PTB Socket Indication

• Primary Amputees - The PTB socket is good for primary amputees as the
socket can be modified to accommodate the changes in the residual limb that
occur for 12-18 months after the amputation.

• Sensitive Residual Limbs - If the amputee has a particular area of sensitivity

on their residuum it is possible in a PTB socket to relieve these areas more
easily than in a total surface bearing style socket.

• Bulbous Residual Limbs - The construction of a PTB socket, an inner liner

and outer hard socket, allows for build-ups to be applied to the inner liner
allowing easier donning and doffing for an amputee with a bulbous residual
limb.

• Poor Hand Dexterity/ Poor Eyesight/ Hemiparesis - PTB sockets are much
easier to don/doff than total surface Bearing socket.

Contraindications (PTB Socket)e bearing sockets.

• Active amputees can find the PTB trim lines and suspension methods too
restrictive, especially with regards to knee flexion.

• Some amputees can find the PTB prosthesis pistons.

• Some amputees cannot tolerate the pressure on their patella tendon required
for a PTB prosthesis to work effectively.
PATELLA TENDON BEARING VARIATIONS

As the patella tendon bearing design became more popular, two variations were
developed to add features that assist in the suspension of the prosthesis, or to better
control the forces around the knee. The patellar tendon supracondylar socket design
was developed to add contact and support on the medial and lateral aspects of the
distal femur .

Socket PTB SC (Patellar Tendon Bearing Supracondylar)

The weight bearing takes place below the patella, at the patellar tendon. The suspension
is generated at the medial and lateral areas of the femoral condyles. Compared to the
PTB socket with belt suspension, this design does not produce problems of blood
circulation or atrophy. For the moment, this type is used worldwide as most basic design
for prosthetic fitting of medium and long stumps.

This controls varus and valgus stresses on the knee for a very short residual limb or
in situations of knee ligament instability. Because of the bone contours of the distal
femur, this design also assists in the suspension of the prosthesis on the patient.
Socket PTB SC SP (Patellar Tendon Bearing Supracondylar
Suprapatellar)

The patellar tendon bearing supracondylar and suprapatellar socket design has
proximal extensions of the socket that are contoured up over the distal femoral
condyles, and anteriorly up over the patella and onto the quadriceps tendon. The
proximal anterior extension places pressure on the associated soft tissue that will aid
in prevention of hyperextension during stance, and by loading all around the patella
at full extension, subtly unloads the tibial regions

The weight bearing takes place below the patella, at the patellar tendon.
The suspension is generated at the medial and lateral areas of the femoral
condyles and at the suprapatelar area. This type is indicated for short
stumps, as well as in cases of antero-posterior instability in the knee.
Total Surface bearing (TSB) socket-
• In the PTB types sockets , the sensitive areas are given relief, while the load
is mainly taken by the load-tolerant areas, which can cause extra piston
motion within the socket.
• The pressure has not been distributed uniformly in PTB socket.
Higher pressure concentration near the proximal brim of the PTB socket (patellar
bar areas).

Total surface bearing is a different concept than total contact. The total contact
techniques that were introduced with the development of the patella tendon bearing
socket originally were targeted as a major change from the open distal end socket
designs. Now, all areas of the limb were to have some contact but weightbearing
areas were altered to increase or decrease loads according to the principle of
pressure tolerant and intolerant anatomy. Although all of the surface of the limb
should have contact to prevent edema, not all surfaces carry weight or equal loads. 6

The total contact theory also included applying contact to the distal end of the limb
which previously had been thought to be intolerant to any socket contact. Although
the distal end of the residual limb is usually intolerant to full weightbearing, it still
needs contact to prevent the distal end edema problems that were so prevalent with
open ended sockets

Early total surface bearing techniques emphasized the importance of obtaining an

extremely accurate impression of the limb and meticulous modification of the mold.
No extra room over the bony areas is provided, yet relief was stated to be obtained
by increasing the pressure on the tissues around these areas to accentuate their
shapes.

Current thought on the total surface bearing theory still involves creating an
environment that applies pressure over all aspects of the limb, however, the focus
tends to be more on the interface material that is used in the liner of the socket.
Although some patella tendon bearing design characteristics may be present in a
total surface bearing socket, the liner material often may be the determinate of how
the weight actually is transferred to the residual limb.

Compared with PTB sockets, TSB sockets may lead to greater activity levels, fewer
pressure problems, and improved satisfaction among active prosthesis users, It
increases gait symmetry, velocity, cadence, and balance with TSB sockets.

TSB sockets have generally been fabricated over elastic liner interfaces, whereas
PTB sockets have generally been fabricated over foam interfaces.

From an economic standpoint, although PTB sockets have a lower initial cost, this is
offset by the need for patients to spend up to three times longer in the fitting process
to achieve a satisfactory socket fit,

Summery

 TSB sockets “uniformly distribute weight over the entire residual

limb” which therefore “delivers a minimal skin pressure
 TSB sockets are volume matched to the residual limb with 100%
surface contact during the gait cycle.
 Successful fitting of a TSB socket requires good control of the soft
tissues, minimised pressure peaks and distribution of load over the
maximum surface area available

Advantages and Indications

 Active amputees benefit from the lower trim lines possible with the
TSB style design
 TSB sockets reduce pistoning of the socket on the residual limb by
providing total contact throughout the gait cycle [1
 Proprioception is increased due to weight bearing over the entire
residual limb and good pressure distribution by the socket walls,
which in turn enables the amputee to have better balance with eyes
open or closed [
 Suspension of the TSB socket is also noted to be better than the PTB
design as it is integrated in the socket using locking pins or suction
 Due to the entire surface of the residual limb accepting weight in the
TSB socket it is believed that these sockets are more comfortable
because overall socket pressure is reduced

Disadvantages and Contraindications

 TSB sockets are not suitable for primary amputees due to volume
changes in the first 12-18 months post-amputation For the same
reason TSB sockets are also not suitable for amputees undergoing
treatments such as dialysis due to volume fluctuation
 Unsuitable for patients with short residual limbs, less then 10cm
long, which require higher trim lines for stability around the knee
 Some amputees may experience pain at the distal end of their
residual limb due to the way a TSB/HST socket weight bears over the
entire limb Also patients with excessive soft tissue may drop down
into a TSB/ socket too much which will cause pain at the distal end [.
Amputees with bony spurs are also not suitable for TSB sockets
 Discomfort during knee flexion may result due to the silicon liner
bunching up in the popliteal region
 Increased perspiration may result due to the silicon liner, which can
lead to irritation of the residual limb .
 TSB/HST sockets are not indicated for amputees with visual/sensory
disturbances or Hemiparesis as they are more difficult to don/doff
than a PTB design
 Amputees with excessive soft tissue may find they get discomfort
upon knee flexion due to creasing of the silicon line.
• Socket SSS (Silicon Suction Socket)The weight bearing takes place all
over the stump surface. The suspension is generated by means of tight
adhesion/friction between stump and silicon liner that has a pin at its distal
part. This pin is installed in a blocking mechanism inside the prosthetic
components, or using a suction mechanism, hence insuring the suspension.
Indicated for all types of stumps.
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