A few entries ago I introduced you to the Aura sealing sleeve from Evolution Liners. It worked very well for the one patient that we had a chance to try it on. But we just tried to order another one and Craig told us he had to take it off the market due to patent issues. Too bad, because it was unique and Craig put a lot of time into it, but hopefully the parties involved can reach an agreeable arrangment so that amputees will be able to benefit from this device, and at the same time everyone gets treated fairly.

There was an excellent set of questions posted by a colleague on the O and P listserv. I will reprint  them here and comment with my initials on each question:

 1. What sleeves have you found to be the best? Obviously, the sleeves tend to be one of the weakest points of the system, and I'm wondering which sleeves have had the greatest durability in actual practice, rather than just theory. I've had patients using the OWW Alpha Flex sleeve, but they haven't lasted longer than their warranty period yet.

JB: For transfemoral, flexiblity is unimportant so resitance to wear, tear, and puncture is key. I have has good success with the Harmony sleeve or its equivalent.  For transtibial, the ALPS Easy Sleeve or its equivalent has worked well.

2. Which of the electronic pumps do you prefer, and why? I got disgusted with the harmony ePulse, due to my having to send nearly every one of them back, but I've heard it's been retooled. I've only used two limblogics, and I wonder how well they do, and how reliable they are.

JB: I have heard no complaints from any pump other than the ePulse, which did not work. I have not tried it lately either. DAW has a new one which looks promising and attaches around the pylon resulting in no added build height.

 3. What do you think of the Harmony mechanical pump in comparison to the electronic ones?

JB: The harmony is an excellent choice if there is suffient room for it with the desired componentry.  

4. Is there some other elevated vacuum suspension mechanism you may know of that you prefer?

JB: Evolution has recently released some exciting componentry. One is a distal attachment plate with a built in resevoir for vacuum, and the other is a sealing liner that allows the prosthetist to decide on the vertical location of the seal  on the liner. They also offer custom made liners fro elevated vacuum.

5. Does your answer differ between AK and BK patients, and why?

JB: Choice of suspension mechanism certainly depends on AK and BK, due to the often limited space available bewteen the AK distal socket and the knee. Almost any system can be used, but it is much less cumbersome if the pump fits between socket and knee.  

6. Especially regarding BK patients, how effective have you found it for them vs other types of suspension?

JB: Harmony offers the advantage of no chargin required, very simple to use, and the built in vertical shock absorber.

Once again we are reminded that every prosthetic wearer is different in their needs and preferences. Patients wearing liners must pay close attention to the skin condition. Certainly some patients may be allergic to the liner material, but many simply need to understand the issue of skin lubrication.  Any one using a prosthesis needs to keep the skin in the prosthesis meticulously clean. But some also need skin lubricatiion. As to the type of lubrication, I have had reports of a variety of favorites including Nutragena Sesame, Cocoa Butter, Alps Skin Lotion, and Otto Bock lotions. Otto Bock offers a selection of cremes for cleaning, moisturizing and lubricating the skin in the prosthesis.

Some patients only require lubrication in selected areas where skin is adhered or invaginated or somehow less mobile and some require no lotion at all.

One caution to prosthetists, don't mistake a localized rash for an allergic reaction to the liner. If the redness of irritaion is very local, try some local lubrication. If the rash is over the entire liner area, you may suspect a problem with either the liner material, the soap bring used,  a need for general lubrication, or the need to maintain better hygiene fo the liner and the skin. Always consider referring to a dermatologist for consultation.

One attendee reported several interesting sound bytes or bites from the seminar. He recalled that Andy from OWW said they have had good results from Alpha Liners when used with the Limb Logic on transtibial residual limbs;  as for tranfemoral, he said they don't encourage using elevated vacuum for transfemoral. He also said the more vacuum the better unless there are unusual skin issues. He likes a minimum of 14 mm Hg for good results.

Since it is my blog, I get to be the first reponder.  As for transfemoral, if people are happy with thier less complicated sytems, I agree that there is no need to change to EV, but it is sure nice to have that tool when you need more stability, better suspension, less volumetic instability, and more hip range of motion.  

Elevated vacuum sockets use gel liners as a skin interface. One of the first decisions required when fitting elevated vacuum is which liner?   I have my answer and, as always, I invite others to share their experiences and opinions.  

There are two saying that I keep in mind when looking for leaks in an elevated vacuum prosthesis.

My first absolute rejection of elevated vacuum was a recent Syme patient. I know that others have worked out well, but this man could not get past the application, fitting and removal of the liner.

He is a large 70 year old gentleman with vascular insufficiency.  In designing his prosthesis,  I had to consider that, when sitting, he is not able to bend sufficiently to touch his shoe or lower half of his Syme prosthesis (therefore a window with a sleeve ovet it was out of the question). Currently he uses a system with a window which slips into a ledge distally and fastens with a strap proximally. For elevated vacuum I decided to try a custom gel liner  which is built up proximal to the malleoli so that he can slip it into a solid outer socket and seal it with a proximal sleeve. Alas, he was unable to don the liner in the normal way, by reflecting it back on itself, due to his limited range of motion. He could apply it with lotion and it was very comfortable. But then he could not remove the liner independently.  After several liner designs and several socket designs, we are abandoning elevated vacuum for him. This does not mean that I would not fit elevated vacuum to the next Syme patient I see, but it means that it is not for everyone.