Responses (part one) Skin grafts and scars in TT

Responses (part one) Skin grafts and scars in TT

Randall McFarland, CPO

Here is the 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 VSP 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!!

    I have switched a pt with adherent scars to a ALPS gel liner with
success. In another, I started with the ALPS and then added a Silipos single
socket gel liner (which is essentially a Silipos gel sheath with a cool max
sock over it instead of a sheath-its stretchier) The Silipos gel was against
the skin but the ALPS added to shear protection with its increased thickness.
There are times when I also give pt with scar tissue Silipos body discs
Many Silipos products are meant to reduce scarring and provide a soft
durometer and oil impregnated gel.
     I have seen success and rejection from Custom TEC liners on scarred
tissue.
    While the Reflex VSP provides nice shock absorption, I would think and
have given my pts torque absorption as well (Total shock on a Sureflex foot)
Of course there are other ways to do it. I think we want to absorb as many
forces as possible with components (multiaxial foot-shock and torque
absorption) before it is translated the residuum. I tried a different
combination components and it was too unstable for the pt...so ,of course,
there is experimentation.
Mark Benveniste CP

I have two such clients in my practice. We have found that using a
TEC liner with a sock on the inside is the most effective and practical
solution. The TEC used with lubricant is ideal if used properly but is
quite messy and failure to use adequate lubricant just once will lead to
skin abrasions. The Alpha will also work but is not nearly as durable as
the TEC.

I have fit many such cases. The latest involved necrotizing faciatis -
90% of the weight =-bearing surface is grafted. He has done well for the
past two years. Socket design is most critical.
   Total-Surface-Bearing [real total-surface-bearing] That is if skin is able
to tolerate - most are.I have used Iceross Dermo, Ohio Willow Wood's Alpha,
Aegis - All have worked well. It is patients preference. I also have the
patient do self-massage, end-bearing practice on a home weight scale to
progressively increase end-bearing capability [again when possible - and most
can increase from practically nothing to upwards of 60% of their body
weight], muscle expansion exercises to increase muscle mass and voluntary
control for increased stability.
Jan

I am neither a dermotologist, orthopedist, plastic nor vascular surgeon, so
I am not sure if I can give an authoritative answer on decreasing the extent
of scarring. However, I think that as soon as the graft will tolerate,
gentle mobilization is indicated. In working with burn patients in a
rehabilitation setting, we mobilize as soon as possible, expecting some skin
fissuring.
   We have had luck with TEC liners for sensitive skin.
Charles E. Levy, MD

A TEC liner is donned with a layer of lubricant of some sort on the
skin. This keeps if from sticking to the skin, and might allow the liner to
slide on the scar tissue in this case. I haven't used many TECs, but have
been
impressed by how well they protected the skin when I have used them.

I believe we are able to achieve the best results using TEC custom liners
with cases like you describe.
Eddie White, CP

You should consider using joints and thigh lacer to offload forces to the
thigh. I use this with the gel liners and best foot/ankle. After the patient
is well healed and the skin is intact I then try the straight BK. This period
also gives the grafted skin time to toughen and become accustomed to shear and
pressure. If no problems with the non-joint BK fine, but if skin breakdown
occurs you can revert back. Allow full knee extension so the patient does not
develop a gait dependent on the joints or extension stop. The joints should be
setup solely for weight transfer.
Mo

Initially the transition needs to be cautious, until healing is complete. You
may find out, the residual limb with skin grafts has significant tolerance
capabilities. I would recommend Tec inserts or Alfa's. I would not use VSP
because of weight.
ABC CP

A TEC or ALPS interface is a good choice. You mention lightweight
components but then mention using a VSP, A heavier component and less
cosmetic. I would want components that would absorb shock shear,
rotational shear, and ground reaction forces. Maybe something from
Springlite or a combination of components.
Steve Childs

I've been in the same situation as your client since 1988. I've tried about
everything out there, and the best thing I've found for the grafted tissue is
to use a 1.5 mm ossur liner, with a non-absorbent lubricant over any
adhesions. SC suspension also helps to
limit skeletal migration within the skin envelope.
Marcus Boren

I have had 2 cases that sound similar to yours. Both of them were men
weighing in between 250 and 300, so there was a lot of weight to bear. After
various attempts at different things, including thigh lacers, both had
success with Custom TEC liners (6mm). I'm not fond of TEC in general
because of their initial chemical odor. BUT, when all else failed, they
worked. Good Luck!

One of our patients, approx 40yr male, also traumatic auto, very short TT
the entire posterior of his limb covered by scar tissue. He was fit to a
dermo liner in his preparatory and whether the motion or the aloe, the
healing process of the scarring even impressed his plastic surgeon. It is a
question of skin tolerance, but worked well in this case.
(P.Thompson, resident- I haven't been here long enough to have most
difficult cases, but this was pretty impressive)


We have a 40 year old bilateral TT patient with total skin grafts below the
patella over the entire limb on both legs. The amputations were the result
of a drug reaction that restricted blood flow. The patient was in
compression garments for many months, which took care of most of the
shrinkage. The skin is smooth with no adherent scars. We used gel socks and
PTB sockets with Pelite liners so that we could unload the tibias. A nylon
sheath goes on right over the skin. The skin looked very fragile. We were
concerned about whether it would work, but the patient has been doing fine,
and walks without assists. One blister early on, but no problems in over 6
months.
   We also have an active 30 year old TT patient with extensive grafting along
the lateral side below the patella, who wears an alpha liner. There is
extensive scarring,and adhesions. The tibias are ok, though. Tissue
breakdowns occur occasionally around the fibula as the limb shrinks and
settles into the socket. But the alphas work.
Ed Neumann

I have had luck with a TEC liner and suction fit with just such a
residual limb. Volume reduces quite rapidly during the initial stages
of fitting - quite expensive replacing liners every 3 months. The
gentleman in this case still experiences quite a bit of pain related to
the trauma in losing the leg, managed with meds and is ablating as much
as he wants to, as well as quite active in the gym. He has both an Icon
variflex and a solid variflex and uses both for different reasons.
Good luck B. van Lenthe C.P.(c)