'BK prosthesis ideas for extremely fragile skin' responses
Musicus, Marina
Description
Collection
Title:
'BK prosthesis ideas for extremely fragile skin' responses
Creator:
Musicus, Marina
Date:
12/31/2012
Text:
Hi list,
Thank you for all the good ideas you sent in regards to my patient. We had her try a liner with a nylon sheath underneath: that didn't work. We are currently trying her in a winter's gel liner. Your ideas will certainly be taken into consideration as we move forward with her care. I'm currently looking into using elevated vacuum- my only concern is that any volume reduction or void in the socket will cause her skin layers to pull away from each other and deglove. I talked to Otto Bock, didn't really get a straight answer. It may just be something we have to try and find out! I'll be sure to post any successes.
Marina Musicus
Original message:
I am currently seeing a patient who has a genetic condition called epidermolysis bullosa, which causes skin blistering and breakdown in response to any pressure or shear force. She recently underwent a transtibial amputation due to a melanoma on her heel caused by repeated skin breakdown.
We started her out in an alpha locking liner, which worked well at first, but as soon as she washed the liner a few times it started to rub on her skin and caused massive blistering. After wearing the prosthesis in physical therapy for 2 sessions her entire residual limb was covered in open bleeding blisters. We switched her to an Iceross dermo liner with no change in skin condition. We are currently trying the iceross dermo with a plastazote liner and 5 ply sock with pin suspension to try to move the shear force away from the skin.
I'm looking for any ideas or experience you may have in dealing with patients with this condition or any condition that causes very fragile skin. The patient understands she may not be able to be on a prosthesis all the time but she lives in a four story house and absolutely hates using her wheelchair. I also have to emphasize the point that there are really no areas on her body that will not break down under shear force or pressure.
Responses:
* I think the best idea would be to use a system that minimizes pistoning. 3s systems inherently have a lot of pistoning. Consider switching her to a VASS system with a custom gel liner. The custom gel liner will intimately fit her limb. Use of a VASS system has been shown to significantly reduce pistoning. The higher the vacuum pulled shows better results in proprioception, decreased pistoning, and anecdotally it can influence wound healing. I would think a harmony style system with a mechanical pump and a carefully modified socket such that she is close to a sheath only fit would be the best indication. The harmony pump will reduce forces translated onto her limb and the elevated VASS will create socket environment that limits pistoning. I would follow the harmony mods exactly presented by ottobock if you have not done one before. Also consider reinforcing the tibial cut end and fibular head with extra thickness gel in the custom liner.
* IS not the liner but the friction between the liner and the skin. I found help by using saran wrap the one from Costco works great. Have patient clean her limb and applied the wrap before the liner. It protects the skin and prevents friction. Its an easy test hope it works.
* Worse case but something I have try but its out of the box. Have the patient applied pure nonpasteurized honey like if it was cream all over and put the wrap over it. It works but it sounds crazy. It seals the blisters and keeps the wrap in place to prevent any friction.
* I have fit a short trans femoral with this condition. It is a very tough fit. We ultimately did not use a silicone liner even though we started with one and it seems the most logical course. If i remember right he used socks and a TES belt and the belt gave him more problems than the socket. It has been a couple years since I fit him and didn't pull his chart. Socks and a hard socket seem to be what I remember. Silicone seems like the best idea however it didn't work. I think it was the heat and moisture.
* Get away from the pin. Go with a suspension sleeve. I haven't tried to resolve this problem with a seal in liner, but getting the suspension away from the distal end and up at the thigh will help a lot. I'd also suggest a liner with a lot of stretch to it, like...Alpha spirit. Have her put a cream on and then don the liner. I'd look to cut down on skin tension as much as possible.
* Total surface socket design and wet fluid fit. A and D ointment, silicone etc.. Custom liners may be needed. Full motion liners (no fabric covering) may be needed. Fit needs to be closely monitored by the drive of material out of the socket. Suspension winds up being the next challenge, but is generally less stressful on skin.
* PeLite liner, sock fit, and get her silver socks, waist belt and pickup billet. Surprise. Sometimes, old ways work the best.
* Perhaps coating the skin with a light layer of baby oil ( mineral oil) prior to donning the Alpha liner may prevent or delay the blistering, etc.
* I haven't fit somebody with this condition but I would advise trying to take her out of a pin system because the pulling can cause excess force and irritation in any patient with sensitive skin. Does the liner cause these issues if she wears it without the prosthesis on? If so you may have to look at a non-liner option. My patients with eczema and psoriasis (which may have no relation at all) find that it sometimes gets worse with a liner than without. Try a silicone liner with grease spread around the limb in the areas covered by the socket. The thigh section needs to remain dry to prevent the liner from sliding off. This combination works well for my own leg which is completely covered in grafts that break down easily.
* A and D ointment works well, but I prefer Bag Balm due to its higher melting temperature.
* I would consider an elevated vacuum socket system. When done properly very little, if any, shear force will be directed to the skin. Also, if done properly, there should be no risk of blistering.
* Have you tried reducing the torque outside of the socket? Try adding a torque absorber as close to the distal end of the socket possible.
Elevated vacuum or suction in conjunction with the TEC liner might not be a bad idea either. TEC liners are urethane and have a unique property in that they can flow under pressure. Otto Bock uses these types of liners with their Harmony system.
* Have you considered vacuum? I would use a custom Polyurethane liner. Stay away from any pin system, it's near impossible to prevent shear forces unless a sleeve is used. A good suction fit with a true custom liner would be my only other recommendation .
* While I have never seen this particular condition, I have had a number of TT patients with very fragile skin, most commonly from burns or degloving injuries. I have had good success with ischial-weight-bearing prostheses, although I have had a few patients who have taken a wheelchair or crutches over one of them, largely due to weight and/or cosmesis. The advantage is that you can use the BK section for knee control only, and move the weight bearing proximally, or at least substantially reduce it distally.
* You may be better off going pelite insert with sock fit if vacuum won't work. The iceross liner is a source of friction in of it's self. If they could not handle TPE, silicone will eat them alive. Urethane relaxes once donned. The plastizote is going to pack out and with the 5 ply and a liner you are going to end up with pistoning I would think.
* I don't have any experience working with patients with epidermolysis bullosa but may be able to help explain why the liners you have previously used on this patient have failed to work for an extended period of time. Most extremely soft gel liners, including Alpha Liners are made out of Thermoplastic Elastomer(TPE) which is usually combined with mineral oil or some other skin softening agent that is not chemically bound to the molecular structure of TPE. This means that when the liner is emitting skin softening agents it is actually losing mass and subsequently liner wall thickness. This causes two issues that may be critical to your case: 1. When mineral oil leaves the TPE gel, it leaves behind open microscopic voids that can trap sweat solids and even soap from washing which can in turn irritate the skin and 2. When you are losing mass (mineral oil) you are losing liner thickness which effectively makes the socket larger as the liner wall continues to thin resulting in compromised fit. The same scenario applies with the Iceross Dermo which is Silicone combined with petroleum jelly and dimethicone which is commonly found in lotions. Great for conditioning the skin, but not so good when it leaves the liner. It may sound counter-intuitive, but you may consider using a more pure and more firm silicone liner such as the Iceross Comfort Plus or a Evolution Origin Liner from Evolution Industries. Incorporating the use of a hypoallergenic lotion for skin lubrication will cut down on the shear from the firmer material. Since high pressure and shear are a concern, maybe try a Total Surface Bearing socket design with sealing/suspension sleeve and one-way valve. You can even incorporate a airtight shuttle lock design if that is preferred suspension method. There are air tight locks available from PDI (EVLS) and Coyote (Air Lock). Next to elevated vacuum, we have found this to be the best fitting technique to stop intra-socket motion.
* How about a sheath or a knit rite liner-liner sock between the skin and the gel liner?
* I wonder if you would consider a TEC socket with passive suction?
* I have no experience using it but the first thing that comes to mind is one of the Freedom liners that has a low coefficient of friction against the skin (not tacky).
* I would get away from the pin and try switching to suction seal or vacuum. The elevated negative pressure value can be fairly low and still eliminate any excess movement between the residual limb and socket. I would consider the harmony system but I would ask them about the lubricating agent that may be most appropriate. You also have to be careful if you have never tried vacuum before because a poorly fitting vacuum socket will not work regardless of skin integrity.
* You could try Winter's Gel through SPS. I have not used it but supposedly it is good for ultra sensitive skin. I think it tends to stick to the skin better so there is no movement/friction over the surface. Let me know if you try it or if it works.
* Also a possibility: Vac-Pin system.
Thank you for all the good ideas you sent in regards to my patient. We had her try a liner with a nylon sheath underneath: that didn't work. We are currently trying her in a winter's gel liner. Your ideas will certainly be taken into consideration as we move forward with her care. I'm currently looking into using elevated vacuum- my only concern is that any volume reduction or void in the socket will cause her skin layers to pull away from each other and deglove. I talked to Otto Bock, didn't really get a straight answer. It may just be something we have to try and find out! I'll be sure to post any successes.
Marina Musicus
Original message:
I am currently seeing a patient who has a genetic condition called epidermolysis bullosa, which causes skin blistering and breakdown in response to any pressure or shear force. She recently underwent a transtibial amputation due to a melanoma on her heel caused by repeated skin breakdown.
We started her out in an alpha locking liner, which worked well at first, but as soon as she washed the liner a few times it started to rub on her skin and caused massive blistering. After wearing the prosthesis in physical therapy for 2 sessions her entire residual limb was covered in open bleeding blisters. We switched her to an Iceross dermo liner with no change in skin condition. We are currently trying the iceross dermo with a plastazote liner and 5 ply sock with pin suspension to try to move the shear force away from the skin.
I'm looking for any ideas or experience you may have in dealing with patients with this condition or any condition that causes very fragile skin. The patient understands she may not be able to be on a prosthesis all the time but she lives in a four story house and absolutely hates using her wheelchair. I also have to emphasize the point that there are really no areas on her body that will not break down under shear force or pressure.
Responses:
* I think the best idea would be to use a system that minimizes pistoning. 3s systems inherently have a lot of pistoning. Consider switching her to a VASS system with a custom gel liner. The custom gel liner will intimately fit her limb. Use of a VASS system has been shown to significantly reduce pistoning. The higher the vacuum pulled shows better results in proprioception, decreased pistoning, and anecdotally it can influence wound healing. I would think a harmony style system with a mechanical pump and a carefully modified socket such that she is close to a sheath only fit would be the best indication. The harmony pump will reduce forces translated onto her limb and the elevated VASS will create socket environment that limits pistoning. I would follow the harmony mods exactly presented by ottobock if you have not done one before. Also consider reinforcing the tibial cut end and fibular head with extra thickness gel in the custom liner.
* IS not the liner but the friction between the liner and the skin. I found help by using saran wrap the one from Costco works great. Have patient clean her limb and applied the wrap before the liner. It protects the skin and prevents friction. Its an easy test hope it works.
* Worse case but something I have try but its out of the box. Have the patient applied pure nonpasteurized honey like if it was cream all over and put the wrap over it. It works but it sounds crazy. It seals the blisters and keeps the wrap in place to prevent any friction.
* I have fit a short trans femoral with this condition. It is a very tough fit. We ultimately did not use a silicone liner even though we started with one and it seems the most logical course. If i remember right he used socks and a TES belt and the belt gave him more problems than the socket. It has been a couple years since I fit him and didn't pull his chart. Socks and a hard socket seem to be what I remember. Silicone seems like the best idea however it didn't work. I think it was the heat and moisture.
* Get away from the pin. Go with a suspension sleeve. I haven't tried to resolve this problem with a seal in liner, but getting the suspension away from the distal end and up at the thigh will help a lot. I'd also suggest a liner with a lot of stretch to it, like...Alpha spirit. Have her put a cream on and then don the liner. I'd look to cut down on skin tension as much as possible.
* Total surface socket design and wet fluid fit. A and D ointment, silicone etc.. Custom liners may be needed. Full motion liners (no fabric covering) may be needed. Fit needs to be closely monitored by the drive of material out of the socket. Suspension winds up being the next challenge, but is generally less stressful on skin.
* PeLite liner, sock fit, and get her silver socks, waist belt and pickup billet. Surprise. Sometimes, old ways work the best.
* Perhaps coating the skin with a light layer of baby oil ( mineral oil) prior to donning the Alpha liner may prevent or delay the blistering, etc.
* I haven't fit somebody with this condition but I would advise trying to take her out of a pin system because the pulling can cause excess force and irritation in any patient with sensitive skin. Does the liner cause these issues if she wears it without the prosthesis on? If so you may have to look at a non-liner option. My patients with eczema and psoriasis (which may have no relation at all) find that it sometimes gets worse with a liner than without. Try a silicone liner with grease spread around the limb in the areas covered by the socket. The thigh section needs to remain dry to prevent the liner from sliding off. This combination works well for my own leg which is completely covered in grafts that break down easily.
* A and D ointment works well, but I prefer Bag Balm due to its higher melting temperature.
* I would consider an elevated vacuum socket system. When done properly very little, if any, shear force will be directed to the skin. Also, if done properly, there should be no risk of blistering.
* Have you tried reducing the torque outside of the socket? Try adding a torque absorber as close to the distal end of the socket possible.
Elevated vacuum or suction in conjunction with the TEC liner might not be a bad idea either. TEC liners are urethane and have a unique property in that they can flow under pressure. Otto Bock uses these types of liners with their Harmony system.
* Have you considered vacuum? I would use a custom Polyurethane liner. Stay away from any pin system, it's near impossible to prevent shear forces unless a sleeve is used. A good suction fit with a true custom liner would be my only other recommendation .
* While I have never seen this particular condition, I have had a number of TT patients with very fragile skin, most commonly from burns or degloving injuries. I have had good success with ischial-weight-bearing prostheses, although I have had a few patients who have taken a wheelchair or crutches over one of them, largely due to weight and/or cosmesis. The advantage is that you can use the BK section for knee control only, and move the weight bearing proximally, or at least substantially reduce it distally.
* You may be better off going pelite insert with sock fit if vacuum won't work. The iceross liner is a source of friction in of it's self. If they could not handle TPE, silicone will eat them alive. Urethane relaxes once donned. The plastizote is going to pack out and with the 5 ply and a liner you are going to end up with pistoning I would think.
* I don't have any experience working with patients with epidermolysis bullosa but may be able to help explain why the liners you have previously used on this patient have failed to work for an extended period of time. Most extremely soft gel liners, including Alpha Liners are made out of Thermoplastic Elastomer(TPE) which is usually combined with mineral oil or some other skin softening agent that is not chemically bound to the molecular structure of TPE. This means that when the liner is emitting skin softening agents it is actually losing mass and subsequently liner wall thickness. This causes two issues that may be critical to your case: 1. When mineral oil leaves the TPE gel, it leaves behind open microscopic voids that can trap sweat solids and even soap from washing which can in turn irritate the skin and 2. When you are losing mass (mineral oil) you are losing liner thickness which effectively makes the socket larger as the liner wall continues to thin resulting in compromised fit. The same scenario applies with the Iceross Dermo which is Silicone combined with petroleum jelly and dimethicone which is commonly found in lotions. Great for conditioning the skin, but not so good when it leaves the liner. It may sound counter-intuitive, but you may consider using a more pure and more firm silicone liner such as the Iceross Comfort Plus or a Evolution Origin Liner from Evolution Industries. Incorporating the use of a hypoallergenic lotion for skin lubrication will cut down on the shear from the firmer material. Since high pressure and shear are a concern, maybe try a Total Surface Bearing socket design with sealing/suspension sleeve and one-way valve. You can even incorporate a airtight shuttle lock design if that is preferred suspension method. There are air tight locks available from PDI (EVLS) and Coyote (Air Lock). Next to elevated vacuum, we have found this to be the best fitting technique to stop intra-socket motion.
* How about a sheath or a knit rite liner-liner sock between the skin and the gel liner?
* I wonder if you would consider a TEC socket with passive suction?
* I have no experience using it but the first thing that comes to mind is one of the Freedom liners that has a low coefficient of friction against the skin (not tacky).
* I would get away from the pin and try switching to suction seal or vacuum. The elevated negative pressure value can be fairly low and still eliminate any excess movement between the residual limb and socket. I would consider the harmony system but I would ask them about the lubricating agent that may be most appropriate. You also have to be careful if you have never tried vacuum before because a poorly fitting vacuum socket will not work regardless of skin integrity.
* You could try Winter's Gel through SPS. I have not used it but supposedly it is good for ultra sensitive skin. I think it tends to stick to the skin better so there is no movement/friction over the surface. Let me know if you try it or if it works.
* Also a possibility: Vac-Pin system.
Citation
Musicus, Marina, “'BK prosthesis ideas for extremely fragile skin' responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed April 29, 2024, https://library.drfop.org/items/show/234343.
