Amputee Prosthetist

Coming Apart on the Hill

Coming Apart on the Hill

Back at Miami University in the winter of 1975; I was having the time of my life. Classes were easy, good friends

surrounded me, and the girls were friendly.

Southern Ohio rarely got much snow but that year we got a good six inches on the ground.    One evening, a good buddy and I decided to go sled riding at a small hill on campus. Of course, we had no sleds so we went to the dining hall and stole a couple of the large trays to use them as sleds. We arrived at the hill where there was already a large crowd of underclassmen having a blast, “traying” down the hill.

  After a couple of runs down the hill, the group formed a train by sitting one behind the other and locking their legs around the person in front. I immediately sought out the best looking girl and elbowed my way behind her, hoping to make her acquaintance. We all locked our legs around the person in front of us and took off down the hill in a big train. Towards the bottom of the hill the train started to break up at the back and to my dismay my buddy fell off dragging me with him.

My leg came off under the arm of the pretty blond in front of me. She made it intact to the bottom of the hill about 15 feet in front of me.

Being a smart ass; I yelled down to her, “Hey you pulled my leg right off!”  Laughingly she turned around to look at me, expecting me to be right behind her since my foot was still under her arm. The look of incongruity on her face was priceless as she tried to figure out how I could be 15 feet away and yet she still had my foot. Suddenly she realized what had happened. She screamed and dropped my prosthesis in the snow as all of the other people on the hill froze in their tracks.

My buddy and I almost split our guts laughing. I scooted down the hill to retrieve my leg from the shocked blond. Later I apologized for any embarrassment that I caused her and she forgave me for coming apart in her hands. She forgave me so much that she accompanied me back to my apartment for the evening. This was not necessarily the traditional way to meet girls but I figured that I needed to take advantage of any opportunity that presented itself.

For More Information call Rick Riley at 775-830-1783

Email rickjillriley@hotmail.com
Visit my website prostheticconsulting.com

Saved by the Leg

Saved by the Leg

In the summer of 1979 I decided to take a bicycle trip with an old college buddy. We flew to Portland, Oregon where we embarked on a two month excursion; bicycling through the stark beauty of the Pacifici Northwest.

We arrived in Portland,Oregon at the beginning of June, during the height of the oil embargo imposed by OPEC. The great thing about this was that there were very few Recreational Vehicles on the road and even the logging trucks were sparse. We bicycled along the coast of Oregon until we crossed the mountains into Eugene, Oregon.

  At that time it was like walking back in time to the sixties. We had a rather good time, staying with friends of Eddy’s and taking in all of the counterculture fun.

While we were in Eugene we were invited to go to a rodeo in the Oregonian tradition, which included a square dance and beer garden. After watching the rodeo for a while we decided that we needed a beer and so we meandered over to the gymnasium where the square dance was also being held. I got in line for beers and struck up a conversation with a large yet attractive woman ahead of me in line. She invited me to dance with her so I gave my beers to my buddy and proceeded to square dance around the gym floor.  This was a free form kind of square dance and during one of the dotsie-does, I picked up the woman and swung her around. She thought this was cool so on the next dotsie-doe, she picked me up and swung me around. This took me by surprise and as I became airborne I felt my leg start to slip. When she let go of me, the leg came flying off. It skittered across the wooden gym floor and came to rest in front of the band. I went flying; knocking over a table with three people and a pitcher of beer before coming to rest in the middle of the gym floor.

The band stopped, all of the people stopped dancing, and you should have seen the look on the woman’s face.

I looked up at her and said,”Darling, you danced my leg right off.”

Some brave soul walked over with my leg and asked me if it was mine. I didn’t have the heart to be a smart-ass; since he seemed very shook-up, so I just thanked him. The people who I knocked over forgave me and I ended up sitting at their table, drinking my beer with this good-looking woman on my lap.

I was thinking that this might turn out to my advantage after all when a mean looking scrawny guy walks up to us. The woman had neglected to inform me that she was married and her husband was about to kick my “you know what” when someone told him the story of what had just happened with my leg. He took his wife and left.

Saved by the leg, again.

For More Information call Rick Riley at 775-830-1783

Email rickjillriley@hotmail.com

Visit my website at prostheticconsulting.com

Inadvertently Playing Footsie

Inadvertently Playing Footsie

Armed with my new leg I embarked on my first overseas adventure.  I left Oxford, Ohio to perform my student teaching in the American school in Monterrey, Mexico.  Monterrey is a large industrial city about 100 miles south of Brownsville, Texas.  I was with a group of student teachers from Miami University that included two other men (this represented half of all the men majoring in Elementary Education) and eight women.  This was my kind of odds plus one of the men was a good buddy of mine and we decided to drive down to Monterrey together.  I traveled to Atlanta to see my family and my Dad gave me the old family station wagon which today would be classfied as a sailing vessel.  Dave was a former Miami football player and a really great guy to travel with.  First I drove up to Akron, Ohio to pick him up where I also decided to visit my former girlfriend who resided close by.   
I had this need to show her that I wasn’t the crippled man that she had seen when I first lost my leg. In retrospect this has been one of the powerful forces in my mania to excel in sports and activities, I had to show people that I was just as good as anyone else. As a matter of fact, I unconsciously developed a philosophy of having to be better at something than anyone else just to be equal. I reasoned that having only one leg put me at a disadvantage in competition for everything, girls, jobs, sports, and girls. Needless to say girls were very important and I was still struggling to come to grips with how I appeared to women. I strove to walk with no limp and rarely showed my pain in public, reserving it for when I was in the relative safety of home.

Dave and I drove south in the mammoth Fury III station wagon, pausing for a stop in

New   Orleans

where we learned to barf hurricanes in the gutter. Dave had a friend in

Houston

so after driving all night we stopped in to visit with him for a day. Dave’s buddy had a waiter’s job and departed for the evening leaving us to ourselves.

We were surprised to hear a knock at the door and when I opened it there was the downstairs neighbor introducing himself. He was quite friendly and invited Dave and I out for Mexican food. Since we had no other plans, we accompanied him to a local restaurant where we had a nice dinner.

I started to get a bit suspicious of his motives as the conversation progressed. Each time I asked where you could meet girls in

Houston

he changed the subject and I began to get the feeling that he was trying to pick up on Dave and I. I did not have extensive experience with homosexuals but I had been approached before and knew where my sexuality lay so I was polite but cautious.

As dinner progressed he began to get very friendly with me, touching my shoulder and leaning towards me as he sat on my right side. I wondered what I was doing to make him think that I was interested. I was not the most effeminate looking guy, having gotten my face stepped on by a 220 pound rugby player only a year and a half prior. As I sat back from the table I glanced down at my prosthesis and noticed that the guy had his leg up against my prosthesis and was rubbing back and forth. He was playing footsie with me and since I had not pulled away from him he assumed that I was interested in something. He must have been impressed by my firm calf muscles when he reached down and gave the hard laminated plastic a squeeze.

What was I to do? The guy had been very nice to us but I was not interested in him so; I feigned sickness. We went back to the apartment and begged off to bed. He invited my buddy Dave down to his apartment. Dave, being totally naïve went with him and after about 30 minutes, burst back into the room. He scowled at me and threw a stack of dirty magazines in my lap on his way to lock himself in the bathroom. The gay man sauntered into the room and took his magazines back. Before he left, he called through the locked bathroom door that if we were ever in Houston again to look him up. Dave was kind of pissed at me for not clueing him in on the situation but he did learn how to handle himself.

For More Information call Rick Riley at 775-830-1783

Email rickjillriley@hotmail.com

Visit my website at prostheticconsulting.com 

The Amputee Survival Kit

The Amputee Survival Kit

  All amputees have a basic dilemma. No matter how well fitting there prosthesis may be, their residual limb doesn't stay the same. It swells, it shrinks, and it gets pimples, muscle cramps, calluses, blisters, and any other maladies that afflict normal human skin. To compound matters, often time’s amputees do not even have normal skin; scar tissue, skin grafts, and skin folds can complicate matters. To add insult to injury, this skin is placed in a warm, moist, and dark environment and placed under pressures that it was never designed to withstand. This is the situation for the residual limb.

How do amputees cope with this dilemma? Most of us utilize some type of survival kit. This article will describe some of the items that amputees have found useful when their residual limb has problems. This information is based on my personal experience as an amputee (since 1974) and having been a Certified Prosthetist for fifteen years.

First we must keep the skin clean. Soap and water work great on a daily basis for most of the body. However, you've got a part of your body in what is essentially a Petri dish, growing bacteria. Even if you utilize an antibacterial soap, within a short time most of the bacteria has regrown. Products that kill lots of bacteria are rubbing alcohol, Phisoderm, Hibiclens, and Betadine. These are all over-the-counter cleansers. Alcohol will dry your skin out, so be cautious using it. The other antibacterial soaps kill most of the bacteria yet provide little long lasting antibacterial protection. A former disabled ski team member, named George Lombard, introduced me to Phisohex. It is a prescription item and must be prescribed by your physician. The difference with Phisohex is that it contains hexachlorophene, which inhibits the growth of bacteria over a long period of time. This means hours after you have washed you still have a low bacteria count, greatly reducing the possibility of irritation or infection. Any skin rash or itch should be a signal to discontinue use of whatever you utilize to clean your skin. Take particular care to dry out any skin folds, dimples, or any place that can trap moisture.

Skin protection materials are a topic I've lectured on for years. When I lost my leg twenty-two years ago, the only product available was Ampubalm, a salve with lots of lanolin and mutton tallow (Yuk) the stuff smelled awful but did provide some friction relief. Then came Ampaid; which smelled better and had a similar effect as Ampubalm. Bagbalm is a lubricant utilized in the dairy industry (use your imagination) and also provides a friction reduction element that can soothe the skin. One of the most common errors that amputees make on skin care is the use of band-aids or gauze bandages on abrasions. Often time’s abrasions are created by excessive pressure on a limited skin surface area. Bandages only increase the pressure and can actually do more damage than good. Also the adhesive on bandages can damage delicate or healing skin when removed.

Over thirteen years ago, I became acquainted with Second Skin, a Spenco product. Second Skin is a thin (1/16 inch) piece of perforated silicone gel. It applies directly to the skin and adheres by its own viscosity. It totally eliminates skin friction, allows the skin to breathe, and can actually promote healing. It can be utilized for prevention or if an abrasion or blister appears. It is expensive and can only be used once, but for anyone who has had to endure days of pain because of a simple abrasion, it is worth it.

Second Skin does not work well on above knee suction sockets unless held in place with their adhesive strips. There are some products that will work; Bioclusive, Tegaderm, Op-Site, and Acuderm are the ones I am familiar with. These products provide a thin, adherent membrane that prevents friction and allows the skin to breathe. The product can be left on for several days and it is best removed under water. Be careful not to leave it on for too long as it prevents the skin from sloughing off and should be replaced every 2-3 days.

For all amputees who wear some type of sock there is a simple way to make temporary socket adjustments. A small hole cut into the sock will provide temporary relief to skin that has been damaged by either an abrasion or a pimple, especially when there is associated tissue swelling. This works best with a five ply sock, (the thinner the sock, the less relief), and the trick is to cut as small a hole as possible. Use an older sock if you have one, and pull onto your residual limb, take a pencil and draw a circle around the affected area. Remove the sock and cut a hole about half the size of what you drew. When the sock is put back on, the hole generally stretches giving plenty of relief. If not, then carefully open up the hole a little more. Too big of a hole does not provide good relief.

What constitutes a good amputee survival kit? I am a below knee amputee and my kit consists of: Second Skin, a tiny pair of scissors (for cutting holes in socks), Hydrocortisone (will lubricate and kill an itch), duct tape (I have hiked many miles on feet taped together), a foot bolt wrench and any other Allen wrenches that my let utilizes. I also carry a washcloth or bandana to wipe perspiration off my residual limb and my sleeves. When I am engaged in heavy activities where I perspire a lot, I sometimes have to wipe my suspension sleeve about every half hour. I carry my kit in a fanny pack with a water bottle.

Above knee amputees will use slightly different materials in their kits, depending on whether they utilize suction or a sock. Tegaderm or one of the other adherent membranes may be substituted for Second Skin. An excellent lubricant for when your skin rubs against any surface is Vaseline. Since it does not absorb into the skin, it provides friction relief for hours. Make sure you use it sparingly. For suction socket wearers who will be engaging in activities that could cause a lot of perspiration, I recommend some auxiliary means of suspension. A removable Silesian belt is an excellent addition to any above knee suction socket but it needs to be built into the prosthesis. There are neoprene suspension belts that give great freedom of motion that can be obtained through your prosthetist.

Upper extremity amputees rarely experience the friction and pressures of ones body weight on a prosthesis. However, under heavy loading, or over delicate skin, pressure and friction can occur. A kit including scissors, Second Skin, and Vaseline can also come in handy.

Each amputee will find the specific combination of skin protection materials to create their amputee survival kit tailored for them personally. Residual limbs change under pressure, over time, especially under increased activity. If you are an amputee and you don't have some type of survival kit then it's like driving around without a spare tire for your car.

  The Survival kits you should have, one for home and one for travel. These kits contain the same proven ideas that we have found that work, you will find that you will tailor the kit to fit your needs as time goes on.

• 1 small pair of scissors

• Bioclusive, Tegaderm, Op-Site, or Acuderm (for abrasions or blisters, 3-5 units depending on time away)

• Hydrocortisone for itch and lubrication

• Talc, Zeasorb, Baby powder or another sweat absorbent (for help f or putting your  Prosthesis on)

• A small towel, to dry your stump for sweat

• If you're on a trip then I would take Phisohex, Hibiclens, or one of the other strong Antibacterial soaps to keep your stump clean

• Waterless hand cleanser, handy wipes, alcohol preps or something similar (to keep the stump and socket clean)

• Extra stump socks and sheaths

• A stocking net and valve tool (to help you get your suction socket on after you've repaired your body parts or prosthesis)

• A Foot Bolt and wrench plus all of the Allen wrenches (for your prosthesis for adjustments and repair)

• Duct tape (for temp repairs, like if your frame, foot, or socket needs temp help - smallest roll you can find)

• Thin cell foam (to help alleviate pressure points on your weights bearing areas)

• Lubriderm or some other Medicated cream (for dryness)

• Stump shrinkers (if you have to take it off to repair then you want to be able to get it back on)

• Topical antibiotic (for minor sores or popped pimples then cover them with Tegaderm)

• 5-10 Pain killers (depending how long you will be away from home)

 

This is just a basic travel kit you can be as elaborate or delete things that don't apply to your situation. You should try to get all of your creams, powders, Duct tape, and cleansing agents in the smallest possible sizes so that you can have them with you at all times. It goes without saying that you should carry all of your necessary medications with you when you will be away from home for any period of time.

 

For More Information call Rick Riley at 775-830-1783

Email rickjillriley@hotmail.com

Visit my website at prostheticconsulting.com                 

Case Management of the Amputee

Case Management of the Amputee

Limb Loss, the Statistics

 There are three causes of amputation in today’s world; disease, trauma, and congenital defects. Statistically these break down to; 70% due to peripheral vascular disease, 22% to trauma, 4% to malignancies, and 4% due to congenital birth defects.

Statistics are not current but the best information that I have found is that there are over 130,000 amputations performed in the US every year and that number is on the increase. It is estimated that there are well over 300,000 lower limb amputees in the

United States

, alone and over 200,000 prosthetic limbs made on an annual basis.

Another interesting statistic that you possibly were unaware of is that there is no state regulation on Prosthetics or Orthotics in

Nevada

. There are only nine states that have some type of licensing for our profession and it is not likely that

Nevada

will invest in the infrastructure to regulate such a small industry. What this means is that whoever cuts your hair needs a license but whoever makes your prosthesis does not. This creates a wide variety of quality of care and service from practitioner to practitioner.   

Functional Capabilities of Amputees

 Prosthetic devices and the materials available to the prosthetist have improved dramatically over the thirty-two years that I have been an amputee. The result is that most trans-tibial (below the knee) amputees can often return to a style of life approximating the life they experienced prior to amputation.

In my experience, the critical factor for success is motivation. No matter what amount of resources that are provided for an unmotivated amputee, their likelihood of success is minimal. On the other hand, a highly motivate individual can even overcome multiple amputations to go on to experience a rich and rewarding life.

How do you change a person’s motivation? First you have to determine the attitude of the individual regarding their future expectations. A small percentage of people will not need any stimulation toward rehabilitation and conversely a small percentage will not respond to any stimulation. Often times, people are subject to their initial experience with the prosthetic and rehabilitation process. If they have a negative experience with their prosthetist or therapist, it can affect their future effort towards rehabilitation. If on the other hand; the experience is positive, than it can maximize their effort and success in dealing with their amputation.

Functional capability is also a factor of the level of amputation. The higher the level of amputation; the more energy that will be required to operate the device. Upper extremity amputees have a low incidence of prosthetic usage, especially if they are not fit with a prosthesis within the first ninety days. Bilateral or multiple levels of amputation also have an increased energy requirement to compensate for lack of musculature. Experience has shown me that with the proper team approach and good prosthetic care will allow an amputee to reach their full potential. Many manual labor jobs can still be accomplished but often times the amputee will require retraining in a field that is more suited to their prosthetic adaptations.

 

State of the Art of Prosthetics

Prosthetics has come a long way since I lost my leg in 1974. Back then there were only two different feet available to amputees, today there are over fifty different feet. One of the biggest revolutions in the comfort of the amputee is the introduction of gel and silicones into socket interfaces. When I first became an amputee the most common problem was skin breakdown and abrasions. Today we see very little skin breakdown due to the friction absorption of the gels or silicones that now interface with the skin.

Does this mean that amputees no longer have socket problems? Not at all. There is still the basic dilemma; that we have to take a living, changing piece of human tissue and place it into a dead, unchanging prosthetic socket. The result is that pressures and forces can alter as the residual limb shrinks and swells. There is no substitute for a well fitted socket designed to accommodate the anticipated changes in the residual limb. Test sockets allow the prosthetist to analyze the socket fit prior to the actual fitting of the prosthesis and are one of our best tools to maximizing the amputee’s comfort.

Most of you have seen television programs or news articles about the newest microprocessor knees. I recently attended the C-leg course put on by Otto Bock, one of the manufacturers of microprocessor knees. The major advantage of these devices is that they provide a lifelike stumble control for the trans-femoral amputee (above knee) during that all important swing phase. If an amputee’s knee is not in full extension at heel strike, then the microprocessor monitors their gait and provides knee resistance even when the knee is flexed. This allows the trained AK to walk step over step down steps, ramps, and to slowly sit into a chair. This can be a huge advantage for the above knee amputee’s confidence in the prosthesis.

Upper extremity amputees also have an electric powered prosthetic option. Myoelectric prostheses have been around for twenty-five years and several companies have produced very viable systems that can return function to the amputee.

My observation over the years is that the most perfect prosthesis is still one that you put on in the morning and don’t have to think about until you take it off that night. Many high tech components are also high maintenance and therefore invasive to the user. Old time amputees invariably gravitate towards equipment that is low maintenance and simple. If you have a life then you don’t want to be spending your time going to the prosthetist for repairs and adjustments.

 

Realities of Our Industry

The prosthetic industry, as has the rest of the medical profession, seen many changes in the past thirty years. Managed care has eroded the team approach to rehabilitation and taken the decision of prescription from the doctor and given it to the bureaucracy of the managed care company.

Medicare sets the fees as the standard for our industry and due to the fact that our profession is very fractured they have continued to cut fees for services even though costs have increased. What does that mean for the amputee? Many companies focus more on what can be justified for their patient then what is necessarily the most appropriate prescription for the amputee. If insurance will pay for an energy storing foot, then the amputee will get one even if a simple SACH foot is more appropriate. Is this unethical? Hey, these guys are just trying to make a living in an industry that continually reduces fees for services and rewards discounts, regardless of quality.

Due to the lack of long term follow up, there is little tracking of costs over time. One way to make a profit in this type of system is to replace sockets frequently. A well designed socket that is adaptable to anatomical change gets the same reimbursement as a socket that is quickly made to the volume of the residual limb. Only difference is that the volumetric socket will need to be replaced frequently since it has not been constructed to be adaptable. If you had to make the business decision, what would you choose?

 

Returning to Work/Recreation and Quality of Life

I believe that most amputees want to return to some type of gainful employment. Certainly there is a minority who are looking for some way to milk the system so that they won’t have to work but they are in the minority.

Employment or vocation is one of the main keys to successful rehabilitation. It is one of the deciding factors in positive self-esteem and the fight to overcome depression. Most amputees will require encouragement and training to achieve this. Another very effective tool to help amputees is for them to associate with other amputees who have returned to employment. Amputee support groups or other amputees within your system will provide an alternative role model to a person’s worst fears.

Amputee sports organizations also provide positive role models as well as a fun way to experience the rewards of exercise. Most trans-tibial amputees can return to recreational activities similar to their pre-amputation life. Trans-femoral amputees and upper extremity amputees may need to alter their activities or use adaptive equipment to reengage a recreational component.

Adaptive prostheses can take many forms. One of the most common types of adaptive limbs is the shower/swim prosthesis. This limb is designed to be submerged in water and allows the amputee to stand safely in a shower, go to the beach or pool, and not to damage their regular prosthesis by subjecting it to moisture.

Other sports and recreational prostheses include; skiing limbs, climbing and hiking, running, hunting, golf, bicycling, and a myriad of upper extremity attachments that allow for specific activities. These limbs are often cost effective when compared to the cost of replacing a regular limb more often due to the abuse it takes while engaging in activities for which it wasn’t designed.

 

Legal Issues and Projecting the Costs of the Amputee

One of my specialties in the prosthetics field is providing expert witness testimony for litigation. I have developed a systematic approach to projecting how much it will cost to keep someone in prostheses for the rest of their life.

I break an amputee’s life expectancy into three phases. The initial phase is the first three to five years (unless the amputee is a child, then the initial phase lasts until the end of their growth phase). This is the time when an amputee encounters the most rapid anatomical changes as well as experimenting with different components to find what combination of materials and equipment works best for them.

The next phase is the stable phase where the amputee’s residual limb has stabilized and they have settled into a more predictable lifestyle. This phase results in fewer prosthetic replacements.

The third phase is the geriatric phase and describes the amputees lessening of activities due to age. This phase sees the least amount of prosthetic replacements.

I also generally project a backup and ancillary prosthesis for each individual. The backup prosthesis is usually made from components salvaged from an older limb. The socket is new to maintain an adequate fit. Ancillary prostheses can be for sports or more often for water applications.

 

Replacement and Maintenance of Prostheses

 Prostheses don’t last forever. The average life expectancy of a prosthesis is four to eight years, depending on the activity of the amputee. Quality of components is also an issue as is initial construction and attention to fit.

Nearly all prostheses require consumable products to keep them fitting comfortably. Stump socks, suction liners, suspension sleeves, cosmetic covers, all need periodic replacement. There will be an annual maintenance expense for any prosthesis and amputees should be made aware of this by their prosthetist. A prosthesis should come with all of the components and supplies to last for a prescribed period of time. I provide a years worth of consumable materials with each prosthesis. If an amputee is going through more supplies than usual it could point to a problem with the fit or design.

 

 

Summary

Prosthetics has come a long way in the past decades. Today’s materials and components provide motivated amputees the ability to return to most employment opportunities. Ancillary prostheses allow amputees to experience and enjoy a recreational component to their lives permitting them far greater integration into normal society. Prostheses require maintenance and soft goods on a yearly basis in order to function optimally, with the average prosthesis lasting from 4-8 years. If the team approach is used and amputees are followed with an adequate plan then they can typically return to a style of life similar to their pre-amputation experience.

For More Information call Rick Riley at 775-830-1783
Email rickjillriley@hotmail.com
Visit my website at prostheticconsulting.com

The Socket fit makes the Leg

The most perfect prosthesis is one that you put on in the morning and don't have to think about till you take it off at night.

Even with today's advanced technology, the fit of the prosthetic socket is still the key to a comfortable prosthesis. There is no magic to making a well-fitting socket, no technological tool will create the perfect fit. It comes down to the skill and knowledge of the prosthetist, whether they use plaster and rasps, or computer aided design. There is no substitute for experience and insight into the changes that a residual limb will go through over time.

The Dilemma:

     Prosthetics has a big problem. The residual limb is a living piece of human tissue that shrinks, swells, and can heal itself. The prosthesis is a dead thing, it can't change its shape or adapt to the anatomy of the wearer. How do you make a socket that allows the amputee to wear a prosthesis all day without having to mess with it?

The Answer:

 Hard work and persistence. As I mentioned before, there is no magic to a good fit. I have been an amputee for over 30 years and have been making legs for 25 and I have developed a system that produces a long lasting socket fit.

     I base the fit of the below knee socket on the bony anatomy of the client. In a residual limb, there is only one part of the anatomy that will not change and that is the bones. Basing the fit of the socket on the volume of the residual limb will produce a temporary comfort level that "gets the amputee out the door" but often times fails over time. The residual limb shrinks or changes and the socket no longer fits. Adding socks will alleviate the shrinkage but can increase pressure on the bones.

     My technique for creating a long lasting, well fitting socket is to cast directly over the skin. On a below knee amputee, I will use a three part cast so that I can spend the time on the front of the residual limb where most of the bony prominences are located. After the cast is modified, I pull a clear plastic test socket that I have the client stand in with full weight bearing. I can see the skin through the clear plastic and the skin talks to me. The skin turns colors under pressure and I can read where to adjust the fit of the socket. I use as many test sockets as it takes to achieve a great fit. When the client can stand or walk on a hard plastic socket, then I know that when I add layers of gel or foam to the socket that this is a fit that will last for a long time.

     Prior to fitting I will make a final test socket using whatever gel or silicone liner we will be using to adjust the volumetric fit of the socket. I also prefer to use socket inserts for redundant padding and to ease future adjustments. One thing I know for sure, whenever you put the residual limb into a new container, it changes.

What this means for the Amputee:

     This means that the socket fits from day one and generally results in a fit that can last many years. Many of you have the experience of getting a new leg then spending months trying to get the socket to fit properly. This is a frustrating experience to the amputee who just wants to be able to go to work, hang with the kids or enjoy a little recreation. If you have never had to depend on someone else for your mobility, you can't imagine how invasive it is to be continually having to mess with your leg. I prefer to get the socket problems solved in the beginning instead of making the amputee come back over and over for adjustments. A great socket fit to begin with is the answer.

     Many prosthetists try to dazzle the amputee with technology that is supposed to absorb impact or create a constant volume in the socket. I believe that the simplest solution is the best. Like I said at the beginning, the most perfect prosthesis is one that you put on in the morning and don't think about it until you take it off before bed. If that is a simple SACH foot and a low tech cuff strap then this is the best prosthesis for the amputee. Many prosthetic facilities will build and prescribe what your insurance will pay for, not necessarily what you need.

     I am a cash only prosthetist; I provide services for half of the agreed upon amount to begin and the balance upon completion. That means that I don't accept insurance or any other third party payers. My agreement is with the amputee and my guarantee is unconditional. If the client is not satisfied with the prosthesis at the end of the process then I will refund their money minus the purchase of components. I can only make this guarantee if I am confident of my skills in making a prosthetic socket.

For more information:

Call me at 775-830-1783

or visit my website at www.prostheticconsulting.com