Amputee 101 Basics
Invaluable List of Lessons Learned

Valuable tricks learned the hard way (from experience):

        Choose a good prosthetist who will work with you to get a comfortable fit and the best alignment!  This is covered elsewhere on the website, but it is the most important thing.

• To prevent a prosthetic leg that uses a pin-system lock from accidentally coming off, cut out the end of a plastic bottle cap to protect the pin-lock release button.  This has saved me many times from accidental bumping of the release button on my steering wheel, car fender etc!
   
• When you put on your leg, get used to counting the number of "clicks" it takes to lock the leg on securely.  It is s good idea to take a spare pin or your empty liner and count how many clicks it takes BEFORE the pin hits bottom.  The pin must NEVER bottom out in the socket! If the pin bottoms out, it will put what is known as "distal-end pressure" on the end of your bone and your leg (a.k.a. your residual limb). OUCH!  Lots of pain!  Several weeks healing!  Inspect your locking pin like a forensic investigator to see where it is wearing.
   
• When putting on your prosthetic leg each day, learn and remember what works best.  I have to lean way over toward my good side to make the pin line up properly. Now that I know what works I have few difficulties in the morning whatsoever.  I also asked my prosthetist to drill a pin access hole for my finger so I could help align the locking pin manually.
   
• To figure out which way your pin naturally likes to go, just take a flashlight and look down inside your leg socket.  Pretend you are a forensic investigator and see where all the pin scratches are.  That is where the 3/4" access hole can be drilled by your certified prosthetist (CP).
   
• If you experience regular pin alignment problems, you can safely drill a hole on one side or the other to allow you to push/pull the pin manually by inserting a your finger or a small tool.  Drilling a hole of 3/4" or less will not cause any structural weakness.  I always recommend discussing these things with your prosthetist first however.
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• When taking your leg off at night there is nothing more frustrating to an amputee to have the locking pin stick and wont release.  If this happens, push in on the push-button release while you put extra weight down on your prosthetic.  Bounce extra weight gently one or twice as you are pressing the release button.  As mentioned below, I have moved from a notched pin to a smooth pin which locks and holds just as well and unlocks with much less effort.
   
• There are three types of locking pins now.  Serrated (notched), smooth, and smooth flexible (I don't like flexible).  I used the serrated pins for 6 years and was counting locking clicks everyday, but a few years ago I changed to the smooth pin system which I now greatly prefer.  There are no counting clicks to worry about and the leg is so simple to release at night.
   
• Speaking of handy tools, be sure to purchase yourself a nice strong shoe-horn.  I was so desperate once on a trip that I cut 1/4" off of my rubber prosthetic toes just to get my shoe on, but you might regret it from an aesthetic point later!
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• When you travel, be sure to take a few spare parts!
   
• Install some safety support bars for yourself.  Now that you are officially disabled, physically-challenged, or handicapped, you will need to have a way to hold yourself up when getting into the shower etc.  Standard towel racks just aren't strong enough.  I replaced all of my towel racks with nice-looking support bars.  Make a note of where you need them and get them.  I still use them for towel racks too.  Safety Note: Be sure to install them so that the mounting screws go directly into a wooden wall stud for added strength, otherwise they will just pull off the wall from the plaster when you put body weight on them.
   
• In the wintertime it feels good to put on a warm clothes right out of the clothes-dryer right?  The same applies when it comes to putting on (donning) your rubber silicone liner.  I lay mine on our old-fashioned water filled radiator. In the morning it feels like I am slipping into clothes fresh out of the clothes-dryer.  You can also use a hairdryer to warm it up in a few seconds.
   
• A spray bottle of very diluted soap and water makes it very easy to roll the silicone liner on.  I don't recommend using a silicone spray for two reasons: It is expensive, and your skin may develop an intolerance to the silicone.
   
• Despite what they may tell you, I leave my silicone liner rolled inside out every night when I am not wearing it.  This way I don't have to struggle with turning it inside out in the morning to put back on (see "donning"). I have been told that this is bad but it has never hurt a thing in 9 years.  I am only on my second silicone liner.
   
• You really don't have to wash the liner every single day in the sink like the books recommend.  Instead I have found that you can just keep a box of "Wet-Ones" or "baby wipes" by the bed and just wipe it down when you take it off at bedtime. This disinfects it too with an antibacterial ingredient.  This is a great time to wipe down your residual limb as well.
   
• A good type of silicone liner to use is an Ossur/Iceross brand (or other available brand) with a fabric "support matrix" inside of it at the bottom for extra strength where the pin is. The exact name of the product is "two color w. stab. matrix."  This is a strong cloth web inside the rubber in the area down where the pin is.  It is designed for strength, and stretches less so the leg stays on better and you don't experience the symptoms of it feeling like it is coming off a bit with each step.  It is important to preload your liner to avoid the feeling that it is coming off.  (See "donning" video)  Do not stretch it tight near the top however or you will experience "skin shear."  Instead, unroll the silicone liner only partially and stop near the top.
   
• When putting your stump socks over your liner, be sure to experiment with using the number that works best for you.  This number can (and will) change over time as you lose/gain weight and from muscle atrophy as well as your diet.  The general rule is to use as many as you can so that the leg feels like a part of you.  It should not be loose at all.  The number of socks you use also determines your height on that side of your body.  Be aware because this can affect the way you walk and also affect the alignment of your hips and your back.  If you are using extra socks, you will be taller, and if you use less socks you will be shorter so think about using shoe inserts to compensate when needed.
   
• Have some stump socks with no hole at the bottom for the pin?  No problem.  It might be common sense, but just fold the sock in half lengthwise and cut a very small piece off the end of the knee with scissors.  It may fray slightly, but at least you have useable stump socks.
   
• The top of the socket should NOT make contact with your groin area.  There are ligaments and a very sensitive nerve there.  Only the back lip (ischial lip) of the socket should slightly ride up under your rear end (buttocks).  Try adding additional stump socks if you need to lift up out of the socket a bit higher.  It took me years to learn this simple and obvious thing.
   
• Be sure your prosthetist cuts out an open area in the hamstring (back part) or posterior part of the carbon-fiber socket!!!  This cutout to expose the flexible area, where the inner flexible liner is able to be exposed makes it much easier to sit down on hard objects like a simple toilet seat.  It will also prevent the back of your pants from getting cut from the friction against any object you sit on like a chair, a wall etc.  Without this cutout area your artificial leg will keep trying to slide off the toilet seat and all restaurant seats in general.  AK amputees will leave a scratch mark on toilet seats.
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• Speaking of toilet seats, if you are an above the knee amputee, you will inadvertently scratch your friends nicely painted toilet seats unless you slip something soft between the hard seat and the bottom of your socket.  A magazine, a handkerchief, or a few pieces of tissue will work to insulate the two and prevent embarrassing scratches.
   
• Be sure the prosthetist cuts out an area on the anterior (front) of your socket too.  This one is not quite as important as the back, but it will give you some tactile sensation when a person sits on your lap.  If you ever itch, you can even press down on it which helps scratch that itch.
   
• Ask the prosthetist to put your favorite color on your socket.  When a prosthetist makes your socket, they can add any design you want.  Don't hide your leg, show it off!  You can also apply your own decals if you like.
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• Use a knee rotator!  I can't recommend this strongly enough.  Use a Otto Bock knee rotator diagram, knee rotator button, Daw rotator, Endolite rotator, Hosmer rotator, or Otto Bock rotator if possible (there may be other brands).  It makes little things like sitting on the floor comfortably, golfing, getting in and out of the car, and yes, even spreading your legs in the bathroom on the toilet much easier!   http://www.waramps.ca/nac/rotators.html
   
• Be very careful when you "don" roll on a silicone liner or it can rip!  Watch out for small nicks especially near the top of the liner that can develop into tears.  Watch out for your sharp fingernails.  These silicon liners aren't cheap. (about $500 each) (see "donning" video)
   
• When your silicone liner is rolled on, the top of the liner should come up to within about 1 or 2 inches from your groin.  Roll it, don't pull it because your skin will get badly irritated if the skin is being stretched all day especially at the top.  See the photos of skin shear ring and folliculitis.  A little bit of lubricant around the top will help prevent and relieve this.
   
• Make sure your silicone liner is the proper size diameter.  If its too tight, it will cut off the blood flow supply to your leg and your leg will appear to get very heavy and very painful!  Being too tight though is not what causes skin shear or skin tearing.
   
• Keep your prosthetic leg away from saltwater if possible!!!  The metal parts are not at all tolerant of saltwater or even salt-spray.  The "Aulie" water-leg might be OK though if you rinse it afterwards.  If used in or around water, especially saltwater, you should spray metal parts with a lubricant and anti-corrosion product called CRC 6-56, WD-40 etc.
   
• I know that new amputees from the war in Iraq can benefit from this shrinker sock idea.  When your leg is first amputated, it is very painful to put a shrinker sock on over the gauze bandages because the nerve ending are so sensitive.  Walter Reed Army Medical Center (WRAMC) needs to start using the shrinker-sock sleeve idea because anyone who has had amputation surgery and then had the nurses try to get the elastic shrinker sock back on over the bandages without pain is impossible.  After one painful experience I said "enough was enough!"  I had a friend take a plastic Rubbermaid bowl large enough in diameter (8") to fit over my residual limb (in this case my thigh) and cut the entire bottom out of it.  From that point on, when it was time for the bandages and shrinker sock to go back on, here is what we did:
  
              1.  First, slide the tight shrinker sock on the round Rubbermaid container with the bottom cut out of it.
              2.  Next, slide the Rubbermaid container gently over the amputation site until the bottom end of the shrinker sock gradually slides itself into place over the gauze bandages.
              3.  Keep sliding the Rubbermaid bowl up your leg until the shrinker sock slips all the way off the bowl and into place on your leg.
              4.  Finally, just simply slide the bare Rubbermaid container off of your leg.
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• For occasional phantom pain (PP) voltage spikes, on an as-needed (PRN) basis,  my doctor gave me a bottle of 400mg Neurontin (Gabapentin) which works wonders.  Check with your doctor first, but I take one here and there as needed.

Notes on Prosthetic Alignment (proper alignment is critical):

• Knee alignment is critical to having a normal and proper walking gait!  The centerline of the body's weight MUST be slightly behind center of the knee so that the knee is just slightly hyper-extended.  Without a slight hyper-extension, the knee will buckle forward when normal weight is applied when standing.  A slight degree of hyper-extension (the knee trying to bend backwards) is required for mechanical knees to prevent buckling.   Assuming that the general alignment of the knee itself is correct, if the knee buckles slightly when wearing a different pair of shoes, you can just remove a pad from beneath the heel or add a new one under the toe area.  You will feel the difference in "toe-over" immediately.
   
• Ankle adjustment is just as important! Once this is done you can "tweak" it by trying different thicknesses of heel inserts in shoes.  If you need any, you might want to readjust the ankle angle first.  Excess heel height (too many inserts) causes you to compensate and lean forward giving the impression of bad posture and makes it look like you are sticking your belly out. I was told I was getting fat all because my body was over-compensating to maintain my balance. Also see low heel height.
   
• After proper knee and ankle alignments, you can add (or remove) heel or toe inserts to fine tune the finished alignment.
• Different pairs of shoes (and legs) may require different sized heel (or toe) inserts.  As your shoe heel gradually wears out you may have to compensate for this. You should actually keep a simple chart to keep it all straight in your mind.  It takes a while to get it right and you don't ever want to forget how you have things setup once its right! I actually even recommend using a permanent marker to write down inside the shoe how many heel or toe inserts you use in that particular pair of shoes. When you add any heel or toe insert, be sure to tape it in place so it doesn't fall out or slide forward out of place.  Once you know what you need, you can even tape the inserts to the bottom of the foot inside your sock.  It is important to know that adding heel or toe inserts affects the overall length of the prosthetic leg.  It will take you awhile to get your leg just the right length.  To long, or too short can make you walk strangely and even give you a sore back.

Notes on hydraulic cylinder adjustment:

• Each hydraulic knee cylinder is different.  Even ones from the same manufacturer will have to adjusted slightly differently for "gait" (speed), "extension" (leg swinging forward) and "flexion" (leg bending back).
   
• There are five basic adjustments on a hydraulic knee cylinder.  Extension, flexion, stance control, knee lock, and knee release (free swing). Get instructions and be sure this gets explained to you because you CAN easily experiment and adjust these by yourself without any warranty issues.
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  Practice walking using a full length mirror.  This is a great way to observe yourself.

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