Responses continued (part 2) Skin grafts and scars in TT
Randall McFarland, CPO
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Title:
Responses continued (part 2) Skin grafts and scars in TT
Creator:
Randall McFarland, CPO
Text:
I have a client almost identical to what you have described
here- 30ish, female, car accident, TT and covered with grafts, scars and
adhered skin. Her residuum resembled an apple core with chunks and
indents here and there. It's amazing how well she is doing. I used a
comfort gel liner (after failed attempts with other brands) and made a
custom silicone filler piece for some larger indentations to try to
obtain total contact. She returned a week later for follow up and
pitched the filler pieces- threw them away!!! She said she didn't need
them and it felt just fine without them. She had a few problem areas
which have been addressed fairly easily actually. The adherent skin did
not present as the problem I had anticipated. Not that all cases will
be this way. Maybe I just lucked out (or maybe I'm just damn good!).
:-) I made a flex inner / rigid outer socket so that I could add more
windows as needed to relieve. I made it with no windows until I could
observe the problem areas. Her windows are not in the typical places,
but instead are over the problem areas to relieve them. Being 30ish,
her skin was very strong even with the grafts, scars, etc. She has
recently had revision surgery and is doing well. Hope your case goes as
well. Good luck to you and I'd be happy to discuss more if needed.
Joan Cestaro, C.P.
Rehab Practitioners, Inc.
Winchester VA
Experience of 5 TT in past year all with very restricted knee rom in
flexion, and split thickness grafting over bulk of residual limb. In all 5
cases (in retrospect) we progressed off a sock fit on a liner too soon (we
used alpha) - the stickiness of the liner on the skin surface caused tearing
and breakdown, even with only wearing the liner and doing gentle rom
exercises.
On a couple of cases the suspension preferred by my prosthetist was pin,
but the distal skin tension proved the worst for the skin grafting and
distal edema and this had to be quickly changed to suction sleeve
suspension.
Using a bk sheath sock inside the alpha liner proved a nice transition - the
stickiness of the alpha liner was then a non-issue on the fragile skin, it
absorbed some sweat for one of the individuals with some normal skin surface
area remaining, and the patients progressed to wearing their liner all day
and the prosthesis 1/2 days which then enabled mobilizing.
Not able to do any mobilizing to prevent adherent scar formation in the
early days. The long term burn patients we've followed who all had adherent
scars eventually went on to have relatively mobile scars 1 year
post-amputation, just by wearing their interface liners and prosthesis.
In hindsight, I feel we've been too aggressive in starting these skin
grafted residual limbs into interface liners on the first temporary
prosthesis. On one older individual, where the ultimate expectations were
lower, the first temporary utilizing a big cushy sock interface proved to
provide the smoothest initial fitting with no skin breakdown that delayed
wearing and mobilizing.
Linda McLaren
Physiotherapist, Amputee Team
GF Strong Rehab Centre
4255 Laurel St.
Vancouver, B.C. V5Z 2G9
FF Dermos and pins just worked well for a similar patient. Keep the patient
out of a chair until they can come to standing using ONLY the hands. Trying
to get them to go slow and not overdo the skin for weeks is the hardest
part.
Don Shurr CPO,PT
I have used silicone lined compression garments in the past for scar
management with surprising success, however not on an amputee. I feel this
may well be an appropriate treatment. The available silicone liners would
probably work well. I wouldn't try with a prosthesis, but as scar
management at first. When the skin is more malleable, then perhaps. Good
luck.
Kevin Matthews, CO
Attached is an image of a late 30's male client who was totally degloved and
multiply grafted following MVA. Within three months he was back at work as
a butcher, and was playing 18 holes at six months. The critical issue is
not direct compressive forces but residuum/interface motion and subsequent
shear (suggest you procure details of Joan Saunders four relevant studies)
hence neg. pressure prescription.
Client was managed with negative pressure gel interface and VSP from initial
fitting, and a gel interface was used in conduction with a class 2
compression garment in early post-op management.
Prosthesis mass and more specifically inertial characteristics are priority
issues. As your client is a female with 6 residuum, I would suggest you
prescribe a light weight foot with an impact reducing heel (such as the
Vari-Flex) in conjunction with the lightest shock module with good linear
force/deflection properties (such as the Total Shock 4400 if moderate-high
activity or Icon if low-moderate). Knee power generation and joint
stability will need to be reviewed to determine ideal component prescription
however.
Suggest you also critically review socket design, residuum shape and the
resultant forces generated at heel-strike and heel-off sub-phases
specifically for optimum outcome.
Good luck
I would suggest using the ICEROSS full thickness comfort liner as an
interface, and if you have access to the total surface bearing casting
device, try it. If not, roll on the sleeve, attach the pin, use a four bolt
endo clutch lock with 1/2 dacron tape screwed to the attachment screw to
provide a loop for a bungee cord. Have the patient don the sleeve, lock the
modified clutch lock in place, attach the bungee cord to the loop, stretch
it to a convenient stable location, then cast with the residual limb in
traction. I would also recommend against the use of VSP. It's an
expense that is not warranted initially, as a new amputee, it would be easier
to learn to walk on a SACH foot with the addition of a shock absorbing
pylon(if you think necessary), than going to the highest tech component
available.
As is true of all practices, this represents my best guess in
the interest of the patient and practitioner.
Best
of luck, the last time I treated burn patients on a regular basis was
1971-1973 at Fitzsimons Army Medical Center in Denver, CO. Steve, CP739
We have fit a few clients/patients (TT and TF) that also have had skin grafts
and scarring from trauma. We have been successful in using viscoelastic
interfaces such as the TECH liners (Profiles, Simplicitys, and Custom), and
the Silipos Cushion liners. From our experience, it appears that the shear
absorbing properties of these materials really does play a part in reducing
further trauma to the skin. With both pin/locking and non-locking with
suction sockets, we have not found any significant skin problems with these
type of clients/patients. With these types of interfaces available, we would
be hesitant to use socks alone. But as you know, the bottom line in
fitting these residual limb conditions lies in the initial modeling; the
design comes first, and if that is on the money, the remaining steps to
protecting the skin are relatively easy.
Eric Schwelke, C.P.O.
here- 30ish, female, car accident, TT and covered with grafts, scars and
adhered skin. Her residuum resembled an apple core with chunks and
indents here and there. It's amazing how well she is doing. I used a
comfort gel liner (after failed attempts with other brands) and made a
custom silicone filler piece for some larger indentations to try to
obtain total contact. She returned a week later for follow up and
pitched the filler pieces- threw them away!!! She said she didn't need
them and it felt just fine without them. She had a few problem areas
which have been addressed fairly easily actually. The adherent skin did
not present as the problem I had anticipated. Not that all cases will
be this way. Maybe I just lucked out (or maybe I'm just damn good!).
:-) I made a flex inner / rigid outer socket so that I could add more
windows as needed to relieve. I made it with no windows until I could
observe the problem areas. Her windows are not in the typical places,
but instead are over the problem areas to relieve them. Being 30ish,
her skin was very strong even with the grafts, scars, etc. She has
recently had revision surgery and is doing well. Hope your case goes as
well. Good luck to you and I'd be happy to discuss more if needed.
Joan Cestaro, C.P.
Rehab Practitioners, Inc.
Winchester VA
Experience of 5 TT in past year all with very restricted knee rom in
flexion, and split thickness grafting over bulk of residual limb. In all 5
cases (in retrospect) we progressed off a sock fit on a liner too soon (we
used alpha) - the stickiness of the liner on the skin surface caused tearing
and breakdown, even with only wearing the liner and doing gentle rom
exercises.
On a couple of cases the suspension preferred by my prosthetist was pin,
but the distal skin tension proved the worst for the skin grafting and
distal edema and this had to be quickly changed to suction sleeve
suspension.
Using a bk sheath sock inside the alpha liner proved a nice transition - the
stickiness of the alpha liner was then a non-issue on the fragile skin, it
absorbed some sweat for one of the individuals with some normal skin surface
area remaining, and the patients progressed to wearing their liner all day
and the prosthesis 1/2 days which then enabled mobilizing.
Not able to do any mobilizing to prevent adherent scar formation in the
early days. The long term burn patients we've followed who all had adherent
scars eventually went on to have relatively mobile scars 1 year
post-amputation, just by wearing their interface liners and prosthesis.
In hindsight, I feel we've been too aggressive in starting these skin
grafted residual limbs into interface liners on the first temporary
prosthesis. On one older individual, where the ultimate expectations were
lower, the first temporary utilizing a big cushy sock interface proved to
provide the smoothest initial fitting with no skin breakdown that delayed
wearing and mobilizing.
Linda McLaren
Physiotherapist, Amputee Team
GF Strong Rehab Centre
4255 Laurel St.
Vancouver, B.C. V5Z 2G9
FF Dermos and pins just worked well for a similar patient. Keep the patient
out of a chair until they can come to standing using ONLY the hands. Trying
to get them to go slow and not overdo the skin for weeks is the hardest
part.
Don Shurr CPO,PT
I have used silicone lined compression garments in the past for scar
management with surprising success, however not on an amputee. I feel this
may well be an appropriate treatment. The available silicone liners would
probably work well. I wouldn't try with a prosthesis, but as scar
management at first. When the skin is more malleable, then perhaps. Good
luck.
Kevin Matthews, CO
Attached is an image of a late 30's male client who was totally degloved and
multiply grafted following MVA. Within three months he was back at work as
a butcher, and was playing 18 holes at six months. The critical issue is
not direct compressive forces but residuum/interface motion and subsequent
shear (suggest you procure details of Joan Saunders four relevant studies)
hence neg. pressure prescription.
Client was managed with negative pressure gel interface and VSP from initial
fitting, and a gel interface was used in conduction with a class 2
compression garment in early post-op management.
Prosthesis mass and more specifically inertial characteristics are priority
issues. As your client is a female with 6 residuum, I would suggest you
prescribe a light weight foot with an impact reducing heel (such as the
Vari-Flex) in conjunction with the lightest shock module with good linear
force/deflection properties (such as the Total Shock 4400 if moderate-high
activity or Icon if low-moderate). Knee power generation and joint
stability will need to be reviewed to determine ideal component prescription
however.
Suggest you also critically review socket design, residuum shape and the
resultant forces generated at heel-strike and heel-off sub-phases
specifically for optimum outcome.
Good luck
I would suggest using the ICEROSS full thickness comfort liner as an
interface, and if you have access to the total surface bearing casting
device, try it. If not, roll on the sleeve, attach the pin, use a four bolt
endo clutch lock with 1/2 dacron tape screwed to the attachment screw to
provide a loop for a bungee cord. Have the patient don the sleeve, lock the
modified clutch lock in place, attach the bungee cord to the loop, stretch
it to a convenient stable location, then cast with the residual limb in
traction. I would also recommend against the use of VSP. It's an
expense that is not warranted initially, as a new amputee, it would be easier
to learn to walk on a SACH foot with the addition of a shock absorbing
pylon(if you think necessary), than going to the highest tech component
available.
As is true of all practices, this represents my best guess in
the interest of the patient and practitioner.
Best
of luck, the last time I treated burn patients on a regular basis was
1971-1973 at Fitzsimons Army Medical Center in Denver, CO. Steve, CP739
We have fit a few clients/patients (TT and TF) that also have had skin grafts
and scarring from trauma. We have been successful in using viscoelastic
interfaces such as the TECH liners (Profiles, Simplicitys, and Custom), and
the Silipos Cushion liners. From our experience, it appears that the shear
absorbing properties of these materials really does play a part in reducing
further trauma to the skin. With both pin/locking and non-locking with
suction sockets, we have not found any significant skin problems with these
type of clients/patients. With these types of interfaces available, we would
be hesitant to use socks alone. But as you know, the bottom line in
fitting these residual limb conditions lies in the initial modeling; the
design comes first, and if that is on the money, the remaining steps to
protecting the skin are relatively easy.
Eric Schwelke, C.P.O.
Citation
Randall McFarland, CPO, “Responses continued (part 2) Skin grafts and scars in TT,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 23, 2024, https://library.drfop.org/items/show/216975.
