Summary of replies: Obese transfemoral patients and proximal socket discomfort

Summary of replies: Obese transfemoral patients and proximal socket discomfort

William Lifford

10/16/2002

Thanks for all of your replies. My original post is listed first, then the responses. I have not included names of the respondents... however, if anyone wishes to contact the author of any of the responses listed below, I will contact them and ask them for permission to give you their name/contact info.


>Hello fellow listmembers,
>
>Recently I've had several transfemoral amputee patients in to be fitted for
>new sockets. What are some typical modifications or changes that you find
>you have to make in order to accomodate these types of patients?
>
>For example: The patient's thighs touch together quite firmly all the way
>up into the perineum. Rolling the medial brim of the flexible inner socket
>is not really possible because then the contralateral thigh is chafed;
>however, cutting the brim shorter but leaving it almost vertical produces
>some discomfort upon weightbearing. If the brim is cut too short, there is
>a medial roll of tissue. What can you do in these circumstances?
>
>Another example: The patient's pendulous abdomen is chafed by the anterior
>flexible brim. A standard size rolled edge helps while standing,
>however, when sitting the edge really irritates the tissue. If you build
>out the brim of the cast and then have a large rolled brim, it protrudes
>too far anteriorly to have an acceptable cosmesis. Any thoughts on what
>other options are available?
>
>I'm sorry if these examples are poorly articulated/worded, but I'm trying
>to illustrate the Catch-22 type situations I seem to find myself in while
>serving these patients. I'd really appreciate your thoughts on this
>matter.... I'll post a summary of responses in a few days.
>
>Thanking you in advance,
>
>Bill Lifford, C.P.



Here's the summary of replies to my post on the fitting of obese transfemoral amputee patients:

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For example #1. When I saw this type of patient I would do the following:
cast the patient standing without a casting brim. while the plaster or
fiberglass casting is still soft cover it with a white plastic garbage bag.
place a thick layer of pelite or T-foam between the legs extending form the
perineum to 1-2 beyond the end of the residuum and it must be equal or
wider than the residuum is from front to back and from perineum to 1-2
beyond the end of the residuum. I then have the patient squeeze his/her legs
together and use a 6-8 Ace wrap around the outside of both extremities. the
wrap should be snug but not tight (as it will just slide off the distal
end). the wrap should cover the body from the Iliac crest to 1-2 from the
distal later al femur and be at least 2 layers thick. when the wrap is in
place I have the patient try to spread his/her legs apart. when modifying
the cast you must rely on the shape and not lower the medial wall too much.
you can hand shape the posterior area during casting but you will also need
a good measurement at the Ischium and shape the posterior to take advantage
of this weight bearing area.

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Cannot help you from a fitting perspective...However I HAVE had to fit
overweight men with pendulous abdomins with LS Corsets...Abdominal
Binders...Belly Belts...in order to hold everything in place for donning
their AK Limb and to also make it easier to reach the Plumbing when going
to the bathroom...I have also fit large women with the JOBST Long leg Post
Op Garments and then they wear their suspension sleeve OVER the
garment...Lycra Long Leg shorts work well also and can be obtained at Lane
Bryant ( Large Woman's Store) and if the woman has too much extra soft
tissue..a binder/maternity binder works well...When we fit TLSOs on Women
that are Fluffy...we oftenRoll the edge proximally AND build in a little
Shelf for the breast to make them more comfortable...always
remember...adding to the brim in the beginning is easier than Redoing
later...and if the roll is that big...cosmesis is out the door...you can
always trim the roll after the patient sits and use the excess tissue as
your guide...Good Luck...

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If you aren't fitting conventional suction sockets perhaps a garment of some
type, incorporating both legs going all the way up, kind of like tights or
stockinette pants. Put the garment, socks and all into the socket. I've seen
a lot of people who wear these lycra type of clothing, with body types close
to what you have described... not too flattering to the figure but it is
evident they can be worn by full figured folk and they are thin enough to
not be a significant factor to your socket fit.

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There are trade-offs, which you have identified. One key principle is to
avoid abrupt changes in a pressure gradient; e.g. a trimline where the
pressure goes from snug inside the socket just distal to the trim line to
zero very rapidly at the trimline. This creates internal shear stresses in
the tissue just proximal to the trimline. Radius of curvature near the
trimline is the key to the pressure gradient, however one can have too much
radius - for example in the medial wall.

Another observation is that it can take time for discomfort to appear.
During fitting, some patients seem to find the socket comfortable, but
after a day or two discern pressure or chaffing. Donning (as well as
shrinkage and swelling) can play a role here, as well as the fact that
where blood flow is not an issue, repetitive stress can be. The greater
the pressure, the faster relative movement between the skin and the socket
will cause tissue breakdown.

Based on research I have been doing with the F-scan pressure measurement
system, it appears as though maximum pressure near the trimline in
scarpa's triangle and the ischial area occurs simultaneously during
terminal stance; one is likely a reaction to the other. Pressure in the
ramus area appears to peak during mid-stance. Needless to say, it is had to
position your fingers in these locations for the finger-squeeze test while
someone is walking. In theory, one has to question the value of and the
need for a brim in any area which does not receive a pressure loading,
since it is likely to have a cosmetic impact and produce wear and tear on
clothing. And this raises the interesting question of the trade-off
between hydrostatic loading via the muscular compartments of the socket
versus the supporting of weight close to the trimlines - by doing more of
the former can one reduce the need for the latter and thereby produce a
more comfortable socket? Marlo Ortiz appears to be taking this approach.
However, obesity (which seems to be the case with your problems) can
complicate things because of the billowy, drapy nature of large amounts of
adipose tissue. Abdomen overhangs and medial roll are examples.

Flexible sockets can help provide pressure relief to some extent, but it
depends on how flexible the socket is. Also, a flexible socket may not
eliminate relative motion between the skin and the socket. I have not had
that many years of experience, but have encountered all the problems you
have mentioned. Generally it involved doing lots of work with the check
socket, sending the patient home with it for several days (knee and foot
attached) when we thought we had a good fit, and making adjustments until
the patient was satisfied for a period of about a week. And of course, we
always kept in mind that it is easier to cut material off the socket than
it is to add material back. In some cases, with obese patients, it appears
as if there may be no happy solution that works in all cases. For example,
one patient we had seemed satisfied until he took an airplane trip and
found that the configuration of the seat caused discomfort in the anterior
brim - his car seat and his armchair at home did not cause problems.

I am looking forward to seeing the other responses you receive.

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The best hope for the future of these obese individuals may be in the form
of bone-anchored, osseointegrated, trans femoral prostheses. Work is being
done in Sweden and the U.K. and successes are being recorded. Dr. Rickard
Branemark, Director of Centre of Orthopaedic Osseointegration, Department of
Orthopaedics, Goteborg University, Sahlgren University Hospital, Goteborg,
Sweden, is a leading researcher in the field.

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William- I had a patient like this several years ago and solved the problem
by having the patient wear pantyhose over the prothesis. The nylon hose let
the legs slide,even though they were touching each other. Good luck.

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I hear you. I recently fit a very large woman with a new trans-femoral socket. I ended up cutting down the medial brim to clear her tissue, and made it vertical (as you suggest) with no roll. I did the same anteriorly, making the front low enough that she could sit without it digging upwards into her belly. I skived out a piece of pelite and glued it along the inside of the anterior and medial brims and folded it over so as to make a soft, flexible roll-over. I also got her using an EZ Proth (yes it really is spelled that way), which if you're not familiar with it, is basically a double layered nylon bag that helps the amputee pull their tissue into the socket. This got her medial roll inside (basically) and prevented problems there. As far as cosmesis is concerned, I'm not sure what to say. It seems to me that the proximal brim is largely obscured anyway and should not be particularly visually prominent. I hope this is useful to you, and not to redundant in light of other responses. Good luck

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