reponses to patella problem

reponses to patella problem

Joan K. Cestaro

7/31/2002

Thanks to all the respondents. Seems like many folks have used a
silicone liner with success in these cases. I might consider giving her
a liner to wear for a week and see what happens to this area before
making my suspension decision.

Original post:

I am seeking advice on an unusual situation. I have a female BK
patient, 80 years old and about 100 pounds. She is 18 months post-op
due to a huge ulcer that occurred over her patella. The ulcer is now
healed but has left adherent skin over most of the patella. There is
about a 1 (2-3 cm) diameter circular area of adherent skin. And at 80
years old, her skin is very fragile anyway. Otherwise, she presents as
a good prosthetic candidate with a K2 potential.

I suspect a gel suction liner would cause added stress directly over the
patella. She is too short to consider cutting it below the patella.
Even the pre-bent ones would likely break down the skin as I imagine she
would be sitting most of the time. A neoprene sleeve would also create
pressure here. I am inclined to use a cuff suspension to completely
avoid pressure. Other suggestions are welcomed.

I am also seeking suggestions for fabrication. I have considered a
large plastazote pad inside the socket to pad the patella. I also plan
to use a flex inner / rigid frame design and cutting the rigid outer
down to the MPT bar area, leaving only thin, flexible plastic over the
patella. Any and all fabrication suggestions are welcomed. Thank you
all in advance.


Responses:

I've had a similar problem which was resolved by using a nylon sheath
under a
silicone liner (preferrably pre-flexed). It sounds too simple to work
but
this particular gentleman hasn't had breakdown since. His skin is as you

described, and his healing rate is very slow. We experienced frequent
breakdown and frustration until arriving at this solution. We do not use
the
liner for suspension, only as protection for his fragile skin.
Use a gel liner but lubricate the skin over the patella.
     You might try the Neocuff, a kind of cross between a cuff strap and
a
neoprene sleeve, cut out patella and reinforced buttress over the
patella
region. I think you can get them from PEL Supply.
My experience with similar cases is that direct total contact pressure
(such as a gel liner would provide) helps to soften, loosen the skin
adhesions and heal the area. Time and regular full range motion
activities will help the process along. The more motion and contact is
avoided the worse the problem becomes.
Ossur has a series of gel type pads of varying sizes that you can
(spot)incorporate into your socket lamination.In effect you create
pressure relief where you want it and the transition if done correctly
is very smooth,the pads are black in color and come in kits or single.If
you call Ossur I'm sure they can help you locate them,and if you need
fab assistance you can call me I'll be glad to assist.
Maybe you could use a PTS type socket with Medial wedge
suspension. You then could leave the trim below the
patella and high on the sides for better ML control. I
would try a pelite type liner with a silipose sock or
something similar.
I see a lot of patella breakdown due to improperly applied post-op
dressings. The result is paper thin skin adhered to the patella itself.
If knee flexion and extension are not a problem they are still
candidates. Cut off the style of insert that you prefer just proximal to
the femoral condyles and curve the trimline down in the anterior
quadrant to expose the patella. It works great without problems. I use
9mm Alpha or Comfort + inserts.
Why are you covering the patella at all? Sounds as if a PTS suspension,
using pelite liner, is more then adequate for this patient. The
flexible inner with rigid outer frame pads the bill but adds unnecessary
weight. For a K2 like you describe I would consider a geriatric foot,
monolithic PP socket/shin, PTS suspension, pelite liner, distal end pad,
gel or wool sock.
Have you considered a supra-condular/supra-patellar design?
Why cover the patella at all?? From your description it seems a PTB
cuff would work fine. And if she will be sitting most of the day, why
put her in a gel liner? KISS is the way to go, I think for this one.
In addition, at 80 and 100 lbs, a Dycor set up would work out extremely
lightweight.
Try the Neo-cuff from Ortho-Remedy It's pretty good! Also, try the
Ultimate ESP liner. This line wouldn't break the skin if you wanted it
to. It is really good for this situation - especially with the A&D
ointment added next to the skin.

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