Answers to Liners and Adhesions-Part II

Answers to Liners and Adhesions-Part II

Ed Neumann

3/14/2005

I sometimes use liners if I can maintain that the gel will not flow as
quickly as some liners allow it to. I might try a more dense silicone with
a flexible inner/frame socket with heavy relief and good suspension.
Depends on how bad or large the adhesion tends to be whether or not I would
make a pelite move. Guess you could even go with slip socket if pelite
doesn't work. I believe it all boils down to socket fit and surface contact
within the socket.Gel or pelite, that's for the skill of the practitioner
to decide. Just my opinion.

Have fit/applied many custom silicone liners as well as my Aegis liner w/o
a pin to these challenging residuums.Liner must fit very well. Liberally
apply a lubricant (i.e., vaseline)at and aboutthe adhesion/invagination
site and then apply the liner. Non-mobile tissue must be free to slide
within the liner or tissue abrasion/breakdown will almost always develop.
Avoid the pin if at all possible. Use good s/c suspension or s/c-s/p
suspension. A well-fit neoprene suspension sleeve is recommended and used
with the aforementioned socket suspensions. A suction socket/valve is often
helpful in minimizing negative compliance of the socket during swing.
Minimal to moderate (-) buildups to the affected region. Good patient
compliance and instruction is critical. Regular follow-ups a must.

ALPS liners (no fabric cover) work great since they have the most shear
absorption of any liners I've seen. I also often use lanolin or silicone
cream to lubricate this interface in the socket.

I would generally consider a TEC (custom if the shape requires it) for the
kind of problem you describe. The reason, I believe, that it works well for
the residual limb with scarring, grafted skin and adhesions is that the
Urethane liner is designed to be used with a non-disappearing lotion and to
flow around the skin, preventing skin traction problems. I would definitely
not use a pin locking system, but a sealing sleeve and valve or even the
Harmony or other vacuum assisted suction system.If you don't have
experience with the TEC, there can be a LARGE, painful and costly learning
curve. My advice would be to really understand how the system works, attend
one of their courses, before attempting to use it. Evaluating, obtaining
and maintaining an optimal socket fit with these liners is critical. This
is complicated by the fact that the residual limbs tend to change shape and
shrink dramatically with the Total Surface Bearing of the TEC, at least
this has been my experience.

The use of silicone, mineral gel or urethane liners on distal skin
adhesions are only contraindicated when the selection does not match the
type or location of the adhesion area. I've found over the years that pin
systems work fine if the distal end of the particular liner is stable and
pistoning is kept to a minimum. In most cases when adhesions are present
especially those that are centered around and betweeen the distal tibia and
fibula it is necessary to either add a suspension sleeve or suction setup
that reduces both the piston or stretching that occurs when flexing the
residual limb. In some instances a custom urethane or gel liner does a good
job both protecting the distal end and helping to break up some of the
adhesions. The one time this is does not work well with a pin system is
with burn or heavily scarred limbs.
Then a good fitting gel liner in a traditional socket or flex socket setup
works the best.

Any patient that has true adhesion at the anterior distal aspect will do
well in a cushion (non pin) style liner.

I believe that the distal suction forces that take place when a pin liner
is going through swing phase might easily cause a distal breakdown... and
definitely pain and discomfort. Cushion liners do not have a stabilizing
matrix like most pin liners, so they can easily adapt to any distal shape
without producing significant pressures across the skin and bony
prominences. Explorer liners utilize a mineral oil gel that actually goes
through the skin layers to moisturize and increase the flexibility of the
underlying layers. This often manifests itself as a slow breakdown of the
actual adhesions. Other items that have worked We manufacture items called
Gel Squares or Gel Disks. This formulation of mineral oil, triblock polymer
had very high oil exudation (much more than the Explorer gel). A piece can
be easily cut to shape, placed on the skin and then a liner rolled over it.
Although it does not sound like there is an evangination, practitioners
often cut slices of the gel square, pull back the sides of an invagination,
place the slice inside, which moisturizes and absorbs any frictional forces
that take place.

I am working with an adhered short, scarred resid. limb at this time
with prominences. (Traumatic/non vas/TT level) Prosthesis del. a few weeks
ago. Pt. was doing well until a small blister devel. over the prom. lat.tib.
flare. Interestingly the very prominent a.d.t. did not blister. This was
after about 8 hours of wear and sig. full wt. bearing ambulation. Patient
will start re-ambulating in a couple days. It seems as though gel liners
are made for these types of patients, if indeed shear is a primary
component to skin breakdown. We chose a fairly flexible foot (Ossur Axia)
and fit him with an Alpha Spirit cushion liner
with an Alpha Suction Seal, sealing the system with a Durasleeve. I think it
is a pretty good combination, but time will tell. Pt. wears a sheath under
the Alpha liner. Hope this helps.



Edward S. Neumann, PhD, PE, CP
Professor of Civil and Environmental Engineering
Director, Center for Disability and Applied Biomechanics
Adjunct Professor of Biomedical Engineering
Box 454015
University of Nevada, Las Vegas
Las Vegas, NV 89154-4015
PH: 702 895 1072
FAX 702 895 3936