hemicorporectomy at the L4-5 level and a right transhumoral amputation. As a reminder, a hemicorporectomy is a radical surgery involving translumbar amputation where the bony pelvis, pelvic contents, lower extremities, and external genitalia are removed following disarticulation of the lumbar spine and transection of the spinal cord. Typical non-traumatic indications include pelvic neoplastic diseases and intractable pelvic infections. As of 2017, a total of only 71 cases had been reported, three of which were related to trauma. So going back to our patient, his course was mainly complicated by post-operative intra-abdominal abscesses requiring IR drain placement. He was not able to receive a double baro-ostomy, which would be the most optimal in his situation, and had bilateral nephrostomy tubes and enclostomy placed, all of which had to be factored into his bucket fabrication. Core stability training and sitting tolerance were main focuses early on in his rehabilitation, but he progressed very well in these realms, moving to using a power wheelchair at bucket prosthesis. Phantom limb pain was difficult to control and functionally limiting for him, but by discharge, he had significantly reduced pain through specialized pain therapies in conjunction with duloxetine, pregabalin, marinol, and opioids. If you see figure 7 in the top right corner, this is a photo of the patient in the middle of pain management therapy with OTs who specialize specifically in phantom limb pain. So after about one month of comprehensive inpatient rehab, he met almost all long-term goals and advanced to supervision for transfers and mod I for locomotion. The patient's distinctive medical complexity, soft tissue volume fluctuations, and multiple external devices presented a very unique challenge to developing a prosthetic system that could allow him to regain functionality. You can see depicted in figure 1 the many drains and the ostomy site that had to be taken into consideration. In figure 2, we performed a pressure mapping analysis with a Roho cushion towards the beginning of his inpatient stay, and found that he had significant amount of high pressures being induced at the lumbar spinous processes and the soft tissue of the inferior abdomen, which is signified by the large red uptick spike on the graph. In figure 6, on the top right, you can even see lumbar and soft tissue erythema that developed early during our pressure mapping and sitting evaluations. Initially, a preliminary thermomoldable plastic bucket prosthesis was used with the pellet foam liner. Before the definitive bucket prosthesis creation, many aspects had to be considered, such as restriction of the abdominal wall expansion that could then lead to stoma prolapse, vertebral bony pressure as seen in figure 2, and management of the large amount of soft tissue at the distal end of the stump. So after taking everything into consideration, a definitive bucket as seen in figure 3 was created. This was created with a laminated external shell and an intricate adjustable inner air bladder liner to allow for improved prolonged sitting. For his transhumeral amputation, he initially used a passive transhumeral prosthetic with locking elbow and inert terminal device for transfers and gross grasping, as seen in figure 4. He was recently fitted for an externally powered myoelectric prosthesis as an outpatient, as seen in figure 5. In conclusion, long-term management and rehabilitation following a hemicorporectomy plus transhumeral amputation is not well documented in the literature. Hemicorporectomy is a very rare diagnosis, and to our knowledge, there are no prior reported cases of a patient with both hemicorporectomy and upper limb amputation. Prosthetic design has to be carefully planned and requires ingenuity to account for essential external devices and the large amount of soft tissue fluctuation seen at the distal end of the stump. The addition of his transhumeral amputation, the traumatic psychological implications of his injury, and the severe phantom limb pain further added to the complexity of his amputee rehabilitation needs. Rehab and prosthetic structure design following an upper extremity amputation and hemicorporectomy truly presents a challenging experience for both the patient and the medical team. A coordinated interdisciplinary approach between the physiatrist, prosthetics, and therapy teams is absolutely essential to improving the function of these patients.

rehabilitation

hemicorporectomy

right elbow disarticulation

phantom limb pain

prosthetic system