P.S. and the Next Phase

March 8, 2013     Post Script notes on my previous post. I had made a checklist to show that I am ready to move on to the final phase of this prosthesis-fabrication journey, but I glossed over one item which needs a bit more attention: my skin. I want the reader to try to understand when I write "zero skin lesions" how enormous this really is for me. I have battled skin lesions on my knee for probably 25 years. If you have ever had a 'corn' on your toe which has developed from shoe pressure or toe misalignment, you have some idea of the type of pressure sores I am talking about. They are thick, calloused areas which are painful even to touch, let alone to bear all the weight of one's body. Over the years, I have had to deal with these in different ways: have a doctor remove them and use crutches for several days until I could wear my prosthesis again; have the prosthetist grind out the prosthesis in the affected area (not very effective); use a scalpel a couple times a week to shave off the built-up callous; avoid weight bearing on 'difficult' surfaces (uneven, hills, stairs). All of these I have done and still over the years the pain I have had from these lesions has grown until (in the past 3-4 years) it had become quite severe. That was what finally brought me to my orthopedist and ultimately, to Metro Prosthetics and Dennis Haun. So, all that to say that I really, really wish I had pictures of my knee with its lesions before....and after. It is amazing. I never thought I would see the skin on my knee look like it does now. It is smooth and has absolutely no callous, even on the large tibial prominence in the front of my knee which caused me the greatest pain. I have no pain from pressure points. At all. Thank you a thousand times to Dennis! This gel liner and suspension system is awesome! Oh, and the foot....the foot. Today I walked all around at the park with the kids, up and down hills, over bridges and across fields without feeling like a knife was stabbing into my knee. This Venture foot is crazy good!

I have been wearing the new (test) socket full-time now since February 16. That marks another milestone; I no longer want to wear the old prosthesis because the new prosthesis is more comfortable. The new socket is now mine. The old prosthesis continues to be useful first thing in the morning before my shower. Because it takes fewer steps to don my old prosthesis (pull on socks, then slip on the limb), I use it to walk to the shower. After my shower, I don the new prosthesis (apply lotion, pull on gel liner,  smooth out air pockets, pull on sock, slide into socket, apply knee sleeve). More steps, but well worth it once it's in place.

Now for the fun part! Today's appointment. Today, Dennis "poured" the final socket and he allowed me and the kids to watch as he and his team worked. It is quite fascinating the way it is done. I have been an amputee for a long time, but I have never watched the prosthetic fabrication process up close. This is a science and Dennis has it down, but it is so much more. There is an art to the process. Each limb is unique because each person using it is unique. Her skin, his residual limb shape, her activity level, his knee, her hip, that one's job, this one's stubbornness. It all has to work. That is the art. The choice of a correct 'medium' to capture the exact needs of the individual. The reason Dennis is so good at what he does? He listens to the needs of the individual and he has the skills to give them what they need. He knows how to choose the correct 'medium.'

First, the jig is set up to hold my test socket in place using a thick pipe and clamps.
Dennis builds up the walls of the socket a bit with tape to prepare to pour the moulding material.










He mixes up the moulding material which he explains is the same material that dentists use to make dental moulds. When it 'hardens' it is a rubbery solid.

Jonathan getting into the process.

He pours this into the socket to make a mould of the adjusted test socket. This is actually an extra step that is not required for all prosthetic fabrications. Because my limb has a bulbous-shaped end (my ankle), the first mould has to be pliable. You will see why in the next step.



The delicate part here is removing the socket from the mould with out breaking or cracking the moulding material. Dennis pulls the socket slowly and removes it with the mould intact.



On the right is the first positive mould of my socket.















Next, Dennis sets up another jig to hold the mould in place while he applies a hard plaster to the mould.  This will be used to make a second (harder) mould. The plaster is applied to the soft mould. The plaster hardens quickly while the softer dental mould material begins to shrink, allowing the mould to be pulled out of the hard plaster mould. This is the extra step needed. Otherwise, the mould would become stuck by the bulbous end of my residual limb. Pretty cool. 

Getting ready to apply hard plaster

Applying strips of plaster

Smoothing the plaster mould

That's all for today's visit. Dennis returns my test socket for my use while he and his team fabricate the final socket over the next week or so. They will use carbon fiber and resin which is very light weight. The carbon fiber alone is black, but they can add layers that are mixed with resin and pigment to resemble flesh tone. This will be fabricated over the final mould made from the plaster in the above photo.

Plaster mould sitting on jig waiting for next phase

Amelia helping clean out plaster residue

OK, I'm Ready Now

March 6, 2013     Since this new prosthesis is very different from any previous limbs I have used, I have wanted to be very conservative and take my time to be sure everything is right before the final "pour" to fabricate the permanent limb. Here's my checklist:

_most importantly, the socket is comfortable
_zero skin lesions or pressure points
_gait is natural
_increased ease of movement on stairs and inclines
_height is right
_knee function is maximized
_BONUS: I can balance for a short time on my RIGHT leg and am working on increasing the time

So, with all of these items in place, I decided to try an early morning workout over the weekend; I did a basic, total body/aerobic workout for about 50 minutes. Now, this is a workout I have used many, many times, but NOT in a few months. I haven't been able to work out due to pain (previously) and not while making all of the changes needed to fabricate the new limb.  During the workout, I felt my right leg working harder than usual (and I have noted this in daily activities as well), but I pushed through and finished the workout. Turned out not to be such a great idea. I hobbled around for the entire day with a very sore right knee, while giving this outcome some thought.
I had a theory. In the evening, I weighed myself wearing my old prosthesis and then wearing my test socket. There was approximately a 4.5 pound difference, the test socket being heavier due to the plaster which covers part of it. So, when wearing my test socket, it is like strapping on a 4-pound weight and wearing it around for the entire day.....and during an entire 50-minute workout. That probably explains the soreness, especially since my knee felt much better the following morning. I am encouraged. All of this time, I've been wearing this extra weight, so I am going to think that this has strengthened my right leg muscles and therefore, when I try out my lightweight carbon fiber permanent socket, it is going to feel fantastic. That is my theory. We shall soon see, because this Friday, I go to have the final socket poured. Then Dennis will fabricate it and sometime in the next couple of weeks, I will see if my theory is correct.
Another note: during my workout, my LEFT (unaffected) knee was less stressed than usual. How do I know? I couldn't hear or feel it making it's usual creaks and groans. Definitely a plus. It's all good.

So, I'm ready now to be done with this test socket. Time to move on!

1/4 Turn Here, 1/4 Turn There

February 19, 2013     I've been wearing my test socket now for 12 days, including the day of my latest checkup with Dennis. He increased the amount of knee flexion that is built into my socket to allow for a slight knee flexion contracture that I've had for a very long time. This simply means that my knee will not completely extend. So, as I've been walking the prosthesis has been causing my knee to extend beyond the contracture and so has been causing the posterior knee pain. Once again, it's a quirky characteristic of my knee, but after making this adjustment and walking for a couple of days, it feels much better. Dennis also slightly changed the 'toe-out' angle to keep my knee in less of a valgus position through the gait cycle.
So, that was Friday February 8. I was still experiencing some knee discomfort, but I decided that I need to just wear the new socket daily, try to push through the discomfort and see if it will work itself out. The idea being that my knee will slowly feel better with the new adjustments. No good. By Thursday, I am feeling more posterior knee pain. But I am certain we are on the right track. I decide to give my knee a break and wear my old prosthesis on Friday (the day of our Valentine's Day date). I call Dennis and after we discuss these results, he gives me instructions to slightly change the flexion in the socket again, trying to add just a bit more. Duane understands how the turn of the anterior and posterior screws changes the angle of the foot, so I let him do the adjustment using Dennis' instructions. A quarter turn each on the anterior and posterior screws and off I go to give it another try. Saturday and Sunday my knee feels nearly perfect. We are so close. On Tuesday, I have Duane turn the A/P screws 1/8 turn again. I am going to let it ride this way for a couple of days and see how it feels.

Valentine's Day Post Script: As noted above, I was wearing my old prosthesis for our Valentine's Day dinner date, so the red-dress-and-pointy-black-shoes worked just fine. We took a few pictures, and they were all lousy iPhone/Pod shots, but I posted one anyway. I will tell you though that after wearing the new socket with the Venture foot for several days, and then switching back to the Seattle foot, I am amazed at the difference! The old Seattle foot is so clunky and uncomfortable, especially with my dress shoes. The Venture foot is a drastic improvement. Like a Cadillac to a 3/4-ton pickup.

Thought for the Day....

February 13, 2013    Switching from my old type of prosthesis & socket to the new is like switching from Pilates to Boot Camp.  At first it's hard and my muscles are screaming, BUT if I persevere, there will be great benefits.

Roses Are Red.....

February 11, 2013     On Friday I decided that I am just going to wear the new prosthesis without a break (except at night) until my next appointment. If this new prosthesis is going to be mine, I have to use it.

OK, so I'm feeling really good about it. Like I can take on the world....or maybe be an Olympian kick-boxer.   Is that an Olympic sport?










Oh, then I remember that this week contains Valentine's Day. We like to go out for a nice dinner on Valentine's Day. What do I do about that?

Roses are red,
Violets are blue,
My prosthesis isn't finished yet,
So what do I do?

Well, would you go out looking like this?
And...would you wear nylons??


So, here's the thing. I want my prosthesis to be comfortable and functional and that is my priority. Really. But I'm also girly. I like wearing dresses and cute shoes. So, as much as I admire the posters of athletes running with their "blades", well the blade-and-pipe look just doesn't go well with a red dress and pointy black shoes. Maybe I'll take a night off and wear the old prosthesis. What do you think?

Weekend Results...

I wore the new (test) prosthesis all day Friday and all day Saturday. Saturday evening Duane and I took the kids for a family swim at Finn's Swim School pool for some fun. I wore my I'm-not-sure-how-old-it-is swim leg that has been uncomfortable for a number of years - but, I have only the one prosthesis which is OK to wear in the water, so I deal with it. It usually causes me discomfort after wear. We had a really great time swimming with the kids, so it was worth it. Sunday, my knee was sore when I first put on the new prosthesis, but there was no worsening through the day. I was able to wear the new socket all day once again. No posterior knee pain. So, all in all, that's good news.

So, that brings us to another problem we are trying to solve, which is, what to do about a new swim leg. We are leaning towards using my current prosthesis. Why can I not simply swim without one? Well, I could. But then what do I do when I am not in the water and how do I help the kids? It's not practical for me. Using the current prosthesis makes the most sense, but I have to figure out how it will work. The swim leg I have now has holes which allow the water to escape, so that removal is not overly hampered by water-induced suction (that sounds technical, but even with the holes, the silly thing has been stuck on my leg before and it is not fun trying to get it off). Note to self: ask Dennis about that one.

Swim Leg

What's Going on Now?

February 9, 2013     After 2 weeks of trying out both the Echelon foot and the Venture foot, we have determined that the Echelon foot is simply making the prosthesis too long. There is just not enough room for the mechanics. I'm totally OK with that. The Venture foot is an excellent alternative. Getting used to the Echelon foot for me was also a challenge because there were several new sensations happening in my gait. I think in the end, even if the height had not been an issue, I may have still chosen the Venture foot. I love the smoothness of my gait and the extra help it gives me on hills.

We checked in with Dennis yesterday at his office. The 2-week trial revealed 3 main things: 1) there is a spot at the top of the plastic socket that needs to be relieved, it is pushing on my knee and causing discomfort. 2) use of the prosthesis is causing posterior knee pain (after 10 hours or so). 3) when I walk, I feel my knee being pushed into more valgum ( my right knee moving toward my left).

After discussing these issues with Dennis, he is going to slightly shorten the height of trim lines (the top of the plastic socket that goes above my knee) to relieve the pressure. Also, he makes an adjustment which will allow less of an extension moment at my knee during the push-off phase of gait (when my right leg is the back leg). This will hopefully put less pressure on the posterior part of my knee and thus relieve the pain. To fix the knee valgum issue, Dennis uses the adjustment plate at the ankle once more and slides the foot to its maximum medial position (towards center) to give me a varus moment. Hopefully this will be enough to give me the proper balance between inward and outward movement at the knee as I walk. If more adjustment is needed, then at the next appointment, he will have to reattach the adjustment jig. Trying the prosthesis at the office with these new adjustments, everything feels pretty good. So, we'll take it home and give it a real workout.

What am I looking for at this point? When having a new prosthesis fashioned, there is a transition which occurs at some point along the journey of fittings, adjustments and trials. The transition happens when my old prosthesis stops being mine and the new prosthesis takes over; when I no longer want to put the old one on so that I am more comfortable, but I prefer the new one because it feels and functions better. There is an aspect to this which involves physical comfort and improved function, but another aspect which is purely 'psyching' myself into this transition. At some point in our visit with Dennis yesterday when we had discussed several negative points, he looked me in the eye and said something like, "Are you OK with all of this?" I very unequivocally replied that "I am not going back." There is a give and take between the prosthetist and the client. We each have our job to do. Mine right now is to persevere through this phase, to be patient as we try different adjustments, to be aware of whatever might be causing the problems and to communicate these very well to Dennis. His job is to work through possible solutions and execute them. He is very good at explaining the reasons behind each of his adjustments or fixes and gives me confidence that we will get to that point where the new prosthesis is mine.

I have some pictures to post later.....