Soft transfemoral residual limb
john
Description
Collection
Title:
Soft transfemoral residual limb
Creator:
john
Date:
9/17/2000
Text:
This is a long request and I apologize in advance.
I have a young woman, early thirties, for whom I have been making prostheses since her transfemoral amputation at the age of ten. She is now married with two children and at her ideal body weight. She takes good care of herself.
Until the last few years providing prostheses has been relatively routine. In recent years, since her two pregnancies in fact, the task has provided a more challenging case.
Her prosthesis is exoskeletal (her choice) with a flexible ischeal containment suction socket and frame.
Over the course of the last few years the presenting problems have been:
1. Folds in the flesh of the anterior residual limb that crease and eventually brake down.
2. Lateral distal femoral pressure that has caused skin breakdown in the area of an invaginated scar that runs vertically along the lateral shaft of the femur.
3. Tissue breakdown in the anterior proximal third of the limb.
4. Distal edema in the proximity of the valve site. (One of her more persistent concerns has been the sensation of trapped air in the distal or posterior socket.)
5. A tearing of some part of the Quadriceps femoris group from its distal anchor while exercising the residual limb in an attempt to increase its strength
6. A distinct sensation of tissue moving abruptly across the distal femur while walking.
I am using Otto Bock Soft plastic to bubble mold the socket. I have made a number of sockets with different surface textures from course (achieved with cotton stockinet over the cast) to a slick shinny finish. Initially I was using a SMC valve designed to be vacuum formed into socket. We did have trouble getting a positive seal with that valve. We also used the Century XXII two part valve. That caused injury to the skin at the point where the skin contacts the valve bleeder hole on the inside center surface of the valve. We are now using the Linn (sp) valve system. Using check sockets to verify contact, I can find no place where the skin is not in good contact with the socket wall.
Her residual limb has little tone below the distal third. The Quadriceps femoris group have so little definition that they are difficult to palpate even when contracted. The primary flexor is the Iliopsoas. The primary extensor appears the be the gluteus maximus. The hamstrings are as atrophied as the Quads. The residual femur appears to be small in circumference. I suspect that the residual amputated muscles were secured by myoplasty rather than myodesis. There are about 24 to 30 mm of redundant tissue below the distal cut femur. The bulk of her limb is extremely soft with no defined shape.
I suspect that the growth of the femoral shaft along its length is minimal since amputation, due to the absence of a distal growth plate. The diameter of the femur is minimal as well since it has had no true weight bearing. The incision scar has migrated laterally because it is adhered to the femur along with amputated muscle and other connective tissue. The diminutive size of the distal femur and its proximity to the migrated incision places greater than normal force at the point of contact with the socket wall where the overlying scar tissue is non-elastic and fragile. Excessive pressure in the anterior proximal third of the socket was responsible for skin breakdown. The pressure was necessary because it maintained the socket atmosphere and also controlled the migration of tissue across the distal femur. The use of Shear-ban and changing from an elastic wrap to an E-Z In pull sock have virtually eliminated the breakdown of anterior proximal skin. A relief in the lateral wall has minimized the problems with lateral pressure but not completely. The concern with the darkening of distal limb tissue in the vicinity of the valve is reduced but not solved. It becomes a dark red or purplish color and somewhat cooler then the rest of the limb but not greatly. The discoloration resolves in ten to twenty minutes after removal of the socket and any edema (when present) is resolved over night. The overall temperature of the residual limb is notably cooler than the contralateral limb though I would expect this to be so.
The most frustrating aspect of this case has been that the solution of one problem has incited another. No more than two or three of the above issues have presented themselves at any given time.
At present the single remaining symptom is a darkening of the tissue in the area of the valve. I am almost 99% certain that there is no air trapped in the socket. I wish I knew of a way to test this definitively.
I am uncertain if I am at the end of what can be accomplished prosthetically and I would be most appreciative of any ideas or suggestions. I would love to see some kind of diagnostic tissue study to give me some idea of the structures I am dealing with within the tissue envelope. The problem is that no physician will order the study. As I said, I suspect that her muscle tissue was anchored by myoplasty.
Given that more than 20 years has elapsed since the amputation; and the present condition of her residual amputated musculature and skeleton, is there any virtue in a revision that would:
1. Reattach the amputated muscles to the femur by myodesis.
2. Reduce the redundant distal residual tissue.
I again apologize for the length of this question but I felt I had to explain all that I knew about the case. Any ideas or referrals would be most appreciated.
John
I have a young woman, early thirties, for whom I have been making prostheses since her transfemoral amputation at the age of ten. She is now married with two children and at her ideal body weight. She takes good care of herself.
Until the last few years providing prostheses has been relatively routine. In recent years, since her two pregnancies in fact, the task has provided a more challenging case.
Her prosthesis is exoskeletal (her choice) with a flexible ischeal containment suction socket and frame.
Over the course of the last few years the presenting problems have been:
1. Folds in the flesh of the anterior residual limb that crease and eventually brake down.
2. Lateral distal femoral pressure that has caused skin breakdown in the area of an invaginated scar that runs vertically along the lateral shaft of the femur.
3. Tissue breakdown in the anterior proximal third of the limb.
4. Distal edema in the proximity of the valve site. (One of her more persistent concerns has been the sensation of trapped air in the distal or posterior socket.)
5. A tearing of some part of the Quadriceps femoris group from its distal anchor while exercising the residual limb in an attempt to increase its strength
6. A distinct sensation of tissue moving abruptly across the distal femur while walking.
I am using Otto Bock Soft plastic to bubble mold the socket. I have made a number of sockets with different surface textures from course (achieved with cotton stockinet over the cast) to a slick shinny finish. Initially I was using a SMC valve designed to be vacuum formed into socket. We did have trouble getting a positive seal with that valve. We also used the Century XXII two part valve. That caused injury to the skin at the point where the skin contacts the valve bleeder hole on the inside center surface of the valve. We are now using the Linn (sp) valve system. Using check sockets to verify contact, I can find no place where the skin is not in good contact with the socket wall.
Her residual limb has little tone below the distal third. The Quadriceps femoris group have so little definition that they are difficult to palpate even when contracted. The primary flexor is the Iliopsoas. The primary extensor appears the be the gluteus maximus. The hamstrings are as atrophied as the Quads. The residual femur appears to be small in circumference. I suspect that the residual amputated muscles were secured by myoplasty rather than myodesis. There are about 24 to 30 mm of redundant tissue below the distal cut femur. The bulk of her limb is extremely soft with no defined shape.
I suspect that the growth of the femoral shaft along its length is minimal since amputation, due to the absence of a distal growth plate. The diameter of the femur is minimal as well since it has had no true weight bearing. The incision scar has migrated laterally because it is adhered to the femur along with amputated muscle and other connective tissue. The diminutive size of the distal femur and its proximity to the migrated incision places greater than normal force at the point of contact with the socket wall where the overlying scar tissue is non-elastic and fragile. Excessive pressure in the anterior proximal third of the socket was responsible for skin breakdown. The pressure was necessary because it maintained the socket atmosphere and also controlled the migration of tissue across the distal femur. The use of Shear-ban and changing from an elastic wrap to an E-Z In pull sock have virtually eliminated the breakdown of anterior proximal skin. A relief in the lateral wall has minimized the problems with lateral pressure but not completely. The concern with the darkening of distal limb tissue in the vicinity of the valve is reduced but not solved. It becomes a dark red or purplish color and somewhat cooler then the rest of the limb but not greatly. The discoloration resolves in ten to twenty minutes after removal of the socket and any edema (when present) is resolved over night. The overall temperature of the residual limb is notably cooler than the contralateral limb though I would expect this to be so.
The most frustrating aspect of this case has been that the solution of one problem has incited another. No more than two or three of the above issues have presented themselves at any given time.
At present the single remaining symptom is a darkening of the tissue in the area of the valve. I am almost 99% certain that there is no air trapped in the socket. I wish I knew of a way to test this definitively.
I am uncertain if I am at the end of what can be accomplished prosthetically and I would be most appreciative of any ideas or suggestions. I would love to see some kind of diagnostic tissue study to give me some idea of the structures I am dealing with within the tissue envelope. The problem is that no physician will order the study. As I said, I suspect that her muscle tissue was anchored by myoplasty.
Given that more than 20 years has elapsed since the amputation; and the present condition of her residual amputated musculature and skeleton, is there any virtue in a revision that would:
1. Reattach the amputated muscles to the femur by myodesis.
2. Reduce the redundant distal residual tissue.
I again apologize for the length of this question but I felt I had to explain all that I knew about the case. Any ideas or referrals would be most appreciated.
John
Citation
john, “Soft transfemoral residual limb,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 7, 2024, https://library.drfop.org/items/show/215038.
