Responses to liners and new amputees

Responses to liners and new amputees

Schafer, Kristin

7/30/2010

Firstly, thank you all so much for your guidance. I am the sole
prosthetist where I work and rely on your kind advice often. Thanks Paul
P. for providing this forum. Here are the responses.... (Oh and to all
the Canadians out there, have a great long weekend!!!)

I would be especially leary of the 5 ring version Seal-in for a new
amputee, especially If you expect significant volumetric change. In my
experience it is hard to predict the degree of future changes. If he is
really compliant with his stump shrinkers and is tightly fitted with
30-40 compression, sometimes you don't see much change at all with a
good AKA. If you want to do suction and want to stay away from lanyards
or pins, then I would suggest you use the older style Seal-in; socks are
easier to use, and more effective with the older, single ring version.
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I use original seal in liners a whole lot on my preparatory Px. I do
choose my patients carefully though. I also make the sure the limb is
well healed and the patient must wear a shrinker for two weeks minimum
prior to casting. If I see a drastic reduction, I will go with a smaller
shrinker for two more weeks. The uppper 2/3 socks work well as does
adding pads to neccessary countours of the socket to snug up. I also can
add full socks between the flexible inner socket and the frame up to
about 3 or 4 ply usually. Your younger more muscular patients tend to
fair better. You do have to be carefull and really take a look at your
tension values, I usaually error on the side of being a little snuger
than usually to start with, knowing they will shrink some soon. I have
also found letting the patient wear the liner home for a week or two can
also serve as a very good shrinker on your larger patients. I have done
many sockets this way and have really good results thus far. However, in
one or two instances, I casted to early and ended up eating an extra
test socket due to volume loss in the early stages.

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I have used the TF Sealin X5 on both new/old amputees. Pt outcomes have
been great. New pt are always going to shrink down, what matters is
intimate fit, function, and progression.

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I notice you use the word preparatory in your question. With the
interchangeability of sockets, knees and feet I find in unnecessary to
build preparatory prosthesis and just build what they need from the
start. In the US we have socket replacement codes that let us bill for a
replacement 6 months or more down the road that covers the need to do
another fitting. The US L-code system does not let us use additional
items to the prep so it makes more sense to just start with a permanent
prosthesis.
The suction fitting of a new AK is common and the different liners makes
great sense for a new AK. You can start with a 3 mm liner and when
shrinkage occurs you can switch to a 6 mm liner. Just something to think
about.
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I see no problems with the application you're inquiring about. I've used
Seal-In Liners on preps for some of my more ideal TF patients and it's
worked well. Bear in mind that once you move to a definitive design
chances are you'll need to adjust for a reduction in volume but for the
time being using socks should be adequate. You may end up padding
proximally at a later time while your patient is still in the prep but
as I said you can accommodate those changes in the definitive. If he/she
is standing for long periods the distal cushion should add to their
comfort and I've found that (especially with long TF's) that you can
move the trim lines distal to the ischium if they have good muscle
structure. One last note...when fabricating, make sure you don't use a
seamed thermal plastic socket of any kind-this will only frustrate you
while fitting and if you use a laminated prep socket use the shiny
surface of the PVA bag for the inner surface of the socket to get even
better suspension. I hope this helps and good luck.
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I would not use a seal-in liner for someone who will be atrophying
quickly as there are only so many socks you can use before you will
loose suction. If they are long and cannot use a pin system, how about
KISS system which will be very secure and you can sock away as needed.

Just my $.02.
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I have used seal in liners several times on a new TF pt and have had
good success. I would have them wear the seal in liner for at least one
to two weeks. The seal in liner itself will produce more compression
than most shrinkers and will cause some volume loss even before
prosthetic fitting. Send them home with a tape measure and have them
monitor their change. This is easy to do if you use the 5x liner because
it is easy to take the measurements in the same spot consistently. Socks
do not work well most of the time, they work better with the original
seal in liner than with the 5x. You can add padding between the proflex
inner liner and the socket if you use an inner liner.
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Suction socket is best used with the ideal limb that is stable in volumn
and health. I still believe that it is best if constructed properly.
That means just enough pressure to induce positive arterial without
conjestion. And then unimpinged negative veinous return. This is
optained by distal 1/3 address properly. This thought can be used with
sealin liner.
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Maybe you can use the thinnest liner, and as patient shrinks, go the a
thicker liner with socks later.
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I use a 3-s pin and lock (Iceross comfort locking liner,ect)and use the
socks with a Hole in them. This works very well and they can adjust the
fit, and still have great Suspension.
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I have been using the seal ins on most AK interims and our success rate
has been fantastic. The system is far more functional than conventional
designs. Patients ambulate quicker, their rehab time is shorter, their
mobilty is far advanced and the usage post discharge is improved and the
discard rate is far lower.
I suggest try it on one then another and see the outcome difference. I
have found that the socket replacement rate for them is no more than for
conventional. Actually casting is easier as the liner holds and controls
the tissues and i find the fitting of them quite easy.
I was concerned initally about a suction on vascular amps but there
have been no issues and the silicon actually offers more protection to
the skin than socks. Patient comfort is also much improved.
Do it and you won't look back.
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Elevated vacuum, Elevated vacuum will speed up the volume reduction.You
will have to keep him in a diagnostic socket for about 3weeks or
more.Typically with a new Pt. I change diagnostic sockets 3x every
2weeks to accommodate volume reduction.Then fit the definative.If you
would like to discuss this procedure feel free to email me @
<Email Address Redacted> We uuse the limb logic system. Pt.s love the fit
&& function and improved proprioception. Reimbursement is also very
good.
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My experience at [my facility] has been that most shrink one size liner
after a month or two. However, a distal gel cup helps buy time. My
advise would be to supply one liner initially then order a second one at
a later date.
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According to Ossur it will hold up suction up to 6 ply of socks. After
that you need a socket replacement
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You should be able to start your surgeon patient on a Seal-In liner, and
as (or if) his limb shrinks you can supplement first with an ALPS Skin
Reliever Gel Sock of appropriate size, and then if something thicker is
needed, the ALPS Full Suction Liner: <URL Redacted>

He will just roll the Seal-In liner over the supplemental liner. You
still have the option of tweaking the fit with Ossur socks that are
designed for the Seal-In liner exterior.

This should take him through his first year reasonably well. There is
of course a little more hassle with the extra liner, but he will only
have to wash the material that is against his skin. Good luck
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I have had good success with using the Ossur hypobaric seal in liner on
new amputees for trans-femoral patients. I use a hand casting technique,
narrow ml design and flexible inner socket with rigid frame. I do try to
have the patient in a shrinker for 2 weeks. I may send them home in a
10mm thick check socket to verify the suspension and fit prior to
completion. The fit can be tightened by placing a leather pad between
flex socket and rigid frame.
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Use the Seal In Liner and replace the liners and sockets as he atrophies
as needed.
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I think either solution can work, depends on what the Patient will
tolerate for re-fittings and futzing the socket. As long as the edema
is not horrendous nor other complications, I would do the seal in IF
the patient will be tolerant of changes and perhaps lots of visits to
you. Also, can you keep up with re-fabrications and other tech work to
keep this higher performing system up and running.
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In my opinion suction suspension should always be considered first. AK
or Bk. If you're not using a liner manage atrophy with pads. Yes it is a
pain in the butt, but worth it for your patient. If you are going to use
a liner with a seal, manage atrophy with a non fabric liner under the
gel liner not socks. Alps make good cheap non-skined liners. The 3mm is
tapered. It's called the Skin Reliever product # encp. The 6mm is the
Full Suction Liner product #FSL.
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We have been fitting AK's with Otto Bock measured sockets which are
nearly perfect every time. The socket is intended for suction
immediately but it doesn't always work out this way. I use Silipos
distal liners or Alps clear liner liners to establish initial suction on
a new amputee and add socks as needed to maintain a snug fit. If by
using a sock you compromise suction then we add a TES belt for secondary
suspension.
Within a few weeks of doing this significant atrophy occurs, then we
measure the patient for a seal in liner. The nice thing about the
Silpos and Alps products we used initially is that they can be reused
under the seal in liner to accommodate the continued atropy and maintain
the liner snugness on the client as well as a snug suction socket fit.
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I would check if billing a prepratory code. Some insurances will not
cover a suction socket on a prep leg.
Your seal in idea leaves a very small area to obtain suction. further,
that is where most are bulbous and shrink the most after a surgery.

--------------------------- That's all folks! Thanks again.







Kristin Schafer, B.Sc. (Kin.), C.P. (c)
Rehabilitation Engineering
Sudbury Regional Hospital- Laurentian Site
41 Ramsey Lake Rd.
Sudbury, ON
P3E 5J1
(705) 523-7100 x3176