Dear list members;
Following are my original description of the problem and all the
responses.
A few comments. The patellar bar is definitely NOT resting or pressing
the tibial tubercle. There are no sock marks on the area and it the wrong
shape to be so. It is definitely NOT a pressure problem. This leads to
the next difficulty, which is that everyone EXCEPT ME, insists that is
from excess pressure, no matter how I try to explain it. Like Pavlov’s
dogs, they see red, it must be pressure, from the clinic chief MD, to
PT’s; everyone. They are basically non-educable. They also insist on very
definite patellar bar pressure and total non-contact with the tibia.
Total weight bearing means nothing to them. Kind of makes you wonder why
you went to school. Again, shuttle locks, poured pads and the like are
not avialable in this particular setting.
I’ve decided to reduce my reliefs, and make sockets the way I used to,
the right way. Only bit by bit. I’ll continue adding soft inner pads in
decreasing amounts of build-ups and pads over time while I wean these
characters off their gigantic build-ups and huge patellar bars. May take
a couple of years, but I’m quite convinced that the source of the problem
is indeed lack of total contact. Thanks again.
Original post:
>>Dear list members;
>>
>>I’m a CPO seeing a lot of the following situation, and given the
>>restrictions under which I must work, I’m open to suggestions.
>>
>>Presented with:
>>BK amputation, first time fittings in a rehab setting. Well-healed,
>>non-edematous limbs, usually diabetic, some bilateral cases. Usually
>>properly using elastic bandages for shaping and edema control, with
>>varying consistency, though the wrapping doesn’t seem to be a factor. I
>>usually see them a minimum of several weeks post-surgery.
>>
>>The general protocol(over which I have very limited control):
>>PTB-PTS total contact endoskeletal, pe-lite liner with soft distal
>>end-cap, simple components (e.g.,Otto Bock steel, SACH foot). Usually a
>>knee sleeve for extra suspension aid. Modifications are
>>by-the-book-normal; relief along tibial crest, fibular head, etc. A lot
>>of PT weight bearing is the norm here. Corsets or strap suspension are
>>about the limits of variety here.
>>
>>Specific problem:
>>A large percentage, not sure how large, are experiencing a hematoma,
>>usually on the anterior, proximal aspect of the tibia. It presents as a
>>roughly triangular, blotchy discoloration, darker red than that which
>>results from pressure, does not blanch from finger pressure. Sometimes
>>accompanied by swelling in that area, sometimes painful. It will become
>>light “black-and-blue” if the prosthesis is used in that state.
>>
>>I think this is a result of blood and fluid pooling in the areas of void,
>>pressed into the area by surrounding areas of total contact.
>>
>>Sometimes a “Silipos” sock helps (we usually try this first, we use them
>>frequently, anyway). Sometimes a soft pad inside the liner helps.
>>Occasionally a corset is used to remove weight bearing. This usually
>>works as a last resort, but has its accompanying inconveniences.
>>
>>Restrictions (they are not in my control):
>>”Exotic” liners, e.g., Iceross, TEC, multi-durometer with leather liners
>>are NOT an option. PT weight bearing for non-corset wearers ARE required.
>>
>>I’ve considered a multi-durometer liner without plaster build-ups on my
>>models except distal anterior (where this problem has not occurred), and
>>without a leather lining, but have to figure out a simple way to make
>>them-if it makes sense to do it at all.
>>
>>I have very limited leeway for experimentation, but could probably swing
>>a little through if it doesn’t require much in the way of material
>>resources.
>>
>>Thanks in advance,
>>Aryeh
>Aryeh,
>
>Sounds like they may not (a) getting total contact and in essence have a
>reverse suction, or (b) pistonning in the socket causing trauma to the
>distal
>portion of the tibia. Have you tried a distal pour pad to insure total
>contact. That has eliminated some problems in the past. I’ve also seen
>suspension sleeves mismananged, in which the patient doesn’t don proximal
>enough resulting in pistonning. Good luck.
>
>Rich Federman, CP
>Can you use a shuttle locking system? If so Silipos makes a new liner
>called: ‘Siloliner’. It is vitamin E enriched and works very well with new
>(especially diabetic) amputees. Try allowing for more weight bearing along
>the medial tibial plateau and the tib/fib interosseous space. The joint and
>corset restrict too much blood flow.
>B.J. Stagner Jr., C.O.
>Hi Aryeh,
>
>Yes I did experience the same problem in the past. I think your problem is
>with the socket design.
>
>In the past I used to create a patella bar as I and many of us were tought
>in the clinical schools. This created a void immidiately beneath the bar,
>and as you suggest the blood pooled there and red to blue discolloration
>did occure. I used to add a soft material in those areas to provide total
>contact, and this helped. I since have changed my socket design to a more
>moderate design, and at times eliminated the PTB bar all together. I
>utilize something similar to the IPOS socket design. I have not experienced
>this problem since.
>
>This may be the answer you are looking for.
>
>Eugene Banziger, CPO
>Aryeh,
>You sound like you are practicing in a vary limited environment.
>Are you in the USA or elsewhere?
>It sounds like a VA hospital in the US that has not become a modern facility!
>
>As far as your problem goes, if you are having the same situation happening
>with many peeople, then maybe it is the way you are making the socket. Maybe
>you can check with some other prosthetists in your area and pick up some
>different techniques.
>
>This field can be very humbling…I am going through some difficulties
>myself
>at the moment!
>
>Mark Benveniste CP
>VA Med Ctr
>Houston, TX
>Is the pt bar resting on the tibial tubercle while sitting with the
>prosthesis flexed and unsupported ?
>
>david hunt, [email protected]
>Hi Aryeh,
>
>A possible solution, or may be just a test to help problem solve.
>
>Try not adding any build up in the area off concern fit, and then cut away
>the hard outer socket in this to give some relief.
>
>Good Luck,
>
>Terrance Bloom C.P.(c)
>Is your patellar bar modification, perhaps, too extreme.
>
>also, whoever is denying the use of ‘exotic’ liners needs to be educated!!!
>these would be highly beneficial to some of your patients.
>We’ll occationally see skin problems over the tibial tubercle from an
>elastic
>bandage. We use shrinkers and sometimes healing casts. Even the shrinkers
>can
>be a problem over hamstrings if client doesn’t keep it pulled up properly.
>
>Randy McFarland. CPO
>Aryeh,
>
>Are you over-relieveing for the tibial tubercle causing lack of total
>contact???
>
>Joel Kempfer CP
>Patella tendon modification is too deep. Make the modification gradual and
>deeper on either side of the ligament than it is right at the ligament
>itself. Look for even sock marks after trial fittings not bright red weight
>bearing indications at the MPT.
>Best of luck
>
>Bob Brown, Sr., CPO, FAAOP
>Good morning-
>
>If you are describing a discoloration in the tibial tubercle area, it is
>most likely a large petechia rather than a true hematoma. True hematomas
>are almost always the result of surgical errors, or so I have been told by a
>wonderful orthopedist; I have seen them only in the vicinity of the suture
>line or pooling at the distal end of the residuum.
>
>Bluish discolorations over bony prominences are almost always caused by
>extreme lack of contact. This hypothesis is supported by the report that a
>gelly sock helps sometimes. I would speculate that these folks have such
>poor peripheral vascularity that they are very sensitive to such pressure
>gradient discontinuities. You do need to be certain that this in not simply
>bruising from an aggressive PTB bar; they may contact it with the tubercle
>while sitting or arising from a seated position.
>
>If you think it is a lack of contact, I would urge you to start routinely
>doing clear test sockets fitted skin tight with a little Vaseline
>lubrication. Overly aggressive modifications and exaggerated reliefs will
>be immediately evident and you can gradually “soften” your mods until the
>skin looks uniformly blanched under weightbearing. If need be, you can use
>polypropylene as it will be clear enough with the Vaseline that you can see
>what’s happening.
>
>Alternatively, try simply reducing your tubercle relief one millimeter at a
>time. Despite the traditional teaching, my experience has been that I
>rarely if ever need tubercle reliefs since the infrapatellar bar bridges the
>socket away from the tibia sufficiently to protect that area. But, without
>a clear test socket, you are “shooting in the dark”.
>
>Hope these ideas help you.
>
>–John W. Michael, CPO [[email protected]]
> Don’t do much modifications, i.e., don’t relieve the tibia. Just reduce
>your cast for a
>good total contact fit and only relieve the fibular head. PT load bearing
>is usually not
>neccessary! Total contact works just fine.
>
>With this technique, we had very little problems with diabetic BKs.
>Pressure casting also
>works very good!
>
>Hope this helped.
>
>
>Felix Carstens
>CO-MET GmbH, Germany
>Try using a pressure casting technique i.e., vacuum casting. When you modify
>the positive mold, use a total surface bearing method to maximize surface
>contact for increased circulation. Make limited relief, if any, over the
>bony
>prominences-tibial tubercle and distal tibia, fibular head- most pressure
>related problems can be resolved after socket fabrication. During the
>fabrication process a pelite liner can be used or hard socket can be made
>with a prominence pad made of aliplast or some other soft material laminated
>directly into the soket and providing relief while maintaining total contact
>(these can also be used together). If a pelite liner is used, pressure
>relief
>can be done on the liner, the socket or both. For fitting I usually
>choose a
>Comfort gel 5 or 3 ply- these tend to provide a gel cushion at a higher
>level
>and a cheaper price and most of my patients prefer these over the Silipos. I
>have had good results with both of these approaches with many diabetic
>patients and they do not require any special liners or other costly
>materials, just a little more time and attention, specifically when casting
>and modiying. I hope this helps, if you would like to discuss this further
>you may contact me at (912) 272-6522.
>
>Ryan Gatlin, BOCP
>Georgia Prosthetics
>Aryeh:
>
>I have fit many new patients under similar conditions and I believe you
>assessment is correct. You have probably over relieved the crest of the
>tibia, created a void and have negative pressure there, much like a “hicky.”
>Often this appears over the tibial tubercle. I simply eliminate the void on
>the inside if the insert with a soft material.
>
>Sincerely,
>
>Alan Kuro C.P.
>The discoloration may be due to lack of contact. Try adding a soft material
>to fill your relief area along the tibia crest.
>
> Good luck
>Steve
>
Fwd by: Don Cummings
>If the problem is on the anterior PROXIMAL tibia, as you stated, it makes me
>think they’re probably sitting a lot with the prosthesis on and are getting
>pressure from your pattellar tendon “bar” upon their anterior tibial
>tubercle.
>Don Cummings, [email protected]
>Aryeh, My case load is similar to yours by the sound of it. I seem to have a
>little more leeway in terms of the “exotic” liners etc but in the set-ups
>that you describe have only had one or two with this problem. This was
>solved by being less generous with the relief over the ant.prox. tibia. In
>fact I rely on reducing the pelite thickness after fabrication to provide
>relief if it is necessary, preferring to reduce the plaster mods required
>and trusting in my casting technique to produce a close total contact
>socket.
>kind regards, Richard
