Summary of Resonses: "Please help with difficult transtibial case"
wilder lafond
Description
Collection
Title:
Summary of Resonses: "Please help with difficult transtibial case"
Creator:
wilder lafond
Date:
10/20/2004
Text:
Thanks for all your quick responses.
I initially mentioned the Harmony system to the patient during
her initial visit. She refused because she didn't want to wear
sleeve. After reading your responses, I decided to look further
into Harmony options. Ottobock told me I could laminate a slip
cover using the patterned fabric. This would slide over the
sleeve and Velcro into place. It could remain in place until the
sleeve needed to be removed. Otherwise, the sleeve would be
reflected over the slip cover. The patient thought this was a great
idea and we're both eager to try the Harmony system. Thanks again
for the advise.
Wilder LaFond
---
This may not make sense but consider a 3mm liner. I prefer comfort liners. This has helped me eliminate pistoning problems in patients with pin locks.
Have you though about the Harmony system from Otto Bock? You may want to talk to someone doing alot of them . Call Bocks Tech service . They may be able to connect you eith someone.
The basis for using a gel liner is good but the pin system may not necessarily be the best. It might be better to use a custom TEC liner with either a VASS set up or pin shuttle lock but I would not recommend distraction for a BK with a short stump. If your problem is as you said just outside the posterior proximal edge of the socket then the custom liner should eliminate that problem, be sure to cast in 15 to 20 degrees of flexion. This will help preflex the insert and reduc bunching posteriorly. I have found that the TEC liner seems to work the best with scarred residuum and it seems to be the lowest in shear problems as long as the patient follows the dooning and doffing protocol. In addition the suspension sleeve is a must if the patient complains of difficulty after short wearing time. If you use the VASS system the urethane liner and suspension sleeve work very well together to maintain a more constant internal socket enviorment. Be sure to cast the patient using the T!
EC
recommend procedure of exterior vacuum while staging the wrap.
Now I know why the suspension sleeve. Before I completely started over, I would add prosthetic socks one ply at a time until the patient could not engage the lock. Then I would remove the last ply, or ply until the lock would engage. Then have the patient ambulate. If this eliminated the discomfort, I would make anew check socket reduced that number of ply. Again, I'm not there, just an idea. Let me know.
Put her in a harmony system
Don't forget to consider a thigh lacer and joints to further unload the residual limb if your socket design and liner/suspension methods do not adequately address her complaints. I have also done a removable lacer and joints that could be temporarily applied for high activity use. Is there a revision option available? If her complaints cannot be addressed by prosthetic options alone, a revision might be necessary.
You do have a difficult case and I'm not certain that there is a definite answer but you seem to be approaching it with some ideas that might work. i will be interested in seeing you responses from others
Consider using the Harmony system. It would require a compromise on the suspension sleeves but would completely eliminate pistoning and would control volume fluctuation very effectively. It is also extremely comfortable for the amputee.
Your patient presents an interesting clinical challenge and I offer these ideas for your consideration. Although there is no reported skin irritation, I would proceed as if there were visible indications and address each area of complaint or risk. First, I would recommend the 6 mm uniform Apls Easy Locking Liner as it has a distal cushion of 9/16. Second, the posterior tissue bunching you mentioned may be better accommodated by a higher rather than lower posterior trim line and perhaps with a flare for the hamstrings. Third, the distal end of the fibula discomfort could be due to a slight undercut over the soft tissue which could be alleviated by not compressing that area during casting and using an STS molding sock rather than a plaster wrap or vacuum molding technique or you could just add plaster to the positive mold to make a channel for the fibula. Fourth, the distal patella pain could be caused by a patellar bar modified just slightly high on the cast which can be av!
oided by
using 1/2 PVC pipe to compress the patella tendon with the knee in slight flexion rather than using thumb prints lateral to the tendon. You can check for pressure by putting on a cotton casting sock under the gel liner and having your patient ambulate and then remove and check for sock marks. The smile modification recommended for the PTB design and a less aggressive modification there may also work. Fifth, the Apha Lock has an air expulsion valve which when used with a sleeve to provide an air seal works great to address pistoning. Sixth, in addition to your high ML trim for stability, I like to use a Suprapatellar trim with a little development over the proximal edge of the patella for suspension for the active BK amputee. I hope this helps. Good luck.
There are few things I might suggest. I know that pins are convenient, but are most times the cause of chronic distal pain. The distal end of the limb is compressed by the liner. In stance phase the limb has positive pressure from weight bearing and in swing phase the weight of the prosthesis pulls down causing distal distraction, again applying pressure. A total surface weight bearing socket with suspension sleeve and an expulsion valve would help pull blood back into the area reducing distal edema. If you would still like to go with a pin system, a liner with a higher durometer would not allow as much distal distraction as a normal pin liner.
try the Harmony system from otto bock
Have you thought about trying the Ossur- Seal-in Liner system? Sounds like she has enough length for it. Hopefully the seal on the liner does not end up in an area she is very sensitive.
I would try a custom Tec with VASS. I know she doesn't want a sleeve but first and foremost she wants a successful fit. I believe the enhanced suspension and volume management benefits will offset the nuisance of having a sealing sleeve proximal to her knee. The distal discomfort could be related to the pin suspension and related accelerated forces. Good luck.
You know, when a patient asks you to solve a problem like this but want To restrict you from using a suspension sleeve, you just have to be firm with her and tell her what the benefits are. I would strongly suggest a VASS system (forget the pin) which does by neccessity include a suspension sleeve. This will solve her suspension pistoning issues, improve lateral stability without an excessively tall socket brim and improve volumefluctuation. Good luck.
Hi I don't want to take a lot of time. You wrote>> complains of significant daily volume fluctuation VGAP Socket (Variable Geometry Anterior-Posterior SocketC) that is patient adjustable/ tight when ambulating loose when sitting taking only 5 sec to adjust, it also allows the knee to bend more. VGAP manages the daily volume fluctuation, my basic feeling about the volume changes since you did not mention any other problems, is daily trauma to the limb. The liner needs to be a custom 3/S silicone graduated in thickness (2ply proximally 6ply distally) contoured to the distal end of the limb. 2plyimproves the knee bending.
Daily fluctuations are a function of nutrition [including H2O],activity, and physiologic quality of residual-limb. It is evident that thereis severely compromised physiologic functioning with respect to muscle, andthereby - blood vessel efficiency - venous stasis. Suggest refiningnutrition improvement, and especially water intake - assure ~1/2 bodyweightin ounces of steam distilled water be consumed daily, follow nutritionalguidelines of Dr. Michael Colgan books, The New Nutrition & HormonalNutrition - Apple Publishing], Dr. Ray Strand [Book, What Your DoctorDoesn't Know About Nutrition May Be Killing You, and Chris Johnson [book,MEAL PATTERNING] #1 Seek eval from interested/competent surgeon for consideration of reconstructive surgery to correct deficiencies. I recommend Dr Jan Ertl inSacramento California, and Dr. William Ertl in Oklahoma city. #2 If #1 not pursued, strongly consider vacuum suspension approach[understand desire to avoid sleeve, but the G-Sleeve!
from
Daw or the EasySleeve from Alps are very skin/tissue friendly, unrestricting. #3 If #1&2 not pursued, encourage her to begin end-bearing exercises todevelop tolerance to tibial loading. Terminal Tibial end-bearing will reduce necessity to use tangential load forces for support, reducing or eliminating pistoning. I would be happy to talk on the phone for more detail consult.
Sounds like an excellent candidate for a thigh lacer to axially unload And spread out some of the pressure over a larger area. I would still use the pin locking system though and make sure you have a matrix in the liner to minimize elongation of the redundent tissue. If the cut end of the tibia is very prominent, the custom liner could be fabricated with extra matereial to better distribute the forces arount that area. I also agree with using the clutch system to create a tension in your suspension system to help prevent pistoning. To address the genu varum, you will probably nee to do a double lamination or use a significant offset to move the foot laterally to reduce the varum moment at midstance. Sounds like you are on the same track that I would take, but I do think with the short residual limb and the discomfort she is having a thigh lacer would do several things for you.1. Axially unload the limb distal to the knee.2. Essentially extend your lever arm to allow gr!
eater
inset of the foot relative to the knee, giving you a narrower base of supprt and reducingenergy expenditure and creating a more anatomical gait pattern.
Wilder, It sounds to me distinctly like a case that will cause you to 'chase your tail' causing you to try all manner of alternatives and still end up finding the same recalcitrant problems. If you have no obvious pressure signs at the problematic points, I think that your socket and interface are not the problem at all. With a crush injury there can be all manner of insults to the nervous matrix: eg neuromas, periosteal anomalies etc. Have you considered that your patient should get thorough investigation of the stump internals and/or adequate analgesia? It seems to me that you have tried most logical things and the issues are only temporarily ameliorated - get her back to square one.
You might consider treating the excess popliteal tissue like you would an adductor roll, and attempting to encapsulate it. This would help to prevent hammocking as well.
I will begin this response by saying that I am a P&O
student and as such my experience in the field is
probably significantly less then many if not all
others who will respond. However, one positive thing
about being a student is that I get to rotate through
a very wide variety of clinics, both private and
hospital based, thus I am able to see many different
approaches to the same situation that different
practitioners take.
With that said I would probably go with the following:
Socket: Total contact Supracondylar & maybe
suprapatellar casted under vacuum with a liner. I have
seen a vacuum assisted system work very well with
several bony/problematic short TT's. I seems to really
capture the smaller details of the anatomy allowing
the practitioner to focus on the larger areas
(condyles, pre-tibs, medial flare ect). You also
mentioned discomfort just superior to the popliteal
trimlines, what about lowering them a bit?
Suspension: Ossur's Iceross Stabilo Seal-In liners are
becoming more popular for TT amputees that have short
(unstable) residual limbs with skin problems. The seal
in liner provides excellent suspension, is fairly
minimalistic and eliminates the milking effect that
may be occurring with the pin system. Of course the
supracondylar system would also be providing
suspension along with stability.
Pylon: Titanium
Foot: Otto Bock's Luxon Max or Journey. Anything with
some dynamic response (K3) and multi axial motion to
reduce the forces at the residual limb-socket
interface. On second thought Ossur's Ceterus may also
be a good fit for your patient as it provides dynamic
response and plenty of shock absorption and torsional
absorption. The Ceterus also requires 9 on clearance
and from the sounds of your patients short residual
limb you easily have it.
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should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
I initially mentioned the Harmony system to the patient during
her initial visit. She refused because she didn't want to wear
sleeve. After reading your responses, I decided to look further
into Harmony options. Ottobock told me I could laminate a slip
cover using the patterned fabric. This would slide over the
sleeve and Velcro into place. It could remain in place until the
sleeve needed to be removed. Otherwise, the sleeve would be
reflected over the slip cover. The patient thought this was a great
idea and we're both eager to try the Harmony system. Thanks again
for the advise.
Wilder LaFond
---
This may not make sense but consider a 3mm liner. I prefer comfort liners. This has helped me eliminate pistoning problems in patients with pin locks.
Have you though about the Harmony system from Otto Bock? You may want to talk to someone doing alot of them . Call Bocks Tech service . They may be able to connect you eith someone.
The basis for using a gel liner is good but the pin system may not necessarily be the best. It might be better to use a custom TEC liner with either a VASS set up or pin shuttle lock but I would not recommend distraction for a BK with a short stump. If your problem is as you said just outside the posterior proximal edge of the socket then the custom liner should eliminate that problem, be sure to cast in 15 to 20 degrees of flexion. This will help preflex the insert and reduc bunching posteriorly. I have found that the TEC liner seems to work the best with scarred residuum and it seems to be the lowest in shear problems as long as the patient follows the dooning and doffing protocol. In addition the suspension sleeve is a must if the patient complains of difficulty after short wearing time. If you use the VASS system the urethane liner and suspension sleeve work very well together to maintain a more constant internal socket enviorment. Be sure to cast the patient using the T!
EC
recommend procedure of exterior vacuum while staging the wrap.
Now I know why the suspension sleeve. Before I completely started over, I would add prosthetic socks one ply at a time until the patient could not engage the lock. Then I would remove the last ply, or ply until the lock would engage. Then have the patient ambulate. If this eliminated the discomfort, I would make anew check socket reduced that number of ply. Again, I'm not there, just an idea. Let me know.
Put her in a harmony system
Don't forget to consider a thigh lacer and joints to further unload the residual limb if your socket design and liner/suspension methods do not adequately address her complaints. I have also done a removable lacer and joints that could be temporarily applied for high activity use. Is there a revision option available? If her complaints cannot be addressed by prosthetic options alone, a revision might be necessary.
You do have a difficult case and I'm not certain that there is a definite answer but you seem to be approaching it with some ideas that might work. i will be interested in seeing you responses from others
Consider using the Harmony system. It would require a compromise on the suspension sleeves but would completely eliminate pistoning and would control volume fluctuation very effectively. It is also extremely comfortable for the amputee.
Your patient presents an interesting clinical challenge and I offer these ideas for your consideration. Although there is no reported skin irritation, I would proceed as if there were visible indications and address each area of complaint or risk. First, I would recommend the 6 mm uniform Apls Easy Locking Liner as it has a distal cushion of 9/16. Second, the posterior tissue bunching you mentioned may be better accommodated by a higher rather than lower posterior trim line and perhaps with a flare for the hamstrings. Third, the distal end of the fibula discomfort could be due to a slight undercut over the soft tissue which could be alleviated by not compressing that area during casting and using an STS molding sock rather than a plaster wrap or vacuum molding technique or you could just add plaster to the positive mold to make a channel for the fibula. Fourth, the distal patella pain could be caused by a patellar bar modified just slightly high on the cast which can be av!
oided by
using 1/2 PVC pipe to compress the patella tendon with the knee in slight flexion rather than using thumb prints lateral to the tendon. You can check for pressure by putting on a cotton casting sock under the gel liner and having your patient ambulate and then remove and check for sock marks. The smile modification recommended for the PTB design and a less aggressive modification there may also work. Fifth, the Apha Lock has an air expulsion valve which when used with a sleeve to provide an air seal works great to address pistoning. Sixth, in addition to your high ML trim for stability, I like to use a Suprapatellar trim with a little development over the proximal edge of the patella for suspension for the active BK amputee. I hope this helps. Good luck.
There are few things I might suggest. I know that pins are convenient, but are most times the cause of chronic distal pain. The distal end of the limb is compressed by the liner. In stance phase the limb has positive pressure from weight bearing and in swing phase the weight of the prosthesis pulls down causing distal distraction, again applying pressure. A total surface weight bearing socket with suspension sleeve and an expulsion valve would help pull blood back into the area reducing distal edema. If you would still like to go with a pin system, a liner with a higher durometer would not allow as much distal distraction as a normal pin liner.
try the Harmony system from otto bock
Have you thought about trying the Ossur- Seal-in Liner system? Sounds like she has enough length for it. Hopefully the seal on the liner does not end up in an area she is very sensitive.
I would try a custom Tec with VASS. I know she doesn't want a sleeve but first and foremost she wants a successful fit. I believe the enhanced suspension and volume management benefits will offset the nuisance of having a sealing sleeve proximal to her knee. The distal discomfort could be related to the pin suspension and related accelerated forces. Good luck.
You know, when a patient asks you to solve a problem like this but want To restrict you from using a suspension sleeve, you just have to be firm with her and tell her what the benefits are. I would strongly suggest a VASS system (forget the pin) which does by neccessity include a suspension sleeve. This will solve her suspension pistoning issues, improve lateral stability without an excessively tall socket brim and improve volumefluctuation. Good luck.
Hi I don't want to take a lot of time. You wrote>> complains of significant daily volume fluctuation VGAP Socket (Variable Geometry Anterior-Posterior SocketC) that is patient adjustable/ tight when ambulating loose when sitting taking only 5 sec to adjust, it also allows the knee to bend more. VGAP manages the daily volume fluctuation, my basic feeling about the volume changes since you did not mention any other problems, is daily trauma to the limb. The liner needs to be a custom 3/S silicone graduated in thickness (2ply proximally 6ply distally) contoured to the distal end of the limb. 2plyimproves the knee bending.
Daily fluctuations are a function of nutrition [including H2O],activity, and physiologic quality of residual-limb. It is evident that thereis severely compromised physiologic functioning with respect to muscle, andthereby - blood vessel efficiency - venous stasis. Suggest refiningnutrition improvement, and especially water intake - assure ~1/2 bodyweightin ounces of steam distilled water be consumed daily, follow nutritionalguidelines of Dr. Michael Colgan books, The New Nutrition & HormonalNutrition - Apple Publishing], Dr. Ray Strand [Book, What Your DoctorDoesn't Know About Nutrition May Be Killing You, and Chris Johnson [book,MEAL PATTERNING] #1 Seek eval from interested/competent surgeon for consideration of reconstructive surgery to correct deficiencies. I recommend Dr Jan Ertl inSacramento California, and Dr. William Ertl in Oklahoma city. #2 If #1 not pursued, strongly consider vacuum suspension approach[understand desire to avoid sleeve, but the G-Sleeve!
from
Daw or the EasySleeve from Alps are very skin/tissue friendly, unrestricting. #3 If #1&2 not pursued, encourage her to begin end-bearing exercises todevelop tolerance to tibial loading. Terminal Tibial end-bearing will reduce necessity to use tangential load forces for support, reducing or eliminating pistoning. I would be happy to talk on the phone for more detail consult.
Sounds like an excellent candidate for a thigh lacer to axially unload And spread out some of the pressure over a larger area. I would still use the pin locking system though and make sure you have a matrix in the liner to minimize elongation of the redundent tissue. If the cut end of the tibia is very prominent, the custom liner could be fabricated with extra matereial to better distribute the forces arount that area. I also agree with using the clutch system to create a tension in your suspension system to help prevent pistoning. To address the genu varum, you will probably nee to do a double lamination or use a significant offset to move the foot laterally to reduce the varum moment at midstance. Sounds like you are on the same track that I would take, but I do think with the short residual limb and the discomfort she is having a thigh lacer would do several things for you.1. Axially unload the limb distal to the knee.2. Essentially extend your lever arm to allow gr!
eater
inset of the foot relative to the knee, giving you a narrower base of supprt and reducingenergy expenditure and creating a more anatomical gait pattern.
Wilder, It sounds to me distinctly like a case that will cause you to 'chase your tail' causing you to try all manner of alternatives and still end up finding the same recalcitrant problems. If you have no obvious pressure signs at the problematic points, I think that your socket and interface are not the problem at all. With a crush injury there can be all manner of insults to the nervous matrix: eg neuromas, periosteal anomalies etc. Have you considered that your patient should get thorough investigation of the stump internals and/or adequate analgesia? It seems to me that you have tried most logical things and the issues are only temporarily ameliorated - get her back to square one.
You might consider treating the excess popliteal tissue like you would an adductor roll, and attempting to encapsulate it. This would help to prevent hammocking as well.
I will begin this response by saying that I am a P&O
student and as such my experience in the field is
probably significantly less then many if not all
others who will respond. However, one positive thing
about being a student is that I get to rotate through
a very wide variety of clinics, both private and
hospital based, thus I am able to see many different
approaches to the same situation that different
practitioners take.
With that said I would probably go with the following:
Socket: Total contact Supracondylar & maybe
suprapatellar casted under vacuum with a liner. I have
seen a vacuum assisted system work very well with
several bony/problematic short TT's. I seems to really
capture the smaller details of the anatomy allowing
the practitioner to focus on the larger areas
(condyles, pre-tibs, medial flare ect). You also
mentioned discomfort just superior to the popliteal
trimlines, what about lowering them a bit?
Suspension: Ossur's Iceross Stabilo Seal-In liners are
becoming more popular for TT amputees that have short
(unstable) residual limbs with skin problems. The seal
in liner provides excellent suspension, is fairly
minimalistic and eliminates the milking effect that
may be occurring with the pin system. Of course the
supracondylar system would also be providing
suspension along with stability.
Pylon: Titanium
Foot: Otto Bock's Luxon Max or Journey. Anything with
some dynamic response (K3) and multi axial motion to
reduce the forces at the residual limb-socket
interface. On second thought Ossur's Ceterus may also
be a good fit for your patient as it provides dynamic
response and plenty of shock absorption and torsional
absorption. The Ceterus also requires 9 on clearance
and from the sounds of your patients short residual
limb you easily have it.
---------------------------------
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********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
wilder lafond, “Summary of Resonses: "Please help with difficult transtibial case",” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/223826.
