difficult AK fitting Response summary Part 2
Ted Trower
Description
Collection
Title:
difficult AK fitting Response summary Part 2
Creator:
Ted Trower
Date:
9/2/2003
Text:
----------------------------------------------------------------------------------------------------------------------------------------------------
We have an obese patient that wears a knit rite brand belt (like the TES,
but more breathable). He does fairly well with it, but is suspended by a
lanyard system.
nathan keepers, CPO
----------------------------------------------------------------------------------------------------------------------------------------------------
I've been thinking on your problem. Have you thought about using an Alps
liner to help firm up the tissue. He can still use a wet fit to go into the
socket. I have used this technique a few times. The socket design I use for
this is the TEC A/K technique that has the groove or ring about 2 inches
from the perineum. A pseudo quad shape may also help to control rotation or
the use of a Silesian belt.
Steve Childs, BOCP
Pacific Orthotic Prosthetic Service
----------------------------------------------------------------------------------------------------------------------------------------------------
Ted ,Just finished a patient just like the one you are explaining. It is
all in the shape of the socket. I use a little scarpus triangle and a
channel post. to the adductor longus/gracilius adductor group which helps
with rotation and gives the adductors an area to fire into. A transverse
channel just under the gluteal muscles can help with suspension. Have more
ideas if you need . You can call me if you want at 813 8753216 in Tampa
Florida Bill Copeland C.P.,L.P.
----------------------------------------------------------------------------------------------------------------------------------------------------
I dealt with a similar client who was appx 450#, had a bell-shaped residum
hanging 3 distal to the contralateral knee, etc. I wound up using a co-poly
socket, enlarged a TES belt by sewing two of them together, left the knee
center distal to provide clearance while he was in his wheelchair (most of the
time) and used an ALPS thin clear liner to compress the distal tissues with a
single-ply sock fit. I did add on a dacron lanyard with proximal D ring for
secondary suspension, but he chose to wear the lanyard with some slack in it,
and used it to pull into the socket more than as a suspension device.
It was an ugly contraption, but he loved it.
Could you use a Coyote Lock (the type that goes on the side of the socket) for
rotation control and partial suspension?
Marcus Boren, CP
----------------------------------------------------------------------------------------------------------------------------------------------------
>just my observation, but the NWU IC socket modification description that i
>saw (thank you jack!) discusses the sub ischial triangle and medial
>proximal socket angle inferior to the ischium in a much more defined way
>than Ivan Long. after calculating the M-L forces at the distal fib and
>balancing that force couple with the proximal ischium, i believe the force
>defined to be on the medial ischium is really transferred to the medial
>aspect of the hamstring mm group. i really cut that medial socket wall to
>30 and 45 degrees from the line of progression (N.S.N.L.). if i don't, my
>narrow M-L sockets internally rotate until they get enough pressure there
>to stop. (this is a LOT of pressure in midstance, thousands of in# of
>torque [look back at lehmanns kines handout if you really want to know how
>much], so if this is a new mod on a squishy limb, it will atrophy over
>time and you might have to pad or fill it in somehow after a while. or you
>could try padding it in your socket now to see if it makes any difference
>before you work too hard making a new one.)
>
>also, the NWU seems to revisit the scarpas triangle as a rotation control.
>between incorporating these two back into my mods, i have reduced I R AND
>as a bonus, terminal stance ramus pressure as the scarpas mods keep the
>ischium where i want it when the pelvis rotates in the socket at terminal
>stance. since this person sounds gushy, putting in a scarpa's at a
>reasonable quad A-P measurements sounds brutal, so looking at what soft
>tissue stops the I R once it maxes out might show you IF the medial wall
>mods would make any difference. since he is on the shorter side, this
>might work. doesn't work on patients with fairly intact (full length)
>hamstrings as that is one big muscle which gives them hip extension, they
>rub over this big a mod (remember hearing that in the quad socket texts?,
>hmmm there is something to this anatomy stuff!), but then, they don't I R
>much anyway.
>
>well and i have a bad reputation about this, so speaking theoretically i
>am sure the coyote suspension will assist your derotation and minimize the
>choking potential if socket mods don't do it.
>
>ramona
----------------------------------------------------------------------------------------------------------------------------------------------------
Have you considered a Zip Whiz sock for pulling in. It makes pulling into
a suction socket a lot easier. I have a 82 year old that says it has made
his life much easier. He has used a standard pull sock for more tan fifty
years and just started with the Zip Whiz and loves it. Might be jsut the
ticket for an obese guy.
Good Luck
Jim Fenton
----------------------------------------------------------------------------------------------------------------------------------------------------
We encountered this quite often in situations where a dynamic foot
transmitted the torsional energy rather than absorbing it. Try a softer
foot or a rotator below the knee.
Good luck,
Jack Richmond
----------------------------------------------------------------------------------------------------------------------------------------------------
I've had a similar situation. Went with an Alpha liner...XL 6mm
uniform cushion liner. Fit a good snug socket and then rolled the
liner over the trimline for a seal. I was surprised but it sealed
excellent. No belt, no redundant adductor roll, and no rotation.
Tom Whitehurst CPO
----------------------------------------------------------------------------------------------------------------------------------------------------
i feel it will be a hard sell getting this
patient away from the lotion ,but it sounds like you have been able to prove
a better fit is possible you might want to explore an 3mm alpha liner with
a coyote lock the summit people say it does not suspend but it does and it
will control rotation no need for any other suspension good luck michael j
beck cpo-
----------------------------------------------------------------------------------------------------------------------------------------------------
Suspenders?
Robert S. Kistenberg, CP, LP, FAAOP
=========================================================================
End of responses:
Thursday PM
So far I've modified a XL Century XXII neoprene suspension belt by
replacing their waist extension with a 36 length of Spenco. This seems to
handle the stretching well and clings to the skin reasonably well. As his
abdomen is quite firm the belt doesn't seem to be rolling up or digging in,
at least not yet. After modifying the socket to reduce compression over
the anterior proximal 1/3 an Alpha cushion liner ( XL, 6mm, uniform) was
rolled over the model (with great difficulty)and a cast was formed over
that. The new socket was made from this cast . Turns out that Wendy's
question as to whether or not he could donn a roll-on liner was on the
mark. He cannot bend over far enough to reach the back side of the distal
end of his limb. He has a very firm and rotund abdomen and it simply
blocks him from that kind of forward movement. In addition the XL Alpha
really isn't large enough and is extremely difficult to control when
donning. As it turns out, all was not lost, while the client was unable to
fully enter the new socket with the Alpha on, or even with a single soft
sock for that matter, he was in fact able to apply lotion to his limb and
slide in for a suction fit! A few minor modifications and he was able to
take the prosthesis back to the hotel for the night with a comfortable
fit. He did choose to take the neoprene belt with him in case he needed it.
Fri.
Well, I was all set to equip the prosthesis with suspenders if necessary
but it won't be. The clients wife called around noon and indicated that
the socket was extremely comfortable and that they were going to return
home without any further adjustments. It would appear that the socket had
been too tight overall and that this was responsible for the rotary
instability. He is not using the neoprene belt at this time. Thanks to all
who responded.
It never hurts to get a little lucky!
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
www.amputee.com
We have an obese patient that wears a knit rite brand belt (like the TES,
but more breathable). He does fairly well with it, but is suspended by a
lanyard system.
nathan keepers, CPO
----------------------------------------------------------------------------------------------------------------------------------------------------
I've been thinking on your problem. Have you thought about using an Alps
liner to help firm up the tissue. He can still use a wet fit to go into the
socket. I have used this technique a few times. The socket design I use for
this is the TEC A/K technique that has the groove or ring about 2 inches
from the perineum. A pseudo quad shape may also help to control rotation or
the use of a Silesian belt.
Steve Childs, BOCP
Pacific Orthotic Prosthetic Service
----------------------------------------------------------------------------------------------------------------------------------------------------
Ted ,Just finished a patient just like the one you are explaining. It is
all in the shape of the socket. I use a little scarpus triangle and a
channel post. to the adductor longus/gracilius adductor group which helps
with rotation and gives the adductors an area to fire into. A transverse
channel just under the gluteal muscles can help with suspension. Have more
ideas if you need . You can call me if you want at 813 8753216 in Tampa
Florida Bill Copeland C.P.,L.P.
----------------------------------------------------------------------------------------------------------------------------------------------------
I dealt with a similar client who was appx 450#, had a bell-shaped residum
hanging 3 distal to the contralateral knee, etc. I wound up using a co-poly
socket, enlarged a TES belt by sewing two of them together, left the knee
center distal to provide clearance while he was in his wheelchair (most of the
time) and used an ALPS thin clear liner to compress the distal tissues with a
single-ply sock fit. I did add on a dacron lanyard with proximal D ring for
secondary suspension, but he chose to wear the lanyard with some slack in it,
and used it to pull into the socket more than as a suspension device.
It was an ugly contraption, but he loved it.
Could you use a Coyote Lock (the type that goes on the side of the socket) for
rotation control and partial suspension?
Marcus Boren, CP
----------------------------------------------------------------------------------------------------------------------------------------------------
>just my observation, but the NWU IC socket modification description that i
>saw (thank you jack!) discusses the sub ischial triangle and medial
>proximal socket angle inferior to the ischium in a much more defined way
>than Ivan Long. after calculating the M-L forces at the distal fib and
>balancing that force couple with the proximal ischium, i believe the force
>defined to be on the medial ischium is really transferred to the medial
>aspect of the hamstring mm group. i really cut that medial socket wall to
>30 and 45 degrees from the line of progression (N.S.N.L.). if i don't, my
>narrow M-L sockets internally rotate until they get enough pressure there
>to stop. (this is a LOT of pressure in midstance, thousands of in# of
>torque [look back at lehmanns kines handout if you really want to know how
>much], so if this is a new mod on a squishy limb, it will atrophy over
>time and you might have to pad or fill it in somehow after a while. or you
>could try padding it in your socket now to see if it makes any difference
>before you work too hard making a new one.)
>
>also, the NWU seems to revisit the scarpas triangle as a rotation control.
>between incorporating these two back into my mods, i have reduced I R AND
>as a bonus, terminal stance ramus pressure as the scarpas mods keep the
>ischium where i want it when the pelvis rotates in the socket at terminal
>stance. since this person sounds gushy, putting in a scarpa's at a
>reasonable quad A-P measurements sounds brutal, so looking at what soft
>tissue stops the I R once it maxes out might show you IF the medial wall
>mods would make any difference. since he is on the shorter side, this
>might work. doesn't work on patients with fairly intact (full length)
>hamstrings as that is one big muscle which gives them hip extension, they
>rub over this big a mod (remember hearing that in the quad socket texts?,
>hmmm there is something to this anatomy stuff!), but then, they don't I R
>much anyway.
>
>well and i have a bad reputation about this, so speaking theoretically i
>am sure the coyote suspension will assist your derotation and minimize the
>choking potential if socket mods don't do it.
>
>ramona
----------------------------------------------------------------------------------------------------------------------------------------------------
Have you considered a Zip Whiz sock for pulling in. It makes pulling into
a suction socket a lot easier. I have a 82 year old that says it has made
his life much easier. He has used a standard pull sock for more tan fifty
years and just started with the Zip Whiz and loves it. Might be jsut the
ticket for an obese guy.
Good Luck
Jim Fenton
----------------------------------------------------------------------------------------------------------------------------------------------------
We encountered this quite often in situations where a dynamic foot
transmitted the torsional energy rather than absorbing it. Try a softer
foot or a rotator below the knee.
Good luck,
Jack Richmond
----------------------------------------------------------------------------------------------------------------------------------------------------
I've had a similar situation. Went with an Alpha liner...XL 6mm
uniform cushion liner. Fit a good snug socket and then rolled the
liner over the trimline for a seal. I was surprised but it sealed
excellent. No belt, no redundant adductor roll, and no rotation.
Tom Whitehurst CPO
----------------------------------------------------------------------------------------------------------------------------------------------------
i feel it will be a hard sell getting this
patient away from the lotion ,but it sounds like you have been able to prove
a better fit is possible you might want to explore an 3mm alpha liner with
a coyote lock the summit people say it does not suspend but it does and it
will control rotation no need for any other suspension good luck michael j
beck cpo-
----------------------------------------------------------------------------------------------------------------------------------------------------
Suspenders?
Robert S. Kistenberg, CP, LP, FAAOP
=========================================================================
End of responses:
Thursday PM
So far I've modified a XL Century XXII neoprene suspension belt by
replacing their waist extension with a 36 length of Spenco. This seems to
handle the stretching well and clings to the skin reasonably well. As his
abdomen is quite firm the belt doesn't seem to be rolling up or digging in,
at least not yet. After modifying the socket to reduce compression over
the anterior proximal 1/3 an Alpha cushion liner ( XL, 6mm, uniform) was
rolled over the model (with great difficulty)and a cast was formed over
that. The new socket was made from this cast . Turns out that Wendy's
question as to whether or not he could donn a roll-on liner was on the
mark. He cannot bend over far enough to reach the back side of the distal
end of his limb. He has a very firm and rotund abdomen and it simply
blocks him from that kind of forward movement. In addition the XL Alpha
really isn't large enough and is extremely difficult to control when
donning. As it turns out, all was not lost, while the client was unable to
fully enter the new socket with the Alpha on, or even with a single soft
sock for that matter, he was in fact able to apply lotion to his limb and
slide in for a suction fit! A few minor modifications and he was able to
take the prosthesis back to the hotel for the night with a comfortable
fit. He did choose to take the neoprene belt with him in case he needed it.
Fri.
Well, I was all set to equip the prosthesis with suspenders if necessary
but it won't be. The clients wife called around noon and indicated that
the socket was extremely comfortable and that they were going to return
home without any further adjustments. It would appear that the socket had
been too tight overall and that this was responsible for the rotary
instability. He is not using the neoprene belt at this time. Thanks to all
who responded.
It never hurts to get a little lucky!
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
www.amputee.com
Citation
Ted Trower, “difficult AK fitting Response summary Part 2,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/221711.
