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Report From:

International Workshop on
Above-Knee Fitting
and Alignment Techniques
by C. Michael Schuch, C.P.O.

An "International Workshop on Above- (CAT-CAM, NSNA, Narrow M-L), were dis­


Knee Fitting and Alignment Techniques" was cussed in great detail. Goals were to determine
held in Miami, Florida, May 1 5 - 1 9 , 1987. differences/similarities, advantages/disadvan-
C o n c e i v e d and o r g a n i z e d by A. Bennett tages, indications/contraindications, as well as
Wilson, Jr. and Melvin L. Stills, C O . , the to develop recommendations for future action
workshop was supported and sponsored jointly with respect to the various socket designs.
by the International Society for Prosthetics and While many prosthetists and/or clinics may
Orthotics and the Rehabilitation Research and have considerable experience with the newer
Development Service of the Veteran's Admin­ above-knee socket designs within the United
istration. Hosting the workshop was the Pros­ States, it is true that there are still many ques­
thetics and Orthotics Education Program of the tions and concerns on the part of consumers,
School of Health Sciences, Florida Interna­ prescribing physicians, third party paying
tional University, and more specifically, Dr. agencies, and educators in the U . S . , as well as
Reba Anderson, Dean of Health Sciences and a great curiosity on the part of our international
Ron Spiers, Director of Prosthetic Orthotic Ed­ colleagues abroad.
ucation. Approximately 50 invited profes­ After introductory remarks from Dr. An­
sionals attended the workshop, representing the derson, Dean of Health Sciences at Florida In­
United States, England, Scotland, Denmark, ternational University, Mr. John Hughes, Pres­
Sweden, Israel, the Netherlands, and Germany. ident of ISPO, and Dr. Margaret Gianninni,
Invited professionals included physicians, engi­ Director of the Rehabilitation Research and De­
neers, educators, and researchers, as well as velopment Service of the Veteran's Adminis­
prosthetic practitioners, all known to be active tration, the program began with a presentation
in the field of prosthetics. by A. Bennett Wilson entitled, "Recent Brief
The intent of the workshop was an organized History of AK Fitting and Alignment Tech­
sharing and discussion of information and ex­ niques." This paper began with the advent of
periences relative to the management of above- the suction socket in the U . S . shortly after
knee amputees. Above-knee socket design vari­ World War II and proceeded with the develop­
ables, specifically the accepted and established ment of the total contact quadrilateral socket in
quadrilateral design and the newer ischial-con- the early 1960's. The audience was reminded
tainment designs known by various acronyms that the total-contact quadrilateral socket, with
or without suction suspension, was the socket biomechanical forces generated, the socket
design of choice from 1964 until very recently, shape, and the alignment. The socket was no
when i s c h i a l - c o n t a i n m e n t socket designs longer described as a cross-section shape at the
emerged. It was noted that, at present, the three ischial level, but rather a three-dimensional re­
senior prosthetic education programs in the ceptacle for the stump with contours at every
U . S . (UCLA, Northwestern University, and level which could be justified on a sound bio­
New York University), in addition to teaching mechanical basis. . . . It should be emphasized
the application of the standard total contact again that the quadrilateral type of fitting is not
q u a d r i l a t e r a l socket, are offering special just a socket, it is a complete system which in­
courses in what at first glance appear to be rad­ cludes the amputee as a most important compo­
ical departures from the quadrilateral design. nent. The socket is the interface between stump
The technique at UCLA is known as CAT- and prosthesis, and its primary functions are to
CAM (Contoured Adducted Trochanteric-Con- provide for weight-bearing in the stance phase,
trolled Alignment Method), based on work by allow the use of the stump and hip musculature
John Sabolich, C.P.O., and inspired by Ivan to control motion and posture of the upper body
A. Long, C P . The technique being presented in the stance phase (Figure 1), and to provide
at Northwestern University is said to be based for control of the prosthesis in the swing phase
more directly on the Ivan Long technique and is of walking."
k n o w n as N S N A ( N o r m a l S h a p e - N o r m a l The next section of Professor Radcliffe's
Alignment). The technique taught at New York presentation focused on biomechanical and
University is usually referred to as the narrow alignment principles of a prosthesis with a
ML socket design based on a special tool de­ q u a d r i l a t e r a l socket. H e r e he related his
signed by Daniel Shamp to facilitate casting. feelings that many of the biomechanically re­
Mr. Wilson concluded his remarks by saying lated claims made by proponents of the newer
"unfortunately, none of these techniques has non-quadrilateral socket designs are equally at­
been subjected to an evaluation program inde­ tainable in the quadrilateral socket if the orig­
pendent of the development group, and a great inal biomechanical principles are followed.
deal of confusion exists among clinicians re­ "Regardless of the fitting method employed,
sponsible for amputee care. I hope that this the socket for any patient must provide the
workshop can be helpful in clearing away some same overall functional characteristics, in­
of the confusion, and point the way for action cluding comfortable weight-bearing, a narrow
that will bring order to the present day practice base gait, and as normal a swing phase as pos­
of above-knee prosthetics." sible consistent with the residual function avail­
The next speaker on the agenda was Charles able to the amputee after amputation. It is pos­
Radcliffe, Professor of Mechanical Engineering sible to provide this with a quadrilateral socket
at the University of California, Berkeley. Pro­ and it is being done routinely in many facili­
fessor Radcliff's presentation was entitled, ties." Professor Radcliffe went on to say, " I n
" R e v i e w of UCB Quadrilateral Socket and most of the recent articles that I have read,
Alignment Theory." Having been a member of statements have been made which indicate
the Prosthetic Devices Research Project of UC clearly that the author is comparing very poorly
Berkeley in the 50's and 60's, Professor Rad- fitted quadrilateral sockets to the results ob­
cliff is still a strong proponent of the quadrilat­ tained using the new technique. They show
eral socket. He presented a detailed review of diagrams of typical fittings and gait deviations
the history and development of the quadrilateral which can only be described as a complete list
socket and summarized this section of his pre­ of horror stories describing what not to do in
sentation with the following comments. "The fitting a quadrilateral socket. Any prosthesis
net result of all of this work in the 1950-1963 with the problems listed in these articles should
period was a better understanding of the com­ never have been delivered. If the average pros-
plex interrelationships between the functional thetist in the United States is having the
capability of the amputee, the rehabilitation problems described by Long, Shamp, and Sa­
goals, the prosthetic components required in bolich, then I must suggest that something is
the prescription, the gait of the amputee, the wrong with the methods being taught and used
from the fundamentals of teaching of overall
objectives, including the interrelationships of
amputee evaluation, components prescribed,
biomechanics, and why sockets are fitted with
particular contours."
Following Professor Radcliffe was Tim
Staats, Director of the UCLA Prosthetics Edu­
cation Program. Mr. Staats' presentation was
on the " U C L A C A T - C A M . " UCLA began
teaching CAT-CAM above-knee prosthetics
with a pilot course in March 1985, which in­
cluded both John Sabolich and Tom Guth as
course instructors. Mr. Staats made it clear that
the UCLA CAT-CAM philosophy of 1987 has
departed from that of Sabolich, Guth, et al. and
that the UCLA philosophy has now evolved to
the point where a third edition of a teaching
manual was published in March, 1987. To
quote Mr. Staats as he spoke about this new
manual, "the third edition of the UCLA CAT-
CAM Above-Knee Prosthesis teaching manual
integrates much additional material, covering
the anatomy/socket relationship and how this is
best achieved—material not yet fully under­
stood and synthesized at the time of preparation
of the previous edition. The UCLA CAT-CAM
above-knee socket is a variation of the CAT-
CAM design developed by John Sabolich,
C.P.O., and Tom Guth, C P . , and the NSNA
AK prosthesis of Ivan Long, C P . Through
countless hours of literature search, discussion,
and intensive training given in this and nine
foreign countries, and through the results of
over 200 students who have fabricated and fit
over 1,000 sockets under the guidance of our
staff, a new insight has been developed. Our
staff has refined the techniques of measure­
ment, casting, and model modification to the
point where it is a clearly teachable and viable
above-knee fitting method. It is with great re­
spect that we continue to recognize the pub­
lished contributions of John Sabolich, C.P.O.,
Tom Guth, C P . , and Ivan Long, C P . , to the
development and evolution of the UCLA tech­
F i g u r e 1. B i o m e c h a n i c a l f o r c e s d i a g r a m , A b o v e -
k n e e a m p u t e e w e i g h t - b e a r i n g in the stance
nique. We would hope that this manual cap­
phase. 1 tures, blends, and enhances their philosophies.
We recognize that our technique and CAT-
CAM evolved from NSNA and we hope that
in daily practice. I am aware that the schools these professionals can appreciate our efforts to
have made significant changes in the way that refine and further evolve their clinical approach
the principles are taught, with each school em­ into a methodical step-by-step teaching
phasizing different aspects of the problem. I manual."
suspect that there may have been a shift away
At this point I will briefly review the high­
lights of the UCLA CAT-CAM sequence, be­
ginning with patient evaluation and measure­
ment and proceeding through model modifica­
tion and bench alignment. For the details, I
suggest referencing the third edition of the
UCLA manual.
The recommended evaluation/measurement
protocol is very complete and detailed, cov­
ering many of the procedures with which we
should all be familiar. Adduction and flexion
analysis of the residual limb are emphasized.
Some new measurements and/or evaluations
are introduced and illustrated:
• Skeletal ML dimension, actually mea­
sured on patient (Figure 2)
• Soft tissue ML dimension, taken from
Ivan Long's chart of circumferences and
related ML values (Figure 2)
• Ilio-femoral angle, actually measured on
the patient (Figure 3)
• Public arch angle, evaluated by palpation
and captured in the wrap cast (Figure 4)
F i g u r e 2 . UCLA CAT-CAM m e d i a l - l a t e r a l d i a m ­ • Ischial inclination, evaluated by palpation
2
eter m e a s u r e m e n t s . and captured in the wrap cast (Figure 5)
The wrap cast is taken with the patient in a
standing position, and all shaping of the cast is
accomplished by hand molding. The goal is
good definition and containment of the medial
and posterior aspects of the ischial tuberosity
and ischial ramus within the wrap cast and sub­
sequent socket, as well as allowance for the
pubic ramus to exit the socket near the midline
of the medial wall (Figure 6).
The initial trimlines for the resultant socket
are as follows:
1. Anteriorly, just proximal to the inguinal
crease. The anterolateral brim must clear
the superior iliac spine when the patient is
sitting.
2. Laterally, the brim extends approximately
3" above the trochanter. The final height
of this wall will be determined during fit­
ting.
3. Posteriorly, the trim line should begin at
least 1" above the level of the inferior
border of the ischial tuberosity. The curve
that defines the posterior to lateral trim
line normally begins at a point between
Figure 3 . Ilio-femoral angle, as measured for the lateral third and the midline of the
UCLA CAT-CAM. 2
socket ML dimension at ischial level.
F i g u r e 4. T h e p u b i c a r c h a n g l e , a s e v a l u a t e d f o r U C L A C A T - C A M . 2

F i g u r e 5 . T h e ischial i n c l i n a t i o n a n g l e , a s e v a l u ­
2
ated for U C L A C A T - C A M .
Figure 6. Medial view of pelvis-socket relation­
2
ship, U C L A C A T - C A M .

4. The medial proximal brim will be " V " the ischial ramus and tuberosity. (Figure
shaped, with the vortex of the " V " lo­ 6) A circumference reduction chart is
cated at the point where the pubic ramus used to attain suction suspension. The
crosses the medial wall. This trim line values used in this chart are slightly less
projects upward from the vortex, posteri­ than those normally used in quadrilateral
orly to encapsulate the medial aspect of suction sockets.
For bench alignment, the following refer­ Long's Line Above Knee Prosthesis," (1981);
ences are used: and as a reprint of the Long's Line article with
new title, "Normal Shape-Normal Alignment
1. Posteriorly, bisect the socket at the level
(NSNA) Above Knee Prosthesis," (Clinical
of the soft tissue ML, this reference line
Prosthetics and Orthotics, Fall, 1985). These
should fall as a plumb line to the center of
articles were the basis for Gunther Gehl's pre­
the heel.
sentation to the International Workshop.
2. Laterally, bisect the socket AP dimension
I will attempt to review and highlight the
at ischial level, this reference line should
NSNA philosophy as I did the UCLA CAT-
fall as a plumb line between 0" and 1" an­
CAM. Again, within the limitations of this re­
terior to the foot bolt.
port, this will only be an overview. With the
3. Socket is set in measured adduction, and
widespread availability of Ivan's publications,
measured flexion plus 5°.
it does not seem necessary to go into details.
4. The distal aspect of the medial wall
NSNA is less detailed regarding evaluation
should be on the line of progression.
and measurements, placing great emphasis on
5. The knee bolt is externally rotated 5°.
the wrap cast, subsequent model modification,
6. The top of the foot, as well as the pros­
and alignment, all based on L o n g ' s Line,
thetic shank should lean medially 4°, or
which is defined as a straight line, starting ap­
alternatively, the socket is hyper-ad-
proximately at the center of a narrow socket,
ducted 4° beyond measured adduction
passing through the distal femur, and on down
with the foot parallel to the floor and the
to the center of the heel (Figure 7). Long's Line
shank perpendicular to the floor.
is not always vertical because it shifts con­
stantly when the amputee goes from a standing
The UCLA CAT-CAM can be fabricated position to a walking position.
using rigid socket or flexible socket techniques.
The wrap cast is taken with the patient in a
If a flexible socket or brim system is desired,
standing position. The important points about
the proximal medial trimline in the ischial area
the wrap cast procedure are identification of the
must be more aggressive during casting to ischium and proper alignment. The hand will
allow for the linear shrinkage factor known in be held to indicate the medial and posterior sur­
most thermoplastics. face of the ischium, but not forward of the is­
A final comment: the manual reflects the ac­ chium. The amputee then adducts as tightly as
cumulated experience of the UCLA staff and possible and extends his thigh to tighten the
includes a section on problem solving the diffi­ hamstrings. At this point a lateral reference line
culties that might be experienced in the CAT- is established.
CAM socket.
The resultant cast model is oversized and
Next to speak was Gunther Gehl, C P . , Di­
will require considerable modification. Practi­
rector of Prosthetic Education at Northwestern
cally all modification will take place on the lat­
University in Chicago. Northwestern has been
eral wall. Following is a brief description of
teaching the NSNA AK techniques of Ivan
modification goals and resultant trimlines,
Long for several years now, and it was Mr.
taken from Mr. Gehl's presentation and from
Gehl's task to report to the workshop on NSNA
Mr. Long's publications.
and Long's Line. He said that he and his staff
taught NSNA as presented by Ivan Long with 1. The lateral wall is to be shaped to give
no changes. Ivan has been fitting Long's Line, support over a wide area, and particularly
now known as NSNA, for more than 12 years, the lateral-posterior aspect of the socket.
and his approach has been consistent, with few 2. The medial wall will be lower than seat
changes. Perhaps changing the name from level, and the wrap cast will be the guide­
Long's Line to NSNA in July, 1985 is the most line as to how low.
significant change. Mr. Long has published 3. Depth of the socket will be the same as
three technical papers describing his technique: the measured length of the thigh.
"Allowing Normal Adduction of the Femur in 4. The seat will be at a right angle to Long's
Above Knee Amputees," {Orthotics and Pros­ Line.
thetics, December, 1975); "Fabricating the 5. Long's Line is drawn from the center of
F i g u r e 8. T a b l e o f M - L v a l u e s d e t e r m i n e d f r o m
c i r c u m f e r e n c e j u s t b e l o w i s c h i u m , used in
3
NSNA.

circumference just below the ischium


(Figure 8).
Circumference reductions for suction suspen­
sion begin at 1" of tension proximally, reducing
3

Figure 7. L o n g ' s L i n e . 3 to /4", then1/2",with the remaining tensions at


1/4".
Mr. Long does not advocate use of an align­
the seat level ML to the center of the ment device. Bench alignment is critical and is
distal femur. The distal femur will be based on Long's Line. The center of the lateral
very close to the lateral surface, probably wall is marked at seat level for TKA and the
only covered by skin. vertical reference line established during
6. The top 1" of the medial wall will flare casting should parallel the TKA line. Long's
outward at 45°. Line is marked on the posterior of the socket.
7. The lateral wall extends above the tro­ For the male, the socket is mounted with the
chanter. inner aspect of the medial wall (which follows
8. The ischium will bear on the flare of the the pubic ramus angle) in 30° internal rotation
socket, both medially and posteriorly. to the line of progression (the outer edge of the
9. The cast is taken down in the ML as medial trimline is on the line of progression),
though the trochanter does not exist. In and with the knee bolt axis 4° higher on the
order to achieve the desired ML, many lateral side. This is the same as adding 4° addi­
casts will be reduced 2" or more. The de­ tional adduction to Long's Line. For the fe­
sired ML dimension is taken from Ivan's male, the socket is mounted with the inner
chart of ML values related to the thigh aspect of the medial wall in 4 0 - 4 5 ° internal ro-
Figure 9. N S N A socket shape and alignment dia­
4
gram, male and female.

tation to the line of progression (again, the


outer edge of the medial trimline is on the line F i g u r e 10. C e n t r a l i z a t i o n o f t h e f e m u r , a s p r o ­
of progression), and with the knee bolt axis 7° posed by D a n S h a m p for N a r r o w M L S o c k e t . 5

higher on the lateral side (Figure 9). Mr. Long


emphasizes that it is not necessary to change
the alignment. When the amputee is allowed
time to adjust to the new prosthesis, then align­ learned and applied by the practitioner who has
ment changes will not be necessary. spent years working with the brim method for
Following Gunther Gehl was Daniel Shamp, quadrilateral socket casting and modification."
C . P . O . , presenting, " T h e Shamp Brim, For Mr. Shamp went on to present detailed biome­
the N a r r o w M L A b o v e - K n e e P r o s t h e t i c chanical rationale for the narrow ML socket.
Socket." Mr. Shamp's system of brim casting Biomechanical descriptions such as bony lock
and evaluation is currently the content of a spe­ on the ischium, ischial containment within the
cial short course offered by New York Univer­ socket, retention of normal adduction, etc., are
sity's Prosthetic and Orthotic Education Pro­ consistently relevant to Mr. Shamp's socket
gram. system, as well as all of the latest ischial-con­
Long and Sabolich, as well as UCLA, advo­ tainment socket designs. Two noticeably dif­
cate that the hand casting technique is the most ferent aspects of Mr. Shamp's technique are (1)
successful in their experience with the narrow the brim forming system itself, which allows
ML, wide AP, or ischial-containment socket for evaluation of brim design under weight
for above-knee amputees. In response, Mr. bearing conditions before proceeding with the
Shamp stated, "Experience with the Shamp wrap cast, and (2) what Mr. Shamp refers to as
Brim system has proven to make the procedure centralization of the femur. To accomplish cen­
more uniformly successful and more easily tralization of the femur, during the casting pro-
cedure, the prosthetist pulls the distal medial
tissue in a lateral direction while stabilizing the
femur with the other hand by means of a 45°
force against the lateral shaft of the femur
(Figure 10). Mr. Shamp stated that this central­
ization procedure is essential to prevent a large
medial-distal bulge with resultant cosmetic
problems when the femur is maintained in a
position of maximum adduction in the AK
prosthesis.
Again, I will present an overview of the
Shamp Narrow ML technique, summarizing
from Mr. Shamp's presentation and from the
"Manual for use of The Shamp B r i m , " which
was provided for the workshop attendees. This
manual was produced by Prosthetic Consul­
tants, Incorporated of Akron, Ohio in coopera­
tion with the Department of Prosthetics and Or­
thotics, New York University Post-Graduate
Medical School, and is published by the Ohio
Willow Wood Company.
The measurement and evaluation procedure
includes a careful observation and recording of
the characteristics, lengths, and circumferences
requested on the Narrow ML AK Information
Chart. Review of this information chart will
show the practitioner who is familiar with the
technique for the quadrilateral socket that only
a small number of measurements are different
for the Narrow ML socket. It is important to F i g u r e 11. D i s t a l I s c h i a l T u b e r o s i t y ( D I T ) , m e ­
dial-lateral d i a m e t e r m e a s u r e m e n t for N a r r o w
note that three ML measurements must be 5
M L Socket.
taken precisely as follows:

1) Distal Ischial Tuberosity (DIT): firm ML


measurement of the anatomy taken 1" to tion of the patient with regard to socket design
2" distal to the ischial tuberosity (Figure before the actual wrap cast is taken.
11). As with all of the ischial-containment socket
2) Oblique ML (OB): firm ML measurement designs discussed at the Workshop, the location
taken from the medial side of the ramus of the ischial tuberosity in the socket is essen­
of the tuberosity to a point just superior to tial to both a comfortable fit and a stable femur
the greater t r o c h a n t e r of the femur in maximum adduction. For the Shamp tech­
(Figure 12). nique, the ideal location is 1/2" inside the me­
3) Ischial Tuberosity ML (IT): firm ML dial-proximal wall of the prosthesis and indi­
m e a s u r e m e n t taken from the medial cates the area referred to as the IT ML measure­
border of the ramus of the ischial tuber­ ment. The medial wall has a 45° angle that
osity to the subtrochanteric area of the assists the wedge effect in stabilizing the femur
femur (Figure 13). and so the location of the tuberosity on this
slope is important. The trimlines are similar to
The Shamp Brim, which is compatible with the both NSNA and the UCLA CAT-CAM, in­
Berkley brim stand, is now set up and adjusted cluding the low anterior wall with clearance for
to the patient's measurements. As stated ear­ the ASIS, the relatively horizontal posterior
lier, the brim allows for weight-bearing evalua­ wall, and the high lateral wall, which extends
F i g u r e 1 2 . O b l i q u e M L ( O B ) , m e d i a l - l a t e r a l di­ Figure 1 3 . Ischial Tuberosity M L (IT), medial-
a m e t e r m e a s u r e m e n t for N a r r o w M L S o c k e t . 5 lateral diameter m e a s u r e m e n t for N a r r o w M L
5
Socket.

generously above the trochanter. Although, not develop a set of design criteria for geriatric
as exaggerated as the UCLA CAT-CAM, the above-knee sockets. As this project is still in
medial wall is lowered as it approaches the an­ the developmental stages, I will not elaborate
terior wall, allowing for the pubic ramus to on this subject.
pass from within the socket. Following Dr. Lehneis was Ossür Kris-
Alignment follows generally accepted quad­ tinsson of Iceland. As the developer of the
rilateral alignment principles for TKA and knee flexible socket-rigid frame system, he was the
bolt external rotation. For alignment in the first to speak on flexible sockets. Mr. Kris-
frontal plane (posterior view, ML plane), Mr. tinsson reported that he was continuing devel­
Shamp advocates the principles of Long's Line. opment of flexible sockets, including walls and
Dr. Hans Lehneis, C.P.O., of the Rusk Insti­ brims. He is conducting an extensive materials
tute of Rehabilitation Medicine was the next search in hopes of finding the materials that
speaker and his presentation covered work done will make possible the ultimate flexible socket
at the Rusk Institute and the New York Vet­ design.
erans Administration. Dr. Lehneis and asso­ Mr. Kristinsson went on to say that we need
ciates are investigating anatomical, physiolog­ some simple definition of flexible socket char­
ical, and biomechanical characteristics of geri­ acteristics. " T o label a socket as flexible, I
atric above-knee amputees in an attempt to would say that you should be able to deform it
by your hands, and the material should not be frame design of the Scandinavian Flexible
elastic enough to stretch under the loads it will Socket. Mr. Pritham went on to say, "It will be
be subjected t o . " Concerning flexible socket appreciated that the design is actually not fun­
design, Mr. Kristinsson stated, " W h e n de­ damentally different, flexible walls aside, from
signing a flexible socket system, the most crit­ a similarly designed socket in the rigid walls.
ical aspect for the comfort of the wearer is how Indeed one of the factors that undoubtedly has­
the frame is designed. It has to be capable of tened its acceptance was the fact that pre­
supporting the flexible socket, preventing per­ viously learned methods of casting and fitting
manent deformation, and the socket-frame quadrilateral sockets were fully acceptable
combination has to be structurally strong and when fitting a flexible walled socket. While the
stable e n o u g h to c o u n t e r a c t the reaction advantages cited are formulated with the quad­
forces." Mr. Kristinsson made a final, impor­ rilateral socket in mind, there is no reason to
tant point: "There may be doubt among profes­ suspect that they are significantly different
sionals and users about the value of the flexible from non-quadrilateral above-knee sockets. In­
wall. I am, however, totally convinced that the deed, flexibility is often considered by the de­
flexible socket is here to stay. If anything, I signers of one another of the various designs as
think it will get more flexible as we gain access an integral factor in their success."
to more suitable materials than we are using Mr. Pritham listed advantages of flexible
today, and some obstacles on the way to proper walled sockets as:
understanding of the socket-stump interaction
are overcome." 1. Flexible walls;
2. Improved proprioception;
Continuing the flexible socket presentations
3. Conventional fitting techniques;
was Norman Berger of New York University's
4. Minor volume changes readily accommo­
Prosthetic Orthotic Program. Mr. Berger's pre­
dated;
sentation was the ISNY (Icelandic-Swedish-
5. Temperature reduction; and
New York) flexible socket design as taught by
6. Enhanced suspension.
NYU. Mr. Berger described the socket and
frame fabrication technique used in the ISNY. Indications for use of the flexible wall socket
Three interesting points are worthy of mention: are:
1. Mature stumps (where frequent socket
1. The flexible socket is fabricated with changes are not anticipated);
p o l y e t h y l e n e , which has a known 2. Medium to long stump (where a signifi­
shrinkage factor. cant portion of the wall will be left ex­
2. The desired wall thickness of the flexible posed and flexible); and
socket is 60/1000". 3. Suspension is not a factor.
3. Lateral distal support for the femur is not
provided for by the frame. While the use of flexible wall sockets has
been well accepted, Mr. Pritham pointed out
The final presentor on the topic of flexible that questions have arisen in at least three
sockets was Charles Pritham, C.P.O. of Durr areas.
Fillauer Medical Company. A co-author and
co-developer of Durr-Fillauer's flexible socket Material
technique, Mr. Pritham described the biome­ Both Surlyn® and low density polyethylene
chanical function of the flexible walled ischial- (in a variety of types and name brands) have
gluteal bearing quadrilateral socket as follows: been used successfully and each has its advo­
cates. Mr. Pritham and colleagues at Durr Fil­
1. Ischial/gluteal weight bearing; lauer prefer Surlyn® for three reasons: clarity,
2. Stabilization of the distal femur laterally; no shrinkage, and ease of rolling the edge.
3. Total contact; and
4. Flexible walls. Thickness
Note the mention of stabilization of the distal Originally socket walls of 30/1000" thick­
femur laterally; this is provided for by the ness were specified, however, this proved to
lack durability. Subsequently, thickness in the Beginning the morning of the second day,
neighborhood of 80-90/1000" were specified John Sabolich, C.P.O., from Oklahoma City,
and are p r e f e r r e d . ( N o t e : N Y U p r e f e r s and Glenn Hutnick, C P . , from New York,
60/1000".) presented another view of CAT-CAM. As
stated earlier, Tim Staats, C.P.O. reported that
the UCLA CAT-CAM is evolving indepen­
Frame configuration dently of the CAT-CAM technique of the orig­
At least three different configurations have inal developers.
been described for quadrilateral sockets. The Sabolich and Hutnick report that the original
differences center on the lateral wall and the C A T - C A M is continuing to evolve and de­
amount of support considered necessary for the velop. Sabolich stated that, "it took five to six
femur. years to develop the current medial wall de­
A variety of designs have been put forth in sign, which has become increasingly more ag­
order to achieve specific features in non-quadri­ gressive in enclosing and capturing the ischial
lateral sockets, including the well known total r a m u s . " They advocate use of the total flexible
flexible brim. brim. " T h e key is the flexible brim system—it
Mr. Pritham concluded his presentation by is totally flexible in the proximal area, where
saying, "the crucial point would seem to be most patients complain." Aside from 100% use
that flexibility is independent of socket shape of the total flexible brim, the Sabolich/Guth
and can be modified to provide specific design CAT-CAM differs from NSNA and the UCLA
features in a socket-frame system. The specific CAT-CAM by not advocating the 4° to 7° me­
configuration depends upon the prosthetist's dial lean of the foot, pylon, and knee bolt in
experience and fitting philosophy and the needs bench alignment as proposed by Long and
of the individual patient." UCLA. John Sabolich went on to say "this ad­
Rounding out the first day of presentations ditional adduction or tilting of the knee bolt is a
was Dr. Robin Redhead, Senior Medical Of­ cover-up for lost stability due to inadequate is­
ficer at the Roehampton Limb Fitting Centre in chial containment." Mr. Long's response was
London. Dr. Redhead's paper was entitled that this was incorrect. Probably the most no­
" E x p e r i e n c e With Total Surface Bearing ticeable aspect of design that separates the Sa­
Sockets." This presentation centered more on bolich/Guth CAT-CAM apart from the other
weight-bearing distribution and biomechanics recent ischial-containment designs is the earlier
than on socket design or shapes. Dr. Redhead mentioned aggressive capture of the ischial tu­
and associates maintain that regardless of berosity and ramus. Sabolich claimed that they
socket shape or d e s i g n , well distributed are enclosing more and more of the ischial
weight-bearing can eliminate the need for ramus, as much as possible and still allow
single point, bony weight bearing (such as is­ pubic ramus comfort. This ramus enclosure
chial weight-bearing). This system of well dis­ provides two biomechanical functions: (1) a
tributed weight-bearing was referred to as a medial bony stop for ML stability, and (2) rota­
total-surface-bearing socket. It infers a hydro­ tional control, especially on soft fleshy residual
static type of socket fit utilizing the incom- limbs. Other than these departures, the Sabo­
pressibility of the fluids in an above-knee re­ lich/Guth CAT-CAM differs very little from
sidual limb. the UCLA CAT-CAM, especially in terms of
brim shape, trimlines, and biomechanics. Sa­
This presentation brought a reaction from of
bolich, unlike Long, does advocate the use of
Professor Radcliffe, who doesn't agree with the
dynamic alignment devices.
hydrostatic concept of weight-bearing in pros­
thetics. He stated that " y o u need a closed At this point in the Workshop, Professor
system for hydrostatics and the AK residual Radcliffe returned to the podium in an attempt
limb is not a closed fluid system. With an open to present and clarify the comparative biome­
fluid system, the fluids are pushed o u t . " chanical principles of both quadrilateral and is­
There was considerable discussion on this chial-containment sockets. The following bio­
topic, both pro and con, and it was never re­ mechanical analyses are taken from Professor
solved. Radcliffe's discussion and from the paper he
later submitted reviewing his presentations. quadrilateral socket is properly fitted and
" I t has been demonstrated that pressure aligned."
against the medial aspect of the pubic ramus "Long's Line as proposed by Ivan Long is
can be used to supplement the weight-bearing the anatomical axis of the lower extremity as
on the tuberosity of the ischium and contribute described in anatomy textbooks. Placing the fe-
to medial stabilization in the upper one-third of mural stump in an advantageous position for
the above-knee socket. In taking advantage of normal use of the hip musculature by adduction
the weight-bearing potential on the medial and flexion of the socket has been a part of
aspect of the ramus, the prosthetist is creating a good prosthetic practice for at least 40 years in
situation much like weight-bearing on the seat the United States and perhaps longer in certain
of a racing bicycle. To prevent the ramus from European centers. Mr. Long's Line appears to
sliding laterally and downward into the socket, be most useful in the cast taking procedure and
the prosthetist must exaggerate the counterpres- subsequent modifications of the model rather
sure from the lateral side. This has been done than have any fundamental bearing on the
by a reduction in the M-L dimension particu­ alignment of the prosthesis. It appears to offer
larly in the area just distal to the head of the no new concepts useful in the bench or dy­
trochanter. The soft tissue must be accommo­ namic alignment of the prosthesis."
dated. Therefore, the A-P dimension is corre­ Professor Radcliffe told the Workshop at­
spondingly increased as compared to the quad­ tendees that the use of "catchy names" should
rilateral socket. As compared to the quadrilat­ be avoided, and he therefore proposed the ter­
eral fitting, the height of the anterior brim is minology of Ischial-Ramal weight-bearing
typically lowered and flared and the gluteal socket, as well as Ischial-Gluteal weight-
area is filled in and fitted higher as a result of bearing socket.
the ischium being encased deeper into the Professor Radcliffe continued his biome­
socket." chanical analysis by saying " T h e biomechanics
" T h e medial brim of the socket must slope of the ischial-ramal weight-bearing socket are
forward and downward to the point where the similar to the ischial-gluteal weight-bearing
pubic ramus crosses the medial brim and quadrilateral socket. The major differences are
emerges from the socket. The ischial ramus in the manner in which the ischium is main­
clearly is capable of providing medial counter- tained in position within or on the brim of the
pressure which supplements the medial pres­ socket. In each case, there must be vertical
sure on the adductor musculature. Since the support with a combination of lateral and ante­
socket slopes downward and inward along the rior counterpressure to maintain the ischium in
entire medial brim, this contour is flared into position" . . . "Some of the socket shape dia­
the medial wall of the socket, which gives the grams I have seen published are so crude and
impression of exaggeration of the medial coun- inaccurate as to be almost meaningless. The
t e r p r e s s u r e in the upper one-third of the level of the cross section shown is often not in­
socket." dicated and a section at ischial level is some­
" T h e adduction of the socket and the use of times compared to a section which is obviously
lateral stabilization should not differ from that higher or l o w e r . " Professor Radcliffe then
achieved by a properly fitted quadrilateral sketched on the blackboard what he believed to
socket. There is an apparent exaggeration of be a more accurate comparison with emphasis
the modification of the lateral wall, but this is on the three-dimensional shape both above and
primarily limited to the area just below the tro­ below the level of the tuberosity of the ischium.
chanter where the M-L dimension has been re­ In each case, he showed a cross section of the
duced to insure that the encased pubic ramus socket at, (1) ischial level with the medial wall
and ischium are maintained in the desired posi­ projected upward to this level; and (2) the out­
tion on the medial brim. The exaggeration of line of the highest points on the brim (Figures
the medial flare and reduction of the M-L di­ 14 and 15).
mension in the upper third of the socket leads to This concluded all presentations of current
the impression of a greater angle of femur ad­ fitting techniques. The remaining presentations
duction, but the actual angle of the femur were concerned with evaluation techniques. Bo
should be similar in both types of fittings if the Klasson of Een-Holmgren Company in Sweden
6
F i g u r e 14. S o c k e t c o n t o u r s for a n I s c h i a l - G l u t e a l w e i g h t - b e a r i n g s o c k e t u s i n g t h e U C B e r k e l e y B r i m s .

Figure 15. Socket contours for an Ischial-Ramal weight-bearing socket of the NSNA type provided by Ivan
6
Long.
presented on "Socket Fit With Reference to evaluation of prosthetic devices and other treat­
Soft Tissue Force Transmission." Briefly, Mr. ments involving the function of the musculo­
Klasson's theory is that we should attempt to skeletal system.
design sockets with physical characteristics that With all presentations complete, the plenary
match the physical characteristics of the re­ group was divided into six panels of six to nine
sidual limb. In other words, where the tissues members with the following charges:
of the residual limb are firm, so should the
matching area of the socket material be; where 1. Determine similarities
the tissues are soft and flexible, so should the 2. Determine differences
socket be. Mr. Klasson refers to this as "sur­ 3. What is the role of flexible walls?
face matching." 4. Indications and contraindications
5. Recommendations for future action
The next speaker was Professor George
a. Evaluation
Murdoch of Dundee, Scotland, presenting " A
b. Education
Method for the Description of the Amputation
c. Application
S t u m p . " Professor Murdoch's paper was based
on his premise that there is a need for an inter­ This first group of panels reported back on
national classification system for residual limbs Sunday morning. The reports were quite con­
to be developed in order to compare one publi­ sistent among the different panels. A synopsis
cation with another, one patient with another, of these reports will be presented in concluding
one fitting technique with another. this report.
The final presentation was made by A. Ben­ On Monday, new panels were formed to re-
nett Wilson on "Physiological Monitoring study the rationale for and possibly develop
Equipment in Evaluation of Lower Limb Pros­ protocol for evaluation. The reports from this
thetic Components and Techniques." He re­ second group of panels was heard in plenary
ported on a system of physiological monitoring session on Tuesday morning.
originally developed by MacGregor of the Uni­ The meeting was adjourned Tuesday, May
versity of Strathclyde in the 1970's. Recently 19, 1987 at noon.
modified for use by the University of Virginia What follows here is a synopsis of the con­
Division of Prosthetics and Orthotics, this clusions and recommendations of the panel re­
system consists of a compact tape recording ports.
component worn on a waist belt that records
electronically, step count, walking velocity,
standing versus sitting, and heart rate, plotted
against time up to 24 hours. The tapes are then
analyzed by a special micro-computer program, I. Similarities & Differences
which subsequently prints the information in A. Biomechanics
digital and graphic format. 1. Ischial Containment:
Under some circumstances the heart rate data a. similarities:
can be useful in providing an energy index, but -all ischial containment sockets
probably more importantly, the step count, advocate and utilize varying
standing versus sitting, and velocity data pro­ degrees of ischial containment
vide specific information about the activity of b. differences:
the subject. Mr. Wilson and colleagues have - q u a d s do not utilize ischial
recently developed a solid state device which is containment
less costly and more reliable. The new system -ischial containment sockets,
has 17 information gathering channels. Mr. amount of ischial containment
Wilson concluded by saying, " A t this point, 2. Weight Bearing Distribution:
we do not have sufficient experience to know a. similarities:
how many subjects have to be monitored and -ischial containment sockets,
how much data is needed to show significant combination of ischial tuber­
differences, but it certainly appears that at last osity and ramus, and periph­
we have a breakthrough in instrumentation for eral (soft tissue)
b. differences: -Shamp Narrow ML & NSNA,
- q u a d s , ischial-gluteal weight use of Long's Line
bearing -ischial containment sockets,
3. ML Stability—maintenance of ad­ TKA bench alignment, socket
duction midline
a. similarities: b. differences:
-goal of all AK socket systems - N S N A does not use dynamic
-greater success and mainte­ alignment device
nance in ischial containment -quad medial wall on LOP
sockets due to ischium acting - n o t all tilt knee bolt
as bony stop or lock - N S N A , varying d e g r e e s of
b. differences: knee bolt tilt, 7°, female, 4°,
-quad, soft tissue lock only, no male
bony lock -quad, bench alignment, more
-less successful maintenance of stable TKA, T reference point
L
adduction, thus less ML sta­ is located at posterior Δ of
bility socket
4. Socket Shape—ischial level cross 8. Rotational Control:
section a. similarities:
a. similarities: -ischial containment sockets,
-ischial containment sockets, bony lock of Ischium and post-
narrow ML, wider AP, con­ trochanteric concavity
cave post-trochanteric shape b. differences:
b. differences - q u a d , muscular-soft tissue
-quad, wider ML, narrower AP cross-section
5. Trimlines: B. Method of Obtaining Cast
a. similarities: a. similarities:
-ischial containment sockets, -quad and Shamp Narrow ML
generally; especially anterior, utilize a casting brim
p o s t e r i o r , and lateral wall - U C L A C A T - C A M &Sabolich/GuthC A T
trimlines
b. differences: molding technique
-quads, especially higher ante­ - N S N A & UCLA CAT-CAM,
rior, lower posterior and lateral standing
wall trimlines b. differences:
-medial wall of CAT-CAM - C A T - C A M & N S N A , hand
6. Suspension: molding technique
a. similarities: -Sabolich/Guth CAT-CAM,
-all compatible with suction sometimes cast lying down
b. differences: C. Anatomical Considerations
-ischial containment sockets, 1. U C L A C A T - C A M detail about
unclear about auxiliary suspen­ pelvic differences:
sion - ischial inclination
7. Alignment: - pubic arch angle
a. similarities: - ilio-femoral angle
-all but NSNA utilize alignment 2. NSNA male, female alignment dif­
devices ferences:
-ischial containment sockets, - bolt tilt
medial wall not on line of pro­ II. Role of Flexible Walls
gression - not linked to any one philosophy of de­
- N S N A & UCLA CAT-CAM, signing an AK socket
tilting of knee bolt in bench - vital to the success of the Sabolich/Guth
alignment CAT-CAM
- improved sitting comfort might include: cinematography,
- improved proprioception force plate, motion analysis, gait
- better heat dissipation mat and other "gait l a b " studies as
- improved muscle activity well as r a d i o g r a p h i c a l data on
- reduced weight alignment and containment, physi­
- ease of socket change within frame, no ological data, residual limb/socket
loss of alignment force analysis, and/or any other rel­
- enhanced suspension, if suction suspen­ evant laboratory studies.
sion 2. A program of clinical evaluation,
All participants agreed there is great need for improved based on previous fittings and con­
flexible materials.
tinuing fittings in clinics already
III. Indications and Contraindications utilizing new fitting techniques.
- there were no specific contraindications This would be a more subjective
noted for any socket design study, and would require a greater
- some advocated not changing successful effort for coordination and pooling
quad wearers of data.
- quads are most successful on long, firm 3. Complete manuals should be devel­
residual limbs with firm adductor mus­ oped for each individual technique,
culature unless the developers can find it
- ischial containment sockets are more mutually agreeable to work to­
successful than quads on short, fleshy gether and blend the new tech­
residual limbs niques. The panels found the latter
- ischial containment sockets are the option to be most desirable.
better recommendation for high ac­ 4. Evaluation should be independent
tivity/sports participation/running of the developers.
- lack of agreement on best recommenda­ 5. Any evaluation needs to be coordi­
tion for bilateral above-knee nated by an authoritative group.
IV. Recommendations ISPO and/or the U.S. Veterans Ad­
The panels' conclusions and recommen­ ministration were recommended.
dations were remarkably consistent. Most The American Academy of Ortho-
consistent was the recommendation for tists and Prosthetists should also be
improved terminology, lumping what I involved.
have referred to as ischial containment into 6. Possible funding sources within the
a single, workable term. Suggestions states include the Veterans Admin­
ranged from "Narrow M L " to Ischial/ istration and the National Institute
Ramus Containment (IRC) andNon-Ischialon Containment
Disability (Non-IRC).
and Rehabilitation Due to
time constraints, arguments about this rec­ Research (NIDRR).
ommendation were never resolved. It is B. Education
hoped that all recommendations can be ad­ The post-graduate, specialized
dressed in a future workshop or through courses for experienced practitioners
some other form of action. appear to be most appropriate for
A. Evaluation teaching these newer techniques at this
time. Incorporation into entry level ed­
There was unanimous agreement for ucation programs should follow as
formal evaluation of the newer above- well written, experience based
knee techniques (NSNA, CAT-CAM, manuals are developed. Any teaching
Shamp Narrow ML) as well as evalua­ course should include " h a n d s - o n " ,
tion of implications of the inferiority patient contact, fitting, and manage­
of the quadrilateral technique. ment as part of the curriculum.
1. A program for scientific/laboratory C. Application
evaluation should be set up at a The application of these new tech­
center or multiple centers, de­ niques, while certainly not as wide­
pending upon resources. This study spread and accepted as the quadrilat-
eral technique, or even the flexible Author
socket technique, is occurring at this C. Michael Schuch, C . P . O . , is Assistant Professor of
time. Growing acceptance and appli­ Orthopaedics and Rehabilitation and Associate Director of
cation will most certainly follow. It is the Department of Prosthetics and Orthotics at the Univer­
hoped that this workshop, as well as sity of Virginia Medical Center, Box 467, Charlottesville,
Virginia 22908.
future workshops, will aid in safe and
proper application of these and future
advances and developments in pros­
thetics.

References
1
UCLA AK Teaching Manual, 1 9 7 7 - 1 9 7 8 .
2
UCLA CAT-CAM Above Knee Prosthesis, Teaching
Manual, Third Edition, March 1987.
3
Fabricating The Long's Line Above-Knee Prosthesis,
by Ivan long, 1981.
4
Ivan Long's business card.
5
Manual for use of THE SHAMP BRIM for the Narrow
ML Above-Knee Prosthetic Socket, The Ohio Willowwood
C o . , 1987.
6
By Charles Radcliffe. Re-drawn by A. Bennett Wilson,
Jr.