Chronology of above knee socket

variant
Presenter:
Abhishek tripathi
 objectives
• Preface:
– Frontal and Sagittal views of the lower limb
anatomy
• Socket design principles/criteria in above knee
socket
Lateral view and frontal views of the lower
limbs

Image retrieved from: BD

Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition
[Crackingpatching-dot-com]\BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition.pdf
COG line/weight line in frontal Mechanical axis and anatomical
view/central vertical line axis with respect to vertical line
Image retrieved from: BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition
[Crackingpatching-dot-com]\BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition.pdf
Image retrieved from: BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition
[Crackingpatching-dot-com]\BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition.pdf
Image retrieved from: BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition
[Crackingpatching-dot-com]\BD
Chaurasia's Human Anatomy -
Lower Limb, Abdomen & Pelvis
(Volume 2) 4th Edition.pdf
 The socket
• An interface between the residual limb and rest of
the prosthesis
• functions:
– Comfort and protection
– Transfer the forces between stump and prosthesis
– Exchange of sensory information between stump and
prosthesis
– Mean of suspension partially or fully
– To capture the motion of the residual joint
– Cosmetic look
 Specific Trans-femoral Socket Design: Rationale
Five important principles of socket design that were intended
as objectives of the quadrilateral socket but apply equally well to any
modern trans-femoral socket
1. The socket must be properly contoured and relieved for functioning
muscles.
2. Stabilizing pressure should be applied on the skeletal structures as
much as possible and areas avoided where functioning muscles
exist.
3. Functioning muscles, where possible, should be stretched to slightly
greater than rest length for maximum power.
4. Properly applied pressure is well tolerated by neurovascular
structures.
5. Force is best tolerated if it is distributed over the largest available
area
 A.K Socket Variant
• Plug Fit Socket (non-biomechanical design)
• Quadrilateral Socket
• Ischial Containment Sockets
• Flexible socket
• Sub-ischial socket
 Plug Fit Socket
• During 1940-50,The plug socket was a design
that used the soft tissues upto the groin level to
support the body weight.
• Lack of stability was controlled by pelvic joint
and band (usually fabricated out of metal)
usually a waist belt .
• These design were not based on specific
transfemoral socket design rationals
• Today, versions of the “plug socket” are still
used in instances where the socket can’t be fit
all the way up to the ischium.
 Quadrilateral socket design

• The quadrilateral socket design

came in the late 1960s
• Four distinguishable sides or
walls of the socket at ischial
level.
• The quadrilateral socket should
be designed with "initial
flexion" to improve the ability
of the amputee to control knee
stability at heel contact and to
help in minimizing the
development of lumbar lordosis
at toe-off
Transverse cross section of the proximal aspect
of a quadrilateral socket.
 ANTERO-POSTERIOR CONTROL
• Weight bearing primarily done
through the ischium and the gluteal
musculature which sit on wide seat
(known as Ischial seat) that is
parallel to the ground posteriorly
just beneath the ischium
tuberosity.
• Countersupport, intended to
maintain the position of the
ischium and gluteus on this
posterior seat, is provided by the
medial-third of the anterior wall of
the socket. The area is known as
Scarpa's triangle area.
 Slipping of the ischial tuberosity during
terminal stance
• In quadrilateral socket, ML>AP at
brim level which maintain the
ischial tuberosity on the ischial seat
in socket
• But during terminal stance in gait ,
the Ischial tuberosity has more
tendency to slip inside the socket
(shown by downward arrow inside
socket) as the socket extends while
the pelvis remain vertical
• This slipping tendency of Ischial
Tuberosity is prevented by 5
degree initial flexion of the socket
with the prosthesis.
 ML Control in quadrilateral socket
• The adduction of femur is accomplishes by flattening
the lateral wall along the shaft of the adducted femur
with the exception of a laterally projected relief for the
terminal aspect of the femur.
• Also, proximal to the greater trochanter, the lateral wall
is contoured inward to discourage abduction of socket.
• Counterpressure is achieved by flat contour of the
medial wall of the socket in the sagittal plane along the
proximal 4 in. of the socket before reversing into a
smooth flare directed away from the residual limb.
ML Control in quadrilateral socket
 Contd..
• Proper contouring of the socket over muscles and tendons
gives proper suspension and hence swing control.
• There are four channels provided at the four corners of
quad socket relieving functional muscle group, namely
– Anterior medial corner: adductor channel
– Postero-medial: hamstring channel
– Postero-lateral corner: gluteal maximus channel
– Antero-lateral corner: Rectus femoris
• Apart from these, the posteromedial wall angle varies from
5 to 11 degrees, depending on the muscular density of the
proximoposterior aspect of the residual limb
 Ischial containment sockets
• The term "ischial containment" is rather self-
descriptive
• Around 1980, Ivan Long used a little of both styles ,
the quad design and the NSNA to create a new
design that has evolved into the “ischial
containment socket”. The design known by various
acronyms such as ( The Shamp Brim for narrow ML ,
UCLA CAT-CAM, Sabolich socket, NSNA), but the
basic idea is to stabilize the pelvis and femur by
controlling the ischium and the femur..
Ischial containment socket design: Principles

Apart from the basic principle of total contact

and Utilization of suction socket suspension
whenever possible, following are some of the
principle of fit:
• Countersupport, intended to keep the ischium and ramus
solidly against the medio-posterior aspect of the socket, is
produced in three ways.
– First, the "skeletal mediolateral" dimension, the distance between the
medial aspect of the ischium and the inferolateral edge of the
trochanter, must be carefully designed into the socket.
– Second, countersupport occurs through the "distal mediolateral"
dimension, a soft-tissue measurement that reflects the diameter of
the residual limb 1 to 2 in. distal to the skeletal mediolateral
dimension.
– The third form of counterpressure, most important in females because
of their pelvic anatomy, is anterolateral counterpressure from the
trochanter anteriorly to the tensor fasciae latae
• Enclosure of the ischial
tuberosity and ramus, to
varying extents, in the socket
medially and posteriorly so
that forces involved in
maintenance of mediolateral
stability are borne by the
bones of the pelvis medially
and not just by the soft
tissues distal to the pelvis,
that is to say, creation of a
"bony lock."
.
• Maintenance of normal
femoral adduction and
narrow-based gait
during ambulation
• Known as Ilio-femoral
angle
• Maximal effort to
distribute forces along
the shaft of the femur
• A decreased emphasis on a
narrow AP diameter between the
adductor longus-Scarpa's triangle
and ischium for the maintenance
of ischial-gluteal weight bearing.
• The design of the medial brim is
so that it covers as much of the
ischial ramus while just cut below
to give exit to pubic ramus
• Again gradually inclines to be
continue with the anterior wall
The physical and functional characteristics of
ischial containment socket
• As opposed to the
quadrilateral socket, in
which the proximal
contours are affected
primarily by muscular
variation, proximal
contours of the ischial
containment socket are
affected by differences in
pelvic skeletal anatomy.
•
• Of particular importance
are the variations in the
position of the ischium
with respect to the
trochanter; in females,
the is-chia are
positioned more
laterally, or closer to the
trochanter, to allow for
childbearing
• Additional weight-bearing support is thought to be provided by the
gluteal musculature and the lateral aspect of the femur distal to the
trochanter, as well as from pressures distributed as evenly as possible
over the entire surface of the residual limb
• It should be noted that significantly more residual limb surface and
volume is contained within the ischial containment socket as
compared with the quadrilateral socket. Therefore, identical residual
limbs have greater force distribution and hence lower pressures with
an ischial containment design.
• Rotational control is provided by the proxiomedial brim and its bony
lock against the ischium, the shape and channels of the anterior wall,
and the post-trochanteric contour of the lateral wall seen in
transverse view8
 Flexible Socket
• In 1983 Kristinsson of Iceland introduced the concept of a
flexible socket design. Taught in the United States under
various acronyms such as ISNY (Icelandic-Swedish-New
York) and SFS (Scandinavian Flexible Socket), these
techniques have gained considerable favor during the past
decade.
• The concept uses flexible thermoplastic vacuum-formed
sockets supported in a rigid (or semirigid) fenestrated frame
or socket retainer
• A silicone roll-on socket (used to enhance suction
suspension) is also a flexible socket used in plastic socket
retainer .
 Flexible Socket

• The advantages of flexible wall sockets as put forth by

Pritham are as follows:
∆ Flexible walls
∆ Improved proprioception
∆ Minor volume changes readily accommodated
∆ Temperature reduction
∆ Enhanced suspension
•
 Mass socket
by Marlo Ortiz
• ischioramal weight-bearing eliminates the need for
gluteal support, so those tissues can be excluded from
the socket
• In the M.A.S. design, the height of the posterior wall
has been lowered to the gluteal fold, so the entire
muscle belly can be free of the socket.
• "This will not only improve cosmesis but with this
configuration, we have found that ischial tuberosity
and part of the ischial ramus are encapsulated more
effectively with no restriction in hip movement,"
 Advantage of MAS Socket
• Patients can sit more comfortably;
• There is no plastic beneath the gluteus;
• The prosthesis is easier to don;
• Patients enjoy full range of motion,
• Better functional gait with improved cosmesis
 CAD-CAM DESIGN
• A computer-aided socket design procedure (CASD) has been developed whereby
an above-knee anthropometric measurements taken from an amputee.
• These anthroometric measurements are used to select a subset of three
reference shapes from a Reference Shape Library stored in the computer in the
form of three-dimensional numerical data.
• Transformation procedures then scale the reference shapes at each cross-
sectional level to match the amputee's cross-sectional areas.
• Blending of the three shapes is determined by tissue mass weighting factors, to
yield a single custom socket configuration, known as the "basic socket shape."
• Subsequent graphical procedures in the CASD system allows further sculpting of
the shape in the form of interactive adjustments of the numerical data to reach
the socket shape desired by the prosthetist.
• The resultant shape data can then be transferred to a computer numerically
controlled (CNC) milling machine to carve a model of the socket shape
Comparison between different socket variant

• Similarities & Differences

– Biomechanics
• Ischial Containment:
– similarities:
» all ischial containment sockets advocate and utilize
varying degrees of ischial containment
– differences:
» quads do not utilize ischial containment
» ischial containment sockets, amount of ischial
containment
• Weight Bearing Distribution:
– similarities:
» ischial containment sockets, combination of ischial tuberosity and
ramus, and peripheral (soft tissue)
– differences:
» quads, ischial-gluteal weight bearing
• ML Stability—maintenance of adduction
– similarities:
» goal of all AK socket systems
» greater success and maintenance in ischial containment sockets
due to ischium acting as bony stop or lock
– differences:
» quad, soft tissue lock only, no bony lock
» less successful maintenance of adduction, thus less ML stability
• Socket Shape—ischial level cross section
– similarities:
» ischial containment sockets, narrow ML, wider AP, concave post-
trochanteric shape
– differences
» quad, wider ML, narrower AP
• Trimlines:
– similarities:
» ischial containment sockets, generally; especially anterior,
posterior, and lateral wall trimlines
– differences:
» quads, especially higher anterior, lower posterior and lateral wall
trimlines
» medial wall of CAT-CAM
 • Rotational Control:
– similarities:
» ischial containment sockets, bony lock of Ischium and post-trochanteric
concavity
– differences:
» quad, muscular-soft tissue cross-section
– Sabolich/Guth CAT-CAM, sometimes cast lying down
– Anatomical Considerations
• UCLA CAT-CAM detail about pelvic differences:
– ischial inclination
– pubic arch angle
– ilio-femoral angle
• NSNA male, female alignment differences:
– bolt tilt
• Suspension:
– similarities:
» all compatible with suction
– differences:
» ischial containment sockets, unclear about auxiliary suspension
• Alignment:
– similarities:
» all but NSNA utilize alignment devices
» ischial containment sockets, medial wall not on line of progression
» NSNA & UCLA CAT-CAM, tilting of knee bolt in bench alignment
» Shamp Narrow ML & NSNA, use of Long's Line
» ischial containment sockets,TKA bench alignment, socket midline
– differences:
» NSNA does not use dynamic alignment device
» quad medial wall on LOP
» not all tilt knee bolt
» NSNA, varying degrees of knee bolt tilt, 7°, female, 4°, male
» quad, bench alignment, more stable TKA, T reference point is located at posterior l? of socket
• Indications and Contraindications
– there were no specific contraindications noted for any socket
design
– some advocated not changing successful quad wearers
– quads are most successful on long, firm residual limbs with firm
adductor musculature
– ischial containment sockets are more successful than quads on
short, fleshy residual limbs
– ischial containment sockets are the better recommendation for
high activity/sports participation/running
– lack of agreement on best recommendation for bilateral above-
knee
 REFERENCES
• Chapter 20B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and
Rehabilitation Principles ;Transfemoral Amputation: Prosthetic
Management by C. Michael Schuch, C.P.O. 
• Biomechanics and shape of the above-knee socket considered in light of
the ischial containment concept C. H. PRITHAM Durr-Fillauer Medical Inc.,
Chattanooga, Tennessee
Prosthetics and Orthotics International, 1990,14, 9-21

• International Workshop on Above-Knee Fitting and Alignment

Techniques" Miami, Florida, May 15-19, 1987; JPO
• Stump socket interface pressure as an aid to socket design in the
prosthesis for the T/F amputees- preliminary study
– V S P Lee, S E Scolomonidis and W D Spence
– Biomedical engineering Unit , UNIVERSITY OF GLASGOW