Thursday, December 1, 2022

Responses to query about managing a fleshy transfemoral residual limb

Harry Phillips

Thanks for the many and varied responses. I am still making up my mind
as to what to do. Here is my original query with the responses
separated by asterisks:

> I have been working with a woman who presents with bilateral
> transfemoral amputations that were the result of a MVA in 1995. She
has
> been doing well on stubbies-improving her strength and ROM through
> strenuous PT and exercise. Of equal importance, she has lost a
> significant amount of weight reducing from 215 lbs to 185lbs. She is
in
> modified MAS sockets with suspension/cushioning from OWW Alpha AK
> Locking liners (extra Large) and KISS strap suspension.
>
> She has had an ongoing problem with donning the suction suspension
> liners on her very fleshy residual limbs. This problem has gotten
worse
> as she has lost weight and volume and the residual limbs have become
> softer and the soft tissue more mobile. (Prior to the Alpha liners,
she
> was wearing Ossur seal-in liners that were even more difficult for her
> to don).
>
> At this point she needs to be refit due to volume loss, and I am
> soliciting suggestions for alternative liners that might make donning
> easier than her present 20-30 minute ordeal of trying to corral her
soft
> tissue within the reflected liner and then rolling the liner on.

Have you tried putting on a juzo shrinker first, and have the shrinker
act similar to a liner-liner, or try a tight liner-liner first, and then
putting on the gel liner?

I have he success with the Alps FSL liners. You need to use the spray
they make for it to roll on, but even on a patient with distal circ over
50cm and fleshy distal ends, it has been relatively easier for most. The
nice thing is that they stretch enough to reflect over the top edge of
the socket for pt. comfort. You must use a sheath or sock for distal 1/2
to 1/3 to allow air to wick out the valve.

Otto Bock has reintroduced the ring seal or gasket seal in for
suspension. This concept allows the patient to have volume change and
still maintain suction. I have used wet fits to donn this style of
suction and had good success with very short limbs.

The other option is sub ischial sockets with vacuum assist with or
without liners. There are 2 different bilaterals here in Minnesota
wearing that style of leg. One uses liners and one does not.

Hi Harry, Trace from Las Vegas. I use a Medi relax tf/tfc liner for
fleshy residuums with good success.Available in standard tf and conical
tfc profiles hope this helps.

Try Alps AK liner. High degree of circumferencial elasticity but very
little vertical elongation. The larger the distal umbrella the better.

arry, have you thought of eliminating the liners all together and have
her donn suction sockets with a VASS system?

What about suction socket, skin fit w/ drylite lotion?

Try PVC 6″ pipe material.

You should inquire of patient if she would be willing to undergo skin
reduction surgery, via a plastic surgeon. This would remove all the
loose tissue and make donning manageable and increase her control of
prostheses. This type surgery is usually elective, but because she uses
prostheses and can document difficulty donning a good case can be made
for being medically necessary. Would need to work with her rehab Dr,
plastic surgeon, PT (to document weight loss and donning problems, and
your input.

Try evolution, you can use it with the aura sealing sock. It has worked
well for me in the past and the liners are easy to slide on. I use only
Medi liners for locking AK’s as they are very thin and easy to manage.
Please email me with any questions.

Over the years I have had patients with the same problem. I never tried
this bit it just occurred to me. Maybe if you made thin poly ethelene
sockets that she wet fit with a hole in the bottom to let out the air.
Then she could roll on some liners to a stable limb as long as the
liners went over the top edge of the thin socket.

Just a thought,

Presently working with a similar case. Former OWW liners are tough for
her to use. I’m trying out Evolution liners (Origin Liners) that have a
silk covering. Give them a call. They were very helpful. Also changing
her over from the KISS system to the Aura Locking Seal using an
electronic vacuum system. My patient is a long AK with excessive
lymphatic tissue, short femur, and over 8″ of excess tissue past her
femur. We are still in the check socket phase, but the liner is much
easier to donn.

We’ve had great success using Otto Bock’s 6Y85 transfemoral liners for
fleshy residual limbs. The OB TF liners have great structural integrity
and also slide easily on themselves when inverted. The Velcro KISS
proximal placards also nicely adhere to the liners.

Alps liners are a lot more stretchy and easier to donn. I have used
them with fleshy AK’s with success. The pt number is AKDT then the size.
They are available in 3 and 6 mm. I’d go with 3 mm and try and fit them
as tight as you can to stabilize the tissue.

Possibly try 6y80 locking liner. Had a larger umbrella and firms up soft
tissue well with minimal elongation. Evolution liner b/c of no fabric is
easier to donn but possibly another option. Hope this helps.

As far as liners go the otto bock TF liner is great. Almost no
elongation and the distal umbrella is size appropriate in reference to
the distal limb size. This makes donning easier. The liner really
firms the tissue as well once it is rolled on. The kiss placard sticks
well to the cloth as well. However you may let the pt wear one for a
while (before getting prosthesis) to allow her skin to get use to it.

The durometer is more firm than the ones you have been using. Sometimes
the firm durometer can cause blisters from skin tension. Good luck.

Unfortunately you will most likely have to continue putting the casing
on the sausage. The firmer durometer liners will best control her soft
tissue issue. Softer more stretchy liners may be easier to don, but
ultimately not work as well. She will piston within her own skin.
Liposuction with a removal of redundant tissue may be the better
alternative. Sounds like a good day to not be you, good luck.

In our facility we use Otto Bock Transfemoral Liners on our fleshy AK’s
and BK’s if indicated.

Harry Phillips, CPO

Triangle Orthopaedic Associates, P.A.

Orthotics and Prosthetics Department

120 William Penn Plaza

Durham, NC 27704

(919) 281-1814

Fax: (919) 281-1877

[email protected]

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