Replies to difficult AK case
Rick Milen
Description
Collection
Title:
Replies to difficult AK case
Creator:
Rick Milen
Date:
11/25/2006
Text:
THANK YOU ALL. EXCELLENT INPUT.
We have a pediatric PT very interested in helping this fella and our plan is: an appropriately fittng socket with lanyard-locking liner suspension, trying a TES (like) belt to see if he has improved proprioception, definately a lock knee to start with the possiblity of utilizing his current Safety knee if and as he progresses. PT will be very fundamental and developmental. Will be very interesting. Thanks again.
Rick Milen, CPO, PTA
ORIGINAL POST:
Synopsis: 37 y/o male with mental retardation since birth and
Dx of bipolar disorder. Has caregivers 24/7/365. Underwent AKA due to Lipomatous Carcinoma ( an aggressive CA w/prognosis of death 5 years after Dx). Was fit w/temp prosthesis: quad-like socket, no ischial wt bearing, no distal contact, a soft distal pad, a 3ply plug fit w/hip joint-pelvic belt, “Safety” knee and Sach foot.
Q: Isn’t he more at risk for falls with an ill fitting socket?
Why not a lock knee? Cognition may not allow for body mechanics required w/knee flxn. Does the use of hip joint & pelvic band decrease chance for hip fractures in a fall?
Why not narrow ML, ischial containment with liner-lanyard system? Easy to don,
reliable suspension and appropriate socket shape.
REPLIES:
#1 - Determine what hurts:
When you take the flexible inner socket out of the frame and don the inner socket to check the fit, what do you see and what feedback is the patient giving you when he is:
1) Non-Weight Bearing - pt. is supine on fitting table while you exert a gentle, quasi-weight bearing force to the socket. Note patient's reaction to the increasing force, change in socket positions, get patient's feedback on what feels good/bad to him (no matter how off-the-wall his reactions are, investigate it.. he communicates differently). This would also be a good time to do a Thomas test/check for any hip contractures/tightness. At some point, you should also check leg length with patient in his prosthesis laying supine (and/or prone w/feet off end of fitting table) with your hands applying equal force to bottom of shoes; and
2) Weight Bearing - while (still) wearing only the inner socket, have him weight bear on a standing fixture in the parallel bars, with your hands firmly holding the socket in an alignment that feels comfortable to the patient. If he can stand comfortably, have his caregiver hold him in this position while you quickly mark a/p/l plumb lines on the socket and shoot a few a/p/l digital pictures. Remove socket, reinstall in frame/prosthesis, compare basic socket alignment to existing prosthesis (without patient in prosthesis). Again, shoot some digital pictures where ever you see something unusual/weird. Documentation is a wonderful thing for insurance companies.
#2 - To answer your questions:
a). Yes, a poorly fitting socket decreases the control of the prosthesis which puts the patient at risk of falling;
b). I hate locked knees, but this patient needs one for starters.. he's too afraid otherwise;
c). A hip joint w/pelvic band MIGHT prevent a hip fx. if this patient had radiation treatments around his hip joint (radiation can zap bone strength/integrity). However, most hip fractures occur in conjunction w/osteoporosis, a stationary foot, the pelvis rotating, femoral head snapping from the rotary force, and THEN the patient falls.
I like your suggested narrow ML, ischial containment with liner-lanyard system. Perhaps tighten the knee extension assist so the BAM of full knee extension can be heard and felt by the patient for security reasons. A TES suspension belt should be tried if patient has weak hip musculature and it may give proprioceptive input to the patient to feel more connected to his prosthesis. Lastly, mandatory physical therapy and home instructions/training for the staff working w/this gentleman. Everyone on the same page.
CPO
We have a pediatric PT very interested in helping this fella and our plan is: an appropriately fittng socket with lanyard-locking liner suspension, trying a TES (like) belt to see if he has improved proprioception, definately a lock knee to start with the possiblity of utilizing his current Safety knee if and as he progresses. PT will be very fundamental and developmental. Will be very interesting. Thanks again.
Rick Milen, CPO, PTA
ORIGINAL POST:
Synopsis: 37 y/o male with mental retardation since birth and
Dx of bipolar disorder. Has caregivers 24/7/365. Underwent AKA due to Lipomatous Carcinoma ( an aggressive CA w/prognosis of death 5 years after Dx). Was fit w/temp prosthesis: quad-like socket, no ischial wt bearing, no distal contact, a soft distal pad, a 3ply plug fit w/hip joint-pelvic belt, “Safety” knee and Sach foot.
Q: Isn’t he more at risk for falls with an ill fitting socket?
Why not a lock knee? Cognition may not allow for body mechanics required w/knee flxn. Does the use of hip joint & pelvic band decrease chance for hip fractures in a fall?
Why not narrow ML, ischial containment with liner-lanyard system? Easy to don,
reliable suspension and appropriate socket shape.
REPLIES:
#1 - Determine what hurts:
When you take the flexible inner socket out of the frame and don the inner socket to check the fit, what do you see and what feedback is the patient giving you when he is:
1) Non-Weight Bearing - pt. is supine on fitting table while you exert a gentle, quasi-weight bearing force to the socket. Note patient's reaction to the increasing force, change in socket positions, get patient's feedback on what feels good/bad to him (no matter how off-the-wall his reactions are, investigate it.. he communicates differently). This would also be a good time to do a Thomas test/check for any hip contractures/tightness. At some point, you should also check leg length with patient in his prosthesis laying supine (and/or prone w/feet off end of fitting table) with your hands applying equal force to bottom of shoes; and
2) Weight Bearing - while (still) wearing only the inner socket, have him weight bear on a standing fixture in the parallel bars, with your hands firmly holding the socket in an alignment that feels comfortable to the patient. If he can stand comfortably, have his caregiver hold him in this position while you quickly mark a/p/l plumb lines on the socket and shoot a few a/p/l digital pictures. Remove socket, reinstall in frame/prosthesis, compare basic socket alignment to existing prosthesis (without patient in prosthesis). Again, shoot some digital pictures where ever you see something unusual/weird. Documentation is a wonderful thing for insurance companies.
#2 - To answer your questions:
a). Yes, a poorly fitting socket decreases the control of the prosthesis which puts the patient at risk of falling;
b). I hate locked knees, but this patient needs one for starters.. he's too afraid otherwise;
c). A hip joint w/pelvic band MIGHT prevent a hip fx. if this patient had radiation treatments around his hip joint (radiation can zap bone strength/integrity). However, most hip fractures occur in conjunction w/osteoporosis, a stationary foot, the pelvis rotating, femoral head snapping from the rotary force, and THEN the patient falls.
I like your suggested narrow ML, ischial containment with liner-lanyard system. Perhaps tighten the knee extension assist so the BAM of full knee extension can be heard and felt by the patient for security reasons. A TES suspension belt should be tried if patient has weak hip musculature and it may give proprioceptive input to the patient to feel more connected to his prosthesis. Lastly, mandatory physical therapy and home instructions/training for the staff working w/this gentleman. Everyone on the same page.
CPO
Citation
Rick Milen, “Replies to difficult AK case,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/227640.
