The First Year of Amputee Care
It is essential that the amputation surgeon be familiar with the course of amputee care and the elaborate nature of the prosthetic fitting process (ref Fergason, Smith). The surgeon must understand that the first year of amputee care is very different from the following ones. Because this first year is so different, what is useful in terms of components and prosthetic technology will change radically after the limb is mature and the patient’s activity level has increased. For example, traumatic amputees are typically younger patients with more muscle mass than commonly seen in the dysvascular and diabetic amputee group. They often suffer more swelling, and have more dramatic volume changes in the residual limb. This can make the first year of socket fitting particularly difficult as the volume of the residual limb is changing dramatically.

It is the amputation surgeon’s job to help supervise prosthetic care. When a leg is swollen and not fully mature, even if the patient and the prosthetist are pushing, the surgeon must resist the urge to form a definitive prosthetic socket too early. The intermediate time period is essential to the healing process, and impatience will only cause later disappointment. One especially frustrated patient had five definitive sockets made the first year following amputation. Following each successive failure, by the fifth socket his insurance provider refused to fund further prosthetic care just when he needed it most. Thanks to impatience, ill-timing and poor decision making by all parties involved, the patient was ultimately left with a prosthesis that did not fit, and a device he could not use. This is far from the appropriate standard of prosthetic care, and scenarios like this should be avoided at all cost. Similarly, it is a grave disappointment when a patient has limited prosthetic funding and the funds are exhausted too early in the course of prosthetic care. In a worst case scenario, the patient has a prosthetic device that looks great and has high tech components but no longer fits, and funds are no longer available to correct the situation. Patience and financial caution should be taken to avoid this predicament.

Reinforced multiple check socket protocols have proved very successful. They allow the patient to walk on each more-or-less temporary socket for two to eight weeks. Ambulatory activity in a check socket or temporary socket can help relieve edema over several months. Pelite liners are also an excellent option for the first socket fitting. Instead of fabricating a brand new socket, the Pelite liner can be padded in appropriate locations and thereby specifically adjusted to take up changes in volume in the appropriate location, thereby saving both time and money.

Typically when a recent traumatic transtibial amputee loses volume they suffer redness and pain at the distal end of the residual limb. The first step to remedy pain is to increase the ply and number of socks to modify fit. The second step is to pad the anterior-medial and the anterior-lateral tibial flair regions of the socket or the liner. These are the regions that support the tibia and push it away from the front of the socket, thus protecting the distal end. Padding can provide a successful fit with fewer socks. When volumes decrease more substantially, the posterior region of the socket can be padded or the tibial regions can be padded a second time. It is not uncommon to pad the liner up to four times before fabricating a new socket. Padding techniques save time, keep the course of rehabilitation smooth and continuous and prevent the hassle of re-authorization for a new prosthetic limb until absolutely necessary.

The elastomeric liners recently introduced on the prosthetic market have gained in popularity. Soft and pliable, these liners have immediate tactile appeal to the amputee and to the provider, but they can be problematic because they can cause skin reactions and are not universally tolerated by every patient. Complications reported include skin irritation, constriction and distal traction edema. One randomized study revealed that patients might actually ambulate less in the elastomeric locking liner systems than they do in traditional systems (ref Coleman). While many protocols have been advanced to use elastomeric liners and total contact socket shapes early in the post-operative period, these systems can be more dificult to frequently adjust and modify than other systems. Personally, I do not typically use elastomeric liners during the first year of care, as the changes in residual limb volume are too dramatic to make fittings routinely successful. Elastomeric liners can be appropriate for select cases in which very fragile soft tissue or scarring is involved, or traditional systems have failed. In these instances a pelite liner can be fabricated to fit over the locking liner and can allow padding and adjustments to take up the volume changes. Unfortunately, after 12 to 18 months many patients are transitioned into a new suspension system or socket shape without the benefit of actually testing or trying the proposed change. Again, ambulatory check socket protocols allow the patient two to eight weeks to decide if the change is indeed beneficial. These protocols can avoid the not infrequent scenario where a patient is "stuck" with a "new and different" system that sounded very appealing, but in reality was not successful for them.

9/10