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Wheeless' Textbook of Orthopaedics

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- PTB sockets:
    - provide some weight bearing support in the area of patella tendon and medial tibial flare;

- city of granite city il Suspension:
    - important design considerations for both sockets include
          - support (pressure distribution)
          - control (based on limb socket interface)
          - suspension (socket and/or corsete)
          - alignment (angular and linear)
    - total contact socket contour suspension is commonly used & can be one of two designs: patella
            tendon bearing (PTB) or patella tendon supporting (PTS);
    - ineffective suspension will manifest as pistoning during swing phase of gait;
    - PTS sockets
         - cover the condyles of the femur and have a high anterior wall enclosing the the patella;
         - provides more support anteriorly & add improved stability & suspension;
    - PTB w/ supracondylar cuff:
         - advantages include a kinesthetic hyperextension stop;

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         - addition of a supracondylar wedge of a flexible material to a PTB socket gives more
               stability by providing locking fit over the condyle (these may be fixed or removable);
    - PTB w/ sleeve suspension:

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         - may cause dermatologic problems;
         - neoprene sleeves can also be used to provide additional skin protection (especially for diabetics);

- Liners:

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     - Pylete:
     - TEM:

- Standard Prosthetic Alignment: (corsetless prosthesis)
    - knee flexion moment (and posterior foot placement):

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                - encourages knee flexion between strike and foot flat;
         - reduces length of keel encouraging knee flexion from midstance to heel off;

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         - encourages "roll over" between mid stance and heel off;
         - limits recurvatum (hyperextension) forces during genotype chart for porphyria to blue raiders baseball fort worth tx of gait;
         - tends to load more pressure tolerant areas of the proximal tibia;

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         - excessive knee flexion (at heel strike) may result from:
                - heel too firm (knee flexes when the heel is fully compressed);
                - foot too posterior
                - foot too dorsiflexed
                - interface too flexed
                - forward placement of socket
                      - causes increased knee entension
                      - patellar pain
                      - instability is not a problem;
    - varus alignment:
         - initial foot placement is 12 mm inset in relation to midpoint of interface;
         - narrows the base of support
         - smooths horizontal displacement of center of gravity
         - makes for efficient gait;

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         - excessive varus moment may be caused by:
                - foot positioned too medially;
                - M-L interface is too large;
                - there is laxity of the lateral collateral ligament;
         - insufficient varus moment may be exhibited by:
                - foot positioned too laterally;
                - loading of pressure sensitive areas (such as a load on the fibular head);
                - in coronal plane fulcrum is about the patellar tendon;
                - gait is excessivel widened;
                - excessive medial shoe wear;
    - translation of socket:
         - lateral translation:
                - excessive translation causes valgus knee strain;
         - medial translation: (excessive translation causes:)
                - varus strain on knee;

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         - anterior translation:
                - slight anterior translation may be useful to minimize the tendency for knee hyperextension at heel strike (instead encourages knee 

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                - knee but excesssive cause knee to buckle into flexion at heel strike;
         - posterior translation:
                - tends to keep knee in hyperextension during stance phase;                

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- Skin Tolerance:
    - pressure tolerant areas:
           - patellar ligament
           - anterior compartment
           - medial flare of the tibia
           - distal end
           - shaft of the fibula
           - gastroc
           - popliteal fossa
    - pressure sensitive areas:
           - anterior distal tibia
           - fibular head
           - crest of tibia
           - peroneal nerve
           - distal cut fibula
           - lateral tibial condyle

- Common Prosthetic Problems:
    - pistoning:
          - pistoning during swing phase of gait is usually caused by ineffective suspension system;
          - pistoning during the stance phase is due to poor socket fit or volume changes in stump (may require a change in stump sock 
    - pressure related pain or redness should be corrected w/ relief of the prosthesis in the affected area;
    - foot related problems:

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    - too much knee hyperextension: (at heel off);
          - foot too anterior or plantar flexed;
          - insufficient flexion of the socket or posterior displacement of the socket;
          - too soft heel cushion (knee flexes when the heel is fully compressed);
          - too long a keel of a portable electric fence chargers foot

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