Responses BK Liner/Suspension Recommendations Part I

Responses BK Liner/Suspension Recommendations Part I

Lisa Urso, CPO

Hi List Members, Many thanks to all who responded. Considering the conical, bony contour of my patient's residual limb, I don't think he'd be a good candidate for Ossur's Seal In system. I am looking into the Medi Relax liners. If anyone else would like to comment on their experience with Medi Relax, I will post those responses. Here's my Original Post (abbreviated): Which liner (and suspension system) would you choose for the following patient? 51 year old, male, long (8 ½” from patella tendon), conical shaped, BKA secondary to trauma at age 17; in good health, active, occasional problems with skin fungus on the distal end of his residual limb; currently wearing a 15 year old, exoskeletal prosthesis with a leather/kemblo liner, PTB cuff & waist belt suspension, Kingsley Strider SACH foot.
 He will only wear an exoskeletal type prosthesis. Additional info/questons:
 The liner material must be a non-irritant to his skin/fungal condition and still have some longevity to it. What has been your experience with Ossur’s Iceross Seal-In Liners with the Hypobaric Sealing Membrane? Which valve works best for the distal end? Would you consider this liner for this patient? What has been your experience with OWW’s new Alpha Max fabric used with the Stabilizing Strip compared to the Alpha Spirit? What about the durability of their gel and their suction socket components? Durability, comfort, low maintenance, component longevity, fairly lightweight, and excellent suspension are what he wants in his new liner/suspension system.

RESPONSES
I would certainly try the seal in liners from Ossur. The dermo sil type (vs. the stabilo) would be my choice because of his skin condition. It has aloe vera in it and seems very dermatologically correct if there is such a term. I fit a dermo (pin liner) on a pt that had very sensitive skin and it was the only thing she could wear and not break out. The seal works very well using the BK Lyn valve (Ossur has it). There will be no pistoning or pulling of the distal end. If he is very active, you may consider using an outside suspension sleeve as well for security like for running or such like activities. Regular activities should not require the outside sleeve. I have not used this liner enough yet to speak for its longevity, but I personally have never had longevity problems with ossur liners. The oww liners would not be my choice. My intention is not to bash any company because I feel oww has quality products; however, I feel the longevity of the oww liner wouldnot match that of the seal in liner.
How does he feel about suction with a knee sleeve? If he is wearing a waist belt, he may not mind the knee sleeve. This suction provides a much greater area than the seal in and the most positive suspension other than vacuum. I think the type of liner is secondary; he will just have to have good hygiene. Cleaning a gel liner is easier that cleaning the pelite liner and he will be more likely to follow through, in my opinion.Use a nice foot and this suspension and he will love you... Good luck... We have been using Alpha liner for years with good results till recently and we have noticed a significant increase in skin problems. Mainly a type of fungus infection is suspected, (Dematologist disagrees), this is a new problem just in the last 4 months. No explanation from OWW. Hygiene appears to been adequate in all cases.As for Ossur seal in liners they work well on some patients. The first thing I'll caution you on is that the patient needs good symmetry on the distal 1/3. No deep scars or sharp prominent bones. My first 3 were rejected by the patients because they caused distal discomfort. You will probably go through one or two sizes during the initial beak in. I personally think they are a good alternative but there are some inherent problems. 1.) cost 2.) difficulty in donning. 3.) difficult to adjust as the patient's residual limb changes. Normally requires several complete new sockets!
I have many patients with this exact same problem and using a silicone liner with proper cleaning techniques have been able to help the fungus or filth problem. I recently started using the Medi Relax liners with the magnetic coil fibers in the distal end. They are easy to adapt to and the silver in the matrix reduces fungal growth. They are easy to retro in an Aplha situation. I prefer locking with a secondary sleeve for kids that are active. This has worked quite well. Since you are using PTB type sockets,have you even thoght of using the silver matrix fitting sockets? I believe that most manufactuers are selling them these days. I use the silicone for the durablity and ease of cleaning.the Alphas will harbor too much smell and bacteria. Don't get me wrong, I use OWW everyday, just not for special needs patients. Good luck. I hope this helps. Would be cautious about using Seal In with a conical limb. I obtain my best results using custom profile liners from Otto Bock TEC, their prolink sleeve suspension and the ESP expulsion valve. The socket must be TSB. Why in the world will he only wear an exoskeletal system?This will only limit his choices. What benefits do the exo vs. endo system give him? He is willing to change to a newer type of leg but not willing to go all the way. A custom liner may be the answer with a lanyard system. Most of the newer feet permit exo attachement. You could foam the endo system too after the alignment is completed.Hope this helps. Response from Lisa on above reply: Patient's last prosthesis started out as an endoskeletal. He wore it for 3-4 weeks, destroyed the cover doing landscaping, climbing ladders, fishing, hiking, etc., brought the prosthesis back to his prosthetist, and asked him to laminate it into an exoskeletal. It weighs 7 lbs.! With 24 years experience, I'm seeing a red flag here.. he's been there, done that.. and he's asked if he will be able to water ski (like he does now) in the new prosthesis I will be making him. Red flag! Red flag!! Too bad this young guy would not consider an energy storing foot and Harmony Vass, but I know it may be too much of a change and possibly complicated for most pt. and their prosthetist.Well here is my reply about the liner issue. The fabric only addresses external forces, Gel is not that durable. Alpha may be the most comfortable but may not have the longevity of silicone. Alpha Liners have been known to cause fungus problems if not maintain as suggested by OWW. Ossurs Seal In liners are a nice option if you again follow Ossurs modifications suggestions and maintain Total Contact, NO Voids. Ossur recommends a valve manufactured by ESP out of New Jersey. But Ossur has not in the past distributed the Flex Connect portion which creates a very clean finish while holding the inner flexible socket to the laminated frame (NO Tape). Make sure you learn how to clean the valve and educate the pt (suggest once per month, need it or not!) and/or supply more than one to the pt. Suspension is only as good as the seal of the valve. Good luck!
I would suggest that you investigate the TSS vacculink system from Jim Smith Sales. This vacuum suspension provides the patient with complete suspension inside the prosthesis. The system utilizes a multi-axial foot and ankle with energy storing features to match natural ambulatory gait of the patient. Liner selection is not as important using this system as the patient does not have pistoning inside of the prosthesis at all. We have had our facility certified in this system by scheduling to have them provide a free patient application clinic in our office. They will hand walk you through the application procedure to include: casting/scanning of the residual limb, modification of the positive model, fabrication of the check socket for initial diagnostics, fitting and dynamic alignment of the prosthesis. We have fit several of these systems on a majority of our amputees that are interested in the newest technology available. The patients have been very impressed with this type of system regarding the additional types of activities that they are able to participate in. The design and fabrication systems are simple and easily learned by your staff. The information is available on their website at: jimsmithsales.com or if you would like to call them: 1-800-826-2334 and ask for Kyle.
I suspect that what you describe as fungus over distal end, is actuallyearly stage or mild verrocous hyperplasia secondary to insufficient endcontact. Call me if you would like to discuss treatment plan. Mike Shower, CPO 916-223-0194
I read your question on the list serv and I wanted to let you know of a new sock that we have started to make at Knit-Rite. It's called a liner-liner sock. It's a thin (about 1/2 ply) prosthetic sock that is engineered to be worn under a liner next to the skin. It has 5% pure silver (called X-STATIC) intertwined into the yarn, The silver fibers fight bacteria and odor as well as transport heat and moisture away from the skin. I think it would be perfect for your patient with fungal problems. The silver will kill the fungus and keep the limb clean and dry. It is available in 3 sizes, regular extra short (1SXLRGEX), regular short (1SXLRGSH) and wide short (1SXLWDSH). Call me if you have any questions. Fred LanierKnit Rite
See Part II for remaining responses.