Wednesday, May 25, 2022

part 2 longer fibula amputation

Randall McFarland, CPO

Responses part 2

I have one patient like that. He happens to be aver 250lbs and does perfectly fine in his prosthesis. I have him in an Alphaliner 6mm suction socket that I got the impression the way TEC recommends with a suction pump and I then global reduction. I also build in a patelly bar, (mild) and pretibial depressions. However, his fib is not quite so long with respect to his tib, maybe 3/4 inch. I would still treat her like a conical limb and gel liner… maybe try tec urethane as it has the flow properties. Sarah

We see many amputees with these kinds of “unacceptable” residuums that would be hard to fit in many ways. Basically, pain, and the option of an open-end socket are the factors between surgical revision. Many of our patients did not get a good surgery with myodesis or myoplasty. Consequently there is not a lot of tissue between the bony end and skin coverage. So if an open end socket is not painful, we generally go with that. It is common here to use a pull sock (hole in liner) to don the BK prosthesis. The issue of distal end verucus hypoplasia is just beginning to take form and total contact sockets are becoming more common at my center for good surgical results. Otherwise, we send for surgical revision as there are no “soft” silicone liners etc. available here. Best regards, John Zeffer American Red Cross-Cambodia Kompong Speu Rehabilitation Center

Since this was a recent amputation, I would venture to say that the surgeon either had a very good reason or knows nothing about prosthetics! You can pad the end with a good plastazoate distal end pad which is built up from the tibia level to match the fibula protusion. If the difference is less than 1/2 inch, you could try a Silipos silicone liner which has 9mm of soft silicone on the distal pad. It shouldn’t be to hard especially since your offloading the distal end of the residual limb anyway in whatever design you make. Mike Kogan, CP

I had a patient with about a 1″ difference in length between the Fib/Tib. Was accomodated in the liner but still caused problems. You do this type of amputatation well by calling it unconventional…I would call it a mistake. Eventually we had Dr. Jan Ertl here at Kaiser do the Ertl proceedure. Have not had any reports on his progress since surgury. My hopes are that he is doing better.

Randy, she is probably looking at revision surgery in her future. What was the length of her limb and could the fibula be shorted and still have good length for a transtibial fitting? Her small wt is in her favor. I would use a custom distal end pad of very soft silicone. You may even have to put light weight joints and a thigh corset on her. Terry

Unfortunately, I have had nine experiences with fibular shafts longer than the tibia. All from the same surgeon. Yours is the worst, as my guy reversed Burgess’ technique and precisely left the fibulas 3/4″ longer.
Throw away any thoughts of using pinned liners of any kind, as they are too symetrical. I have success with liners with sleeves and valves, but you must really concentrate on molding the distal end while casting to differentiate the distal ends of the tibia and fibula. Your patient’s two inches will probabaly preclude even that, so I would retreat to a more conventional Pelite or equal liner with 1/2″ or better molded distal end pad.
Again, careful molding so as to load the tibia and relieve the fibula with plaster buildup prior to fabbing the insert. I have had success with them. Regards, Bill Schumann, CPO

I have a young patient (6yo) that has a similar situation due to traumatic amputation. I used an alpha liner and show her how to “squeeze” her calf area while donning the liner to push the tissue over the pointed fibula. This worked for a long while. The surgeon want her to grow as much as possible before limb revision to have more good skin tissue to wrap around the limb where skin grafts are now.
I used a locking liner with a fillaur shuttle lock. Needless to say this patient is very active (trampoline, swimming, running, ballet) I know your patient probably won’t be doing these activities, but it does show it can work under extreme circumstances
If I can be of further help let me know glen waldner, cpo

This is sacrilegious – if the surgeon feels this is a definitive surgery – it is malpractice or whatever term you want to use to describe it . I HAVE FIT MANY WITH THIS CONDITION, ONLY ONE MAINTAINED IT TO THE DAY HE PASSED-ON. All others had reconstruction/revision to correct. To either even or slightly shorter.
-Jan

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