[AMP-L] Symes Amputation : Liner & Foot Recommendations
renardwc at ctrvax.vanderbilt.edu
Tue May 17 12:03:23 PDT 2005
Ms. Kristin Schafer, CP(c) asked via OANDP-L about her symes patient:
She asks if you have any suggestions to reply direct to her:
<hergladness at cyberbeach.net>
"If any amputees out there would like to lend their two cents worth to
the cause, it would also be appreciated." KS
>From the AMP-L lexicon:
Symes: An amputation through the ankle joint that retains the fatty
heel pad portion and is intended to provide end weight bearing.
I have a very tall gentleman with a long symes amputation. He has no
(protruding) malleoli [either of the hammer-shaped bony protuberances
at the sides of the ankle joint that project from the lower end of the
tibia and fibula] and is a very cylindrical shape. At present we have
him in a segmented liner with a cuff suspension. He finds it big and
bulky, and is having problems with what he calls "rubbing" on the
distal end. The distal end is calloused but I am wondering if it is
actually due to lack of distal contact. He is very sensitive to any
weight-bearing pressure (distally) so I wonder if I have created a
choking situation. I would like to switch him to a liner and a more
dynamic foot as he is a very active construction worker.
What liners have you used and what feet would you recommend? I am
contemplating the Iceross sport (since he has very mobile tissues) and
some sort low profile Ossur product.
I would appreciate all comments/opinions.
Kristin Schafer, CP(c)
Try the Silipos Molding Distal Roll-On gel liner article #1496 to add
some padding without too much bulk to the distal end. Regarding feet,
the Otto Bock (Springlite) Lo Rider Foot, is a good choice for this
gentleman. Nice gentle roll-over action, dynamic, and easily adapted
to Symes prosthesis
Expandable bladder system symes which is much more cosmetic and creates
very good suspension.
As far as I can see, the fellow to contact is Jan Stokosa. His e-mail
address is <jan at STOKOSA.COM>
There was a story in Reader's Digest years ago about Jan and his father
doing work with a family. The father in the family lost his leg in a
car explosion and the son was a partial foot amputee due to trauma.
The father went to see Jan Stokosa's father and the son went there
after they had both been elsewhere with less than desirable prosthetic
results. The Stokosa's made a prosthesis for both father and son that
worked and the story in Reader's Digest said they were happy. A quick
search for Jan Stokosa turns up this page.
Another I can think of is an 80+ year old fellow in Sweden that I
stumbled across his web site. He became a Symes amputee in the 1950's
from a streetcar accident. The web site traced what had been done for
him in the 50 years since his traumatic amputation and what about each
thing he tried that didn't work. I can't find that web page to save my
hide right now. The purpose of this Swedish man putting the web page
up was to help people learn the right things to do with partial foot
I have fit many symes amputees with custom silicone liners made to
special specs by Freedom innovations. If you decide to go this way
talk with Craig MacKenzie at 407-841-6335. As far as tension or shear
forces on the distal end, , sometimes we are have overcome this using A
and D ointment to keep these forces from occurring at specific areas.
In my experience I often find prefabricated liners too short for some
Symes amputations. If so, I have had good success with Otto Bock's
custom TEC liners. You can specify added thickness where you want.
My choice of feet depends on the length of amputation. I recently used
an Impulse Symes System from Ohio Willow Wood. It went well.
I had two very similar cases and used a custom TEC liner and a TSB
symes socket. I used suction suspension. Your guy would probably not
get much life out of a suction sleeve. I put this on a Low Profile
Vari Flex (Ossur). The system works great.
Consider using a Seal-In liner. Same cushioning and a no-pistoning
suspension. He will love it.
I've had good luck with Ohio Willow Woods liners. Also consider a valve
in the distal end (or close to it)to reduce pistoning and shear forces.
How about a custom made TEC liner with suction suspension? I have had
success with this method. My PT also wears an Otto Bock DP II foot .
You can order one with low clearance.
I have recently used the new low profile Variflex, although it does not
have as good an energy return as the standard Variflex. My patient
loved it compared to his Quantum foot. If you have room I would
recommend it or Freedom's low profile foot which has a slightly bigger
build height. I have used this a couple of times and had positive
In regard to the liner, one of the least bulky builds is to custom make
a silicon or polyurethane inner socket and laminate outer.
Otto Bock has a new lowrider symes set up that is very nice. The liner
I use for this situation is an OWW with a extra distal cup for the
patient to add when the distal end packs down.
I'd use a 1C20 Otto Bock symes foot and a custom Tec liner.
Speaking from personal and professional experience the best liner for a
symes is probably the Alpha Max. The Iceross sport has a distal
attachment which will be uncomfortable. The same is true for most of
the Iceross gel liners with the exception of the Comfort and the Dermo.
The sizing on these may not necessarily work for your symes amputee.
The Alpha Max has better protection of gel over the distal seam. The
regular Alpha liner can wear down in this area and cause skin
irritation. If your client has been wearing socks for a long time, it
may take a while for him to become accustomed to a gel liner. I would
suggest trying a nylon next to the skin.The following feet will work
well with a symes---Freedom Innovations symes foot or the Otto Bock
Axion. I am not sure about durability for the Axion, but the Freedom
Innovation foot is very durable and the split toe works well. I have
found the Ossur feet to be functional, but stiff.
If he has calluses on the distal end he definitely has too much distal
We just worked on a woman with a symes and used an Ossur Seal-in liner
and a Springlite low profile dynamic foot (I don't have the part
number, but the clearance was the lowest I could find. It had the
pyramid attached directly and clearance of only about 1".) As long as
you can get the seal in liner long enough to cover the entire leg to
The 3mm sports liner sounds like a good option. I had a very long
patient one time for who the standard liner wasn't long enough. I made
a special request to get an "untrimmed" liner which gave me about an
inch more length.
I have a similar case resulting from congenital absence of fibula.
Being a congenital malformation ,I don't have the same build height
problems as your case -the lack of tibial bone growth provided just
enough space to accommodate most types of feet.
However, I was presented with an aspiring paralympian with a very long
and tapered residual limb. I found that the best liner for him was an
Iceross Comfort+ cushion liner size 16 (a custom made liner was not an
option). Of course that size liner isn't designed to fit an adult with
highly developed calf musculature; nor is it rated for his extreme
activity level. However, the Comfort+ proved to provide superior
comfort whilst being exceptionally durable. The extra length that
Iceross manufacture into their liners, combined with the elasticity of
the grade of silicone in the Comfort+, gives just enough length in the
liner to fit his Symes length amputation.
Freedom Innovations offers the Evolution SP Liner, a custom silicone
interface that can be used for difficult Symes applications. The custom
design of the liner ensures a perfect fit and the firmer material
durometer (low 50s) reduces skin reactions caused by shear forces. The
Evolution SP Liner is manufactured using platinum-cured silicone,
adding the additional benefit of odor elimination and dramatically
improved hygiene. Amputees truly enjoy this!
While custom Symes liners can be challenging to fabricate (due to
issues in de-molding a mold with a bulbous distal end) and would not
fall into our standard 72 hour lead-time guarantee, it may be just what
your patient requires. We will provide you with a liner that not only
fits well but is extremely durable in a very timely fashion (usually
within a week of cast receipt.)
I am proud to say that we have had great success with several Symes
amputees after their return from Iraq and Afghanistan and I am
confident that we would be able to assist you with your needs.
(As a side note about Symes applications, some practitioners have
requested extra material build-ups in the liner, above the bulbous
portion of the limb, which allows the amputee to slide into the
prosthesis without a door. They report that this has worked very well
Freedom Innovations also offers a number of dynamic foot options for
your patient. I am happy to speak to you about our new Symes option,
which is currently in trials, and the Evolution SP Liner in more detail
if you like
I have one out and one going out soon on the Veriflex LP with direct-
lamination adapter. You need a good 3+ inches of clearance though...
but a great foot! AFAIK, the only dynamic symes-type foot with split-
toe/heel. It seems to make a difference for symes with that long, long
lever! Good luck with the liner side of things.
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