Difficult AK/BK responses

Difficult AK/BK responses

Schafer, Kristin

2/16/2004

WOW! What a super response. Thank to all those who took the time to email me
their great advice. Responses are separated by bold/ unbold type.

Original question:
Hi All,
  We have a 17 yo young man who entered our hospital system with meningitis
a few months back. (The other teen who had the same strain died.) The result
of the disease left him with transtibial and transfemoral amputations, no
fingers on either hand, limited wrist motion ( I believe he has difficulty
extending, but can use flexion), serious skin grafting on his wrists and
forearms, and I believe he also suffered some brain injury. This is all I
know so far. (I have yet to meet this young man.) The physiatrist gave me a
heads up that they are thinking of getting him moving towards prosthetic
rehab next in a few weeks.
 My questions are: What would your prescription be for his AK and BK
prostheses? Are people able to don liners without fingers? Or are they
better off with sock fits? (I am unsure if there is significant skin
grafting on the lower extremity.) What other considerations come to mind?
I'm thinking we'll have to use a lot of larger loops somehow affixed to
socks to assist in donning. What would be the best method of suspending
these prostheses? Would you train on one type of knee first and then switch
as his function improves? Do I cast and fabricate both limbs at the same
time ( or BK first).
 Obviously, I'd love to learn from your experiences.

 Thanks! Will post anonymously when all responses are in.

 Kristin Schafer, CP, CP(c)

Responses:
  I guess a big question is whether he will have an assistant or someone to
help him. I had a similar patient several years ago (reaction to a drug
that shut down the circulation in his extremities), but he was bilateral BK,
and had some palm use and a thumb remaining on one hand. He was grafted
extensively with a synthetic material. I used PTB's with pelite liners,
silosheaths, and cuffs, which he was able to manage. The grafts held up
surprisingly well, and I never had problems with traumatization. Of course,
he was not on his feet that much, and probably your patient will spend most
of his time sitting. Though the grafts looked flimsy and discolored, the
skin was actually very smooth and there was no scaring . He had worn
pressure garments for some time, and there was little volume loss after
fitting. I think he waited about a year for fitting. I would imagine a pin
system might work, if someone can help him don the liners. But he is the
only data point I have, so others may have more experience. Good luck!
PS - I used K2 Sensations for feet.

I had a very similar case that I have been very successful with. I am
currently fitting definitive prostheses on an individual who had the exact
same limb losses. The patient is able to independently don both of his
prostheses without fingers or thumbs. He was fitted with the transtibial
prosthesis first, which incorporated a cushion gel liner with a total
contact suction transtibial socket with a thin suction suspension sleeve.
The transfemoral side was casted with the patient sitting on the edge of a
casting table. He was fitted with a suction socket, using a wet fit.
Patient was able to lubricate his limb, press the valve button while
donning.
Donning the Gel liner was not a problem. Donning 1-ply socks was the most
difficult.
The initial gait training was the most important part of the process. He
had initiated an aggressive rehabilitation program, which was very time
intensive, but it was very successful in getting him up to daily independent
ambulation.
The first transfemoral prosthesis incorporated a weight activated stance
control knee (Safety knee) with extension assist and single axis foot. He
has now progressed (1 year later) to a hydraulic knee and multiaxial feet.
Feel free to ask any additional questions.

Kristin,
I've worked with some of these young people in the past. I would first of
all consider the mental capacity, may not be a candidate. Suspension and
donning-doffing are the major hurdles. No fingers=no liner/3S suspension.
Big loops to don both the socks and the prosthesis as well both AK&BK.
BK cuff suspension-keep it light to prevent rejection. Remember that he/she
will probably get a powered chair.
AK belt with big loops & Velcro. If funding is appropriate, C-Leg for
stability otherwise- Otto Bock 3R80 knee/single axis foot-firm dorsiflexion
bumper.
        These kids do very well in my experience. The scars are usually very
thick and durable. The kids are motivated and find ways to do anything they
want. Often the scars are so think that roll on liners are contraindicated
but we have done well with the traditional favorites, socks, pelite liners
etc. get creative and have fun, the biggest challenge is the extent of brain
injury and how to deal with that. Otherwise, this should be a rewarding
case. Good luck.


Hi Kristin,
        When you say 'no fingers' do you mean amputated at the mcp's or at
some level of IP joints?
        Have had 3 patients who were TF + TT, who had amputations of both
hands between the MCP's and PIP's and all three of them progressed nicely to
interface liners with pin suspension, with the BK side's augmented by
supracondylar for added ML stability. The liners can be donned easily with
a pulling motion from the palms of the hands, and wrists in relative neutral
position.
        The early mobilizing involves a lot of mat work, floor work and
learning to move the body with the prosthesis on. We aim to have full time
wearing in 2-3 weeks of receiving the first temporaries, but this obviously
depends on skin integrity. This would be the focus, without any standing.
As the length of wear time increases without skin breakdown, we add in small
amounts of standing from a height adjustable bed and then progress to
teaching both stance phase and swing phase exercises in prep for walking.
        I think it is very difficult on early mobilizing because of both
legs amputated - with no other leg to unload some of the weight, so I think
liners provide more shear protection and comfort than a sock fit/pelite
liner/more traditional PTB style of socket.
        I ideally think that both sides should be fitted together, as it is
also very difficult to stand up on only the BK side, particularly with the
involvement of the upper extremities. We routinely use thermalyn check
sockets for many months before progressing to laminated sockets - it makes
it much easier to see the fit for both the therapists and patients, it
enhances the education process, and even cut an anterior hole in the distal
transfemoral socket to enable guiding the pin in the shuttle mechanism.
        We have started with manual locking knee for stability, and then
worked on swing phase with the knee unlocked in standing in the parallel
bars and active hip extension exercises on a recumbent shuttle (with the
knee unlocked). I have always wanted to work on supported standing where
some of the patient's weight is taken up with a harness from a frame or the
ceiling, however we don't at present have access to that equipment. Once a
reasonable swing phase is achieved with no toe scuffing, have progressed to
Otto Bock 3r60 or Century total knee, then to Mauch SNS and finally C-leg
(depending on funding).
The other thing we do is lower their height significantly; the height of the
BK side will probably dictate this. The closer the patient is to the ground
the easier balance and vertical transfers are, and as they progress with
their function, we increase their body height.
Hope that helps, and look forward to your post with summary of replies.

Kristin,
I casted over an ESP AEGIS Cushion Liner (they are soft, thick, and
preflexed)- less sticky than some others, so this was my rationale for
choosing this liner. The suction was attained with a one-way expulsion
pyramid from Ohio Willow Wood. Intimate total surface bearing socket
modification is a must. Don't skip out on any diagnostic sockets... With
the combination of the 1 way expulsion valve and the Ossur Iceflex
suspension sleeve, the suction is attained. I have not tried the Alps sleeve
with the valve incorporated.
I did make the TT first. We still ended up casting in a seated position
with residual limb hanging over the side of the casting table. He did not
have enough strength to stand at this point.
The patient WAS cognitively sound... so that was advantageous.
No belt needed to control rotation. Aggressive ischial ramal containment
cast modifications with contouring of the socket to prevent rotation. I
hardly ever use belts for transfemoral sockets unless a lot of shrinkage has
occurred and recontouring of the socket through addition of pads in the
socket and between the flexible inner socket and the rigid retainer don't
help. I'll use a belt for some preparatory limbs in the final months before
recasting for definitive fitting. The challenge is all in aggressive
shaping during the casting procedure.
Hope that helps!!!

Kristin

Just received your email. We just fabricated prosthesis for quad amputee
(Bilat wrist disartic and BK). We had exceptional response from patient,
family and therapists. If you would like to discuss please call. Fast Track
Fabrication (800) 758-4404. We are in Florida.
Thanks

Kristin
From the description of your case, I would suggest that the method which
requires the least fine finger tip dexterity is the best on both sides. I
think that this patient is going to need heavy O.T. involvement with either
socks or liners to practice the roll-on/roll-off process of either. Maybe
the brain injury will be the telling condition anyway, if his learning
capacity has been affected. Liners certainly can be donned without fingers
and given the brain injury, it may be a case of setting him up with a BK
first. Assimilation to the process may be necessary and at least he would be
regaining some balance and transferring stability.
 So: 1. find out from the OT what his cognitive capacity is
2. tell the OT what either system will require ( do this by demonstrating -
OT's as a species need this - then repeat it twice - for the same reason)
and she/he should be able to help you decide.
3. The knee choice should be made once. Change can often be a difficulty in
cases of Acquired Brain Injury.
Good luck, happy to help more as you wish.

I have a wonderful woman (40 y/o, Bilat BE, RT AKA, 62, 98 lbs.) that I
work with. She lost her limbs secondary to severe burns, which covered 95%
of her body (in a house fire that killed her mother 30 years ago). She
recently went from a BK to an AK due to complications with her severely
compromised skin. She is amazing. She does not wear upper extremity
prostheses. She does wear her new AK prosthesis. Like you I was concerned
about the liner donning issue so she wears a 1 ply sock fit (no valve), a
TES belt with big loops (for extra security), a 3R49 knee (for now) and a
Dycor ADL foot. Her prosthesis weighs about 4 pounds. We modified a walker
so she can slip her arms in and use it for stability. She does very well.
Eventually we will upgrade her prosthesis to higher tech components, if she
wants to.
I believe this is a good start. We are fortunate to get to work with someone
with so much determination.
I hope this helps.

Yes, I have seen someone with no fingers don liners. Believe it or not, the
woman was a transradial on one side and transhumeral on the other and a
bilateral transtibial (congenital).Managing to push the button to release
the pins was difficult for her though, even though we enlarged and padded
them. Since your patient has longer arms I don't think this would be an
issue.
Perhaps a locking liner for the transfemoral with a short pin, and
supracondylar socket with cushion liner for the transtibial.
Looking forward to reading all responses!

Dear Kristin,
I have fit a woman who is a bilateral BE and a unilateral TF for her TF
prosthesis. As a congenital amputee, she does not wear arm prostheses and
is probably more adaptive than your individual will ever be. Anyway, she
has no problem rolling on the suction locking liners, and, has the add bonus
of never pulling too hard, never poking a finger through one. They last
much longer on her than on most individuals. Whenever I am fitting a new
amputee, I fit both legs simultaneously. That way, as they adapt to one,
they are adapting to the other. Balance is always an issue. Make certain
you give a good wide base of support with not very flexible feet! Mushy
feet are a disaster, especially when the person is first learning to control
their center of mass. Good Luck!


Kristin, when I have an AK/BK, I always do cast the BK first, then if he is
able to stand during the check socket I will then cast the AK side. You
might need to do a cad-cam socket for the AK, which can be done by just
circumferential measurements. Then you can deliver the BK and finish
working on the AK. Who knows if he will be able to don liners without
fingers until you give him a chance. The OT can be working on this skill
NOW! I have had people with one arm successfully don liners so don't make a
ny assumptions about this guy. But if he can't don liners, how will you be
modifying the suspension belts and sleeves? I would highly recommend that
you start working with the OT on the skills he will need. Good luck.

Hi Kristin - I talked to XXXXX today about the case and he said that you
should definitely fit both legs at the same time. He said he would go for
locking pin on both sides if the pt. can manage the liners. Also the pt.
will have to have a tall walker built (elbows bent at 90degrees, bearing
weight on forearms, which I know are scarred and sensitive so maybe line the
trough with gel liner???) with some sort of wrist sockets or straps so he
can lift the walker and be stable on it. Just a few more ideas to add to the
ones I'm sure you're getting!
[I might also] suggest a locking knee at first and then possibly change
later.


This may not be a lot of help, but the scars often react a lot like burn
scars. Brain injury is not usual with meningococcemia. I would confer ahead
of time with his occupational therapist for ideas on what he can do with his
hands as they are, if he can grasp by using both hands together. Possibly,
prosthetic or orthotic intervention for the hands will be indicated also
once healing permits.

Kristin,
I had a patient who had no fingers or thumbs on both hands and he was able
to apply Ossur sleeves to AK and BK fairly easily. He was able to turn them
inside out and lay them onto the limb and pull them up with his palms. He
also applied socks and the legs. We used OWW and Ossur pin locks for him
over several years until he died. I would try to use pin systems because of
the great suspension and ease of application and removal. Good luck.

AK suction socket using cream to don it. BK alpha liner with locking pin (to
don it using a PVC pipe wide enough to fit liner inside out so that when he
dons the liner he just push into the pipe as the liner rolls on.


Many thanks again to all who responded.

Kristin Schafer, CP, CP(c)

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