Large skin graft on residual limb?
Mark T. Maguire, CPO
Description
Collection
Title:
Large skin graft on residual limb?
Creator:
Mark T. Maguire, CPO
Text:
Hello Colleagues:
I have a client/patient that has a left knee disarticulation amputation secondary to a tractor rollover. He has a large skin graft, 4 inches wide by 6 inches long, that symmetrically starts on the distal anterior portion of the RL and extends 6 inches posterioriorly up the back of his leg.
The client/patient is one year post-amputation and has been in a preparatory prosthesis for about a 6 months. The overall fit of the prosthesis, especially with regards to the graft, up until about 2 months ago, has been very fine. He is now experiencing some form of drainage/sweating on the graft and even some very minimal bleeding from what I would call micro-cracks in the graft. Common sense tells me these problems are now surfacing as a result of increased activity relative to when he first receives the prosthesis. I have him in what I call a 50/50 suction socket; it's partial end bearing and partial circumferential bearing socket.
Additional information that may be relevant.
In my opinion the quality of the graft is questionable and has been questionable since the leg was amputated. There is good area of grafted tissue posteriorly and a compromised grafted tissue on part of the distal end. The compromised area distally is more of a scar looking tissue instead of the traditional pseudo-skin looking graft you'd find with a good graft. The patient states that the good part of the graft seems to be the site of the drainage/sweating I noted above while the micro bleeding is occurring in the area of the less viable distal grafted tissue.
Good Grafted area: Sweating/drainage.
Poor Grafted area: bleeding from micro cracks.
I believe the patient/client could be downplaying a severe fall a couple of months ago that I believe could have significantly compromised the integrity of the distal scar tissue, thus resulting in the micro bleeding. What do you think?
The patient can get a pseudo flexion-extension action on the distal end of his residual limb, creating some significant tissue movement. The client/patient states that this tissue flexes and extends inside of the socket when he walks. I believe this tissue movement could be rubbing on the inside of the socket, thus causing a sheer force the graft cannot tolerate.
He is currently in a test socket with a dermo liner that only extends about 5-6 inches up his RL. This liner is of course intended to reduce sheer forces on the graft. This liner has minimized but not completely eliminated the secretion/drainage problems on the good grafted tissue but done nothing for the distal end.
My specific questions?
Do any of you have any experience that might explain the problems with the skin graft?
Do you think that the partial end bearing of the socket is a big or small component of the problems with the graft?
Any other thoughts or suggestions would be greatly appreciated.
Thank you in advance.
Mark T. Maguire, CPO
I have a client/patient that has a left knee disarticulation amputation secondary to a tractor rollover. He has a large skin graft, 4 inches wide by 6 inches long, that symmetrically starts on the distal anterior portion of the RL and extends 6 inches posterioriorly up the back of his leg.
The client/patient is one year post-amputation and has been in a preparatory prosthesis for about a 6 months. The overall fit of the prosthesis, especially with regards to the graft, up until about 2 months ago, has been very fine. He is now experiencing some form of drainage/sweating on the graft and even some very minimal bleeding from what I would call micro-cracks in the graft. Common sense tells me these problems are now surfacing as a result of increased activity relative to when he first receives the prosthesis. I have him in what I call a 50/50 suction socket; it's partial end bearing and partial circumferential bearing socket.
Additional information that may be relevant.
In my opinion the quality of the graft is questionable and has been questionable since the leg was amputated. There is good area of grafted tissue posteriorly and a compromised grafted tissue on part of the distal end. The compromised area distally is more of a scar looking tissue instead of the traditional pseudo-skin looking graft you'd find with a good graft. The patient states that the good part of the graft seems to be the site of the drainage/sweating I noted above while the micro bleeding is occurring in the area of the less viable distal grafted tissue.
Good Grafted area: Sweating/drainage.
Poor Grafted area: bleeding from micro cracks.
I believe the patient/client could be downplaying a severe fall a couple of months ago that I believe could have significantly compromised the integrity of the distal scar tissue, thus resulting in the micro bleeding. What do you think?
The patient can get a pseudo flexion-extension action on the distal end of his residual limb, creating some significant tissue movement. The client/patient states that this tissue flexes and extends inside of the socket when he walks. I believe this tissue movement could be rubbing on the inside of the socket, thus causing a sheer force the graft cannot tolerate.
He is currently in a test socket with a dermo liner that only extends about 5-6 inches up his RL. This liner is of course intended to reduce sheer forces on the graft. This liner has minimized but not completely eliminated the secretion/drainage problems on the good grafted tissue but done nothing for the distal end.
My specific questions?
Do any of you have any experience that might explain the problems with the skin graft?
Do you think that the partial end bearing of the socket is a big or small component of the problems with the graft?
Any other thoughts or suggestions would be greatly appreciated.
Thank you in advance.
Mark T. Maguire, CPO
Citation
Mark T. Maguire, CPO, “Large skin graft on residual limb?,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 8, 2024, https://library.drfop.org/items/show/216351.
