







































McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound 
healing: a case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 

 

 

 

 

ISSN: 2561-987X 

VOLUME 2, ISSUE 1 

 2019 

 

(ONLINE) 

CASE STUDY 

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M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
1 

 
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CASE STUDY  

 

THE INFLUENCE OF PERFORATED PROSTHETIC LINERS ON RESIDUAL LIMB 
WOUND HEALING: A CASE REPORT 

 
McGrath M.1*, McCarthy J.1, Gallego A.1, Kercher A.2, Zahedi S.1, Moser D.1  
 

1  Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK. 

2  Endolite North America, Miamisburg, OH, USA. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The interface between the residual limb and the prosthetic 

socket is, arguably, the most crucial part of successful 

prosthetic prescription.1 Without a comfortably fitting 

socket, the patient will not wear their prosthesis.  

The skin and soft tissue of the residual limb are particularly 

susceptible to damage. Contrary to historic biomechanical 

assumptions, there is evidence to suggest that this 

interface should be considered as an extra joint in the lower 

limb, with translation and rotation,2,3 which lead to 

unnatural loading profiles. There may also be scar tissue 

and, if the amputation aetiology was dysvascular, the 

tissue is at greater risk of pressure ulcers,4 which cannot 

heal as well5 and could result in revision surgery or 

reamputation.6 

Another issue that exacerbates the problem is excessive 

sweating.1,7–10 When questioned about the factors affecting 

ABSTRACT 

CASE DESCRIPTION: Good residual limb skin health is vital to successful 

prosthetic prescription. Unnatural loading profiles and excessive sweating can 

lead to skin and soft tissue problems. Perforated liners allow the transport of 

moisture away from the skin and allow negative pressure (a condition that has 

been shown to aid wound healing) to act directly on the residuum surface. 

AIM: Assess the effects of perforated prosthetic liner use, particularly with respect 

to wound healing. 

METHOD: Three patient histories were retrospectively reviewed following 

prescription of perforated prosthetic liners due to excessive sweating or prolonged 

residual limb health concerns. Photographic records from patient files were used 

to document changes in residual limb condition. Patients also provided subjective 

feedback regarding their experiences. 

FINDINGS: Two cases described active amputees with persistent blistering 

irritated during exercise. Another case described a patient of low mobility level with 

a history of residual limb skin infections. All saw their conditions heal and reported 

a reduction in problematic sweating. Two patients reported cancelling surgical 

interventions after substantial improvements with the perforated liner. 

DISCUSSION: These findings provide evidence that the use of perforated 

prosthetic liners allow improvements in residual limb health, while still permitting 

prosthetic use. 

CITATION 

McGrath M, McCarthy J, 

Gallego A, Kercher A, Zahedi 

S, Moser D. The influence of 

perforated prosthetic liners on 

residual limb wound healing: a 

case report. Canadian 

Prosthetics & Orthotics 

Journal. 2019; volume2, 

Issue1, No.3. 

https://doi.org/10.33137/cpoj.v

2i1.32723 

KEYWORDS 

Perforated Liner, Residual 

Limb, Wound Healing, 

Sweating, Vacuum, Lower 

Limb Prosthetics. 

*CORRESPONDING AUTHOR 

Dr. Michael McGrath, 

Research Scientist – Clinical Evidence 

Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, United Kingdom 

Email: mike.mcgrath@blatchford.co.uk  

Website: blatchford.co.uk  

DOI: https://doi.org/10.33137/cpoj.v2i1.32723 

ARTICLE INFO 

Received: May 23, 2019 

Accepted: July 29, 2019 

Published: August 1, 2019 

 

https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v2i1.32723
https://doi.org/10.33137/cpoj.v2i1.32723
mailto:mike.mcgrath@blatchford.co.uk
https://doi.org/10.33137/cpoj.v2i1.32723


 

 

M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
2 

 
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their quality of life and their satisfaction with their 

prostheses, up 70% of lower limb amputees have reported 

that they consider sweating a problem7,11 and up to two-

thirds claim that sweating adversely affects their activities 

of daily living (ADL).12  

The causes of excessive sweating in amputees are clear. 

It has been reported that trans-tibial amputees use 10-40% 

more energy than able-bodied people to walk and perform 

daily tasks.13,14 They also have a reduced surface area 

(approximately 10-15% less), which affects the capacity to 

transfer heat energy and cool down.15 Consequently, the 

body’s natural response is to produce more perspiration. 

Furthermore, the use of prosthetic liners, made of silicone, 

polyurethane or TPE gel, creates an even warmer 

environment locally, around the residual limb because they 

often have poor thermal conductivity.16,17 This 

impermeable18 micro-climate is moist, warm and nutrient-

rich, making it ideal for bacterial growth. The sweat is stasis 

on the residuum surface instead of evaporating, which can 

lead to skin problems, such as dermatitis.19–21 

There is evidence that liner material selection can reduce 

residuum temperatures,22 such as the Alpha SmartTemp 

liner (WillowWood, Roseburg, OR, USA), which uses 

Phase Change Material that stores and releases heat 

energy. However, it is unknown whether this is sufficient to 

reduce thermal discomfort.23 Regardless, even if sweating 

is reduced, what perspiration does occur will remain on the 

skin, so associated problems remain. In light of this, 

“breathable” prosthetic liners have been developed, which 

have permeable surfaces to allow the transfer of air and 

moisture away from the skin, such as Silcare Breathe 

(Blatchford, Basingstoke, UK) with laser-drilled 

perforations and SoftSkin Air (Uniprox, Zeulenroda-

Triebes, Germany) with micro-pores. This report describes 

cases of patients with residual limb health conditions who 

were fitted with perforated liners. 

METHODOLOGY 

Participants 

The case histories in this study were collected 

retrospectively. Once relevant cases were identified, the 

patients were approached and they were asked to provide 

written consent for their case to be described. The 

inclusion criteria included being over the age of 18, being 

able to provide informed consent, having a trans-tibial 

amputation, being a prosthetic limb wearer, having a 

history of residual limb health issues and having changed 

to a perforated prosthetic liner. 

Perforated liners 

There were two types of perforated prosthetic liner used in 

these cases; one (Silcare Breathe Cushion,a Blatchford, 

UK) used with elevated vacuum suspension (EVS) or a 

passive vacuum and the other (Silcare Breathe Locking,b 

Blatchford, UK) used with a pin-lock. The ‘cushion’ version 

has a rounded distal cap and is used in conjunction with a 

suspension sleeve. A distal one-way valve in the socket 

allows the use of suction suspension or EVS. Laser-drilled 

perforations are distributed along the length of the liner. 

There are also perforations in the distal cap. On the pin-

lock version, the perforations stop a short distance from the 

distal end. At the distal cap, a valve opens when the wearer 

bears load and closes again when the limb is lifted from the 

ground, creating a small area of passive vacuum in the 

area distal to the perforations in the wall of the liner, which 

facilitates the retention of the residuum within the liner.  

Data collected 

Demographic data were collected from the patients in each 

case. These included gender, age, K level and any relevant 

comorbidities. Their prosthetists were asked to describe 

the patients’ prosthetic prescription, including suspension 

and ankle/foot technologies, before and after they were 

fitted with the perforated liner, to identify any potentially 

compounding factors for consideration. 

Photographic evidence of residual limb health conditions 

was gathered to verify the clinicians’ own patient notes. 

Since the analysis was performed retrospectively, photos 

were only available when the clinician, or the amputee 

themselves, had seen fit to take one. These images were 

used for a qualitative examination of changes in residual 

limb health. 

FINDINGS 

Three case histories were collected, covering different 

demographics, prosthetic preferences and residual limb 

health issues. Since the analysis was retrospective and 

gathered from different centres, the detail included in the 

patient records was variable between cases (Table 1). 

Case #1 

The patient was a 41-year-old male with a right-sided, 

trans-tibial amputation caused by a road traffic collision 

approximately four years prior. He was 90kg in mass, with 

a body mass index (BMI) of 28.4 and he had been 

classified as a K3-K4 level walker. 

Following limb loss, the patient wished to return to his 

previously active lifestyle, including regular jogging, 

walking and cycling. However, exercise, combined with his 

silicone liner had led to excessive perspiration building up, 

remaining on the surface of his residuum and collecting 

distally. The patient reported that this caused relative 

movement between the residuum and the liner and 

chaffing. Blisters would develop in and around the scars at 

the distal end of his residuum, where sweat collected 

(Figure 1a). Jogging on consecutive days led to prosthetic 

disuse on the third day because the blisters made limb 

wearing too painful.  

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M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
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In fact, the patient had booked a surgery to revise the 

scarring at the distal end of his residuum, in the hope that 

it would help to reduce blister formation. As a result of 

sweating issues, the patient was fitted with a locking, 

perforated liner on 19th June 2017. It was believed that he 

would prefer the pin-lock version because it removed the 

necessity to wear a suspension sleeve. At initial fitting, the 

patient reported finding the liner comfortable to wear and 

easy to don.  

A follow-up appointment was carried out after a month on 

24th July 2017. The patient reported that the liner remained 

comfortable, with good prosthetic control. He had 

continued jogging and walking and although he felt that his 

limb felt about the same temperature, there had been 

considerably less sweat on his limb after doffing the liner, 

which he described as only a “slight glisten” on the skin. 

His prosthetist reported no skin breakdown and 

improvements in the existing blistering had led the patient 

to postpone his surgery. There was a review appointment 

after three months in September 2017, at which time the 

patient was regularly going for 8km jogs, the blistering had 

healed (Figure 1b) and he had cancelled the surgery. 

 

Figure 1: The condition of the Case #1 patient’s residual limb (a) 

before being fitted with a perforated liner and (b) after three 

months of use. 

Case #2 

The patient was a 45-year-old male with a right-sided, 

traumatic, trans-tibial amputation. He was 100kg in mass, 

with a BMI of 30.2 and he had been classified as a K3-K4 

level walker. 

Prior to and since his amputation, the patient enjoyed 

competing in motocross endurance races. For these 

competitions, he would wear a carbon blade-style 

prosthesis with a sole plate and pin-lock silicone liner. 

However, he struggled with excessive sweating on his 

residual limb and had skin issues since 2014. An ulcer 

developed on the posterior-distal aspect of his residuum 

(Figure 2a) and it worsened to the extent that his doctor had 

mentioned the possibility of further amputation to a trans-

femoral level. The ulcer had persisted for over a year 

before he was initially fitted with a locking, perforated liner 

on 27th August 2018 (Figure 2b). In that time the patient 

used “no medicine, no cream, no lotion” and was advised 

to use “only soap and water” to clean the wound. When 

asked what the dermatology clinic advised him, the patient 

explained “they said the white heavy skin that look like a 

callous around the wound (Figure 2b), was from moisture. 

They told me I would have to take my leg off for 3 to 5 

months for it to completely heal”, which was impractical for 

him as he was in full-time employment. 

The residual limb condition was monitored at regular 

intervals over the first three months of perforated liner use 

at 4, 7, 9, 11 and 13 weeks. When compared to the initial 

fitting stage (Figure 2b), at 4 weeks (24th September 2018 

- Figure 2c), the ulcer had visibly reduced in size and the 

wound was no longer suppurating. At 7 weeks (15th 

October 2018 - Figure 2d), Tissue was granulating and the 

affected area/ulcer had reduced in size. It was at this point 

that the patient changed to a cushion, perforated liner and 

Northene socket, copolymer polypropylene frame, passive 

vacuum adaptive expulsion valve system. Over the 

following 6 weeks, the ulcer reduced in size considerably 

(1st and 12th November 2018 - Figure 2e and f), before 

being considered fully healed 13 weeks after initial fitting 

(28th November 2018 - Figure 2g). 

Since healing, the patient has been fitted with a hydraulic 

ankle unit for use with his passive vacuum system. He has 

also continued to compete in motocross endurance events 

(for which he uses the locking perforated liner), achieving 

‘top 5’ finishes against able-bodied competitors. 

 

a b 

 

Case 
Age 
(years) 

Mass 
(kg) 

BMI 
K 
level 

Amputation 
type/side 

Residual limb 
issue 

Previous prescription New prescription 

#1 41 90 28.4 
K3-
K4 

Trans-tibial 
/Right 

Distal blisters 
around scarring 

Cushion silicone liner 
with suction 
suspension 

Pin-lock perforated liner 

#2 45 100 30.2 
K3-
K4 

Trans-tibial 
/Right 

Posterior 
ulcer/wound 

Pin-lock silicone liner 
with BladeXT foot 

1st: Pin-lock perforated 
liner 
2nd: Cushion perforated 
liner with suction 
suspension 

#3 50 106 31.0 
K2-
low 
K3 

Trans-tibial 
/Right 

Distal 
maceration and 
infection 

Cushion silicone liner 
with suction 
suspension and Tres 
foot 

Cushion perforated liner 
with EVS and K2-specific 
hydraulic ankle 

Table 1: Summary table of the cases described 

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M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
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Figure 2: The condition of the Case #2 patient’s residual limb (a) 

approximately one year before being fitted with a perforated liner, 

(b) at the point of fitting, and after (c) 4 weeks of use, (d) 7 weeks 

of use (the point of changing to passive vacuum suspension), (e) 

9 weeks of use, (f) 11 weeks of use and (g) 13 weeks of use. 

Case #3 

The patient was a 50-year-old male (mass: 106kg, BMI: 

31.0), with a right-sided, trans-tibial amputation, classified 

as a K2 to low K3 level walker. He habitually wore an 

energy-storing-and-return (ESAR) foot. 

The patient had chronic residual limb skin issues for 

approximately eight years. Excessive perspiration had led 

to the skin becoming macerated and infected (Figure 3a 

and b). The patient had reported “being on the brink of 

revision surgery” to remove the affected skin.  

He was fitted with a perforated cushion liner, in conjunction 

with a passive vacuum, in 2016. In 2017 this was upgraded 

to an EVS system that used the movement of a hydraulic 

ankle unit to draw greater vacuum levels. After three 

months of using this prosthetic prescription, the patient 

reported that he thought it was “doing a great job” of 

keeping his skin dry; he was wound free and had had no 

residuum problems. The patient has continued to use this 

prescription for over a year, during which time his residuum 

remains in good health (Figure 3c). 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 3: The condition of the Case #3 patient’s residual limb (a) 

in its worst condition in 2011, (b) in 2013 and (c) in March 2019, 

after continued use of a perforated liner (since 2016) with elevated 

vacuum suspension and hydraulic ankle (since August 2017). 

DISCUSSION  

This research illustrates the health benefits of maintaining 

a dry residuum/socket interface by the use of perforated 

liners. While the use of silicone liners is primarily for 

comfort and impact absorption, providing a close fit and 

suspension,10 they can create warm, moist environments 

in which bacteria can thrive.  Creating a dry environment 

mitigates against the risks of skin maceration and infection. 

Such conditions lead to uncomfortable socket fits and 

prosthetic abandonment. Also, intuitively, the presence of 

a b 

c d 

e f 

g 

a 

b c 

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M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
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sweat will lubricate this interface, increasing relative 

motion between the residuum and the liner. This may affect 

prosthetic control and/or suspension, potentially reducing 

swing clearance and become a tripping hazard. 

Subsequent compensatory movements to improve 

clearance increase energy expenditure24 and may have a 

degenerative effect on musculoskeletal health.25–27 

In their review of prosthesis thermal discomfort in 2014, 

Ghoseiri and Safari10 described available options for 

management of excessive heat and perspiration in the 

prosthetic socket. They refer to antiperspirants, local 

ointments and topical sprays to inhibit the physiological 

process of sweating but cite unpleasant odors and 

potential allergies as drawbacks.10 An alternative is the use 

of Botulinum Toxin (Botox) injections but this is described 

as invasive, requiring repeated treatment to maintain 

effectiveness and may potentially cause pain and/or side 

effects.10 They ultimately concluded that prosthesis thermal 

discomfort was still an unresolved problem. Notably, this 

review was published prior to the commercialisation of 

perforated prosthetic liners. 

The wounds arising from sweating can also have a 

substantial impact on the economics of healthcare. 

Treatment and care of patients with skin health conditions, 

such as pressure ulcers and chronic wounds, cost the UK 

National Health Service (NHS) up to £3.1 billion per 

annum.28,29 Although this number is for the population as a 

whole, amputees will be disproportionately affected, 

particularly those with vascular comorbidities. These 

issues can lead to socket adjustments or replacements, 

which studies have shown constitute a sizeable proportion 

of clinical appointments,30,31 creating a time and financial 

burden for limb centres. Additionally, two cases in this 

analysis reported considering surgical interventions as a 

result of their skin conditions, which were cancelled after 

tissue improvements following the use of perforated liners. 

Other reported treatments to reduce excessive sweating, 

such as Botox injections32 or daily antiperspirant use,32 can 

be expensive, inconvenient, produce side effects or have 

limited effectiveness. If a change in prosthetic liner 

prescription can provide the desired effect, it may be the 

most cost-effective approach. 

As far as the authors are aware, this is the first published 

evidence for the effects of “breathable” liners. Some 

practitioners may be concerned that the perforations in 

liners may create areas of stress concentration that may 

increase the rate of deterioration of the liner itself or 

damage the surrounding skin. Many liner manufacturers 

offer warranty periods of between six and 12 months, or 

three months for suspension sleeves. Perforated liners 

have a six month warranty so although there may be a 

greater risk of degradation than a non-perforated liner, the 

longevity is still within typical industry standards for this 

type of prosthetic component. Although none of these 

three cases reported any skin issues around the 

perforations, the manufacturer’s Instructions For Usec 

warn that “enlarged perforations can trap the skin and 

cause blisters” and recommend that should the 

perforations become damaged, the patient should cease 

the use of the liner. 

It should be noted that there might have been other 

influences present in these cases. Although Cases #1 and 

#3 didn’t report the use of other wound healing treatments, 

such as creams or ointments, it is possible that the patients 

might have used these therapies without reporting such to 

a member of their treatment team. Han and Ceilley’s33 

review of chronic wounds describes many topical therapies 

and dressings that could assist wound healing but the 

practicality of these treatments within a prosthetic socket 

environment is unclear. One of the patients also began 

using EVS with their perforated liner. EVS has previously 

been shown to reduce residuum volume fluctuation34–38 

and relative movement,34,37,39,40 which reduces interface 

pressure.41 This, combined with encouraging healthier, 

more hydrated, more oxygenated tissue,42 might explain 

why residual limb wounds have been observed to heal 

faster with EVS,43 without discontinuing prosthetic use.44–

46 Negative pressure wound therapy (NPWT) is a widely 

used technique to aid wound healing47,48 and has been 

demonstrated to be effective even for diabetic amputees.49 

The perforations in the liner allowed the vacuum to be 

applied directly to the wound surface, potentially further 

helping healing. 

Two of the cases began using hydraulic ankles with their 

perforated liners. These devices significantly reduce 

interface pressures, loading rates and deep tissue 

trauma,50 which may also have contributed to 

improvements in residual limb condition. 

The current study was also limited in that the analysis was 

performed retrospectively, each clinical team had their own 

methods of monitoring the patients’ skin conditions and 

there were other prescription changes that may have 

influenced wound healing (e.g. prosthetic suspension 

method). Future work will consist of a more regimented, 

scientifically rigorous analysis with a wider cohort of 

patients. Patients will be divided into two groups; the 

control group will use regular silicone liners and the 

intervention group will use perforated liners. Patients will 

be monitored at pre-defined, regular intervals. The 

progress of wound healing will be quantified, using metrics 

such as wound surface area, as described in Hoskins’ 

work.46 Compounding factors, such as prosthetic 

componentry and suspension method will be controlled to 

isolate the effects of liner perforations only. 

ACKNOWLEDGEMENTS 

The authors would like to thank the prosthetists and 

patients involved in providing the information for the cases 

in this study.  

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M McGrath M, McCarthy J, Gallego A, Kercher A, Zahedi S, Moser D. The influence of perforated prosthetic liners on residual limb wound healing: a 

case report. Canadian Prosthetics & Orthotics Journal. 2019; volume2, Issue1, No.3. https://doi.org/10.33137/cpoj.v2i1.32723 
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DECLARATION OF CONFLICTING 

INTERESTS 

The authors are full time employees of the manufacturer of 

the prosthetic liners evaluated in this study. 

SOURCES OF SUPPORT 

Blatchford Clinical Services who documented and provided 

patient care. 

AUTHOR CONTRIBUTION 

• Michael McGrath,  

Conceptualization, case collation, writing original, review 

and editing.  

• Joseph McCarthy, 

Conceptualization, case collection, analysis, writing 

original, review and editing.  

• Ana Gallego, 

Analysis, writing original, review and editing. 

• Alan Kercher, 

Conceptualization, case collection, analysis, review and 

editing. 

• Saeed Zahedi 

 Analysis, writing original, review and editing. 

• David Moser 

Analysis, writing original, review and editing. 

MANUFACTURERS’ DOCUMENTATION 

a  https://www.blatchford.co.uk/endolite/silcare-breathe-cushion-

liner/ 

b https://www.blatchford.co.uk/endolite/silcare-breathe-locking-

liner/ 

c https://www.blatchford.co.uk/catalogue/liners/silcare-breathe-

locking/ifu/938398_Iss1%20-%20Locking%20Liner.pdf. 

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2.Tang J, McGrath M, Laszczak P, Jiang L, Bader DL, 

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4.Gary Sibbald R, Woo KY. The biology of chronic foot 

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7.Hagberg K, Brånemark R. Consequences of non‐

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8.Hachisuka K, Nakamura T, Ohmine S, Shitama H, 

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