Page #2 - Burn Victim
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Page #2 - Burn Victim
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Wade - I have one client in the same situation. He is 21 years old, 250+
lbs, and a very active bilateral BKA with exactly the adherent split
thickness graft you describe over 100% of both limbs. He has done well in
TEC liners on bilat. VSP's and sleeve suspensions. He is not, and I suspect
never will be totally free of skin breakdown. He has the occasional
ulceration, largely due to the insensate nature of the grafted and scarred
skin surface. Total contact, total surface bearing is definitely the way to
go.
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--------------------------------------
I read with interest your post. We are working with a bilateral bk amputee
secondary to mva and fire, both of her residuals are full thickness skin
grafts extensively, with much adherent tissue. It took a LONG time, ie
greater than 1 year, using alpha liner interface, but this product has done
remarkable things for her skin and many areas are gradually becoming more
elastic and less adherent. Her prosthetist made a suction suspension
prosthesis - we had small problems with tight areas, but little problems with
pistoning. Perhaps trying her wearing alpha liners first might give you an
indication of her skin tolerance, before pursueing the prosthesis.
------------------------------------------------------------------------------
--------------------------------------------
I have recently fit a patient dealing with a lot of the same situations you
have described.
She is 37 yr. old female involved in a kerosene heater fire at age 16. 80-90%
of her body was burned. She has limited use of her hands due to amputated
digits. Both legs were treated by performing symes amputations. Both Residual
limbs are covered with very delicate skin grafts.
Previously she was wearing bilateral symes prosthesis with pelite liners,
medial opening, Seattle lite feet.
I provided her with Bilateral symes prosthesis. 9mm Alpha Cushion liners.
medial opening. Springlite lowprofile dynamic response feet. The Alphas have
helped tremendously with the skin-breakdown she was continuosly having with
her previos prosthesis. She has still had her problems with this set-up, but
she says that overall it has been a great improvement, the breakdown she has
with the Alphas has decreased substantially.
If I had a chance to be starting from scratch now.... I would maybe give
these new Ossur Aloe Vera liners a try??? The moisture any type of liner
makes may be a contraindication for the skin graffed skin.
It is certainly a challenge working with such a diverse patient population.
But that is also what makes our work so rewarding!
------------------------------------------------------------------------------
-------------------------------------------
Wade I have a chap fitted with bilateral (1xAK, 1xBK) prostheses for the
past 17years.
Similar situation in terms of his skin and anatomical residua. Wears leather
lined pelite liner Bk and a Proflex ISNY Quad socket AK. Manages well and
has had only two break downs in the time that I've known him.However, he
does have some underlying musculature (which was a graft from the sole of
his foot on the BK side and the AK musculature is depleted but present.
------------------------------------------------------------------------------
----------------------------------
Our preferred treatment for these cases, during the interim stage, is to use
a standard PTB configuration with a liner but the amputee needs to wear a
silicone sock. The socks are brand named Silipos Silosheath Original or
Otto Bock Dermaseal Single. A word of caution, both brands have an
extensive range and the sock must be of the variety that has no inner
lining. The unlined soft silicone sock provides a nice stress free
environment for the residuum to heal, flatten scarring and begin to accept
loading. Definitely do not use a cotton sock, it will lacerate very
quickly. A bonus with these socks is that they are at the bottom of the
respective product ranges and therefore an affordable option for your
client.
At the definitive stage, the point at which you are at, we use either OWW
Alpha liners or Ossur Iceross depending on how fragile the tissue. We have
a preference for locking liners and shuttle because there are no cuffs or
straps (a source of irritation) and very little pumping. We cast using the
Iceross classic pressure casting vessel but do depart from total surface
bearing principles by posterior flattening to prevent axial rotation. A
bonus with these liners is that it permits lower posterior trims and
therefore avoiding affected hamstrings. Again, at all costs avoid the use
of cotton socks.
We have now done a number of these difficult cases with good outcomes. In
one case the shape of the residuum precluded the use of a locking liner with
pin and we resorted to a plain Alpha with a USMC pyramid valve again with
good results. We believe our success is largely due to attention to socket
dimensioning combined with the silicone/urethane interface being directly
next to the skin.
------------------------------------------------------------------------------
----------------------------------------
As you well knoow there are several concerns here. The first is the adherent
scar tissue. This needs to be dealt with now while the scar tissye is
immature. This can be addressed by the use of deep friction massage with some
type of lubricant (my choice is Bag Balm). The massage must be done
faithfully over a period of months to break up the adherent scar tissue. When
done frequent( 1-2x/day) this is a very effective modality. I have
successfully fit several simmilar situations with TEC liners (custom molded
only) and a suspension sleeve. In this situation you might want to consider
TEC's new sleeve or the new Alps sleeve. Foot selection must also be taken
into consideration for absorbing as much of the shear force as possible
------------------------------------------------------------------------------
------------------------------------------
I have a patient that has a simular stump. We used an
alpha cushion liner 3mm thick with a PTS type of
suspension and a molded joint and corset for a secondary
suspension. The alpha liner comes in a thinner 3mm
version that will not cause stretching across the
patella when the knee is flexed. The PTS suspension was
not as normally tight due to the fact of the scarring.
But it was also used to give him ML stability.
------------------------------------------------------------------------------
--------------------------------------------
We have worked with a few clients that had skin grafts covering their
residuum although they were not burn victims. We have used both the Alpha
liners and Tec liners with good success, both with locking pins and with
suction sleeves and valves. Because of the traction inherent with the pins,
we are using more of the sleeves and valves. We have also provided a
TransHumeral client who appears to match your description with a custom
silicone liner w/ pin in a cosmetic TH prostheses. He has all skin grafting
on the residuum, adherence, and no soft tissue to speak of. Assuming your
client is ready, able, and motivated, our suggestion would be a custom TEC
liner with sleeve and valve.
------------------------------------------------------------------------------
-------------------------------------------
You have a (great) challenge with this patient. Sounds like a case for a
TEC liner with valve, sleeve?, mild PTS. anything to reduce movement inside
socket. I only use TEC in extreme cases but they have always worked on
extremely boney, grafted or adhered skin. If you could get some proximal
addition maybe you could use a 9mm alpha to line the corset, or quad
socket if possible. I would also consider a torque absorber of some kind.
There is also probably the need to limit knee extension to not over stress
hamstring problem.
------------------------------------------------------------------------------
-----------------------------------
Wade, I know that each case is different and one person's reaction to a type
of prosthesis isn't going to be the standard for everyone, but I have had
good luck with the ALPS comfort liner without the fabric cover. I would
also suggest an 'extra' pelite (or equivalent) 5mm firm density liner
between the hard socket and the comfort liner, then use a comfort suspension
sleeve to finish it. Pylons and feet are up to the individual need. The
reasoning for the pelite liner is for a 'dual-density' liner similar to the
diabetic applications for footwear. Consider that the stump is the 'foot'
for the amputee and with all the scar tissue and boney prominences
complicated no doubt by a lack of circulation throughout the stump, real
care will have to be taken in crafting a good total contact socket for her
to bear the pressure evenly throughout her stump. Take care and good luck
with your decision.
lbs, and a very active bilateral BKA with exactly the adherent split
thickness graft you describe over 100% of both limbs. He has done well in
TEC liners on bilat. VSP's and sleeve suspensions. He is not, and I suspect
never will be totally free of skin breakdown. He has the occasional
ulceration, largely due to the insensate nature of the grafted and scarred
skin surface. Total contact, total surface bearing is definitely the way to
go.
------------------------------------------------------------------------------
--------------------------------------
I read with interest your post. We are working with a bilateral bk amputee
secondary to mva and fire, both of her residuals are full thickness skin
grafts extensively, with much adherent tissue. It took a LONG time, ie
greater than 1 year, using alpha liner interface, but this product has done
remarkable things for her skin and many areas are gradually becoming more
elastic and less adherent. Her prosthetist made a suction suspension
prosthesis - we had small problems with tight areas, but little problems with
pistoning. Perhaps trying her wearing alpha liners first might give you an
indication of her skin tolerance, before pursueing the prosthesis.
------------------------------------------------------------------------------
--------------------------------------------
I have recently fit a patient dealing with a lot of the same situations you
have described.
She is 37 yr. old female involved in a kerosene heater fire at age 16. 80-90%
of her body was burned. She has limited use of her hands due to amputated
digits. Both legs were treated by performing symes amputations. Both Residual
limbs are covered with very delicate skin grafts.
Previously she was wearing bilateral symes prosthesis with pelite liners,
medial opening, Seattle lite feet.
I provided her with Bilateral symes prosthesis. 9mm Alpha Cushion liners.
medial opening. Springlite lowprofile dynamic response feet. The Alphas have
helped tremendously with the skin-breakdown she was continuosly having with
her previos prosthesis. She has still had her problems with this set-up, but
she says that overall it has been a great improvement, the breakdown she has
with the Alphas has decreased substantially.
If I had a chance to be starting from scratch now.... I would maybe give
these new Ossur Aloe Vera liners a try??? The moisture any type of liner
makes may be a contraindication for the skin graffed skin.
It is certainly a challenge working with such a diverse patient population.
But that is also what makes our work so rewarding!
------------------------------------------------------------------------------
-------------------------------------------
Wade I have a chap fitted with bilateral (1xAK, 1xBK) prostheses for the
past 17years.
Similar situation in terms of his skin and anatomical residua. Wears leather
lined pelite liner Bk and a Proflex ISNY Quad socket AK. Manages well and
has had only two break downs in the time that I've known him.However, he
does have some underlying musculature (which was a graft from the sole of
his foot on the BK side and the AK musculature is depleted but present.
------------------------------------------------------------------------------
----------------------------------
Our preferred treatment for these cases, during the interim stage, is to use
a standard PTB configuration with a liner but the amputee needs to wear a
silicone sock. The socks are brand named Silipos Silosheath Original or
Otto Bock Dermaseal Single. A word of caution, both brands have an
extensive range and the sock must be of the variety that has no inner
lining. The unlined soft silicone sock provides a nice stress free
environment for the residuum to heal, flatten scarring and begin to accept
loading. Definitely do not use a cotton sock, it will lacerate very
quickly. A bonus with these socks is that they are at the bottom of the
respective product ranges and therefore an affordable option for your
client.
At the definitive stage, the point at which you are at, we use either OWW
Alpha liners or Ossur Iceross depending on how fragile the tissue. We have
a preference for locking liners and shuttle because there are no cuffs or
straps (a source of irritation) and very little pumping. We cast using the
Iceross classic pressure casting vessel but do depart from total surface
bearing principles by posterior flattening to prevent axial rotation. A
bonus with these liners is that it permits lower posterior trims and
therefore avoiding affected hamstrings. Again, at all costs avoid the use
of cotton socks.
We have now done a number of these difficult cases with good outcomes. In
one case the shape of the residuum precluded the use of a locking liner with
pin and we resorted to a plain Alpha with a USMC pyramid valve again with
good results. We believe our success is largely due to attention to socket
dimensioning combined with the silicone/urethane interface being directly
next to the skin.
------------------------------------------------------------------------------
----------------------------------------
As you well knoow there are several concerns here. The first is the adherent
scar tissue. This needs to be dealt with now while the scar tissye is
immature. This can be addressed by the use of deep friction massage with some
type of lubricant (my choice is Bag Balm). The massage must be done
faithfully over a period of months to break up the adherent scar tissue. When
done frequent( 1-2x/day) this is a very effective modality. I have
successfully fit several simmilar situations with TEC liners (custom molded
only) and a suspension sleeve. In this situation you might want to consider
TEC's new sleeve or the new Alps sleeve. Foot selection must also be taken
into consideration for absorbing as much of the shear force as possible
------------------------------------------------------------------------------
------------------------------------------
I have a patient that has a simular stump. We used an
alpha cushion liner 3mm thick with a PTS type of
suspension and a molded joint and corset for a secondary
suspension. The alpha liner comes in a thinner 3mm
version that will not cause stretching across the
patella when the knee is flexed. The PTS suspension was
not as normally tight due to the fact of the scarring.
But it was also used to give him ML stability.
------------------------------------------------------------------------------
--------------------------------------------
We have worked with a few clients that had skin grafts covering their
residuum although they were not burn victims. We have used both the Alpha
liners and Tec liners with good success, both with locking pins and with
suction sleeves and valves. Because of the traction inherent with the pins,
we are using more of the sleeves and valves. We have also provided a
TransHumeral client who appears to match your description with a custom
silicone liner w/ pin in a cosmetic TH prostheses. He has all skin grafting
on the residuum, adherence, and no soft tissue to speak of. Assuming your
client is ready, able, and motivated, our suggestion would be a custom TEC
liner with sleeve and valve.
------------------------------------------------------------------------------
-------------------------------------------
You have a (great) challenge with this patient. Sounds like a case for a
TEC liner with valve, sleeve?, mild PTS. anything to reduce movement inside
socket. I only use TEC in extreme cases but they have always worked on
extremely boney, grafted or adhered skin. If you could get some proximal
addition maybe you could use a 9mm alpha to line the corset, or quad
socket if possible. I would also consider a torque absorber of some kind.
There is also probably the need to limit knee extension to not over stress
hamstring problem.
------------------------------------------------------------------------------
-----------------------------------
Wade, I know that each case is different and one person's reaction to a type
of prosthesis isn't going to be the standard for everyone, but I have had
good luck with the ALPS comfort liner without the fabric cover. I would
also suggest an 'extra' pelite (or equivalent) 5mm firm density liner
between the hard socket and the comfort liner, then use a comfort suspension
sleeve to finish it. Pylons and feet are up to the individual need. The
reasoning for the pelite liner is for a 'dual-density' liner similar to the
diabetic applications for footwear. Consider that the stump is the 'foot'
for the amputee and with all the scar tissue and boney prominences
complicated no doubt by a lack of circulation throughout the stump, real
care will have to be taken in crafting a good total contact socket for her
to bear the pressure evenly throughout her stump. Take care and good luck
with your decision.
Citation
“Page #2 - Burn Victim,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/214647.
