TF amp with lymphoedema
Orthopaedic Appliances Ltd
Description
Collection
Title:
TF amp with lymphoedema
Creator:
Orthopaedic Appliances Ltd
Date:
9/12/2011
Text:
Hi list
here are the replies to my question.
Original question
Dear list
I have a 35yo lady who had a transfemoral amputation 11 years ago due to severe lymphodema-congenital.
She ahs been well managed in a conventional suction socket. However over the 11 yrs the stump elongated to the point where the stump was 3longer than her existing knee. The bottom 5-6 was just fluid filled tissue. She has just had this revised and now the stump is supra-conylar in length which is the bone length.
My question is, what is the best socket design to minimise this recurring or is it inevitable it will recur?
I am thinking if an Ossur seal-in socket/silicon would help to contain it better? I am hessitant about this as I find that after some time of using them with early amputees or with the first few sockets that peoples stumps tend to narrow and elongate, which is exactly what we would like to try and avoid.
I am also thinking the evolution liner with the sealing sheath- this may be better as the seal can be made quite proximal on the socket.
Your thoughts, experiences and suggestions are welcome.
Many thanks
Andrew Cox
Prosthetist and Orthotist
Maybe I was not clear enough explaining. This lady (who is actually 40 not 35, boy time flies!) had severe malformation/malfunction of the lymph system. She travelled to the large lymph clinics in Europe for treatment but the strength of the lymphoedema and the interstitial pressure and the pressure of bandaging etc was so great and the stretching of the tissues also, that the blood supply to limb was affected and the limb became necrotic and had to be amputated. She understands her lymphoedema very well, works as a nurse and knows how to bandage properely. Whenever the limb is off the stump is bandaged otherwise it swells+++. So her thigh and her buttock on the amp side are still affected by lymphoedema and she has compression shorts to control the buttock swelling which continue down over the top of the socket.I can also assure you categorically that each socket was total contact and the correct length - there was no void. I beleive that the milking effect of the weight of the limb during stance slowly over time elongated the stump. I discussed with her the use of suspension straps to limit this affect but she was very reluctant to try.
I feel that a silicon with its little bit of compression and a proximal seal will be the best way to go for her.
I still beleive that whatever is done that the stump will most likely elongate over time again, this may be due to the prosthesis and also in part to when it is bandaged with the limb off. When a foot is present in a complete limb with lymphoedema there is a skeletal lock to stop the limb lengthening due to the swelling, this is not present in the transfem stump.
Many thanks for your replies
Andrew Cox
Prosthetist
-------------------------------------------------------------------------------------------------------------
The opposite of what you suggested. The tighter the fit to the stump, during the swing phase of walking, the more the limb will elongate. The best way would be to have the lightest leg possible to limit the milking forces during swing, as well as a waist belt. A flexible inner socket for room to expand in the thigh area so this will be lower pressure than the distal end. Thus, as the soft tissue (which is liquid at body temperature) will flow from higher pressure to lower pressure. By having higher pressure at the distal end, then, the lower pressure would be where the flexible inner socket allows expansion.
Agree in part, but concern with creating a mushroom at the top, also it is strong swelling and would not be contained adequately. She refuses to wear any waist straps etc so M-L stability would be a problem. Cannot get bony lock on tuber as her buttock is big and you cannot even palpate I.T.
-------------------------------------------------------------------------------------------------------------
total contact is the key. the stump can not elongate if it has no ware to go
True but that was what I thought, but the milking affect during swing occurs over time.
-------------------------------------------------------------------------------------------------------------
Conventional suction socket puts lot of stress on the amputation and if there is any lymphedema it leads to fluid accumulation and distal hypertrophy ( lengthening of soft tissue). This is a very easily controlled by a gel suction linerwith locking pin and similar suction suspensions. Gen suspensions do not elongate the amputation. They instead bring the tissue together and pressure they generate brings tissue tobether. There are literally half a dozen locking liners on the market and each one is as good as other. My preference is a silicone liner. Suspension is good and patient does not have to tug and pull on soft tissue. Paatient can don the liner like a sock and if [atoemt is over sensitive he can put a liner liner and if patients tends to be over sensitive the liner liner are silver impregnated and can avoid any skin infections. Stump elongation is not because of liner. It is because of poor distal shape of the socket. Sooner you learn to use this approach faster problems likes yous will become a history. Distal socket shape was always good and well contained thank you very much. Disagree in that a locking liner will most certainly put more of an elongation force on the stump especially at the distal end plus you lose rotational stability. Agree that conventional and having to pull in could be contributing to elongation hence my preference for a sealing silicon- but rolling on of silicon in itself does have a bit of an elongation element about too.
-------------------------------------------------------------------------------------------------------------------------------
Hi,
I think you are right to worry about doing the right thing. If the tissue is allowed to balloon with fluid then you will see the skin stretch out and watch the worst case scenario happen before you eyes.
The woman is only 35yrs. old mate, and needs full on attention. Contact her PT for exercises to firm up her limb for tone and strength. If her PT is not familiar with amputees then help her out with explaining the reasons for your interest in the long term wearing of your patients new limb. TENS stimulation will it work? Probably, but let the PT take that job. Can your patient end bear yet? Is she able to end bear wearing a decent and functional limb shrinker? End bear in a preliminary wrap cast?
Ossur showed us here in the U.S.A. how to manage better TC contact with elongation. It does not mean you have to use that advantage; since in your case it is not an advantage. So do not elongate, but lock in your anatomy and control the volume shifts in your socket design. A company here in the US called Coyote Designs has an external ring pad to fit external of the sleeve pin system if you are using a pin system. I do not think your patient wants more socket. Keep it simple and perhaps a external strap will do the trick., and with all the surface area you have a suction valve would keep it simple. You also have the option of a suction sock with a seal ring. I look forward to seeing your other suggestions, Do not htink any exercise etc will help due to her lymph situation.
--------------------------------------------------------------------------------------------------------------
Dear Mr cox,
The simple solution to your query is
Try custom made compression stump socks and fit the total contact socket
with or without silicon socket of any company its purely upto you.As per my
opinion Lymphoedema can not be treated with silicon/silicon socket. you
required the good custom made compression stockings to reduce lymphoedema .
fitting your patient with lymphoedema stockings you can think of any linear
you want of any company.
This is my experience of fitting prosthesis to the patients with
lymphoedema. we got good results with this pattern.
we do this from last 15 years.
please feel free for any inquiry.
Thanks
Regards
See above about the severity of her lymphoedema. Bandaging is the only thing for her. Shrinker would not work as well.
-------------------------------------------------------------------------------------------------------------
I would try a double walled socket made by velocity labs. Call them up to get details.
Zach Harvey, CPO
Not familiar with this but will look into it.
-----------------------------------------------------------------------------------------------------------
Evolution industries has recently released a liner, the Aura locking seal liner, that the hypobaric seal can be moved. By getting the seal more proximal I would think that it would be less likely to elongate. Evolution is in Orlando, FL and phone # is (888) 839-6213. Hope this helps. Call with any questions
Yes I think this is my preference. Silicon with a proximal seal seems theoretically the best way to go. And yes I met Craig when he came to Australia a couple of years back and I have a close working re;lationship with his distributer.
--------------------------------------------------------------------------------------------------------------
Please post responses. Excess redundant tissue presents to all
prosthetists from time to time.
See all above. I would not call it redundant as it not loose and floppy but was rather firm.
-----------------------------------------------------------------------------------------------
Many thanks for all your replies
Andrew Cox
Prosthetist
+oapl Health and Mobility Centre
Orthopaedic Appliances (Bendigo) Pty Ltd
PO Box 158
Golden Square Vic 3555
Ph: (03) 5441 4333
Fax: (03) 5441 6555
here are the replies to my question.
Original question
Dear list
I have a 35yo lady who had a transfemoral amputation 11 years ago due to severe lymphodema-congenital.
She ahs been well managed in a conventional suction socket. However over the 11 yrs the stump elongated to the point where the stump was 3longer than her existing knee. The bottom 5-6 was just fluid filled tissue. She has just had this revised and now the stump is supra-conylar in length which is the bone length.
My question is, what is the best socket design to minimise this recurring or is it inevitable it will recur?
I am thinking if an Ossur seal-in socket/silicon would help to contain it better? I am hessitant about this as I find that after some time of using them with early amputees or with the first few sockets that peoples stumps tend to narrow and elongate, which is exactly what we would like to try and avoid.
I am also thinking the evolution liner with the sealing sheath- this may be better as the seal can be made quite proximal on the socket.
Your thoughts, experiences and suggestions are welcome.
Many thanks
Andrew Cox
Prosthetist and Orthotist
Maybe I was not clear enough explaining. This lady (who is actually 40 not 35, boy time flies!) had severe malformation/malfunction of the lymph system. She travelled to the large lymph clinics in Europe for treatment but the strength of the lymphoedema and the interstitial pressure and the pressure of bandaging etc was so great and the stretching of the tissues also, that the blood supply to limb was affected and the limb became necrotic and had to be amputated. She understands her lymphoedema very well, works as a nurse and knows how to bandage properely. Whenever the limb is off the stump is bandaged otherwise it swells+++. So her thigh and her buttock on the amp side are still affected by lymphoedema and she has compression shorts to control the buttock swelling which continue down over the top of the socket.I can also assure you categorically that each socket was total contact and the correct length - there was no void. I beleive that the milking effect of the weight of the limb during stance slowly over time elongated the stump. I discussed with her the use of suspension straps to limit this affect but she was very reluctant to try.
I feel that a silicon with its little bit of compression and a proximal seal will be the best way to go for her.
I still beleive that whatever is done that the stump will most likely elongate over time again, this may be due to the prosthesis and also in part to when it is bandaged with the limb off. When a foot is present in a complete limb with lymphoedema there is a skeletal lock to stop the limb lengthening due to the swelling, this is not present in the transfem stump.
Many thanks for your replies
Andrew Cox
Prosthetist
-------------------------------------------------------------------------------------------------------------
The opposite of what you suggested. The tighter the fit to the stump, during the swing phase of walking, the more the limb will elongate. The best way would be to have the lightest leg possible to limit the milking forces during swing, as well as a waist belt. A flexible inner socket for room to expand in the thigh area so this will be lower pressure than the distal end. Thus, as the soft tissue (which is liquid at body temperature) will flow from higher pressure to lower pressure. By having higher pressure at the distal end, then, the lower pressure would be where the flexible inner socket allows expansion.
Agree in part, but concern with creating a mushroom at the top, also it is strong swelling and would not be contained adequately. She refuses to wear any waist straps etc so M-L stability would be a problem. Cannot get bony lock on tuber as her buttock is big and you cannot even palpate I.T.
-------------------------------------------------------------------------------------------------------------
total contact is the key. the stump can not elongate if it has no ware to go
True but that was what I thought, but the milking affect during swing occurs over time.
-------------------------------------------------------------------------------------------------------------
Conventional suction socket puts lot of stress on the amputation and if there is any lymphedema it leads to fluid accumulation and distal hypertrophy ( lengthening of soft tissue). This is a very easily controlled by a gel suction linerwith locking pin and similar suction suspensions. Gen suspensions do not elongate the amputation. They instead bring the tissue together and pressure they generate brings tissue tobether. There are literally half a dozen locking liners on the market and each one is as good as other. My preference is a silicone liner. Suspension is good and patient does not have to tug and pull on soft tissue. Paatient can don the liner like a sock and if [atoemt is over sensitive he can put a liner liner and if patients tends to be over sensitive the liner liner are silver impregnated and can avoid any skin infections. Stump elongation is not because of liner. It is because of poor distal shape of the socket. Sooner you learn to use this approach faster problems likes yous will become a history. Distal socket shape was always good and well contained thank you very much. Disagree in that a locking liner will most certainly put more of an elongation force on the stump especially at the distal end plus you lose rotational stability. Agree that conventional and having to pull in could be contributing to elongation hence my preference for a sealing silicon- but rolling on of silicon in itself does have a bit of an elongation element about too.
-------------------------------------------------------------------------------------------------------------------------------
Hi,
I think you are right to worry about doing the right thing. If the tissue is allowed to balloon with fluid then you will see the skin stretch out and watch the worst case scenario happen before you eyes.
The woman is only 35yrs. old mate, and needs full on attention. Contact her PT for exercises to firm up her limb for tone and strength. If her PT is not familiar with amputees then help her out with explaining the reasons for your interest in the long term wearing of your patients new limb. TENS stimulation will it work? Probably, but let the PT take that job. Can your patient end bear yet? Is she able to end bear wearing a decent and functional limb shrinker? End bear in a preliminary wrap cast?
Ossur showed us here in the U.S.A. how to manage better TC contact with elongation. It does not mean you have to use that advantage; since in your case it is not an advantage. So do not elongate, but lock in your anatomy and control the volume shifts in your socket design. A company here in the US called Coyote Designs has an external ring pad to fit external of the sleeve pin system if you are using a pin system. I do not think your patient wants more socket. Keep it simple and perhaps a external strap will do the trick., and with all the surface area you have a suction valve would keep it simple. You also have the option of a suction sock with a seal ring. I look forward to seeing your other suggestions, Do not htink any exercise etc will help due to her lymph situation.
--------------------------------------------------------------------------------------------------------------
Dear Mr cox,
The simple solution to your query is
Try custom made compression stump socks and fit the total contact socket
with or without silicon socket of any company its purely upto you.As per my
opinion Lymphoedema can not be treated with silicon/silicon socket. you
required the good custom made compression stockings to reduce lymphoedema .
fitting your patient with lymphoedema stockings you can think of any linear
you want of any company.
This is my experience of fitting prosthesis to the patients with
lymphoedema. we got good results with this pattern.
we do this from last 15 years.
please feel free for any inquiry.
Thanks
Regards
See above about the severity of her lymphoedema. Bandaging is the only thing for her. Shrinker would not work as well.
-------------------------------------------------------------------------------------------------------------
I would try a double walled socket made by velocity labs. Call them up to get details.
Zach Harvey, CPO
Not familiar with this but will look into it.
-----------------------------------------------------------------------------------------------------------
Evolution industries has recently released a liner, the Aura locking seal liner, that the hypobaric seal can be moved. By getting the seal more proximal I would think that it would be less likely to elongate. Evolution is in Orlando, FL and phone # is (888) 839-6213. Hope this helps. Call with any questions
Yes I think this is my preference. Silicon with a proximal seal seems theoretically the best way to go. And yes I met Craig when he came to Australia a couple of years back and I have a close working re;lationship with his distributer.
--------------------------------------------------------------------------------------------------------------
Please post responses. Excess redundant tissue presents to all
prosthetists from time to time.
See all above. I would not call it redundant as it not loose and floppy but was rather firm.
-----------------------------------------------------------------------------------------------
Many thanks for all your replies
Andrew Cox
Prosthetist
+oapl Health and Mobility Centre
Orthopaedic Appliances (Bendigo) Pty Ltd
PO Box 158
Golden Square Vic 3555
Ph: (03) 5441 4333
Fax: (03) 5441 6555
Citation
Orthopaedic Appliances Ltd, “TF amp with lymphoedema,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/232992.
