Stimulating and reflective exchange

Stimulating and reflective exchange

George Boyer

9/15/1999

{Reactions of a prosthetist}

Hello George,

> Hi ANON - what you say about AK fitting being the most challenging is
> the opposite of the way I had imagined it, my
> impression being based on the lack of complaining posts by AKs....most

> of the traffic is by BKs on amp-l and they persist in their
> dissatisfaction.

This is most likely because almost 75% of all lower-limb amputations are

transtibial (BK). New techniques in amputation surgery and
determination of viable tissue along with the development of the
preserve all length possible, especially joints concept have literally

reversed the AK/BK percentages. It used to (years ago) be that about
75% of all amputations were above-knee.

With a higher percentage of BK's there will naturally be a higher number

of BK's with botched surgeries and unusual/painful bony prominences.
Ideally, we'd like every BK to have nice rounded bone edges, nonadherent

skin or scarring, no tenderness or pain upon palpation, full range of
motion and good strength, etc. But since I haven't won the lottery, we
know that it's far from a perfect world... :)

I also think that BK tend to assume that they will recover more quickly
and sometimes have unrealistic expectations based on things they've seen

or heard about. If you didn't run before you had an amputation, it is
highly unlikely that you will compete in the Boston Marathon on your BK
preparatory prosthesis. Novacare's video is unbelieveable in this
respect. It shows one guy running with bilateral AK's. the man is
undoubtedly one of the strongest and highest functioning double amputees

in the world, and yet the video makes it seem that everyone will be able

to do it once they visit Oklahoma City.

> My perceptions of BKs is that they are bony-er (sp) therefore more
> sensitive, stumps move more & with wider range, are more distal and
> are more difficult to 'claim' and protect being more
> vulnerable....maybe involved also is that these people may discount
> their disability thus think to bite off more activity than they can
> chew and their invisibility makes them more apt to try to 'pass' with
> a wider menu of activity.

I don't know to what extent this is true, although the notion seems
sound. I think a lot of AK socket problems are due to the fact that an
AK socket, especially an Ischial containment design, must fit very
intimately around areas that really don't enjoy having anything up
there! I know of very few patients/clients who successfully wear truly
ischial-ramal containment sockets because of the extremely intimate fit
required... by far and away the majority of wearers repeatedly request
that the prosthesis be cut down so as not to touch sensitive areas in
the groin, etc. But to do this ruins some of the function of the
socket.

There are also issues of perspiration, weight, etc. When someone has
tissue hanging over a socket there are bound to be problems. But can we

really build a socket with proximal flared trimlines three feet wide to
support all the extra tissue? Often every situation creates more
issues.

I would say that the vast majority of BK's are significantly easier to
fit and align than the average AK. BK's tend to have better rotational
control, more well-defined areas to apply pressure to and to relieve
pressure from, have less componentry, and tend to be better suspended
(with the exception of AK suction suspension). They also require less
energy to walk than an AK.

> Do I come across as imagining there is ONE true method?? Not my
> intention. What I think important is to emphasize
> 1.talented interchange and 2.knowing examination and 3.'laying on of
> hands' in the casting and alignment....to develop and
> hone these skills is, I believe, to be a truly top notch prosthetist.
> And we should make a point of impressing entrants into
> the field with this.

Well, I once heard someone say, I've taught you the ABC's of
prosthetics, now in your residency you'll get to learn D through Z. I

think it's more like: school, ABC's, then residency, DEFGH's, and I
through Z over the next twenty years. I think an openness and a sense
of urgency to not settle for what always worked all right is crucial
to becoming a good prosthetist.

I don't think it's possible for any residency to cover all the
essentials. Even the German meisters would say they continue to learn

all their professional lives. Is the residency better than the 1900
hours? Certainly. Are all residencies equal? NO. Is the residency
truly comprehensive and exhaustive? Of course it can't be in a year.
Please do not think I don't support the residency concept; I am one of
its strongest advocates and in fact, my Survey of ...... was
published as a Best of the Resident Research Series paper. But I
think we need to be realistic and expect that every youngster or
newcomer is going to have a learning curve that extends beyond the last
day of the residency.

Patients/Clients understandably don't want to be seen by someone who is
still learning, etc. But that is often where you as a client can have
the most input and get what you want while helping educate the young
practitioner. Your patience and understanding will have a concrete
effect. Granted, some people just don't have any aptitude for anything,

but in general, the new prosthetist is striving hard to help and serve
you as best he can.

> Yeah....'business stuff'. I am convinced that a step of major
> importance is for prosthetists to somehow get out of marketing
> and sell truly professional services, as eg the MDs. Cheers, GeorgeB.

Whenever there is the mixing of a service with a product, there is bound

to be such confusion and problems. It does drive me crazy at times.