Responses (part three) Skin grafts and scars in TT

Responses (part three) Skin grafts and scars in TT

Randall McFarland, CPO

ORIGINAL POST:

I have a mid 30's female client who sustained a traumatic vehicular accident
resulting in a 6 inch TT amputation. Virtually the entire remaining part of
the skin below the patella on her amputated leg is split thickness skin graft
and scars- some of which are open and still a ways from healing. Because
of her relative youth, I don't blame the doctors for trying to save her
knee... she will still have the option of going TK in the future if weight
bearing is not tolerated by the skin.
 My questions for discussion are:
1) What has been your experience in fitting such extensive scarring and skin
grafts? Is the physician able to take any steps during healing to minimize
the formation of adherent scars or so we just have to deal with them after
all healing is completed?
(With normal skin, we try to mobilize the skin, but I fear that grafted skin
is less tolerant of such manipulation.)
2) My initial thought is that a viscoelastic liner would be the way to
supplement the dermal layer loss, but does this liner's ability to absorb
shear forces compensate for it's propensity to adhere to the skin? (For the
liner to actually absorb shear, the skin would have to participate) Would a
thick, soft, cushy, dry sock actually be friendlier to such skin by actually
allowing some slide at this interface?
3) Obviously, an optimum combination of good suspension, lightweight
components and a shock absorbing pylon would help minimize shear forces, but
I'd like to hear what has or hasn't worked for you in your most challenging
cases.
    I will post the responses for the benefit of the list members. (If for
any reason you don't want your name included, put it in parentheses.)
    Consider this...the better we all can do for our clients, the better our
profession will be recognized as a whole. In turn, this will eventually have
it's rewards for all which will attract more good people to the field!
 Thanks for your concise input!!

Randy McFarland, CPO

Here are the RESPONSES (separated by a blank line) Thanks to all respondents!!

      Don't wait for the physician to deal with the healing skin grafts.
Massage with any kind of cream (I like Bag Balm) available, starting early
and often will help prevent the scar tissue from becoming adherent. When the
patient is not massaging the scar tissue the use of pressure helps prevent
and reduce hypertrophic scar formation. The pressure needs to exceed
capillary pressure of 26 mm Hg to be effective so any stump shrinker will
work.
   As far as a liner goes, the goal as you mentioned is to reduce the shear
forces. Any of the viscoelastic liners will work, but you don't want the
liner to adhere or link to the tissue as Carl Caspers likes to say, at this
point. A lubricant that will not evaporate under the liner is best. A&D
Ointment, Bag Balm etc. work well.
  Emphasize to the patient and PT that Massage and Pressure are the best
things the patient can do for herself at this time. This effort now can
prevent the scar from becoming adherent. The areas that heal last by wound
contraction will be the areas that tend to scar the most. Also the areas
between the grafts can be problematic and form a raised or hypertrophic scar.
  My four years as the chief PT on a burn unit before O&P have prepared me
well for these types of problems.
John Wall PT, CPO, FAAOP

I have had good luck with saran wrap under alpha suction liners. Meds can be
applied, the saran covers the wound or entire limb and the liner is donned.
The benefits are that the saran takes up no space, puts up a barrier against
outside contaminants, protects the liner from breaking down from the meds and
the suspension is maintained. I also fit soft with socks. I don't use thick
liners as they put too much pressure on the limb on donning, 3mm will do. I
really like whirlpool too as this cleans out all those cracks and fissures.
I tend to do alot of these and have been successful.
Kate Penney CP FAAOP

During my career I have successfully fitted several patients as described by
you. While this kind of residual will always pose a problem for the
prosthetic team it is 1000 times better than a higher amputation.
Virgule

We have several heavily scarred clients at our facility, and we routinely use
gel liners on them. Alpha or Tec seem to work particularly well, despite your
well taken point about skin participation. As to your question about scar
mobilization, it would seem logical to mobilize the tissue before the
adhesions occur, rather than after. As long as the tissue is well-anchored to
the basement membrane, I would think you could begin gentle mobilization. I'm
no dermatologist, but that's my guess. As far as the choice of VSP goes,
would that not fly in the face of your criterion of lightweight components?
We have had very good results with an Allurion and a titanium Total Shock
(gaining us shock and torsion absorption). We are currently exploring the
option of a Luxon foot from Springlite instead. Either way, the weight is
significantly less than a VSP while providing function that is at least as
good. Good luck.
Bryan Steinnagel C.P. (c)

I have had a few individuals just as you have described. Very adhered
grafted skin. In these cases I will cast the limb with plaster making sure
I'm not manipulating the skin but getting all the contours. Have TEC
interface systems make a custom urethane non-locking liner, without the
non-stick coating on the inside. They can also make a test socket to go
with it if you want, I recommend it and have had good fitting sockets nearly
every time. Give them a call and you can discuss using a softer or firmer
shore of urethane as well. When the individual wears the liner they will
need to coat the entire surface of the limb in contact with the liner with
A&D ointment. It will not absorb into the skin during the day and provide a
layer of lubricant for interfacing with the liner. Use an expulsion valve
in the socket and a gel type sleeve to suspend the prosthesis (assuming the
thigh tissue is tolerant of a sleeve). I used an Endolite dynamic foot with
the TT pylon and went a little soft on the ankle ball for more motion. I
still ended up using a gel sock over the TEC liner after some shrinkage.
This is a 21 yr old college student that is very active and has only
contacted me in the last two years for supplies. He still gets some
breakdown of tissue from time to time when he is particularly active and he
has told me he knows how much is too much ( usually a full day of sports).
I hope this will help you and I would be interested in finding out other
ways of tackling this situation. If you will post the replies I would be
grateful.
Kevin Warner CP
Lloyd-Silber Orthopedics
<Email Address Redacted>

We have had good luck with the Iceross dermo liners with shuttle lock,
but you still have some pistoning. While the transtibial sport Iceross
should reduce the movement the best way to go is possible a cushion
dermo and an expulsion valve with some sort of suction sleeve. The best
for ease of donning and doffing is the silipos suction suspension sleeve
which comes in standard and heavy duty.
will graybeal

I have been successfully fitting a couple with extensive split skin grafts
on both TT and TF residua. Neither tolerated visco elastic suspension modes,
more because of the intolerance of the mineral oils in the liners than the
shear forces...their experiences of this skin irritation was actually what
put them off trying other types of liners. I have had consistent success
with leather lined pelite liners and wool stump socks. Cast mods have been
TSB rather than PTB and IB.
I have never tried anything other than skin mob's after healing and wonder
what the surgeon/physician can do to minimize adhesions prior. The grafts do
actually respond well to mobilization after healing if done sensibly and
gradually intensified. Hope this helps, Richard Ziegeler P&O /OT