TT and Scar tissue
Richard Z
Description
Collection
Title:
TT and Scar tissue
Creator:
Richard Z
Date:
9/1/2005
Text:
Firstly, thankyou very much for the responses, which I include for others interested. I am grateful for all the brilliant help that contributors have given. I will post the details of results of the attempts that I will make to eliminate movement by trying a pinless system.
Thanks again.
Richard Ziegeler (original question has not been included because of the large post-I will be happy to repost that if necessary individually)
*ESP (Engineered Silicone Products) makes the AEGIS pre-flexed silicone liner. Our 6mm Ultimate has proven successful on many patients with the problems you describe.
*I have done this a few times and it has worked out well. I use a silipos single socket gel liner because the gel is soft and has mineral oil in it. Then I use an ESP Ultimate gel liner on top of that for the extra cushion.
One could make an argument for using an Alpha liner but my experience is that they thin relatively easily.
................
*This sounds a little basic, and I assume you probably tried, but did you try removing the pin and using the liner as a cushion liner with a suspension sleeve? Sometimes the pin can pull on the tissue, causing discomfort.
...................................
*KEEP THE GEL LOSE THE PIN.
...................................
*Tec customs from Otto Bock are the only way to go for your patient, been there, done that a multiple of times.
....................................
*In my opinion it would be the urethane TEC liner from Otto Bock. If you haven't used it you should know that there can be quite a learning curve A sound understanding of there fitting principles is a must..
...................................
*try the 9mm Alpha liner and a vertical shock absorber
......................................
*I have found that the Alpha liner works for my burn patients. I usually use the 9mm thick ones.
.....................................
* have had good outcomes utilizing a custom urethane liner on residual limbs similar to your description. Otto Bock (North America)fabricates several types of urethane custom liners. They refer to the product line as TEC (Total Environment Control). In my opinion a custom liner is indicated when irregular shapes or scars are present as well as senstivity issues.Another option may be the Alpha liner (North American manufacturer...Ohio Willow Wood). The Alpha liner can be customized. The customization is carried out
by heating the liner on a cast of the patients extremity in a oven at 65 degrees C for up to 15 minutes. Before giving up on your present design may I suggest the addition of a
suspension sleeve encompassing the exterior of the proximal portion of the prosthesis and terminating on the thigh proximal to the trim of the locking liner. It has been my experience that extremely sensitive limbs or ones with
redundant tissue distally seem to expeience problems secondary to the traction effect on the residual limb caused by the weight of the prosthesis during swing phase. Addition of an suspension sleeve virtually eliminates that slight movement. Elimination of any motion is probably why the patient has utilized waist belt suspension for the past 20 years.
Lastly you may wish to consider a Vacuum Assisted Socket System (VASS) with a custom urethane liner. The very positive linkage eliminates any movement and subsequent shear. I was unsure if in Australia you are familiar with Otto Bock's TEC liners or the Alpha liner. If you are, my apologies for the unnecessary information on
their products.
.........................................
*In my opinion, do not use locking pins in this situation. Use sleeve suspension to equalize the pull in the system.Custom liners Otto Bock TEC Urethane or Alpha custom are indicated here. Also Try Knit Rite USA Liner
liner socks for use under your liner for reduced shear and more comfort.
.................................
*Your current selection of liner is sound. The low density PVC polymer gel liners (Silipos & OWW) are a good choice when shear is the major consideration. However I would recommend using these in a negative pressure setup (not pin). They allow too much elongation during swing phase when fitted with a pin. This elongation can itself cause shear problems. I would also consider using the TEC liners (also negative pressure setup) with such a client. We've had tremendous success with heavily scarred, degloved or adherent residuums with the TEC liners. My experience is motion is the enemy.
..........................
*Try one of the new liner socks from Knit Rite with the Silver in it under the liner. It works well and ussually does not effect suspension
...............................
*Why did you fix it? When it wasn't broke?
...................................
*This may sound strange, but in cases like this one I have used the silicone
gel (available from Fillauer) to first fill the deep scar and split skin graft areas, then applied an ESP pre-flexed liner over that. The results have been very good. The patient controls the gel, but the amount used does not need to be precise; too much will ooze out of the desired areas and fill any other vacant areas that may develop as the residuum matures.
............................................
*I have had good results with the Iceross dermo (for locking liner) or an Alps ELFR (suction socket) in similar cases.
.........................................
*Otto Bock Harmony system.
..........................................
*The use of a pin system and gel liner on extensive burns may not be your best route. You should consider a cushion liner with either suction or sleeve suspension. The other choice would be to use a custom liner either TEC urethane or Silicone, I've used both the TEC and the Alpha gel custom liners with great success on burn and heavy scar tissue. When the coefficient of friction is not matched to the elasticity of the tissue the shear forces increase dramatically, this is when the TEC custom urethane liner works better than most silicone liners because the coefficient is so close to natural skin. Also the pin causes to much distraction by itself using a suspension sleeve reduces this problem. Even the Ossur sleeve with
the distal ring might be a good choice if he can tolerate the pressure at the suspension ring level. In any case the most important thing is to be sure that the liner itself does not cause excessive friction, also use the skin cream as instructed when using TEC Urethane liners.
................................
*I might suggest staying with the pelite liner if that's what he's used for over 20 years! You may find he won't be happy with anything different even though you think it will work better for him.
.....................................
..................................
Thanks again.
Richard Ziegeler (original question has not been included because of the large post-I will be happy to repost that if necessary individually)
*ESP (Engineered Silicone Products) makes the AEGIS pre-flexed silicone liner. Our 6mm Ultimate has proven successful on many patients with the problems you describe.
*I have done this a few times and it has worked out well. I use a silipos single socket gel liner because the gel is soft and has mineral oil in it. Then I use an ESP Ultimate gel liner on top of that for the extra cushion.
One could make an argument for using an Alpha liner but my experience is that they thin relatively easily.
................
*This sounds a little basic, and I assume you probably tried, but did you try removing the pin and using the liner as a cushion liner with a suspension sleeve? Sometimes the pin can pull on the tissue, causing discomfort.
...................................
*KEEP THE GEL LOSE THE PIN.
...................................
*Tec customs from Otto Bock are the only way to go for your patient, been there, done that a multiple of times.
....................................
*In my opinion it would be the urethane TEC liner from Otto Bock. If you haven't used it you should know that there can be quite a learning curve A sound understanding of there fitting principles is a must..
...................................
*try the 9mm Alpha liner and a vertical shock absorber
......................................
*I have found that the Alpha liner works for my burn patients. I usually use the 9mm thick ones.
.....................................
* have had good outcomes utilizing a custom urethane liner on residual limbs similar to your description. Otto Bock (North America)fabricates several types of urethane custom liners. They refer to the product line as TEC (Total Environment Control). In my opinion a custom liner is indicated when irregular shapes or scars are present as well as senstivity issues.Another option may be the Alpha liner (North American manufacturer...Ohio Willow Wood). The Alpha liner can be customized. The customization is carried out
by heating the liner on a cast of the patients extremity in a oven at 65 degrees C for up to 15 minutes. Before giving up on your present design may I suggest the addition of a
suspension sleeve encompassing the exterior of the proximal portion of the prosthesis and terminating on the thigh proximal to the trim of the locking liner. It has been my experience that extremely sensitive limbs or ones with
redundant tissue distally seem to expeience problems secondary to the traction effect on the residual limb caused by the weight of the prosthesis during swing phase. Addition of an suspension sleeve virtually eliminates that slight movement. Elimination of any motion is probably why the patient has utilized waist belt suspension for the past 20 years.
Lastly you may wish to consider a Vacuum Assisted Socket System (VASS) with a custom urethane liner. The very positive linkage eliminates any movement and subsequent shear. I was unsure if in Australia you are familiar with Otto Bock's TEC liners or the Alpha liner. If you are, my apologies for the unnecessary information on
their products.
.........................................
*In my opinion, do not use locking pins in this situation. Use sleeve suspension to equalize the pull in the system.Custom liners Otto Bock TEC Urethane or Alpha custom are indicated here. Also Try Knit Rite USA Liner
liner socks for use under your liner for reduced shear and more comfort.
.................................
*Your current selection of liner is sound. The low density PVC polymer gel liners (Silipos & OWW) are a good choice when shear is the major consideration. However I would recommend using these in a negative pressure setup (not pin). They allow too much elongation during swing phase when fitted with a pin. This elongation can itself cause shear problems. I would also consider using the TEC liners (also negative pressure setup) with such a client. We've had tremendous success with heavily scarred, degloved or adherent residuums with the TEC liners. My experience is motion is the enemy.
..........................
*Try one of the new liner socks from Knit Rite with the Silver in it under the liner. It works well and ussually does not effect suspension
...............................
*Why did you fix it? When it wasn't broke?
...................................
*This may sound strange, but in cases like this one I have used the silicone
gel (available from Fillauer) to first fill the deep scar and split skin graft areas, then applied an ESP pre-flexed liner over that. The results have been very good. The patient controls the gel, but the amount used does not need to be precise; too much will ooze out of the desired areas and fill any other vacant areas that may develop as the residuum matures.
............................................
*I have had good results with the Iceross dermo (for locking liner) or an Alps ELFR (suction socket) in similar cases.
.........................................
*Otto Bock Harmony system.
..........................................
*The use of a pin system and gel liner on extensive burns may not be your best route. You should consider a cushion liner with either suction or sleeve suspension. The other choice would be to use a custom liner either TEC urethane or Silicone, I've used both the TEC and the Alpha gel custom liners with great success on burn and heavy scar tissue. When the coefficient of friction is not matched to the elasticity of the tissue the shear forces increase dramatically, this is when the TEC custom urethane liner works better than most silicone liners because the coefficient is so close to natural skin. Also the pin causes to much distraction by itself using a suspension sleeve reduces this problem. Even the Ossur sleeve with
the distal ring might be a good choice if he can tolerate the pressure at the suspension ring level. In any case the most important thing is to be sure that the liner itself does not cause excessive friction, also use the skin cream as instructed when using TEC Urethane liners.
................................
*I might suggest staying with the pelite liner if that's what he's used for over 20 years! You may find he won't be happy with anything different even though you think it will work better for him.
.....................................
..................................
Citation
Richard Z, “TT and Scar tissue,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/225493.
