Current Transfemoral Sockets CCUINICAL ORTHOPAEDICS AND RELATED RESEARCH Numosr 3, pp 48-54 (01999 Lippingat Willams & Wikies, Ine C. Michael Schuch, CPO; and Charles H. Pritham, CPO Clinicians have two types of prosthetic sockets for patients with a transfemoral amputation: the quadrilateral socket introduced in the 1950s and the ischial containment socket intro- duced in the 1980s, For many years, the quadrilateral socket was acceptable to clini cians and patients alike. With the introduction of the ischial containment socket claims were made that the quadrilateral socket had been inadequate from its inception. It also was claimed that the ischial containment design was the answer to all problems that patients with transfemoral amputations may have, Un- fortunately, there is only one scientific study that lends any support to claims of the ischial containment socket’s superiority and its find- ings are limited. Still, clinicians must make recommendation and prescription decisions daily regarding what is best for their patients. There are two acceptable socket designs for patients with transfemoral amputations, Expe- rience with both supports the concept that they have more similarities than differences and that each has a legitimate place in the treatment of patients with transfemoral ampu- tations. A comprehensive understanding of ‘cach socket design and its biomechanical in tentions is essential for successful clinical ap- plication and treatment of patients with ampu- tations, From the *Depantent of Prosthetics and Onhoiies, Duke University Medical Center, Dutham, NC, Reprint requests to C. Michael Schuch, CPO, Depart: ‘ment of Prosthetics and Orthotics, M04 Davison Build- ing, Duke University Medical Center, Durham, NC 270. 48 The basic goals for fitting and aligning pros- theses for patients with a transfemoral ampu- tation seem simple enough: comfort, func- tion, stability, and cosmesis. Obtaining these goals is significantly more challenging than might be expected. One reason is the opinion that many practitioners have taken too many shortcuts in trying to treat the patient with a tansfemoral amputation, It is disturbing to note the number of new practitioners who have never read the publications of Rad. liffe, who is considered worldwide to be the founding expert of transfemoral (above knee) biomechanics and socket design.* It is ‘equally disturbing to consider the number of, experienced practitioners who do not follow these time proven principles. Simple formu- las for the quadrilateral socket design have been ignored, forgotten, or replaced with shortcuts, New transfemoral socket designs that incorporate the principle of ischial con tainment have been developed and Michael* reports that “these new designs represent evolutionary rather than revolutionary ad- vances”. Pritham? has stated his belief that the principle of ischial containment “is fully compatible with Radcliffe's biomechanical analysis of the function of the quadrilateral socket and that the varying socket configura- tions are not at odds, but rather, are separate but related entities in @ continuum labeled above knee sockets” The biomechanical requirements of the patient with a transfemoral amputation func- tioning with a prosthesis do not vary because of socket design: the outcomes may vary, but the needs remain the same. SuspensionNumber 351 Apa 1999 should not be influenced to any substantial degree by socket design. Alignment in the sagittal plane should be the same from socket to socket, with variations arising only from the stability afforded by different knee and foot components and/or the patient's de- sire for more or less alignment stability. There are no documented or stated sagittal plane alignment variations attributable to socket design. Coronal plane alignment might vary with mediolateral socket stabil- ity, but the variations ultimately are not sub- stantial The goals of this paper are for the reader to: (I) recognize and acknowledge that there are two acceptable socket designs for trans- femoral amputations: (2) understand the sim- ilarities and differences of these wo designs; (3) understand the indications for each; and (4) be able to relate accepted transfemoral biomechanical principles to cach. ASSESSMENT AND EVALUATION OF THE RESIDUAL LIMB RANGE OF MOTION Careful measurement and evaluation of the patient’s anatomy and kinesiology are essen- tial for correct socket design and initial socket alignment. Important and less under- stood is the need for accurate measurement and evaluation of the range of motion of the residual limb in the sagittal and coronal planes, that is, flexion and adduction analy- sis, Proper planning and incorporation of these angular measurements into the socket ‘and overall prosthesis design allows for cer- tain biomechanical and alignment principles that are advantageous to the patient during the various phases of gait. {tis the authors’ contention that this is the most neglected area of evaluation and treatment of a patient with a transfemoral amputation BIOMECHANICS Four key phases of the gait eycle are consid- eed when meeting the biomechanical objec- Current Transtemoral Sockets 49 tives for a transfemoral prosthesis. The bio- mechanical objectives may be met or as sisted by any or all of the following: socket esign, prosthetic alignment, and component selection. The relevance of socket design to each of these four key phases of the gait cy- cle is discussed below. Heel Strike and Initial Stance Phase For the patient with a transfemoral amputa- tion, dissipation of forces at heel strike is not possible in the normal manner. Thus. heel strike and initial stance phase are a period of potential knee instability for these patients. ‘The biomechanical requirement is that of knee stability, maintaining the prosthetic knee in complete extension, and overcoming the tendency of the shank to rotate forward and cause the knee to buckle. The transfemoral socket must be designed in a position of flex- ion at least 5° greater than the resting flexion angie of the patient’s residual limb. This posi- tions their hip extensors on stretch allowing, them to more effectively control the knee flex- ion moment at heel strike. Midstance Saunders et al!® described the six determinants of gait that provide efficiency in locomotion. ‘The hip abductors, primarily the gluteus medius, maintain pelvic control during mid- stance through eccentric and isometric con- traction. This determinant of gait allows for a narrow based gait and upper trunk control, and minimizes excursion of the center of gravity. However, in the case of the patient with a transfemoral amputation, the femur is not part of a structure that terminates in a foot firmly planted on the ground. The residual femur is only a lever of less than half of the normal length of the entire lower leg and floats in a mass of muscle, tissue, and fluid. As a result, in midstance, the residual femur tends to dis place faterally in the mass of residual muscle and tissue, making it difficult to. maintain horizontal stability of the pelvis and trunk. Effective pelvis and trunk stabilization and the resultant narrow based gait only can be80 Schuch and Pritham achieved in a transfemoral prosthesis by pro- viding adequate lateral support to the entire femoral shaft, maintaining normal or maxi- ‘mum possible adduction of the femur, and dis- tributing the proximal medial component of the resulting midstance force couple evenly against the adductor muscle mass of the upper thigh of, as is the case of the ischial contain- ment socket, against the medial aspect of the ischium and ramus (Fig 1). This is accom- plished by appropriate socket design and alignment. Heel Off and Terminal Stance Phase Effective heel off and terminal stance propulsion are provided in a transfemoral prosthesis via properly assessed hip flexion analysis and proper initial hip flexion de- signed in the socket. By designing and align- ing the socket in a position of initial flexion, the patient is allowed to more easily reach the 15° of extension required on the pros- thetic side to provide a normal stride length on the sound side. Swing Phase Swing phase tracking addresses the smooth- ness of the pathway of the prosthetic limb during the swing phase of the gait cycle. Goals are lack of vertical displacement of the prosthesis with respect to the residual limb, and lack of deviation in the sagittal plane as the prosthetic limb advances forward during the swing phase. Problems regarding vertical displacement are the result of poor suspen- sion and resulting piston action, Deviations in the sagittal plane include whips during the swing phase, which may be caused by im- proper socket shape, Socket design geometry and volume are critical for smooth swing phase tracking AMPUTATION TECHNIQUE AND. SOCKET DESIGN In their study published in 1989, Gottschalk et al} reported: “We believe that socket con- Clinical Ornapaedics and Folated Research alters | Fig 1. Transtemoral midstance force couplo di- gram. The force couple creates significant sta: bilization pressure at the proximal medial socket, The adluctor muscle mass of the upper thigh must be capable of withstanding and sta- bilzing these forces in the quadrilateral socket design. (Reprinted with permission from Bray J, Staats T: University of California, Los Angeles, Above-knee Teaching Manual 1977.) figuration does not influence the position of the residual fermur and that a proper surgical procedure for above knee (transfemoral) am- putations is essential for functional restora- tion and success of prosthetic fitting”. This point is reiterated in their most recent paper.* ‘The present authors do not disagree with the premise of Gottschalk et al; in fact, it would bbe ideal if all transfemoral amputations were performed by surgeons with such a sure knowledge of, and passion for, surgical bio- mechanics. However, this is mot the case. Transfemoral amputation is morbid and morNurroer 361 foe 1909) tal surgery, and more frequently than not is performed by surgeons other than or- thopaedists, Who are muich more concerned with life saving measures than postamputa- tion rehabilitation potential."? The authors contend that even in the best transfemoral amputations. proper detail to socket design amd biomechanics is crucial to transfemoral outcomes, SOCKET ANALYSES ilarities and Differences General Overview Similarities between the quadrilateral and is- chial containment sockets are biomechanical principles, socket volume, distal socket de- sigh. and socket alignment in initial flexion and adduction. There is one striking differ- cence between the sockets, which is direct is- chial bearing in the quadrilateral socket, as ‘opposed to ischial containment in that so hamed socket design. AS a result, the con- touts of the proximal brim of the ischial con- tainment socket are different from the proxi- mal brim contours of the quadrilateral socket. Ischial containment may be defined as a Proximal extension of the posteromedial brim of the socket so that it bears against the pelvis, specifically the medial aspects of the ischial tuberosity and the ramus of the is- chium (Fig 2), Ischial beating has been ac- cepted as ditect inferior support to the ischial tuberosity by means of a flat, relatively hori- Zontal surface of the posterior brim that pro- Vides vertically directed upward forces. This, is opposed to the rather oblique and sloping contour of the proximal most posteromedial brim of the ischial containment socket. Dis tal fo this oblique and sloping contour of the ischial containment socket, at a point ap- proximately 3 or 4 em below the edge of the brim, contouring beneath the ischial tuberos- ity may occur and thereby provide the same "measure of ischial bearing as is present in the ‘quadrilateral socket? (Fig 3) Current ransfemoral Sockets 81 Fig 2. Schematic sagittal plane view of a right ischial containment socket showing the concept of ischial containment and the significantly low- ered medial wall allowing the inferior ramus of the pubis to exit the socket comfortably. (Reprinted with permission from Pritham CH: Biomechanics and shape of the above-knee ‘socket considered in light of the ischial contain- ment concept. Prosthet Orthot Int 14:9-21, 1990.) Distribution of the proximal and medial concentration of forces to the ischium helps reduce trauma to the soft tissue of the per- ineum. Obtaining rotational stability in the quadrilateral socket is dependent on muscle channel contours and generally is unsuecess- ful in an unstable residual limb. Rotational forces are better controlled by purchase against the medial border of the ischium and balanced by the accurate diameter between the medial ischial surface and the greater trochanter.52__Schuch and Pritham Fig 3. Schematic sketch of a coronal view of the ischial containment concept. The high pres- sures from the medical component of the mid- stance force couple aro stabilized against the pelvis, specifically the ischial tuberosity and ra- mus. (Reprinted with permission from Pritham CH: Biomechanics and shape of tho abovo- knee socket considered in light of the ischial containment concept. Prosthet Orthot Int 14:9-21, 1990.) Anteroposterior and Mediolateral Diameters ‘The anteroposterior (AP) dimension of the quadrilateral socket will be smaller than that of an ischial containment socket, because the ischium rests proximal and posterior to the inner AP dimension of the quadrilateral socket. Conversely, the ischium is within the Glinioal Onthopacdies and Felaied Resuarch ischial containment socket, necessitating 2 greater inner AP diameter. Measurement of the mediolateral diame. ter is referenced differently by various prac- joners. There is no consensus as to the best ‘anatomic landmarks, The term narrow medi- olateral socket is misleading because this di- mension varies between males and females because of anatomic differences between the male and female pelvis® (Fig 4). Fig 4. Schematic transverse views of the vary- ing pelve configurations ft with ischial contain- ment brim shapes. Note the medial wall variations based on pelvic variations. In the top view the ischial walls are wide, as in a fomeale The lowest view shows ischii that are closer (0 cone another, and the midline of the body, as in a male. (Reprinted with permission from Hoyt CP. LitigD, Lunct J, Staais TB: The UCLA GatCam Above Knee Prosthesis. Los Angoles, University of Caliomia, Los Angeles Prosthetics Education ‘and Research Program 14-49, 72, 1987.)‘umber 364 ‘ont 1999) INDICATIONS, CONTRAINDICATIONS, AND RECOMMENDATIONS FOR SOCKET DESIGN The indications and contraindications for transfemoral socket design were considered by a panel of experts in 1987." A sum- mary of their conclusions follow. There were no specific contraindications reported for any socket design, Some advocated not at- tempting to change successful quadrilateral socket users to the newer ischial containment socket design, Successful fitting of quadri- lateral sockets is more likely to be attained on long, firm residual limbs with intact ad- ductor musculature, whereas ischial contain- ment sockets are more successful than ‘quadrilateral sockets on short, fleshy, unsta- ble residwal limbs, [schial containment sock- ets are the better recommendation for high activity sports participation and ronning. Fi- nally, there was lack of agreement on the best recommendation for patients with bilat- eral transfemoral amputations. Ic has been the authors” experience that is chial containment sockets are preferred by ‘most patients with bifateral transfemoral am- purations. Correctly designed quadritateral sockets function fine in the authors’ experi- ence when used on Ionger amputations that reveal principles of surgical biomechanics.>4 ‘The more of the adductor magnus intact, the more successful the quadrilateral fit. Quadri- lateral sockets ate recommended for the geri- atric or debilitated patient. These patients ambulate with canes and walkers for assis- tance, thereby canceling out or greatly de- creasing the typical medial lateral pelvic and trunk stability demands of midstance. For the very short fleshy, and rotationally unstable residual limb, ischial containment sockets have provided suecess where quadri- lateral sockets have failed previously. In ad- dition to enhanced stability and perineal Comfort for these patients with transfemoral amputations, the additional socket volume afforded by the higher brims enhances the Current Tanstemoral Sockets 63 ability to obtain and maintain suction sus- pension, Flexible brim sockets are recommended for use with ischial containment sockets. The socket frame or retainer should provide rigid support in the posteromedial comer of the proximal brim, under and beside the ischium: however, the remainder of the proximal frame ‘can be lowered below the level of the flexible socket brim. Use of thermoplastic flexible sockets is common practice. Discussion has focused on the tans- femoral socket designs of quacrilateral and ischial containment, including. similarities and differences, indications and recommen- dations. The authors strongly propose the case for recognizing and clinically using both socket designs, depending on the indi vidual patient and his or her prognosis, level of amputation, and residual limb characteri tics. A comprehensive understanding of each. socket design and their biomechanical inten- tions is essential for successful clinical ap- plication and treatment of patients with am- putations, References 1. Donovan RG. Prtham CH, Wilson AB (eds): Report (of ISPO Werkshops: International Workshop on ‘Above-Knee Fitting and Alignment, Gasgow, Iner- national Society for Prostetes and Orthotics 31-37, ‘Appendices AF. 1987 2, Gailey RS, Lawrence D, BuntitC, etal The eatcam socket and quadrilateral socker ‘comparison of en- ergy cost during ambulation. Prosthet Orthot Ink 1798-100, 1998, 3. Gowchalk PA, Kourosh S, Stills M, MeClellan B, Robens J: Does socket configuration influence he position ofthe femur in above-kace amputation? J Prosthet Onthot 2:94-102, 1989. 4. Gowtschalk FA, Stills M: The biomechanics of trans femoral amputation. Prosthet Onthot Int 18: 12-17, 19s 5. Hoyt CP, Litig D, Lundk J, Staats TB: The UCLA CatCam Above-Knee Prosthesis, Los Angeles, Uni versity of California, Los Angeles Prosthetics Educe tion and Research Program 14-49, 72, 1987 6. Michael JW: Courrem concepts in above-knee Socket design. Instr Course Lect 30:373-378, 190. 7. Pritham CH: Biomechanics and. shape of the above-knee socket considered in light ofthe ischial containment concept, Prosthet Ortot {nt 49-21 1990.54 Schuch and Fritham 8 Radelife CW: Functional considerations in the ft- ting of above-knee prostheses. Af Limbs 2:35.60, 1935, Sabolich J: Contoured adducted trochanteric = con twoed alignment method (ct-cam): Introduction and basic principles. Clin Prosthet Onhot 9:15~26, 1985. Saunders 18, Inman VT, Eberhart HD: The major de= terminanis in eormal and pathologie gnit. 1 Bone Joint Surg 35A°543-558, 1953, ‘Schuch CM: Repor from interational workshop on Clinical Othopaedics and Related Research above-knee fiting and slignment techniques. Clin Prosthet Onhot 12:81-98, 1988, ‘Sehuch CM: Modern abovesknee fitting. practice. ‘Prosthet Onhot ln 12-77-90, 1988, Schuch CM: Above-Knee Amputation: Literature Review and Prosthetic Experience. In Murdoch G. Jacobs NA, Wilson Jr AB (eds). Report of ISRO ‘Consensus ‘Conference on Amputation Surgery: Copentiagen, Inernational Society for Prosthetics sind Onhoties 66-68, 1992