Cambodian School of Prosthetics and Orthotics: CSPO Manual

Code: IE-CSPO-038
Reference: QP 5-6
CSPO Manual Version: 1
Issued/Reviewed Date: 11-Mar-13
Cambodian School of Prosthetics and Orthotics
ANKLE DISARTICULATION PROSTHETICS
TRAINING COURSE MANUAL
D: ISO 9001\ QMS\ WI\ CSPO I&E doc\ Code: IE-CSPO-038 (Ankle disarticulation Prosthetics Training Course Manual) Eng.doc Page 1 of 60
Code: IE-CSPO-038
Reference: QP 5-6
Objectives
The objectives of the Ankle Disarticulation -course at CSPO are that after the course students
should know the advantages and disadvantages of ankle disarticulation amputation, basics of
surgical procedures and related anatomy and physiology. Students should understand the
biomechanics of ankle disarticulation, casting and rectification procedure.
Students have to know various socket variations, materials and components, that they can
make appropriate prescription of AD prosthesis for the amputee. It is important to know
manufacturing techniques and how to make bench, static and dynamic alignment.
It is essential students to understand normal gait, recognize gait deviations and do corrections
if possible. They have to understand possible fitting problems with ankle disarticulation
prosthesis and find solution to them.
Finally it is to know the importance of good checkout procedure and to make it correctly.
Code: IE-CSPO-038
Reference: QP 5-6
Acknowledgements
This course manual results from a major commitment by many individuals. The CSPO
management and teaching team are profoundly grateful to all contributors for their hard work
during book’s preparation and editing. The Substantial parts of the information and reference
material provided in this course manual has been compiled from various medical and
university sources. Without their long practice, know-how and extensive publications, this
manual would simply not exist. All chapters have been read and commented on by expert
reviewers; we are grateful to them for their invaluable but anonymous contribution. Finally,
we would like to mention in particular previous CSPO teaching staff who have contributed to
compile this course manual.
October 2012
CSPO management and teaching team
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Reference: QP 5-6
Table of Contents
Objectives ......................................................................................................................................................... 2
Objectives ......................................................................................................................................................... 2
Acknowledgements ............................................................................................................................................ 3
Chapter 1 ............................................................................................................................................................ 6
Introduction and features ................................................................................................................................... 6
1.1 Introduction.......................................................................................................................................... 6
1.2 Main features ....................................................................................................................................... 6
1.3 Advantages .......................................................................................................................................... 7
1.4 Disadvantages ...................................................................................................................................... 8
1.5 Indications............................................................................................................................................ 8
1.6 Contraindications ................................................................................................................................. 9
Chapter 2 .......................................................................................................................................................... 10
Anatomy ........................................................................................................................................................... 10
2.1 Surface Anatomy ............................................................................................................................... 10
2.2 Bony Anatomy ................................................................................................................................... 11
2.3 Muscular Anatomy................................................................................................................................. 11
Chapter 3: Amputation Surgery .................................................................................................................. 13
3.1 The aim .............................................................................................................................................. 13
3.2 The objectives .................................................................................................................................... 13
3.3 Surgical procedure ............................................................................................................................. 13
3.4 Physiotherapy .................................................................................................................................... 15
3.5 Prosthetic treatment ........................................................................................................................... 16
Chapter 4: ......................................................................................................................................................... 17
Socket Biomechanics ....................................................................................................................................... 17
4.1 Rotational control .............................................................................................................................. 17
4.2 Suspension ......................................................................................................................................... 17
4.3 End bearing ........................................................................................................................................ 18
4.4 Socket forces during gait ................................................................................................................... 18
Mid-stance.................................................................................................................................................... 19
Patient using a long socket............................................................................................................................... 20
Push-off ........................................................................................................................................................ 21
Chapter 5 .......................................................................................................................................................... 24
Assessment and casting procedure................................................................................................................... 24
5.1 Objectives .......................................................................................................................................... 24
5.2 Patient assessment ............................................................................................................................. 24
5.3 Assessing the height .......................................................................................................................... 25
5.4 Marking the residual limb .................................................................................................................. 26
CSPO Lower Limb Patient Assessment Form ......................................................................................... 28
CSPO Casting/measurement Chart .......................................................................................................... 29
5.5 Casting Procedure .............................................................................................................................. 31
5.5.1 Wrap Casting ..................................................................................................................................... 31
5.5.2 Slab Casting ....................................................................................................................................... 34
5.6 Producing the positive model ............................................................................................................ 35
Chapter 6: Cast rectification ...................................................................................................................... 36
6.1 Purpose .............................................................................................................................................. 36
6.2 Rectification Procedure ..................................................................................................................... 37
6.3 Plaster removal .................................................................................................................................. 37
6.4 Plaster addition .................................................................................................................................. 39
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Reference: QP 5-6
Chapter 7: ......................................................................................................................................................... 41

Socket variations and materials ....................................................................................................................... 41
7.1 Trimlines ............................................................................................................................................ 41
7.2 Conventional design Leather and steel .............................................................................................. 42
7.3 Panel opening socket ......................................................................................................................... 43
7.4 Push fit socket .................................................................................................................................... 44
7.5 Materials ............................................................................................................................................ 45
Chapter 8 .......................................................................................................................................................... 46
Components for Ankle Disarticulation Prostheses .......................................................................................... 46
8.1. The AD Prosthetic foot ...................................................................................................................... 46
8.2 Cosmesis for Ankle Disarticulation ................................................................................................... 48
8.3 AD socket and cosmesis .................................................................................................................... 49
Chapter 9: ......................................................................................................................................................... 51
Ankle Disarticulation Alignment ..................................................................................................................... 51
9.1 Definition ........................................................................................................................................... 51
9.2 Bench Alignment ............................................................................................................................... 51
9.3 Static Alignment ................................................................................................................................ 53
9.4 Dynamic Alignment........................................................................................................................... 54
Chapter 10: ....................................................................................................................................................... 56
Ankle Disarticulation Prosthetic problems ...................................................................................................... 56
10.1 Assessment of the problems .............................................................................................................. 56
10.2 PROXIMAL DISCOMFORT ........................................................................................................... 56
10.3 DISTAL DISCOMFORT .................................................................................................................. 57
Chapter 11 ........................................................................................................................................................ 58
Ankle Disarticulation Prosthetic Checkout ...................................................................................................... 58
Check-out List .............................................................................................................................................. 58
Check with the patient standing ................................................................................................................... 58
Check with the patient sitting ...................................................................................................................... 58
Check with the patient walking.................................................................................................................... 58
Check with the prosthesis off the patient ..................................................................................................... 59
Final instructions .......................................................................................................................................... 59
References ........................................................................................................................................................ 60
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 1
Introduction and features
1.1 Introduction
The ankle disarticulation amputation is also commonly called the Symes amputation.
The Syme amputation between the end of tibia and talus is a disarticulation with minor trimming of
the distal bone surface in tibia and fibula. Syme does preserve important soft tissues of the hind
foot.(Partial Foot Amputation, 2001)
The surgery was first carried out and documented in 1842 by the Scottish surgeon James Symes. The
technique still carries his name. The method of surgery that he used remains virtually unchanged and
is still widely used today. His idea was to perform a surgery that was quick and had less risk of
introducing infection into the body, cutting through the ankle joint provided this advantage.
1.2 Main features
The main features of an ankle disarticulation residual limb are

seen
in the photographs
The AD residual limb has:
• Bulbous distal end
• Long length
• Heel pad
• Atrophied muscles
Figure 1.1 Anterior View – left ankle disarticulation residual limb
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1.3 Advantages
1. The residual limb is usually end bearing.
The amputee can usually bear all of his or her weight on the end of the stump. This eliminates the
problems with bearing weight on sloped surfaces of the stump, like in Trans-tibial sockets.
2. It is usually possible to walk without a prosthesis.
The length of the stump is only slightly shorter than the sound side, between 8-12 cm. When the
stump is end bearing, there is the advantage that the amputee can walk without a prosthesis. But the
difference in length and the absence of anterior support during roll-over will cause the patient to
limp.
However this may be beneficial in a developing country where P/O care is not readily available. Also
if the patient wishes to move quickly without having to put on his prosthesis they are able to do so.
For example if the amputee wants to go to the bathroom in the middle of the night they can do so
quickly.
3. It is usually possible to make the prosthesis self-suspending.
The shape of the distal end of the stump is usually bulbous. This makes it possible to make a socket
that grips the stump above the bulbous end. No straps or other type of suspension are usually
needed.
4. The residual limb provides a long lever arm.
The long lever arm helps to distribute the socket forces over a large area, decreasing pressure and
increasing control over the prosthesis. This helps to make walking easier, more comfortable and
more energy efficient.
5. Ankle disarticulation is a good level of amputation for children.
Bony overgrowth can be seen in children who have a trans-tibial amputation. In a TT amputation in
children there is a possibility that as they grow, the bone grows longer than the tissue of the stump,
causing a prominent bony end with minimal soft tissue coverage. In an Ankle disarticulation
amputation this is avoided because the shafts of the tibia and fibula are not cut.
A secondary feature, which can be viewed as an advantage, is that the amputated limb will
not grow as much as the sound limb as the child develops. As there is less muscle action the bone
will not be stimulated to grow as fast as the sound limb. The stump will appear to shorten compared
to the sound limb. This produces a stump which remains
end bearing, while increased distance from the end of the stump to the floor provides space for
"normal" prosthetic components and feet.
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1.4 Disadvantages
1. Cosmesis is poor.
The bulbous shape of the distal end of the stump makes the ankle area of the prosthesis very big
compared to the sound limb. There are a few socket designs (covered in Chapter 7) but the results are
either a prosthesis that has cut-out sections and straps, or is quite "fat".
2. Choice of prosthetic feet is limited.
Because the stump is long, it is difficult to fit many types of prosthetic feet in the space available. A
special SACH foot that has a lower profile often needs to be used. This foot usually has a reduced
heel cushion, which offers less shock absorbtion and less "simulated" plantarflexion at heel strike.
Fig. 1.2 Ankle Disarticulation Foot
Other commercially available feet for this level of amputation are expensive
3. Difficulty donning/ doffing prosthesis
Because of the bulbous distal end , this type of prosthesis is a little more difficult to put on and off .
There are different socket designs to allow this , each with their own advantages and disadvantages.
4. The heel pad may become unstable
Sometimes the heel pad may become unstable or wobbly on the end of the stump. This can reduce
the ability to fully weight bear the weight on the distal end.
1.5 Indications
The indications for ankle disarticulation are similar to those for other amputation levels. These are:
Trauma
When the foot is severely injured, an amputation at the Trans-tibial level is not always the best
option. If the foot is injured, ankle disarticulation surgery can be done to obtain the advantages of
end bearing, the ability to walk without a prosthesis, and self-suspending socket design.
There are special considerations for injuries with much dirt and debris in the wound. This is
especially true for landmine injuries. In these cases, surgery must be done in two stages to prevent
infection. Refer to the Transtibial Prosthetics manual for more information on this subject.
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Reference: QP 5-6
Infection
Amputation may be needed in cases of severe infection of the forefoot. Surgery should be done in
two stages. The patient is treated with antibiotics and the wound is left open. The infection is
allowed to clear and the wound is then closed.
Tumor
If a malignant tumor is present in the foot, amputation may be necessary to prevent the tumor from
spreading to other parts of the body.
Congenital deformity
Ankle disarticulation amputation can sometimes greatly improve function and cosmesis in the case of
severe foot deformity, or in very rare cases of an absent fibula.
1.6 Contraindications
Vascular disease
Ankle disarticulation is usually not recommended in the case of vascular disease. This is because
there might not be enough blood supply around the ankle and heel pad to allow good wound healing.
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Chapter 2
Anatomy
Good knowledge of anatomy is the key to the correct assessment, prescription and casting
2.1 Surface Anatomy
When assessing the stump of the ankle disarticulation it is very important to assess the condition of
the distal end. The distal end may have a firm heel pad that it is fully weight bearing. It may have a
heel pad that is unstable or it may have no heel pad at all. The condition of the distal end will
determine how you cast your patient and how you design the prosthesis.
Fig. 2.1a Anterior View Fig. 2.1b Posterior View
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2.2 Bony Anatomy
Assessment of the ankle disarticulation

is similar to assessment of the
transtibial amputation. Sensitive bony
areas include the:
 Lateral condyle
 Medial condyle
 Head of fibula
 Tibial tuberosity
 Lateral tubercle
 Tibial crest
In addition, the distal end of the stump

must be carefully assessed. The
sensitive areas are the:
 Medial malleolus
 Lateral malleolus
Carefully inspect the distal end of the

stump for any other sensitive bony
areas.
2.3 Muscular Anatomy

Fig. 4.2 Tibia and fibula
The main muscles that plantarflex the
foot are:
 Gastrocnemius
 Soleus
Fig. 2.2 Tibia and fibula
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They are shown in figures

4.3 and 4.4. Together, they
are called the Triceps Surae
muscle.
After ankle disarticulation

surgery, gastrocnemius can
continue to flex the knee.
But soleus ceases to have
any function. Both muscles
begin to atrophy and
become very small.
Fig. 4.3 Gastrocnemius Fig. 4.4 Soleus
Fig. 2.3 Gastrocnemius Fig. 2.4 Soleus
The main muscle that dorsiflexes the ankle is:
 Tibialis anterior
Fig. 2.5 Tibialis anterior
This muscle is shown in figure 4.5
After ankle disarticulation surgery, this muscle does not work to dorsiflex the ankle. It will soon begin to
atrophy and become very small.
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Chapter 3: Amputation Surgery
3.1 The aim
The aim of ankle disarticulation is to create an ideal residual limb that is end bearing and non
painful.
3.2 The objectives
The goals of ankle disarticulation surgery are:
 To make the distal tibial and fibular surfaces broad and horizontal
 To firmly attach the heel pad to the end of the tibia and fibula for end bearing
 To make a scar that is not painful or adherent
3.3 Surgical procedure
The incision
The incision (Fig 2.1) begins at the apex of the malleoli, goes proximally and anteriorly across the
ankle joint, and then proceeds straight down across the plantar surface of the foot.
As with other amputations, the arteries and veins are ligated and the nerves are pulled down, cut, and
allowed to retract.
Fig. 3.1 Incisions
The ankle joint is opened up by cutting the supporting ligaments. Some of these ligaments can be
seen in figure 2.2. The talus is then taken away from the tibia and fibula.
Finally, the calcaneus is removed from the heel pad. This leaves a flap that is used to cover the end
of the tibia and fibula. This flap acts as a cushion for the stump.
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Tibio- fibular ligament
Deltoid Ligament
Distal calcaneo fibular
ligament
Fig. 3.2 Supporting Ligaments
Treatment of the tibia and fibula
The tibia and fibula are cut at right angles to the long axis of the weight bearing line. This provides a
broad, flat weight-bearing surface that is parallel to the floor. Sharp edges are smoothed with a rasp.
Figure 2.3 shows a normal tibia and fibula in the center and abnormal ones on either side. The dotted
line shows them all being cut horizontal to the long axis. The cut must be low enough to leave a flare
of the tibia for suspension of the prosthesis.
Fig, 3.3 Making the distal end broad and flat
Treatment of the heel pad
Stabilizing the heel pad is very important. If the heel pad is not securely fastened to the ends of the
tibia and fibula it will later become very unstable on the end of the stump and will not be suitable for
end bearing.
The heel pad is carefully measured and trimmed to fit the end of the stump. It should not be too large
and it must allow closure of the wound without tension.
Holes are drilled around the edges of the tibia and fibula. Then the heel pad is secured with sutures.
Finally, the wound is closed and dressed.
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3.4 Physiotherapy
Physiotherapy should begin soon after surgery. The goals of physiotherapy are:
 To control edema
 To prevent joint contracture
 To help the muscles stay strong
 To maintain the sense of balance
 To watch the patient for signs of infection
Control of edema
Elastic wrapping or a rigid plaster dressing can be used to control edema. A rigid dressing is usually
applied immediately after surgery.
The advantages of a rigid dressing are that:

 it controls edema very well
 it can protect the stump from bumps and knocks
 it can be used to begin weight bearing.
The disadvantage is that it is not possible to inspect the wound for infection without removing the
cast.
The advantage of the elastic wrapping is that:

 it is easy to check the wound and stump for healing progress
 any sign of infection is easy to see and appropriate action can be taken.
The disadvantage is that it requires the patient or nursing staff to apply the bandage correctly. An
incorrectly applied bandage can restrict blood flow, apply pressure over bony prominences and cause
ulceration.
With either treatment, the patient should keep the stump elevated when resting, to help blood
circulation and reduce edema.
Preventing joint contracture
If the patient does not remain active or keeps the leg flexed at hip or knee while the stump is healing,
the knee or hip joint may become contracted. The physiotherapist teaches the patient stretching
exercises to maintain full range of motion, and advises on the correct way to position the limb when
sitting or lying.
Maintaining muscle strength
If the patient does not remain active while the stump is healing, muscles in the whole body may
become weak. The physiotherapist teaches the patient exercises to help keep their muscles strong.
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Reference: QP 5-6
Maintaining sense of balance
If the patient does not do some standing activities while the stump is healing, they will begin to lose
their sense of balance. This will make it more difficult to learn to walk with the prosthesis. The
physiotherapist teaches the patient how to stand and walk with crutches and/or between walking rails.
Watching for signs of infection
Signs of infection are:
 Heat, redness, or swelling at the wound site or in the stump

 Fever that is not explained by any other condition
 Pus at the wound site
Infection is dangerous. It can cause the patient to get very sick and may require that the stump be
amputated once more at a higher level. The doctor should be contacted immediately if signs of
infection are seen so that it can be treated.
3.5 Prosthetic treatment
As the stump heals it is important to continue wrapping with elastic bandage. This will reduce the
swelling and shape the stump so that it will be ready for fitting the first prosthesis. If the stump has
too much edema, it will not be possible to fit a prosthesis. After about 6-8 weeks the suture line has
healed completely and bandaging reduces the initial oedema, the first prosthesis can be fitted.
It is best if the prosthesis is fitted as early as possible to avoid the possibility of joint contracture,
muscle weakness, and loss of balance. Also for the patient early fitting has great psychological
advantages, greatly improving their outlook on the future. The prosthetist and the physiotherapist
should work closely together to make sure that the patient resumes normal activities as soon as
possible. The fitting of prosthesis should be followed up regularly due to muscle atrophy makes the
prosthesis loose.
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Reference: QP 5-6
Chapter 4:
Socket Biomechanics
There are 4 main features that affect the biomechanics of the AD prosthesis
 Triangular shape
 Bulbous distal end
 End bearing
 Length of stump
4.1 Rotational control
The socket must not rotate on the stump during gait. The natural triangular shape of the proximal end
of the stump is emphasized during casting and rectification. The traingular shape is further
emphasised as the muscle atrophy. When the triangular shape of the stump is fitted into the
triangular shape of the socket, rotation is prevented.
Fig. 4.1 Rotational control using a triangular

shape
4.2 Suspension
The wide and bulbous shape of the distal end of the stump makes it
possible for the socket to be self-suspending. The socket is molded in
the area above the malleoli for suspension. Pressure will be felt in
this area during swing phase. This type of suspension is usually
comfortable and secure.
One problem which can occur with this form of suspension is pressure
over the malleoli. If the posterior wall of the socket is too high, and
the patient flexes their knee, pressure in the popliteal area will push
the prosthesis distally. This will cause pressure on the malleoli.
One challenge with this type of suspension is allowing the big bulbous
end to pass the narrow area of the socket. Different socket variations
that solve this problem are discussed in Chapter 6.
Fig. 4.2 Suspension above the malleoli
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Reference: QP 5-6
4.3 End bearing
The ankle disarticulation residual limb is end bearing. Ideally the residual limb has the potential to
carry all the patients weight on the end of the stump.In some cases the patient may not be able to
tolerate all the pressure here. If this is the case some of the load can be taken more proximally
4.4 Socket forces during gait
Throughout the Gait cycle the location and magnitude of the forces on the AD residual limb change .
These are considered below.
Heel-strike
Fig. 4.3 Forces just after heel-strike
During heel-strike, a knee flexion moment is created. This is shown in the first picture of Fig. 4.3.
The knee tends to be pushed forward and the foot rotates toward the floor. This moment is resisted
by the action of the knee extensors and by force within the socket. Pressure is located on the
posterior-proximal part of the socket. This force is labeled P in the figure.
Force P can be calculated by the formula P x a = F x b.
P= the force on the posterior-proximal part of the socket
a= the length of the socket
F= the ground reaction force which equals the mass of the patient multiplied by the force of
gravity (10 m/sec2) ( F= mxa)
b= the distance between the point of contact and the pressure at the end of the stump
(labeled D)
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Reference: QP 5-6
Force P can be large or small depending on the length of the socket that is designed for the patient. In
the table below force P is calculated during heel-strike for a patient wearing a long socket and a
short socket.
Mid-stance
The results of a study done by Murdoch (1976) showed that end bearing for ankle disarticulation
patients in a prosthesis varied from 34 – 90%. If the patient can not fully bear weight on the distal
end of the stump, the socket must be designed to bear some of the weight more proximally. But if
the patient can fully bear weight on the end of the stump, we can assume that socket forces will be
mostly distal as shown in figure 4.4
Fig. 4.4 Forces during mid-stance
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Reference: QP 5-6
Patient using a long socket Same patient using a short socket

Mass of patient = 60kg Mass of patient = 60 kg
b = 10cm b = 10cm
a = 40cm a = 20cm
1. First, calculate force F in Newtons by 1. Again, first calculate force F in Newtons

multiplying the mass of the patient by the by multiplying the mass of the patient by
force of gravity: the force of gravity. As you can see this is
the same.
F = 60kg x 10 m/sec2
 F = 600kg m/sec2 F = 60kg x 10 m/sec2
 F = 600 Newtons  F = 600kg x 10 m/sec2

 F = 600 Newtons
2. Now use the formula P x a = F x b 2. Now, again use the formula

Pxa =Fxb
P x 40cm = 600N x 10cm P x 20cm = 600N x 10 cm
 P x 40cm = 6000 Ncm  P x 20cm = 6000 Ncm
 P = 6000 Ncm / 40cm (The centimeter units  P = 6000 Ncm / 20cm (The centimeter units
cancel out) cancel out)
 P = 150 Newtons  P = 300 Newtons
Thus, we calculate that force P at Thus we can see that force P is twice the
the posterior wall during heel-strike force in the short socket when compared
is equal to 150 Newtons. to the long socket because the socket is
twice as short.
This is why we try to keep the trim lines of the ankle

disarticulation socket as high as possible. The
height of the posterior wall must be a little lower,
though, than for a transtibial patient. If it is too
high, pressure in the popliteal area will be too much
during sitting. This will tend to push the socket off
the stump during sitting and create discomfort on
the malleoli.
This is where the greatest difference between an AD prosthesis and a TT prosthesis can be found. In
a TT prosthesis the distal end of the bone can move freely in the socket, and
as such we can have many problems during the gait cylce especially at shortly after heel strike. At
heel strike the quadriceps act to control the knee flexion moment, and cause the distal end of the bone
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to move anterior, until it is stopped by the socket. This produces high pressures on the distal anterior
end of the stump.
But in an AD prosthesis the distal end is fixed and does not move, because it is weight bearing. So
when the quadriceps act to stabilise the knee, the tibia is fixed and there is no (or little) anterior
movment. The Quadriceps act more efficiently and the patient does not have high forces generated on
the distal anterior end of the stump.(Think about yourself standing on one leg. Can someone move
your distal tibia?)
Push-off
Fig. 3.4 Forces during push-off
Fig. 4.5 Forces during push-off
During push-off, the forces are reversed. A knee estension moment is created. This is shown in the
first picture of Fig. 4.5. The forces tend to push the anterior-proximal socket in a posterior direction.
This creates pressure on the anterior-proximal part of the stump. This force is labeled A in the figure.
Force A can be calculated by the formula A x a = F x b.
A= the force on the anterior-proximal part of the socket
a= the length of the socket
F= the ground reaction force which equals the mass of the patient multiplied by the force of
gravity (10 m/sec2)
b= the distance between the point of contact and the pressure at the end of the stump (labeled D)
Let’s compare the forces for a long socket with forces for a short socket. This will help you to see
that there is more presure on the anterior part of the stump for the short socket than the long socket
during push-off.
Code: IE-CSPO-038
Reference: QP 5-6
Short Socket
Calculate force A when:
Mass of the patient = 60kg

b = 15cm
a = 20cm
F = 60kg x 10 m/sec2
 F = 600kg m/sec2
 F = 600 Newtons
Ax a = Fxb
A x 20 = 600 x 15
A = 600x 15 / 20
= 450 N
If a longer socket is used the force is reduced
Advantages of the high proximal trim line
Long lever arm provides good lever arm, power and control for the prosthesis.
Pressure is less if longer lever arm. Pressure can be distributed on weight bearing areas.
Stump lenght and corresponding components
For the long stump it is difficult to fit a high performance foot. Options are to use modified Sach foot,
Syme Sach foot or energy recover foot.
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Reference: QP 5-6
Biomechanics and Alignment
Normally the alignment is set at 0º of flexion in the knee or even a slight hyperextension. There is a
marked adduction of the stump in the coronal plane due to natural curve of tibia. The socket is placed
as medial as possible over the foot to avoid a lateral thrust in the knee joint. The prosthetic foot must
also have the correct heel height and it should be externally rotated to match the toe-out of the sound
foot. (Partial Foot Amputations, 2001)
Fig. 4.6 ML forces
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Reference: QP 5-6
Chapter 5
Assessment and casting procedure
5.1 Objectives
The objectives of assessment and casting are to:
o To gain an accurate model of the stump in a load bearing position

o To obtain correct measure to allow prosthesis to be correctly set up for fitting and alignment
o To gain information to enable the best prescription choices to be made for the patient
5.2 Patient assessment
Patient assessment is very similar to TT patient assessment. The standard patient assessment
procedure is conducted to determine the muscle strength of the patient, ROM, balance, general health
and living/work conditions. The residual limb is also assessed
To assess the residual limb:

o Note any scar tissue, bony prominences and skin areas that
must be accommodated in rectification.
o Look at the distal end and observe to see if it is full end
bearing or partial.
 Ask the patient to stand on a piece of EVA for 10-15
minutes. If they can do this without discomfort the
stump is suitable for full end bearing.
o Study the heel pad to see if it is secure on the distal end or
if it migrates when weight bearing. Make a decision as to
how you are going to cast this patient, fully weight
bearing, or partial. You may have to position the heel pad
with your hands, under the bony end if it migrates (moves
around, i.e., supinates)
Fig 5.1 Interview with the patient
Code: IE-CSPO-038
Reference: QP 5-6
Fig 5.3 Assess for weight bearing

Fig 5.2 Assess for bony tolerance
prominences
This part of the assessment helps us to decide
o How much weight is taken by the patient during casting
o The casting procedure
5.3 Assessing the height
The sound limb is measured to determine proper length

of prosthesis and foot size.
o Measure the distance from MTP to the floor to
confirm the overall height.
 Some patients may have suffered multiple
fractures that may result in tibia/femur that are
of different lengths. The height of the sound
side is only a guideline for bench alignment,
while the measurement found with a level
pelvis is more useful in the case of traumatic
amputation.
o Measure the length of the foot and check the shoe
size and heel height if the patient has them
o Take circumference measurements for any
cosmetic goals that may be reached
Fig 5.4 Make the pelvis level
Code: IE-CSPO-038
Reference: QP 5-6
The patient is asked to stand with some blocks under

the amputated side. Material should be added or
removed until the patient has a level pelvis.
A thin layer of plastazote/ EVA is added for comfort
 Measure the height of the build-up
 Measure the overall height from the floor to the
MTP of the amputated side.
 Remember to take into account the compression of
the EVA
Fig 5.6 Measure the height

of sound limb. MPT–floor.
Fig 5.5 Measure the height of the build-up

5.4 Marking the residual limb
Note landmarks and measuring points.
 Pull a stocking onto the stump (slightly wet is
easier to draw on and it sticks to the patient a little
better).
 Mark with an indelible pencil the following areas:
o Patella - patellar tendon
o Medial and Lateral Femoral condyles
o Tibial Crest
o Tibial Tubercle
o Medial and lateral borders of the tibia.
o Lateral condyle of tibia
o Medial tibial flare
o Medial malleolus
o Fibular head
o Shaft of fibula
o Lateral malleolus
o Mid-Patella tendon
o Hamstrings tendons
o Any other bony spurs, scarred areas,
sensitive tissues, etc.
Fig 5.7 Mark landmarks
Code: IE-CSPO-038
Reference: QP 5-6
Measurements of the amputated side.

1. Circumference measurements:
 At the knee or femoral condyles
 At the apex of the fibular head
 At the mid calf where the stump is largest
 At the distal end above the bulbous end
where it is smallest
 At the largest part of the bulbous distal
end. Take this measurement while
applying some amount of pressure to
simulate weight bearing and be sure the
heel pad is positioned if it is mobile
 Measures can be taken at 5cm increments
Fig 5.8 Measure the

distal circumference.
Code: IE-CSPO-038
Reference: QP 5-6
CSPO Lower Limb Patient Assessment Form
Name: File # Date:
Hip Joint ROM Muscle Strength

L R L R Sensation:
Flexion: (120)
Extension: (30)
Abduction: (45)
Proprioception:
Adduction: (30)
Internal Rot. (35)
External Rot. (45)
Knee Joint ROM Muscle Strength
Muscle Tone:
L R L R
Flexion: (130)
Extension: (0-10)
L R
Leg Length Shortening:
M-L Stability
A-P Stability
Ankle Joint ROM Muscle Strength
Joint Deformities:
L R L R
Dorsiflexion: (30)
Plantarflexion: (45)
Inversion: (30)
Eversion: (15) Spinal Deformity:
Gait Deviation
Left Leg Right Leg

Phase of Gait Trunk
(Hip / Knee / Ankle) (Hip / Knee / Ankle)
Stance Phase
Swing Phase
Code: IE-CSPO-038
Reference: QP 5-6
CSPO Casting/measurement Chart
Date: Name: File #

Side: L R Sex: M F Age: Year of Amputation:
Reason for Amputation:
Primary Patient: Yes No Revision: Yes No
Occupation:
General Health:
Upper Limb Condition:
General Condition of Stump:
Functional Deficit:
Stump Position: Flexion- Adduction- Abduction-

Socket: Panel Opening Push Fit PTB Foot:
Shoes Provided: Yes No Shoe Size: Heel Height:
Special Remarks:
CPO: Fitting Date: Delivery Date:
Code: IE-CSPO-038
Reference: QP 5-6
2. Diameter measurements:
 ML at the knee or femoral
condyles
 ML and AP at the narrowest
part of the distal end above
the bulbous pad
 ML and AP at the largest
circumference of the
bulbous distal end. Take this
measurement while
applying some amount of
pressure to simulate weight
bearing and be sure the heel
pad is positioned correctly.
Fig 5.9 Largest distal M-L
3. Length measurements:
 Stump length—from MPT to distal
end of the stump (simulate weight
bearing or use the floor)
 Length from the distal end of the
stump to the floor.
 Length from distal end of the stump
of the circumference measurements
you took above.
Sound leg measurements Fig 5.10

Length measurements
MTP - floor
MTP - end of stump
All of these measurements must be entered on the measurement/assessment form with the rest of the
patient information.
Code: IE-CSPO-038
Reference: QP 5-6
5.5 Casting Procedure
There are 2 methods of taking a cast for AD

o Wrap casting – a plastic tube or strip of metal is inserted so that the cast can be removed over the
bulbous distal end by cutting the plaster. This can be used when the patient is full or partial distal
weight bearing. The patient usually stands
o Slab casting – the cast is taken using longitudinal slabs of plaster with a seam anteriorly which
can be opened to allow removal. This can be taken when the patient is non or partial distal
weight bearing . The patient remains seated
1. Decide whether you will take the cast with the patient standing with full weight bearing, partial
weight bearing or non weight bearing. This will depend upon
o the distal end of the stump
o if the patient can bear weight or not
o whether the heel pad is stable or not. If the heel pad is mobile full weight bearing during casting
is contraindicated. The heel pad needs to be placed under the stump.
o Health / strength of patient. If the patient is weak they may not be able to stand for a long time.
If the cast is taken with the patient sitting, be prepared to apply a flat surface to the distal end and be
careful that it is at 90 degrees to the shaft of the tibia. (you can also use the flat of your hand)
5.5.1 Wrap Casting
Because the distal end is bulbous, the cast can not be pulled off like a trans-tibial cast. Special
consideration must be taken to remove the cast after it has hardened. At least one cutting strip must
be used and sometimes two.
o If only one, place it on the medial side of the tibia for the length of the stump.
o If two, place one on the medial side and one on the lateral side. The cast is less likely to deform
if you use two and cut the cast into two pieces. (known as a bi-valve cast) for removal.
Code: IE-CSPO-038
Reference: QP 5-6
Cast the patient in two stages.

a. First cast the distal half with the
patient sitting down. Carefully
mould around the bulbous distal
end and the flare of the malleoli.
As the plaster is beginning to
harden, weight bearing is
provided to flatten out the
bulbous distal end either by
having the patient stand on the
block you made, or by applying
a flattening pressure as described
above if the patient continues to
sit. At this time, take care to be
sure that a mobile heel pad is
positioned correctly (do not
allow it to supinate).
Fig 5.11 Cast the distal half
b. Second, wrap the rest of

the cast up to the level of
the proximal patella.
Mould the cast to flatten
out the posterior area and
mould into the tibial
flares to create a good
triangular shape. This
will control rotation of
the prosthesis on the
stump as well as help to
share weight bearing.
c. Like with a trans-tibial
cast we need to mark the
position of the patella
tendon with our thumbs.
d. Stand the patient once Fig 5.12 secondly wrap
more. the entire stump.
Code: IE-CSPO-038
Reference: QP 5-6
Fig 5.13 mark the position Fig 5.14 stand the patient once
more Fig 5.15 Apply plumb line
of the patella tendon
e. When the plaster has hardened, we need to make reference marks. These marks are very
important as they will show us the adduction and flexion angles of the stump when the patient is
standing. Make sure that your patient is standing straight and looking straight ahead.
Use a plumb line/ metre stick to make a reference mark on the anterior or posterior side of the
cast to show the patient’s adduction angle.
Use a plumb line/ metre stick to make a reference mark on the lateral side of the cast to show the
patient's flexion angle.
f. Make reference marks before cutting down the cutting

strips so that two halves of the cast can be realigned when
the cast is sealed.
Carefully remove the cast and reassemble it according to
your reference marks. When putting the cast back together
it is important to not deform the shape. Take care.
Even though the cast is complete, there is more work to be

done;
 Clean the patient's leg of all plaster residue.
 Help the patient to don their prosthesis.
 Discuss with the patient the date and time of the fitting
of the new device.
Return and clean the casting area.
Fig.5.16 Take off
Code: IE-CSPO-038
Reference: QP 5-6
5.5.2 Slab Casting
Because the distal end is bulbous, the cast can not be pulled off like a trans-tibial cast. The cast is
made with slabs of plaster with a seam that can be opened to allow removal
The patient remains seated throughout the procedure
a) Preparation:
o The same measurement procedure is followed
o The slabs must be prepared to the correct length 3-4 layers thick .
o Depending on the circumference: approx 4 x 15 cm slabs are needed
b) Applying the cast
o The first slab is wet and

applied longitudinally with
a triple thickness on the
medial edge
o The seam is applied
anteriorly
o Vaseline is applied along
the edge to allow easy
separation
o The slab is smoothed and
moulded
o The other slabs are applied
in quick succession ensuring
good overlap and a smooth
cast
o When the two slabs meet
anteriorly another thick
Figure 5.17 : applying the plaster
edge is created
bandage longitudinally
c) Applying pressure
Slight pressure is also applied to the patellar tendon and posteriorly popliteal fossa. The amount of
pressure depends on the amount of distal weight bearing
As the plaster sets pressure is applied to the distal end while the patient remains seated
d) Removing the cast

When the plaster is hardened the patient stands and reference lines are drawn.
Reference marks are also made over the anterior seam to allow the cast to be joined together after
removal
The two edges are teased apart to allow removal of the cast
Code: IE-CSPO-038
Reference: QP 5-6
5.6 Producing the positive model
 Seal the cast along the areas you cut, build up on the proximal brim (if needed) and place the cast
in the sand box.
 Position the cast so that the plumb lines are vertical.
 Fill the cast with Plaster of Paris.
 Place the pipe in the cast parallel to the adduction and flexion angle plumb lines you marked on
the cast, in this way you will be duplicating the alignment of the patient and this will make it
easier to produce the prosthesis.
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 6: Cast rectification
6.1 Purpose
The purpose of rectification is to create a positive cast that will provide:

 A comfortable socket that supports the limb in weight bearing stance phase.
 By loading weight tolerant areas, while unloading sensitive areas.
 Suspension of the prosthesis during swing phase.

 By utilising the natural shape of the AD stump proximal to the malleoli.
 Control of the prosthesis in both swing and stance phase.

 By creating a triangular shape and thus locking the socket on the limb in the proximal area.
In order to do this, plaster is removed from pressure tolerant areas, and added to the pressure
sensitive areas. The cast is shaped for weight bearing, suspension and rotation control.
For an Ankle Disarticulation stump the weight bearing areas are typically:
 Distal end (heel) pad
 Tibial flares
 Patella tendon
 General total contact
The pressure sensitive areas are typically:

 Tibial crest and tuberosity
 Fibular head
 Neck of the fibula
 Patella
 Medial and Lateral malleoli remnants
 Other bony areas or scars
Code: IE-CSPO-038
Reference: QP 5-6
6.2 Rectification Procedure
1. The plaster bandage that made up the negative cast is removed and any obvious irregularities are
cleaned up.
 Re-draw all the stump markings.
 Check the cast against the measurements taken from the patient. Take note if there are any large
discrepancies. Especially take note of the distal end ML, AP and circumference measurements.
 Assess the positive cast:
 Are the markings in the correct place?
 Is the heel pad in the correct position?
 Are the indentations in the correct place?
 Are the measurements taken from the patient close to the cast measures?
2. Medial-Lateral (ML) diameter of the knee

 Compare the diameter taken from the patient. Be sure to take the measurement at the same place
on the cast as you did on the patient. There should not be too great a difference.
 If the cast is too large – remove plaster from the model until the measurement is
approximately halfway between the patient measurement and the cast measurement.
 If the cast is too small – add some plaster on both sides, until the measurement is
approximately halfway between the patient measurement and the cast measurement.
6.3 Plaster removal

 The rectification of this region is
similar to the rectification for TT
1. Patellar Tendon amputation ,but is much less severe
 The stump should bear most
weight at the distal end, with the
remainder of the weight being
borne over the entire surface.
 Only in cases where end bearing
is not possible do we require a
deep patella bar.
 Contour the cast in the area distal to
the patella, so that the patella will be
cradled by the socket. This will help
produce a more stable prosthesis by
locking onto the patella.
Fig.6.1 Patellar tendon
2. Tibial Flares
Code: IE-CSPO-038
Reference: QP 5-6
Plaster can be removed along the medial

tibial flare and in the region of the
Tibialis Anterior muscle group. This is
done primarily to produce an intimate fit
with the stump shape, thus providing an
area for distributing weight bearing
forces and additionally creating a
triangular cross section. Because it is
triangular in cross-section this helps give
rotational control by locking the
prosthesis onto the tibia.
Fig.6.2 Tibial flares
 Be careful not to over rectify. Often the AD patient has a very thin stump. The muscles of ankle
movement atrophy, just like a Trans-tibial stump. It is very easy to rectify too much, especially
in the distal region.
3. Distal end
This is the main load bearing area and requires the most care.
As the end pad is loaded it becomes flatter and wider.
As the cast will have been taken with the appropriate amount of load the tissue should already have been
deformed.
Check to see if the heel pad is in the right position – if it has moved off-centre
4. Popliteal Fossa
The popliteal fossa should only have a minimal indent. Because pressure is mainly taken at the distal
end a counter pressure for the patella tendon is not needed. A small indent provides stability to the
socket.
If the cast is taken correctly this area only needs to be smoothed.
5. Posterior aspect of tibia
The posterior aspect of the cast should be flattened slightly, adding to the triangular shape that will
stabilise the prosthesis in stance and swing.
In the case where distal weight bearing is not possible, the popliteal area should be modified as per a
standard PTB design.
Code: IE-CSPO-038
Reference: QP 5-6
6.4 Plaster addition
Plaster is added to pressure sensitive areas.
1. The Fibular head
The fibular head and neck are built up

in the same way as a transtibial cast.
Approximately 3mm should be added.
The build up should taper out at the
border of the fibula head. Distally the
build up should be continued down the
shaft of the fibula for about 1cm to
prevent pressure on the peroneal nerve
Fig.6.3 Fibular head
2. Tibial crest and tibial tuberosity
A build up of 2-3 mm should be made

along the length of the tibial crest
The build up is greatest the tibial tuberosity

and reduces gradually along the length of
the shaft
Fig.6.4 Tibial crest and tibial tuberosity
Code: IE-CSPO-038
Reference: QP 5-6
3. Remnants of the malleoli

Small buildups over the medial and lateral
malleoli are required – usually 2-3 mm
The diameter of the area is usually larger

than the measure. This is because when the
distal end is loaded it will flatten and widen.
Do not reduce to the measures !!
Fig.6.5 Malleoli
4. Posterior wall – The posterior wall can be lower than a transtibial prosthesis by 2-3 cm. In an Ankle
Disarticulation socket a high posterior trimline will push the socket distally when the knee is flexed,
but due to the bulbous distal end the socket will not piston. Instead the socket will press on the bony
prominences of the malleoli causing discomfort and pain.
5. Any other sensitive scarred areas
6. Re-check all the measurements of the cast and compare them with the measurement chart. Ensure that
there are no areas that have unusual discrepancies.
Finally clean up the entire surface, making it smooth and ready for the manufacture.
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 7:
Socket variations and materials
The variations in socket design and materials reflects the 3 main characteristics of the ankle
disarticulation limb
o Bulbous distal end
o Self suspension
o Distal End bearing
Socket design must provide the following:
1. Stabilize against rotary forces about the long axis. Three-point or triangular stabilization against the
flares of the tibia plus a flattening across the posterior portion of the gastrocnemius will provide a
good share of stability.
2. Weight support can be distributed between the end of the prosthesis and the proximal portion of the
socket brim. Dispersion forces against the proximal surface of the leg at push\-off can be
accomplished through a careful fitting against the medio-lateral surfaces of the tibia.
3. Dispersion of force encountered at heel contact is accomplished through contact from heel to the
upper gastrocnemius. The cup like contour for the stump end must extend superiorly enough to
prevent motion between the socket and the stump in an antero-posterior direction. (Atlas of Limb
Prosthetics, p.426. 1992)
In this chapter three main designs for ankle disarticulation are described.
o Conventional design- leather and steel

o Panel opening socket made of polypropylene or GRP
o Push fit socket with Pelite/ EVA liner and Polypropylene / GRP socket
7.1 Trimlines
The trim line of the Ankle Disarticulation prosthesis is similar to that of a Trans Tibial socket but the
posterior trim line should be 2-3 cm lower, because of the suspension over the malleoli.
A high posterior trim line will push the prosthesis off the stump when the knee is flexed. This will
cause pressure and pain in the suspension areas.
A secondary consideration is that the distal end of the stump is weight bearing and thus proximal
weight bearing pressure is often unnecessary.
If good suspension is achieved over the malleoli, no proximal suspension features are needed.
Code: IE-CSPO-038
Reference: QP 5-6
2-3 cm
Fig. 7.1 AD prosthesis- Fig. 7.2 AD prosthesis-

anterior trimline posterior trimline
7.2 Conventional design Leather and steel

Earlier methods for making Ankle Disarticulation prostheses included devices made of leather
and steel. In this design, the leather section formed the socket and was “lace-up” to allow for
donning and doffing. The steel sidebars and ankle joints need to be very strong to withstand the
very high forces generated throughout stance phase. Unfortunetly most systems like this wear out
very easily and break often.
This type of prosthesis is not suitable for wet environments as the leather absorbs moisture and
can rot, and the steel sidebars will rust.
It is extremely uncosmetic and heavy
Fig 7.3 Lace-up leather socket and side Fig 7.4 A leather socket with side bars
Code: IE-CSPO-038
Reference: QP 5-6
Indications:
Contraindications: if any other system is available
Advantages:
Disadvantages: not durable, poor cosmesis, heavy, leather not suitable for wet/ humid environments,
difficult to manufacture, not total contact
7.3 Panel opening socket
A section of the socket wall is cut out to allow passage of the stump through the narrow section
and then put back in place to give suspension.
This panel or removable wall is best placed on the medial side, where it is a more cosmetic and
does not overly alter the strength of the prosthesis in the sagital plane.
The opening can also be placed on the anterior or posterior side but the stress forces of heel strike
and toe off are large and will be focused on the remaining structure. This may be acceptable if we
are using a strong material, like GRP that can be specially reinforced in one section, but
polypropylene is not so strong and will eventually fail.
Panel opening sockets are usually , but not always made without a pelite liner. If the patient
requires more padding or shock absorption, a liner can be made.
Fig 7.5. Glass Reinforced Plastic (GRP,

laminated) socket with posterior panel
opening
Fig 7.6 Polypropylene socket
Code: IE-CSPO-038
Reference: QP 5-6
Fig 7.7 A GRP socket with a medial panel opening.
Indications: best design for someone with poor hand function/ eyesight(?) Excessive sweating (no
liner)
Contraindications: If made without liner Scarred / sensitive residual limb is contraindicated , may not
be suitable for heavy person
Advantages: if no liner used, ankle is kept reasonably thin, easy to manufacture (PP), easy to don/
doff
Disadvantages: limited adjustment, straps needed to hold panel in place – cosmesis compromised
both by panel and strap, panel weakens structure of socket (PP)
7.4 Push fit socket
An inner liner is made of Pelite or similar

material. Like a Trans-tibial socket the
liner is made to fit the stump snugly. The
next step is to build-up the outside of the
liner with more Pelite, so that the outside
has straight, but slightly tapering sides.
The liner is then split along the long axis
so that it can expand and allow passage of
the bulbous end of the stump.
Then the stump and the liner can be
pushed into the socket.
This method of suspension depends

mostly on the friction between the liner
and the socket. This can be very good, but
if the liner material compresses, the
suspension can be lost.
Fig 7.8. Push-fit liner and socket.
Code: IE-CSPO-038
Reference: QP 5-6
Fig 7.9. A Push-fit liner and socket. The split in the liner allows the liner to deform to allow the
stump in, and then it can be pushed inside the socket.
Indications: obese / heavy person, scarred/ sensitive residual limb
Contraindications: poor hygiene; excessive sweating, elderly –with little strength/ poor hand
function/ eyesight, hyper mobile heel pad
Advantages: easy to adjust, no straps needed, strong
Disadvantages: cosmesis compromised- large ankle circumference; can be difficult to don/ doff
7.5 Materials
lass Reinforced Plastic (GRP)
The strength of a socket is greatly weakened by a cut out panel, so Glass (or Carbon) Reinforced
Plastic laminate is best for the panel opening design. The stress forces mentioned above will often
cause polypropylene to bend.
A two-stage lamination will allow design of a removable panel that will lock into place for
suspension.
The first lamination is reinforced with extra Fiberglass fibers or Carbon Graphite material to account
for the additional stress created by the panel design. The panel is cut out, and then replaced for a
second much thinner lamination.
This creates a thin layer of lamination over the entire prosthesis. It is removed and trimmed down to
provide only the panel with a "lip" of 1-2 cm overlap. This can then be held in place with straps.
Polypropylene
Polypropylene is frequently used because of the easy manufacture techniques and low material costs.
It is not the best for a panel design, as it is flexible, it will often bend at the edges of the cutout. The
larger the panel the more that the strength is reduced
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 8
Components for Ankle Disarticulation Prostheses
There are 5 component parts of a AD prosthesis
• Socket
• Liner
• Suspension
• Foot
• Cosmesis
Chapter 7 considered The socket design , liner and suspension. This chapter considers the prosthetic
foot and the cosmesis
8.1. The AD Prosthetic foot
The Symes, or Ankle Disarticulation stump is very long. The space between the stump end and floor
when the amputee is standing is generally between 5-10 cm. This is a limiting factor in the choice of
components that may be used in manufacture of this type of prosthesis. Most prosthetic feet are
between 7 to 9 cm high, if we also include alignment apparatus the total height can be in excess of
10cm.
There are 3 options:
1. Use a modified SACH foot
Wooden Keel
Cushion heel
Figure 8.1 Modified SACH foot
When a GRP Laminated socket is used, a specialized wooden keel SACH foot can be used. The
wooden top of the SACH foot is hollowed out so that the end of the socket can be placed inside. It is
important that the carving of the foot is done carefully to ensure the correct height of the prosthesis.
The foot is then bonded to the socket with either acrylic or epoxy resin.
Once the foot is bonded to the socket, alignment adjustments are very difficult. The foot must be
"broken" off the socket, re-aligned and re-bonded.
Code: IE-CSPO-038
Reference: QP 5-6
2. Use low profile foot (VI)
A special Symes foot is available from Veterans International and/or Handicap International that is
fabricated to fit with the ICRC technology used in Cambodia and other countries. This system uses
the polypropylene convex disc outside the socket to attach on to the on the foot. This allows minor
alignment changes, both tilting and shift adjustments.
Fig 8.2 The VI Symes foot – when combined with the ICRC
alignment system it has a total height of 5.5cm
The build is seen in Figure 8.3
Polypropylene
Liner
Convex PP disc
Modified PP cup
Figure 8.3 : manufacture of socket with VI foot
The standard PP cup needs to be slightly modified to fit the contour of the foot. It is important in to
ensure the correct fitting of the cup onto the foot, and also the correct height.
If the height needs to be further reduced, the ICRC convex disc can be draped inside the PP socket.
This means that the modified PP cup seen in Figure 8.3 can be removed , reducing the height.
However this means there is only tilting adjustments can be made in dynamic alignment, no shift
adjustments are possible.
Code: IE-CSPO-038
Reference: QP 5-6
3. Use low profile foot (Western)
Newer designs of feet for Ankle Disarticulation from companies that manufacture energy storing feet
such as Flex Foot, Springlite, and Quantum offer some alternatives. By using carbon fiber and
advanced techniques they can provide feet with "normal" characteristics that are light and compact.
These feet have low profiles that allow the use of a modified alignment device between the foot and
the socket. This provides a limited amount of tilt, slide, and rotation adjustment, which can allow for
greater tuning of the prosthesis in dynamic alignment. These products are expensive, and for
developing countries the cost often prohibits their use.
Fig 8.4. Feet designed for Ankle Disarticulation

prostheses, from a company called Otto Bock
(Springlite). Both require less than 5cm between
the end of the socket and the floor.
Fig 8.5. Similar feet from Össur (Flexfoot) that can be used for Ankle Disarticulation. These
feet require less than 5 cm (left) and 6.5cm (right)
8.2 Cosmesis for Ankle Disarticulation
The cosmetic finish is often dependent on the socket design. The ankle will always be more bulbous
than the sound leg. Often there is no cosmesis in the calf and only the ankle area is blended in.
Code: IE-CSPO-038
Reference: QP 5-6
8.3 AD socket and cosmesis
• The PP also forms the cosmetic cover

• There is poor cosmetic shape – it
appears tubular
• However there is no need for
additional straps
• The outer finish is waterproof
To improve the cosmesis :

• A Polypropylene socket can be built
up with EVA in the calf region
• Stockings can be pulled over the top
to disguise the calf build up
• By making the calf slightly bigger the
size of the ankle looks smaller
Fig 8.6 Push fit design
Code: IE-CSPO-038
Reference: QP 5-6
A panel socket can also be built up

with EVA at the calf to give a
reasonable cosmesis in the sagittal
plane
Once the basic cosmetic shape has

been done a 3 mm wrap of EVA covers
the whole prosthesis.
However straps are needed which

reduces the cosmetic appearance
The outer finish is water resistant
Fig 8.7 Panel opening design
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 9:
Ankle Disarticulation Alignment
9.1 Definition
Alignment of a prosthesis is the relationship between the different components and how this
relationship affects the biomechanics of gait
It is the relationship between the components, which is the focus of this chapter. With an Ankle
Disarticulation prosthesis this involves the socket-foot connection. As in Trans Tibial alignment
procedures, there are 3 stages of alignment:
o Bench Alignment
o Static Alignment
o Dynamic Alignment.
9.2 Bench Alignment
Bench alignment principles will attach the foot to the socket in a position that is the best starting
point for most amputees.
The Coronal plane
M It is possible to place the attachment point for

L the foot directly under the socket, which
produces a cosmetic appearance, but will
produce a less efficient gait.
If the foot is attached directly under the end of

Weight line the socket the difference between the
weightline of the body and the GRF will
produce a lateral thrust.
Some people will be able to tolerate this, but in
the long term it can be detrimental to the
ligaments of the knee.
If the foot is attached directly under the end of

GRF
the socket it will also be positioned too anterior
it will produce a long toe lever. This can
produce difficulty walking up slopes and knee
hyperextension.
Fig 9.1 Foot positioned directly under the

socket producing lateral thrust.
Code: IE-CSPO-038
Reference: QP 5-6
For the best biomechanics the attachment point of the foot should be a little posterior and a little
lateral. This will be less cosmetic in appearance, but will produce a much more efficient and
biomechanically sound gait.
In this case the body weightline and

GRF GRF are much closer together. This
reduces the tendency to lateral thust.
Cosmesis is affected and this will have

to be discussed with the patient.
Weightline
Figure 9.2 Bench alignment – foot outset laterally
The assessment of the patient should have determined individual adduction angles and this should be
built into the distal flattening of the pelite liner or end pad. This will ensure that when the patient is
standing, the foot will be flat on the floor.
The Sagittal plane
In this alignment the flexion-extension position of the tibia is taken into account. For the average
stump, the midline of the socket is set at 90 degrees to the floor.
 Too much flexion will cause strong ground reaction force at heel strike and “drop off” at the end
of stance phase.
 Not enough flexion will cause a “jackknife” effect when at foot flat the toe lever reacts to the
floor, and an extension moment at the knee at push off.
Code: IE-CSPO-038
Reference: QP 5-6
As in Trans Tibial alignment, a plumb

line from the middle of the socket
should fall approximately 1/3 the
distance from the heel.
This will require that the foot is attached

more towards the posterior aspect of the
socket.
Figure 9.3 Bench alignment in Sagittal plane
Rotation
The foot should be set at 5 degrees external rotation, or the medial border of the foot on the line of
progression.
9.3 Static Alignment

This procedure is done to check that the prosthesis is fitting well and that it is ready to be walked
upon.
Before static alignment check the following :

 Review the information on the measurement chart and the assessment results – ensure that you
are familiar with the details of the patient.
 Check the prescription to be sure that the leg you are about to fit is the same as the prescription.
 Observe the patient walking on the old prosthesis. Notice any gait habits, deviations, and unusual
characteristics. Take note of the other side, the upper limbs, and the position of the trunk to see if
there is any other habits or deviations. You may identify gait problems that you hope to improve
with the new prosthesis, or problems that may have other causes that cannot be corrected with
your prosthesis.
 Check the Bench Alignment to see if it is correct.
 Make sure that the socket/foot connection is secure and it will not rotate.
 Examine the patient’s stump. Take note of any cuts, abrasions, or skin conditions. Look for
oedema (swelling). This is important to be sure that the new socket is not causing new problems
or continuing old problems.
Code: IE-CSPO-038
Reference: QP 5-6
Fitting :
If using a Push-Fit prosthesis, have the patient put on a stump sock and don the liner. The stump
should go in all the way and be a close fit. Then put on the hard socket. It should go in all the way
with no gaps or uncomfortable pressure. Check with the patient to be sure that the fit is comfortable
before standing.
 With the patient still sitting, check the trim lines. Make sure that there is room for the hamstring
tendons. If there is not enough space, the amputee will have pressure here. Pressure here will
cause the prosthesis to be pushed distally when the knee is flexed and will cause pressure on the
malleoli.
Static alignment:
Ask the patient to stand. Have a balance support for the patient to hold.
 Check the socket fit and comfort. If the socket does not fit and has problems, you must correct it.
If the problem cannot be corrected a new cast must be taken.
 Check the height of the prosthesis.
 Check the ML alignment
o The foot should be flat on the floor
o The amputee should be stable
o There should not be excessive pressure on the medial or lateral brim
 Check AP alignment
o The foot should be flat on the floor
o The knee should not be forced forwards or backwards
9.4 Dynamic Alignment
If the Static Alignment procedure was successful and the patient is comfortable and stable, you may
ask them to walk for a few minutes. It is best to have them begin within the parallel bar or rails. If
rails are not available, a pair of crutches should be used.
Coronal plane
 Make sure that the foot is flat on the floor during stance phase.
If the patient is walking on the lateral border the foot needs to be everted / abducted
If the patient is walking on the medial border of the foot the foot needs to be inverted / adducted
 Observe the knee for any medial or lateral deviations
If there is lateral thrust - shift the foot laterally

If there is medial thrust - shift the foot medially
 Observe toe out angle and match to sound leg, or to their preference
Sagittal plane
 Check to see that the toe-raise at heel strike is not excessive or inadequate.
o If the toe-up is excessive reduce socket flexion (or plantarflex the foot.)
o If the toe-up is not sufficient, increase socket flexion (or dorsiflex the foot.)
 Check the flexion of the knee at mid stance
o If it is too much, shift the foot anteriorly
o If it is not enough, shift the foot posteriorly
Code: IE-CSPO-038
Reference: QP 5-6
Other deviations
Study the patients gait .The patient should have even timing , equal step lengths while walking, Even
arm swing and even trunk movements
Final checks
 When the alignment appears to be correct and the amputee has been wearing the prosthesis for
several minutes, take the prosthesis off and check the skin for pressure problems. Any red marks
must be carefully assessed to see if the socket fit needs to be adjusted before taking the
prosthesis for finishing.
 When both you and the patient are happy with the fit and function of the prosthesis you can
complete the cosmesis and deliver the completed product to the patient.
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 10:
Ankle Disarticulation Prosthetic problems
10.1 Assessment of the problems
When patient comes to the prosthetist with a problem, the prosthetist must make a careful
assessment. As described in the TT manual the important parts of the patient assessment are:
1. Listen to the patients complaint.

2. Carefully observe the patients gait. To determine whether an alignment error could be the cause
of the problems.
3. Examine the stump for signs of unwanted pressure.
4. Compare the measurements of the stump with measurements taken before, and compare the
stump shape with the socket shape.
In the following some of the problems that may occur are listed.
10.2 PROXIMAL DISCOMFORT
a. Discomfort at Patellar tendon

The patellar tendon bar may be too deep, too wide, positioned in the wrong place or have a
wrong shape.
In some cases it will be possible to change the shape of the tendon bar by heating the socket or
by grinding away some material. If this is not possible a new socket will have to be made.
b. Discomfort at the Fibula head.
In some instances the socket relief for the head of fibula is not enough, causing discomfort.
To correct this problem it may be possible to heat socket and change the shape, or to grind some
material away from the inside of the socket.
Just posterior-distal to the fibular head runs the common peroneal nerve, pressure on this nerve
will cause pain.
Pressure on the nerve can also cause what is called refereed pain. The patient will complain
about pain at the distal part of the stump, but the cause of the problem lies proximally with
pressure on the common peroneal nerve or on a neuroma.
c. Discomfort at the Popliteal area.
The patient may experience that the top of the socket is too lose. This may be corrected by
adding some material to the popliteal area, or by heating this area and compress it a little.
In the case where discomfort is caused by a too high or improperly shaped posterior brim, the
brim may be lowered to better allow for the Hamstring tendons (particularly on the medial side).
Or the flare of the brim may be made more generous.
Code: IE-CSPO-038
Reference: QP 5-6
10.3 DISTAL DISCOMFORT
a. Discomfort over anterior aspect of tibial

If the patient complains pain at the anterior aspect of the stump, it could be because there is too
little relief for the bone over this area.
To correct this some material is ground away inside the socket. Or a new socket should be made.
b. Discomfort at the edges of the distal end

In the case where the casting of the patient has been done without weight bearing, a general
relief is needed around the edges of the distal end of the stump. In some cases this build up is too
small and the patient feels pressure on the sides of the stump.
Some material can be ground away from the insides of the socket or a new socket has to be
made.
c. Discomfort under the distal end of the stump

Some patients can not tolerate total weight bearing at the end of the stump. Relief can be
provided by adding material to the general proximal weight bearing areas.
Adding material is relatively easily done in the socket with an inner liner, but more difficult in a
hard socket.
In some cases the patient has developed a pressure point or a bone spur under the end of the
stump. The point must be accurately located and very localized relief must be made.
d. Discomfort over the trimmed malleolies

The malleolies are very sensitive to pressure so if the patient feels pain here a proper relief must
be provided by grinding some material away from the inside of the socket or by making a new
socket.
Discomfort at the malleolies can also be caused by general shrinkage of the stump causing a loss
of suspension so that the prosthesis is sliding distally on the stump.
This can sometimes be helped by adding some material to the area along the shaft of tibia and
fibula. Otherwise a new socket must be made.
In very few cases it is possible to relieve the problem of stump shrinkage by adding more stump
socks. But mostly this will cause problems at the edges of the stump and at the malleolies.
Code: IE-CSPO-038
Reference: QP 5-6
Chapter 11
Ankle Disarticulation Prosthetic Checkout
Check-out List
1. Is the prosthesis as prescribed?

If this is a second checkout, has the new instructions been followed?
2. Can the patient easily put on the prosthesis?
Check with the patient standing
(for point 3,4,5 and 6 patient should stand with good posture, even weight on both feet and heel
centres not more that 15cm apart)
3. Is the patient comfortable while standing?

4. Is the anterior-posterior alignment good? (the patient should not feel that the knee is unstable, or
that the knee is forced backwards.)
5. Is the medio-lateral alignment good? (the shoe should be flat on the floor and there should be no
pressure at the lateral or medial brim of the socket).
6. Is the prosthesis the correct length?
7. When the patient lifts the leg up a little, there should be no piston action.
8. Are the proximal socket walls the correct height?
9. Are the medial and lateral walls in contact with the epicondyles?
Check with the patient sitting
10. Can the patient sit comfortably?

There should be no pinching of the soft tissues in the popliteal area when the knee is flexed 90
degrees.
11. Is the posterior wall high enough?
12. Do any of the modifications make the patient uncomfortable when sitting?
Check with the patient walking
13. Is the patient walking well on the level ground? Indicate below any gait deviations that needs
attention.
14. Is piston action between stump and socket minimal?
15. Does the patient go up and down inclines and stairs well?
16. Are the socket and suspension system comfortable?
17. In the case of a socket with a medial panel, does the panel fit properly and is pinching of the
patient's skin avoided?
18. Is the patient able to kneel satisfactorily?
19. Does the prosthesis function quietly?
20. Are size, shape and colour of the prosthesis approximately the same as the sound leg? (With
most ankle disarticulation amputees the cosmesis will be a compromise due to the bulbous end).
21. Does the patient consider the prosthesis satisfactorily?
Code: IE-CSPO-038
Reference: QP 5-6
Check with the prosthesis off the patient
22. Is the stump free from abrasion, discolouration and excessive sweating just after the prosthesis is
removed?
23. Is the weight bearing occurring at the end of the stump?
If total end bearing can not be tolerated is the weight bearing distributed over the proper areas of
the stump?
24. Is the general workmanship satisfactory?
Final instructions
Give the prosthesis to the patient ONLY when you are sure that everything listed above is as correct
as possible. But before the patient walks away with the prosthesis, you must give instructions and
check that the patient knows and understands the following:
 How to take care of the prosthesis

 How to clean the stump and stump socks
 How to know when there is a problem with socket fit.
 How to adjust socket fit by adding or taking away stump socks
 When to come back to you for socket adjustments or repairs
Code: IE-CSPO-038
Reference: QP 5-6
References
CSPO. Ankle Disarticulation Prosthesis, Cambodian School of prosthetics and Orthotics, Phnom
Penh, Cambodia. 1994
 Atlas of Limb Prosthetics Surgical Prosthetics, and Rehabilitation Principles. J.H.Bowker,
J.W. Michael. American Academy of Orthopaedic Surgeons
 Amputation Surgery & Lower Limb Prosthetics. G.Murdoch, R.G.Donovan. Blackwell
Scientific Publications.
 National Center for Training and Education in Prosthetics and Orthotics. University of
Strachclyde, Scotland. Below Knee manual.
 New York University Medical Center. Post-Graduate Medical School, Prosthetics and
Orthotics. Lower-Limb Prosthetics Manual.
 Physical Examination of the Spine and Extremities. Stanley Hoppenfeld.
o Clinical Aspects of Lower Extremity Prosthetics, The Canadien Association of Prosthetics and
Orthotics, Second edition 1991
o Söderberg B., Wykman A., Schaarschuch R., Persson R. Partial Foot Amputations. Second
edition. 2001. Helsingborg, Sweden
o Atlas of Amputations and Limb Deficiencies, Third Edition, Douglas G. Smith, John W.
Michael, John H. Bowker, American Academy of Orthopaedic Surgeons, 2004

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Cambodian School of Prosthetics and Orthotics

ANKLE DISARTICULATION PROSTHETICS

TRAINING COURSE MANUAL

Chapter 7: ......................................................................................................................................................... 41

Introduction and features

1.2 Main features

The main features of an ankle disarticulation residual limb are

The AD residual limb has:

• Bulbous distal end

Figure 1.1 Anterior View – left ankle disarticulation residual limb

1. The residual limb is usually end bearing.

2. It is usually possible to walk without a prosthesis.

3. It is usually possible to make the prosthesis self-suspending.

4. The residual limb provides a long lever arm.

5. Ankle disarticulation is a good level of amputation for children.

Fig. 1.2 Ankle Disarticulation Foot

3. Difficulty donning/ doffing prosthesis

4. The heel pad may become unstable

2.1 Surface Anatomy

Fig. 2.1a Anterior View Fig. 2.1b Posterior View

2.2 Bony Anatomy

Assessment of the ankle disarticulation

In addition, the distal end of the stump

Carefully inspect the distal end of the

2.3 Muscular Anatomy

Fig. 2.2 Tibia and fibula

They are shown in figures

After ankle disarticulation

Fig. 4.3 Gastrocnemius Fig. 4.4 Soleus

Fig. 2.3 Gastrocnemius Fig. 2.4 Soleus

The main muscle that dorsiflexes the ankle is:

Chapter 3: Amputation Surgery

3.1 The aim

3.2 The objectives

The goals of ankle disarticulation surgery are:

3.3 Surgical procedure

Fig. 3.1 Incisions

Tibio- fibular ligament

Fig. 3.2 Supporting Ligaments

Treatment of the tibia and fibula

Fig, 3.3 Making the distal end broad and flat

Treatment of the heel pad

The advantages of a rigid dressing are that:

The advantage of the elastic wrapping is that:

Preventing joint contracture

Maintaining sense of balance

Watching for signs of infection

Signs of infection are:

 Heat, redness, or swelling at the wound site or in the stump

3.5 Prosthetic treatment

4.1 Rotational control

Fig. 4.1 Rotational control using a triangular

Fig. 4.2 Suspension above the malleoli

4.3 End bearing

4.4 Socket forces during gait

Fig. 4.3 Forces just after heel-strike

Force P can be calculated by the formula P x a = F x b.

P= the force on the posterior-proximal part of the socket

a= the length of the socket

Fig. 4.4 Forces during mid-stance

Patient using a long socket Same patient using a short socket