Fitting and Fabrication Training
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Version 160610
Table of Contents:
3. Socket-less Socket™ Basics
4. Socket-less Socket™ Sub-Components
5. Fitting Components Sub-Components
6. Our of the Box, Getting Started
7. Suspension and Selecting the Right Gel Liner
8. Pin and Lanyard Suspension Considerations
9. Suction and Vacuum Suspension Considerations
9. Velcro Suspension Considerations
10. NASA-Based Mesh Fabric Inner Socket Considerations
11. Pre-Fitting the Socket-less Socket
12. Initial Static Fitting
13. Positioning the Lateral and Medial Struts
15. Cross Connector Adjustments Overview
17. Positioning the Lateral Cross Connectors
18. Positioning the Posterior Cross Connectors
19. Positioning the Medial Cross Connectors
20. Swing Webbing Adjustments
21. Anterior Ratchet and Ladder Straps
22. The Dynamic Strap
23. Donning and Doffing
24. Trimming the Struts to Length
25. Attaching the Fitting Components
27. Dynamic Fitting
29. Final Fabrication
32. SwingBrim™ Retrofit Instructions
35. Socket-less Socket™ Coding
35. SwingBrim™ Coding
35. Socket-less Socket™ Trouble Shooting
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Fitting and fabricating the Socket-less Socket™ requires certified prosthetist
training.
Find the most recent additional training resources at
MartinBionics.com, as we update this documents regularly. If you have any
questions about the fitting, contact our clinical services team at 844-MBIONIC.
Socket-less Socket™ Basics:
The Socket-less Socket™ is a
single use modular
component set and
fabrication kit to enable a
practitioner to fabricate and
align a custom molded
socket specific to each user.
There are numerous possible
configurations that can be
customized, and every
element of the final socket
design, including socket
shape, contouring, and
suspension used, are custom
selected and fit to each
user’s specific needs. Click on
the video images for an
overview, including its various
configurations and amputee
perspectives.
The Socket-less Socket™ is
ordered as a Right or Left,
and comes as an assembled
fabrication kit.
There is no
sizing chart, unless you are
fitting a pediatric or junior
sizes. In such a case, both a
true pediatric size (0-50 lb
user) and junior size (50-100 lb
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user) versions are available.
Socket-less Socket™ Sub-Components:
16
19
15
7
12
21
5
23
20
22
4
8.1
9
24
9
2
8.3
17
18
11
11
8.4
6
10
8.6
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1. Dynamic Tab
2. NASA-based mesh fabric
3. Z-Straps
4. Blue Laminating Plate
5. Ratchet Buckles
6. Ladder Straps
7. Single Hole Cross Connectors
8.1. Proximal Lateral Cross Connector
8.2. Distal Lateral Cross Connector
8.3. Posterior Proximal Cross Connector
8.4. Posterior Distal Cross Connector
8.5. Proximal Medial Cross Connector
8.6. Distal Medial Cross Connector
9. Lateral Struts
10. Medial Struts
11. Strutserts
12. Flower Distal Cup™
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6
8.5
10
8.2
3
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13
13. Dynamic Strap
14. Horizontal Pad
15. Medial Pads
16. Lateral Pads
17. Arch Pad
18. Swing Webbing
19. Dummy Struts
20. Single and Double Velcro Dots
21. Allen Wrenches
22. Extra Truss Nuts
23. 1/4" Rivets
24. 3-Bar Buckles
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Fitting Components:
1.
2.
3.
4.
5.
6.
7.
2
2
3
3
5
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Dynamic Tab
Though Hole Tube Clamps
Blue Pylons
Blue Laminating Plate
Male Pyramids
Lollipop Base Plates
Female Pyramid
The weight limit of fitting a
Socket-less Socket™ is driven
by the weight limit capacity
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of the Fitting Components.
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The weight limit of the various
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Fitting Component sets is
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found in the chart below.
The Heavy Duty Fitting
Component set simply uses heavier duty Lollipop Base Plates, with the remainder
of its component
set the same as
Fitting Component Set
Weight Limit
Distal Connector
the Standard
Heavy Duty Fitting Components 350 lbs / 158 kg Standard 4 Hole
F i t t i n g
Components. As
Standard Fitting Components
250 lbs / 113 kg Standard 4 Hole
such, Heavy Duty
Junior Fitting Components
180 lbs / 81 kg Standard OR Pediatric
Lollipop Base
Pediatric Fitting Components
100 lbs / 45 kg Pediatric 4 Hole
Plates can be
o r d e r e d
separately as
needed.
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The Junior Fitting Component set can be used from a pediatric up to a
moderate weight adult (180 pounds).
The overall weight of the Fitting
Component set is considerably less than the Standard Fitting Components, as it
uses pediatric sized pylons and pyramids - and offers both a standard and
pediatric distal 4 hole connection.
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The Fitting Components are an in-office tool set only, to help establish the
alignment of the two lateral struts with respect to the knee, and will be used
during the static and dynamic alignment phase of the fitting process. These will
be transferred out during the final fabrication and replaced with the Rabbit Ear
Lamination, which will retain the same geometry and relationship between the
two Lateral Struts and the prosthetic knee.
Out of the box:
The Socket-less Socket™ comes as an assembled fabrication kit, largely
resembling a socket. The proximal band of Cross Connectors, the proximal
Ratchet, and the brim’s Swing Webbing will, in most cases, remain in their
current height position on their respective Struts for the fitting, and only their
span between their adjoining Struts will need to be adjusted to fit to the user.
The distal band of Cross Connectors span and height locations will need to be
adjusted during the fitting process.
Connectors highlighted with the red circles will likely NOT need to be adjusted in
height position along the Struts during the fitting. Rather, only their span will
need to be adjusted (green arrows).
The remaining distal band of Cross
Connectors height positions and span will likely need adjusted.
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An extra parts bag is located in a compartment in the back of the product’s
box. This extra parts bag includes parts such as the Allen Wrenches, extra Truss
Nuts, Horizontal Pads, Single Hole Cross Connectors, Loctite, and others, and will
be helpful for the fitting process.
Suspension and Selecting the Right Gel Liner:
The liner type will be selected based on the type of suspension that will be used
for the fitting. You can integrate any form of suspension within the Socket-less
Socket™, including pin/lanyard, suction/vacuum, velcro, sock-fit with Lateral
Stabilizer (or Silesian belt), or others.
Just like in conventional
socket fittings, there is not
one best form of suspension,
but rather, the suspension
should be selected based on
each user’s individual needs.
Click the image to the right
to watch the Limit-less
Configurations video and see
some of the creative
configuration and suspension
options available to
customize the socket to each
user’s needs.
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vimeo.com
/164781960
The flexible inner socket material will be selected based on the end user’s
selected suspension and specific needs. The Socket-less Socket™ configuration
may use any form of conventional inner socket material, as well as may use the
Flower Distal Cup™ and/or NASA-Based Mesh Fabric for the inner socket. The
flexible inner socket simply needs to prevent circumferential ballooning of the
limb tissue from between the Struts, so even if a thermoplastic socket is
integrated, it can be thin and flexible - typically about 1/8” thick is sufficient.
THINK FORWARD: When using a thermoplastic inner socket within the Socketless Socket™ framework, all four struts are typically connected to the common
thermoplastic inner socket by velcro or rivets, and the inner socket’s trim lines
will typically be modified to below the brim level, to maintain the conformity
and comfort of the Socket-less Socket™ brim. Connecting all four struts to a
common inner socket can help provide a more consistent donning position of
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the medial panel and simplify donning for the end user.
Many users actually prefer the familiar
containment of a thermoplastic inner socket on
the distal 1/2 to 2/3 of the limb. Regardless of
which type is used, most Socket-less Socket™
fittings will use some type of flexible inner socket to
contain and control the limb tissue.
Integrating a thermoplastic inner socket can be
accomplished by removing the pads off the struts
at the level of the flexible inner socket down, and
velcro-ing (and/or riveting) the thermoplastic inner
socket directly to the struts.
This can be
advantageous by providing a more consistent
medial wall positioning during donning, making it
simpler to donn.
Likewise, the position of the
thermoplastic inner socket with respect to the brim
can be modularly adjusted by moving it up or
down if more or less space is needed between the
brim and distal end of the socket. In effect, you’ll never ‘short-socket’ a patient
again.
Pin/Lanyard Suspension:
The Flower Distal Cup™ can be a great solution for providing a pin or lanyard
attachment for a fabric-covered cushion liner. It’s integrated pin attachment
allows for a fabric-covered cushion liner to be turned into a locking liner.
However, because of the breadth that the Flower Distal Cup™ spans across the
distal aspect of the limb, it effectively eliminates the milking effect found in
conventional locking liners. You can also modularly place the pin’s location on
t h e l i n e r, p r o v i d i n g m o r e
customization of the pin
attachment alignment.
The Flower Distal Cup™ with Pin
Attachment can be used with
or without a thermoplastic inner
socket. If using a thermoplastic
inner socket, the pin lock can
be integrated within its distal
end.
As with any socket
configuration, it is helpful to control the tissue dynamics with some form of
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containment - whether the NASA-Based Mesh Fabric or thermoplastic inner
socket. In some cases, the Flower Distal Cup™ alone may not be enough
support to prevent ballooning of limb tissue.
The petals of the Flower Distal Cup™ can be trimmed in width or length with
scissors. If the user has trouble reflecting the gel liner inside out, simply trim the
width and/or length of the Flower Distal Cup’s™ petals until the user is able to
effectively invert the gel liner for donning.
Suction and Vacuum Suspension:
Integrating a thermoplastic inner socket provides opportunity to use suction or
vacuum within the Socket-less Socket™ configuration. Suction suspension can
utilize either skin fit suction or a sealing gel liner. This thermoplastic inner socket
can be a modified version of an existing flexible inner socket, or a mold may be
taken within the Socket-less Socket™ structure as a weight bearing cast.
To take a weight bearing cast,
the Socket-less Socket™
structure can first be custom fit
to the user, then cast the limb
(typically with fiberglass wrap),
pull a trash bag over the cast
and step back into the Socketless Socket™ structure in
weight bearing while the cast
is still wet. Allow the weight
bearing socket fit to form the
cast shape to the appropriate
inner socket shape. This new order for casting provides a more intimately
contoured cast shape by accounting for the actual weight bearing forces
within the socket. You can then modify the positive model of the flexible inner
socket shape according to your suspension needs, and fabricate a traditional
flexible inner socket to fit within the Socket-less Socket™ structure. When using a
sealing liner, it is typically helpful to round out the shape of the inner socket’s
cast, to ensure that the sealing rings maintain a seal - as the instructions of using
such liners describe.
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vimeo.com
Velcro Suspension:
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Using Velcro for suspension to a fabric-covered liner tends to work well with limbs
that are longer, firmer, and more cylindrical in shape. With short, soft, or conical
limbs, users may feel too much movement within the system if this is the sole
suspension used. To use this form of suspension, simply attach at least two of the
Velcro Dots onto the proximal 2/3 of the two lateral struts. These will engage
with either a fabric-covered liner, or with the NASA-Based Mesh Sock, which
would be engaged to the fabric-covered liner.
When attaching the Velcro Dots, clean the foam padding with rubbing alcohol,
allow to fully dry, and apply the adhesive Velcro Dots. The adhesive on the
back of the Dots will need to fully cure for at least 48 hours before it reaches its
full strength. Prior to that they may pull off the foam when doffing the prosthesis,
as the velcro’s hold to the liner may be stronger than the un-cured adhesive.
Other than for long muscular limbs, most users prefer other forms of suspension
for their main suspension method, such as the Flower Distal Cup™ with pin
attachment.
NASA-Based Mesh Fabric Inner Socket:
Making a flexible inner socket out of the NASA-Based
Mesh Fabric is simple. Simply take a section of the
fabric and lay it around the limb, with the top edge at
the groin level. It is helpful to have the diamond mesh
pattern oriented with the diamonds in a horizontal
position. This will help minimize the stretch of the sock
under load. Use clamps or binder clips to connect the
two ends of the fabric around the limb, creating a
sock with a long seam down the length of the limb.
Make sure the fabric is pulled snug around the limb. It
may be helpful to leave a little extra material toward
to top of the sock, to provide ‘handles’ for the user to
help donn the sock. Sew the marked seam, and simply
trim off extra fabric. If the sock is too loose, simply sew a new dart to tighten it
up. The NASA-Based Mesh Fabric sock should fit as snug as a traditional inner
socket would normally fit, to
help contain and control the
limb tissue.
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To connect this NASA-Based
Mesh Fabric inner socket to a
fabric covered liner, simply sew 4 of the included Velcro Dots to the top inside of
the sock. These will engage with the fabric covered liner to hold it in place.
This NASA Mesh Sock can be used as the flexible inner socket to contain the limb
tissue and is often in coordination with the Flower Distal Cup™ for suspension.
The NASA-Based Mesh Fabric comes with the purchase of the Flower Distal
Cup™, and can be purchased separately as well, as needed.
THINK FORWARD: The Socket-less Socket™ allows you to test various suspension
types, without having to make any significant modifications to the socket
configuration. In conventional fitting methods, changing suspension strategies
typically requires re-casting the limb, or fabricating a new socket. With the
Socket-less Socket™, various suspension options can be integrated and tested
within the same socket configuration, with only minor fitting adjustments at
most.
For instance, if you go from fitting the Flower Distal Cup™ pin
attachment to a thermoplastic inner socket with suction, likely the only
modifications to the Socket-less Socket™ configuration would be to un-velcro
the blue pads from the struts at the thermoplastic inner socket height down,
and velcro the new flexible inner socket to all four struts in its place, with
perhaps minor Cross Connector span adjustments at most. This provides
significantly greater control for the practitioner to test various suspension
options during the fitting process, in real-time.
Pre-Fitting the Socket-less Socket:
Martin Bionics offers Pre-Fitting Clinical Services to help expedite and improve
the fitting process of Socket-less Sockets™. Simply mail us a cast or existing
conventional socket, and we
will pre-fit the Socket-less
Socket™ for you, getting you
80% of the way there before
you begin fitting. We’ll cut the
Struts to length, and position all
Cross Connectors to place the
Struts in the correct position
around the limb shape. The
socket will come fully
assembled and can even
have the Fitting Components
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attached and cloned to an existing sockets alignment.
Alternatively, you can do the same process in your own office. Simply begin a
clone of an existing socket by pouring a conventional socket in the jig to
capture its shape and alignment, then build the Socket-less Socket™ around
that plaster model. It may be helpful to modify into the hard plaster model to
account for tissue compression of the Socket-less Socket™ fitting. The Socketless Socket™ fitting process is really no different on a plaster model than on the
actual user, with the exception that the plaster does not conform like soft tissue.
Our Pre-Fitting Clinical Services can be a great way to expedite the fitting
process with the patient, as it is often more time efficient to pre-fit the socket,
and then begin working with the patient once the socket is 80% pre-fit.
Initial Static Fitting:
If you are fitting the Socket-less Socket™ from scratch on the user, begin by
having the patient donn their gel liner. The liner should extend the length of the
limb as proximal as possible without causing medial rolling, and typically will be
slightly longer on the lateral side, similar to standard liner trim lines. Trimming
liners straight across at the level of the perineum is fine as well, but some users
find it more comfortable to extend the gel liner higher on the lateral side.
Donn the Socket-less Socket™ around the limb to get an initial gauge of what
adjustments will be needed. The Socket-less Socket™ can be splayed open by
loosening the Anterior Ratchet Straps.
Systematically begin adjusting the Cross Connector’s spans to place each of
the Struts in the correct positions around the limb. The proximal ring of Cross
Connectors will typically not need to adjusted in their height position along the
Struts, but rather just in their circumferential span only. The distal ring of Cross
Connectors should be
adjusted in height along
the Struts to roughly sit
near the distal 1/3 of the
limb length, as well as
adjusting their span.
An high-level overview of
the Socket-less Socket™
fitting process can be
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viewed in this Static and Dynamic Fitting video.
Positioning the Lateral and Medial Struts:
The four thermoformable Carbon Struts are generally positioned along the
length of the limb. The two Lateral Struts are used to capture and control the
femur position within the socket, and they are mounted to the knee. The two
Medial Struts suspend from the Swing Webbing and create a floating panel that
holds the limb into the two Lateral
Struts, replicating the effect of a
“hammock”. The horizontal Cross
Connectors and Ladder Straps (or
Z-Straps) connect adjacent struts.
The orientation of the four Struts
around the limb are generally
placed with a cross-section, or top
view, of approximately 45 degrees
to the line of progression: AnteriorLateral, Posterior-Lateral, PosteriorMedial, and Anterior-Medial.
The two Lateral Struts (long Struts) create the foundation and anchor for the
Socket-less Socket™, and will be positioned just anterior lateral and posterior
lateral to the femur, and should rest flat against the limb. The proximal end of
the Lateral Struts will be approximately 2/3 the anterior/posterior dimension of
the limb at the trochanter level. This will create the “hammock stand” for the
Swing Webbing brim and medial panel (the posterior-medial and anteriormedial Struts). The distal end of the Lateral Struts posts and locks the distal femur
from its anterior lateral and posterior lateral sides. The two Lateral Struts are the
only rigid section of the socket, being anchored in specific relation to each
other, and in rigid connection to the prosthetic knee.
Click on and watch this Femoral
Capture and Control video for
additional insights on how to
maximize the stability of the limb
within the Socket-less Socket™.
With the correct socket
configuration for the user, the
limb and femur should be at
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least as stable within the socket as in conventional sockets.
The proximal ends of the two Lateral Struts should sit at or just above the
trochanter level, with the Posterior-Lateral Strut typically at 1” more proximal
than the Anterior-Medial Strut.
Initial gapping away from the body of the
proximal end of the two lateral struts is normal, as the limb shape often contours
inward in the ‘wallet-hollow’ region.
These will ultimately be heated and
cosmetically contoured to the body in a later step.
Watching this user walking in a
well fitting Socket-less Socket
demonstrates just how well the
limb and femur can be
controlled.
Unlike
conventional hydrostatic fitting
principles, the femur can now
be more effectively controlled
by the positioning of the two
Lateral Struts, and still leaving
the sensitive distal femur free
floating in space with no rigid
structure to hit.
https://
vimeo.com/
The Posterior-Lateral Strut should be placed with its proximal end just posterior
and proximal to the greater trochanter, in the 'wallet hollow', and with the length
of the strut in the channel along the posterior-lateral femur, on the lateral border
of the hamstrings.
The Anterior-Lateral Strut should be placed with its proximal end at about 1”
lower than the Posterior-Lateral Strut, at about 2/3 the anterior/posterior
dimension of the limb from the other Lateral Strut, and run just anterior to the
length of the femur. This more distal location of the Anterior-Lateral Strut is to
allow for full range of motion in hip flexion during sitting and bending at the hip,
without impinging on the ASIS or abdomen.
The distal end of the Lateral Struts taper toward each other to lock and control
the distal femur and help prevent it from abducting between the Struts. It is very
important to make sure that the distal femur is effectively captured and
controlled. If the user feels lateral instability during walking, it is often because
the femur is not being effectively controlled within the socket.
Simple
adjustments to the Lateral Strut placement around the femur typically resolves it.
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The Posterior-Medial Strut should be located along the medial border of the
hamstrings muscle belly, maybe slightly shifted more to the posterior of the
hamstrings, rather than shifted towards the full medial border of that muscle
group, but certainly not directly along the posterior aspect of the limb. The
Posterior-Medial Strut is attached proximally to the Swing Webbing via the
flexible Strutsert. That attachment point, although not a rigid ischial seat, does fit
near the ischium.
The Anterior-Medial Strut should be positioned so that its proximal end is just
anterior to adductors. The proximal end of this Strut’s assembly has a Velcro
Swivel, which connects to the anterior end of the Arch Pad.
The two Medial Struts create a panel, and their proximal ends share connection
with the Swing Brim and Arch Pad. All four Struts should be roughly equal
distance apart from each other, and will generally match the shape and
contouring of the limb. Although, typically only the proximal ends of the two
Lateral Struts will ultimately be thermoformed in shape, with the remainder of the
struts typically remaining straight.
The Struts will be trimmed to length, and typically do not need to extend past
the end of the residual limb, unless if extra Strut length is desired to account for
adding space between the end of a short residual limb and knee center. Do
not trim the Struts yet. It is typically helpful to complete the dry fitting before
trimming the Struts, in case if you reconfigure the the Socket-less Socket™
around the limb and need extra Strut length. The Struts will be trimmed once the
dry fitting is complete.
Keep in mind that the Through Hole Tube Clamps will mount at the distal three
holes of the two Lateral Struts, and typically sit at about the height of the end of
the residual limb. Any Cross Connectors located in this area will likely need to
be moved to allow for the Through Hole Tube Clamps mounting. As such, either
the Distal Lateral Cross Connector position may need to be slightly adjusted
higher, or you can leave the Lateral Struts one or two holes longer to account for
spacing requirements.
Cross Connector Adjustments:
The Cross Connectors are used to establish and secure the Strut positions around
the limb. The Thumb Screws make for quick adjustments to their span and
positioning along the Strut lengths.
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The numbered holes on the
Cross Connectors are 1/2"
apart. The distance between
hole "0" and hole "1" however is
3/4”. This allows for down to a
1/4” resolution in adjustability to
the span of the Cross
Connectors. Typically use hole
“0” for Cross Connector
mounting. However, if you find the need to have a hole spacing between two
numbered holes (like between hole "8" and hole “9”), you can get a 1/4"
difference by moving the Cross Connector’s end mounting from the "0" hole to
using the "1" hole instead.
A single Cross Connector should not
attach three Struts together, but rather
only two adjacent Struts. Each adjacent
pair of Struts will have its own individual
proximal and distal Cross Connectors, so
that the Struts can move freely in relation
to one another.
Adjacent Cross
Connectors can share the same hole in
the Struts if needed, and a longer Truss
Nut can be used for the additional
thickness of two Cross Connectors in the
same Strut hole.
The Distal Cross Connectors are usually one or two holes shorter in span than the
Proximal Cross Connector counterparts, since the overall limb is typically conical
in shape. The Distal Cross Connectors should be placed at least a couple inches
proximal to the end of the residual limb in most cases. The Cross Connectors
should be fairly perpendicular to the long axis of the femur, and will also typically
be parallel to each other.
Keep in mind that for the final assembly the Thumb Screws will be exchanged for
the male end of the Truss Nuts and Loctite will be applied to each Truss Nut
mounting location. Make sure that the Truss Nut assembly is slightly longer than
the stack up of whatever layers of materials it is connecting to ensure that it is
fully seated into itself. The Truss Nut should never clamp the layers together,
because the Cross Connectors, Webbing and Straps need to have freedom to
swivel on the Carbon Struts. Clamping the pieces will cause the Truss Nuts to
16
loosen as the layers shift and move. During the fitting, ensure that the Thumb
Screws are all sufficiently hand tight and have not backed out.
Begin the dry fitting process by adjusting the Cross Connectors span between
the Struts, to place the Struts in their preferred locations around the limb.
Typically begin by adjusting the Lateral Cross Connectors, to define the
placement of the two Lateral Struts. Then adjust the Posterior Cross Connectors,
and then the Medical Cross Connectors.
In general, the Cross Connectors should fit the Struts’ holes as follows:
Lateral Cross Connectors:
The Proximal Lateral Cross Connector is
connected with its hole “0” to the AnteriorLateral Strut on the third hole from the top.
It’s other end is connected to the fourth
hole down on the Posterior-Lateral Strut
(often within the range of the Cross
Connector’s holes 9-11).
This Proximal
Lateral Cross Connector is purposely
positioned down one extra hole on the
Posterior-Lateral Strut to raise the PosteriorLateral Strut approximately 1" higher than
the Anterior-Lateral Strut. This helps prevent
the Anterior-Lateral Strut from impinging on
the ASIS, or stomach in full hip flexion, and
places the Posterior-Lateral Strut such that
the Gluteal Swing Webbing sits within the
Gluteal Fold.
The Distal Lateral Cross Connector will be connected between the AnteriorLateral and Posterior-Lateral Struts, and placed about one inch to three inches
proximal to the distal femur. This will be used to help post the distal femur. If
additional posting is needed during the weight bearing fitting, a pad can be
placed between the distal lateral cross connector and the limb to further post
the femur. The span of the Distal Lateral Cross Connector is typically at least 1
hole shorter than the span of the Proximal-Lateral Cross Connector, as the limb is
typically conical in shape. This shorter span should help to position the two
Lateral Struts to more effectively capture and control the femur, and prevent it
from abducting through the space between the two lateral struts.
17
THINK FORWARD: Keep in mind that the Through Hole Tube Clamps will mount
at or near the end of the residual limb length, and will use the three distal holes
in the Lateral Struts for mounting. As such, the Distal Lateral Cross Connector’s
mounting position will likely be two holes proximal to the mounting position of
the Through Hole Tube Clamps. To ensure that the Short Pylons can extend
through the Through Hole Tube Clamps, the Thumb Screws will be swapped
with the male end of the Truss Nuts in this area.
Posterior Cross Connectors:
The Proximal Posterior Cross Connector is
connected with its hole “0” to the fifth
hole down on the Posterior-Lateral Strut just distal to the connection of the
Proximal Lateral Cross Connector.
It’s
other end is connected to the first hole in
the Posterior-Medial Strut (often within the
range of the Cross Connector’s holes
9-12). The span of this Cross Connector
will ultimately be driven by the span of
the Gluteal Swing Webbing distance,
which is proximal to this Cross Connector.
The Gluteal Swing Webbing should fit
snug along the gluteal fold.
The Distal Posterior Cross Connector should be connected with its hold “0” to the
Posterior-Lateral Strut, just distal to the connection of the Distal Lateral Cross
Connector on that Strut. Keep in mind that this Distal Posterior Cross Connector is
probably going to be the most distal connection for a Truss Nut on the PosteriorLateral Strut, just above the necessary 3 distal holes required to mount the
Through Hole Tube Clamps.
18
Medial Cross Connectors:
The Proximal Medial Cross Connector is
typically connected at hole “0” on the
second hold down on the AnteriorMedial Strut, just distal to the aluminum 3Bar Buckle. This Cross Connector will then
attach to the second hole down on the
Posterior-Medial Strut, just distal to the
Posterior Proximal Cross Connector (often
within the range of the Cross Connector’s
holes 9-11).
The Distal Medial Cross Connector is
typically connected to its hole “0” on the
Anterior-Medial Strut, and to the PosteriorMedial Strut at a height just proximal to
the Distal Posterior Cross Connector’s
mounting position on the Posterior-Medial
Strut (often within the range of two holes
shorter than its proximal Cross
Connectors’ counterpart, to
accommodate for the typical conical
limb shape).
THINK FORWARD: The Proximal Medial Cross Connector’s length in relation to
the length of the Medial Swing Webbing will determine the amount of medial
brim pocket for the adductors. The shorter this cross connector is compared to
the Medial Swing Brim will result in a larger pocket at the brim for the
adductors. Watch this video to see it in action.
19
Swing Webbing Adjustments:
With the Socket-less Socket™ donned onto the limb and all four struts in their
correct positions around the limb, you can now adjust the Swing Webbing by
tightening the webbing ends through the 3-Bar Buckles. The Swing Webbing
ends should remain connected to the proximal end of the Posterior Lateral Strut
and the proximal end of the Anterior Medial Strut. It will also be anchored to the
Strutsert that extends from the Posterior Medial Strut. The Swing Webbing is
broken in two two separate adjustable sections - the Gluteal Swing Webbing
section and the Medial Swing Webbing Section. Begin by adjusting the Swing
Webbing section lengths to fit snug around the limb in these two areas.
Adjusting the Posterior Swing Webbing
The posterior Swing Webbing
should fit in the gluteal fold,
supporting the tissue similar to
a well-fitting rock-climbing
harness. Adjusting the tension
of the Swing Webbing through
the 3-Bar Buckle that is
connected to the proximal
end of the Posterior-Lateral
Strut will provide more support
for the limb through the
posterior brim.
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Adjusting the Medial Swing Webbing
The medial Swing Webbing spans between the proximal end of the AnteriorMedial Strut and the proximal end of the Posterior-Medial Strut. The two Medial
Struts form a flexible, floating Medial Panel that is suspended from the Swing
Webbing.
The Arch Pad pad will typically need to be un-Velcro-ed to allow for the Medial
Swing Webbing adjustments. Once the Medial Swing Webbing is adjusted,
place the Arch Pad back in place by attaching it to the Swivel on the Anterior
Strutsert and re-velcro it along the Swing Webbing toward the back.
20
The shape and contouring of the medial brim can be highly customized through
simple adjustments of the relationship between the Medial Swing Webbing,
Proximal Medial Cross Connector, and Gluteal Pad.
The length of the Swing Webbing between the two Medial Struts, as compared
to the length of the Proximal Medial Cross Connector just below it, determines
the contouring of the brim’s adductor relief area. The longer the Swing Webbing
is in comparison to the Proximal Medial Cross Connector provides a larger
pocket for the adductors. The size of the adductor relief pocket within the
Socket-less Socket™
configuration can typically be
smaller than in conventional
sockets because the brim is so
conforming and forgiving that
it is typically much more
comfortable regardless of the
adductor pocket size or shape.
Therefore, keeping the
adductor relief area as small
as possible will provide more
inherent socket medial/lateral
control.
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The Arch Pad can also be adjusted in its position along the Swing Webbing by
simply un-velcro-ing it from the Swing Webbing and velcro-ing it back on.
Moving it up or down with respect Swing Webbing can change the dynamics of
the Medial Brim, as well as changes how far medially the brim extends. The Arch
Pad can also be trimmed, though is rarely needed.
Anterior Ratchets and Ladder Straps
The Ratchets and Ladder Straps offer quick
and efficient donning during the static and
dynamic fitting process, and are often
swapped for the included Z-Straps when
transferring to the definitive stage since
they are lower profile.
However, The
Ratchets and Ladder Straps are able to be
used definitively as you see fit for your
patient.
21
Typically, the Anterior Ladder Straps will be at a diagonal, rather than horizontal
to the floor, with the Proximal Ladder Strap at a steeper angle than the distal
Ladder Strap. Usually, the Proximal Ladder Strap has the Ratchet connected to
the most proximal hole on the Anterior-Lateral Strut. The Ladder Strap base is
mounted to first hole on the Anterior-Medial Strut, underneath the 3-Bar buckle
for the Swing Webbing.
The Distal Ladder Strap typically has the Ratchet mounted just distal to the Distal
Medial Cross Connector on the Anterior-Lateral Strut, and its corresponding
Ladder Strap base is mounted just proximal to the Distal Lateral Cross Connector
on the Anterior Lateral Strut.
This Distal Ladder Strap is positioned across the distal 1/3 - 1/2 of the limb, and
should be more proximal than the end of the femur. A third Ratchet and Ladder
Strap can be used with long limbs if necessary, although this is rarely needed.
If the Ladder Straps are roping into soft tissue, adhere sticky backed hook Velcro
to the back side of the Ladder Straps, and velcro the included Horizontal Foam
Pads (3" x 6” pads) to the back of the Ladder Straps to spread the loads. These
pads can be trimmed to size as needed. Likewise, the same Horizontal Foam
Pads can be velcro-ed to the back of the Z-Straps as desired, using double
sided hook Velcro Dots.
The Dynamic Strap
The Dynamic Strap is used to solidify the medial
panel of the Socket-less Socket™, and prevent
it from migrating proximally during use. When
donning, the socket should be tightened
circumferentially and then the distal Dynamic
Straps should be tightened. As the Dynamic
Strap is tightened it will slightly lower the Medial
Panel and acts like a 4-bar linkage, swinging the
Medial Panel (and the limb) laterally, to help
post the femur into the two Lateral Struts.
THINK FORWARD: If a thermoplastic inner socket is integrated within the
Socket-less Socket™ configuration, and all four struts are affixed to the
common thermoplastic inner socket, then the Dynamic Strap’s function is not
as critical, and can typically remain in more of a fixed position in some cases.
22
The Dynamic Strap’s 3/4” Ratchet or velcro Z-Strap replacement should be
mounted to the Distal Medial Cross Connector between the Posterior Medial
and Anterior Medial Struts, at about 1/2 to 2/3 the way toward the Anterior
Medial Strut. The closer the Ratchet is to the middle of the Distal Medial Cross
Connector, the more the Dynamic Strap will pull the entire Medial Panel distal
and lateral as a unit. The closer the Ratchet is to the Anterior-Medial Strut, the
more it will pull down just the Anterior brim for adductor relief.
If you see the Dynamic
Strap bowing as weight is
being applied into the
Socket-less Socket™,
then the Dynamic Strap
needs to be tightened to
prevent the proximal
migration of the Medial
Panel.
Any slack will
result in the user feeling
more movement in the
system while walking.
https://
vimeo.com/
151340469
THINK FORWARD:
To properly donn the Socket-less Socket™, it is very
important that the Dynamic Strap is loosened before donning to allow the
Medial Panel and Medial Brim (Medial Swing Webbing and Arch Pad) to be
pulled as proximal as possible. Think about the Swing Webbing and brim
acting as a hammock support around the proximal limb, similar to a rockclimbing harness. Watch the above donning video to see this process.
The Socket-less Socket™ can be donned in sitting or in standing, making it
simpler for users who have poor balance. Since the limb tissue no longer has
to be pulled or pushed into a confined bucket, the donning process should be
no more challenging than putting on a pair of tennis shoes. The anterior
Ratchets or Z-Straps enable the end user to have more daily control over how
the socket fits, by adjusting its donning tightness and support in real-time.
Trimming the Struts to Length:
Once the dry fitting is complete you can prep the socket for the dynamic fitting.
Start by determining where you will trim the Struts to length. In most cases, the
struts will not need do extend past the end of the limb. You will need at least
23
three free holes at the distal end of the two Lateral Struts to attach the Through
Hole Tube Clamps. If the Distal Lateral Cross Connector is in the way of where
you would want to mount the Through Hole Tube Clamps, either move the Distal
Lateral Cross Connector slightly higher (as long as it is still in an appropriate
position to post the distal femur) or just plan to trim off the Lateral Struts with
enough extra length to have three free holes distal to the Distal Lateral Cross
Connector.
THINK FORWARD: The position of the Blue Laminating Plate within the Fitting
Components will likely be the same position as the end of the socket in the
final fabrication. Configuring the setup with the Blue Laminating Plate in the
most optimal position for final fabrication will simplify the transfer process.
Swap out the Thumb Screws with 3/8” LowProfile Screws for any Cross Connector
mountings that are within 2 holes proximal
to where the Through Hole Tube Clamps will
mount. The Thumb Screws are too high
profile to fit between the Blue Pylons and
the Struts.
Next trim the Medial Struts to a length of just
proximal to the end of the residual limb.
The Distal Medial Cross Connector should
be mounted to the two Medial Struts
proximal enough in relation to the Dynamic
Strap to allow for necessary tightening of
the Dynamic Strap without running out of
adjustment.
The Struts should be cut to length directly between the mounting holes with a
bandsaw, hacksaw, or cast saw. Use a grinder or sander to knock off any sharp
edges. The Strutserts will also be trimmed to the same length. Typically leave
the Foam Pads trimmed about 1/2” longer than the underlying Struts.
Attaching the Fitting Components:
The Fitting Components are an in-office alignment tool used to establish the
alignment between the two Lateral Struts of the Socket-less Socket™ to the knee
24
components. They are not designed for rigorous or definitive use. The same
fitting component set can be used for a right or left fitting. The Lollipop Base
Plates can be flipped over to switch between a right and left fitting. The Lollipop
Base Plates have a dot on one side of their peripheral end - the dots face up
when they are configured for a left fitting, and dots face downward for use in a
right fitting. If additional
angle adjustability is
needed in one of the
Lollipop Base Plates, it
can be flipped to provide
additional range of
motion. In most fittings,
both dots will be facing
up for a left fitting and
both dots facing down
for a right fitting. Proper
assembly has the
posterior Lollipop Base
Plate positioned over the
top of the anterior.
https://
vimeo.com/
169382346/3f
THINK FORWARD: The Standard Fitting Components are rated for a weight limit
of 250 pounds. Heavy Duty Lollipop Base Connectors are available and
increases the Standard Fitting Components weight rating to 350 pounds.
Junior Fitting Components are available, with a weight rating of 180 pounds,
and use smaller and lighter pediatric size sub-components. If needed, true
pediatric sized Lollipop Base Plates are available for fitting pediatric users.
Attach the fitting components onto the knee. Keep the four mounting screws
loose, to allow for the Lollipop Base Plates to freely rotate. Mount the Through
Hole Tube Clamps, with attached Blue Pylons and Male Pyramid Adaptors, onto
the distal three holes of the two Lateral Struts.
Begin by bench aligning the Socket-less Socket™ to the Fitting Components by
attaching just the posterior Blue Pylon’s Male Pyramid onto the posterior Lollipop
Base Plate in the correct bench alignment flexion and abduction angle. It is
helpful to have the Socket-less Socket™’s anterior Ratchet Buckles tightened to
about the same tightness as used when the socket is donned. Twist the Blue
Pylon within the Through Hole Tube Clamp to establish the correct angle of the
Male Pyramid so that it lays flat on the Lollipop Base Plate in the correct
alignment.
The male/female adaptor between the Blue Pylon and Male
25
Pyramid may be used to
micro-adjust the socket
alignment over the knee.
Once the correct Blue
Pylon rotation and Male
Pyramid angle are
established, hand tighten
the mounting screw to
connect the Blue Pylon’s
Male Pyramid to the
Lollipop Base Plate.
https://
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169332258
The Lollipop Base Plate has multiple holes in which the Blue Pylon’s Male Pyramid
can be mounted into. Choose the hole which establishes the Socket-less
Socket™ over the knee in the correct alignment - similar to standard alignment
principles as a conventional socket.
The hole placement will somewhat
determine the medial/lateral position of the knee with respect to the socket,
while the rotation angle of the Lollipop Base Plates will somewhat determine the
anterior/posterior placement of the socket with respect to the knee.
Once the correct socket alignment is established with the posterior Blue Pylon to
the posterior Lollipop Base Plate, rotate the anterior Blue Pylon and anterior
Lollipop Base Plate such that they both line up, and determine the most
appropriate hole to mount into. Similar to mounting the posterior Blue Pylon and
Male Pyramid, twist the anterior Blue Pylon and micro-adjust the Male Pyramid’s
angle so that it lays flush against the Lollipop Base Plate, ensuring that the
Lateral Cross Connectors are at full tension.
Make sure that the Dynamic Tab’s position is facing directly toward the medial
side before tightening up the four base mounting screws on the Fitting
Components. The four base mounting screws solidify the angular position of the
Lollipop Base Plates to its distal Female Pyramid, the proximal Blue Laminating
Plate, and the Dynamic Tab.
Donn the Socket-less Socket™ and confirm that the overall height is correct, as
well as the height of the Blue Laminating Plate with respect to the end of the
residual limb. If additional space is needed, loosen the Blue Pylons within the
Through Hole Tube Clamps to allow the Blue Pylons to extend further upward,
providing additional space for the end of the residual limb. Micro-adjust the
angle and alignment of the two lateral struts to ensure adequate capture of the
distal femur within the socket.
26
THINK FORWARD: All conventional alignment tools are still able to be used
within the Socket-less Socket™ fitting.
Offset plates, slide units, flexion
contracture plates, and the like may still be helpful tools in establishing final
socket alignment, just as in conventional socket fittings. If you anticipate
needing additional alignment tools for your fitting, add them when bench
aligning the socket onto the knee.
Dynamic Fitting:
Now that the socket is attached and bench aligned to the knee and foot
components, have the patient donn the prosthetic again and micro-adjust any
Cross Connectors and Swing Webbing as needed. Make sure that each of the
four Struts are in the correct position around the limb. Each of the four Struts
should have approximately equal distance between each.
Integrate a flexible inner socket (NASA-based mesh fabric, Flower Distal Cup, or
thermoplastic inner socket) to contain the limb tissue and prevent ballooning
between the struts in weight bearing. Once the inner socket and suspension has
been integrated, you can perform dynamic alignment as normal. The socket
likely will not feel right to the user without some form of inner socket limb tissue
containment.
The form of suspension used, and the integration of a flexible inner socket are
two of the most important factors in achieving a successful fitting. The Socketless Socket™ easily allows for various suspension methods to be tested in realtime without having to make significant modifications to the socket. Just as in
conventional socket fittings, the form of suspension used and the contouring
and containment of the flexible inner socket largely determine the comfort and
usability of the device for the user. If one form of suspension or inner socket
material or shape is not providing the desired results, it may just not be the most
optimal option for that user. The Socket-less Socket™ is so modular that you can
simply replace with another method.
The Socket-less Socket™ should ‘look like a socket’. It should fit the limb very
similar to how and where a conventional socket would fit the limb. If it doesn’t,
go back through the fitting steps and make sure that the four Struts are in the
correct positions, that the Cross Connectors are each to the correct span, and
that the brim and Swing Webbing is tensioned correctly.
27
Perform dynamic alignment just the same as you would in conventional socket
fittings. The difference though, is that if you need to make socket adjustments
during the dynamic fitting, it no longer requires new test sockets, but rather
simple adjustments with Truss Nuts and 3-Bar Buckles.
Once the dynamic fitting is near complete, you can heat modify the proximal
few inches of the two Lateral Struts to fit to the user’s anatomy. This is largely just
a cosmetic impact. Typically remove all Cross Connectors and Swing Webbing
connections where you will be heating the Struts, but keep the male and female
ends of the Truss Nuts in the Strut’s holes used during the heating process.
Typically just heat the outside of the Struts, whereas to not damage the Velcro
on the backside of the Strut. Once the Struts begins to become malleable,
gently bend the Struts over a broad area, versus a short sharp angle change.
Be sure to not bend the proximal end of the two Lateral Struts too much toward
each other and lose the wide hammock stand effect.
Next smooth any rough areas on the Struts as needed, and re-attach the Cross
Connectors and Webbing. The proximal lateral Cross Connector and Gluteal
Swing Webbing may need to be slightly adjusted due to a change in the Lateral
Struts contouring.
During the fitting periodically check the connections of the Thumb Screw and
Truss Nut fasteners to make sure none have backed out - especially at the brim
level.
The user could fall, for instance, if the Swing Webbing comes
disconnected while the user is pressing weight into the socket.
28
Final Fabrication:
Once ready to transfer to
the definitive configuration,
place the Socket-less
Socket™ into a standard
transfer jig at the female
pyramid that is distal to the
Lollipop Base Plates.
Remove the vertical blue
pads. Tape up around the
distal end of the socket, as
we will pour plaster within
the socket and need to
prevent the plaster from
ballooning out between the Struts. Place a small plastic bag (such as a trash
bag) into the socket, and fill the plastic bag with plaster up to the top of the
height of the Through Hole Tube Clamps. This will keep the socket components
clean, and free of plaster.
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150494495
Once the plaster is hard, remove it from the jig. Make sure that the mounting
holes for the Through Hole Tube Clamps and Blue Laminating Plate are all well
defined in the mold, as these will become the mounting locations of the Rabbit
Ear Lamination to the Lateral Struts and endoskeletal knee components.
THINK FORWARD: If you intend to extend the Rabbit Ear Lamination further up
the Lateral Struts to increase their strength, then pour plaster up to the height
that you want to extend the Rabbit Ear Lamination to. This may typically be
done for users who are heavy, very active and/or have long limb lengths (and
hence considerable torque on the Lateral Strut connections). The ultimate
durability and strength of the Lateral Struts is determined by how far the Rabbit
Ear Lamination extend up the Lateral Struts. For short limbs (and hence short
Lateral Struts) or low activity level users, the standard Rabbit Ear Lamination
length is typically sufficient.
29
Modify the plaster mold so that its shape will be cosmetically contoured close to
the residual limb shape. The Rabbit Ear Lamination does not need to contact
the residual limb directly, but rather should just cosmetically contour near it. Be
sure to keep the overall shape of the plaster, and what will become the Rabbit
Ear Lamination to have somewhat of a bowl shape to enhance the geometric
structural stiffness of the piece. The trim lines of the Rabbit Ear Lamination can
be trimmed small or can be left more encompassing, to make it stronger.
Draw the trim lines on the mold to pre-define the cut out pattern, and smooth
the mold. Screw the Dummy Struts to the mold in the position as the mounting
locations of the Through Hole Tube Clamp impressions from the original
mounting on the Lateral Struts. Dig in a groove on either side of the Dummy
Struts. This groove will allow the Rabbit Ear Lamination to have a C-channel
shape where it connects to the Struts, and hence will have greater strength and
stiffness. You can also add plaster to the distal end of the Dummy Struts to
provide a smooth transition within the lamination.
Laminate the area within the trim lines, using standard lamination procedures for
a single stage grace plate lamination. Use a lamination layup that is sufficiently
strong for your patients weight and activity level. Keep in mind your intended
trim lines, as you may require additional layup strength if you intend on
minimalistic Rabbit Ear Lamination trim lines, as there would not be as much
geometric structural support to the lamination. It is important that the Rabbit Ear
Lamination be strong enough to not flex during loading. If it flexes, the user will
likely have insufficient support and cause bowing of the socket over the knee.
Trim out the lamination, drill holes at the noted mounting holes to the Struts and
Laminating Plate. Mount the Struts to the Rabbit Ear Lamination with Truss Nuts or
Rivets, as you see most appropriate for your patient’s weight and activity level.
The final fabrication of the Rabbit Ear Lamination will be customized to account
for the end user’s weight and activity level. In most cases, the Rabbit Ear
Lamination will extend about 3 holes up the distal end of the two Lateral Struts,
and will be mounted with Truss Nuts or Rivets, as the practitioner feels is
appropriate strength depending on the end user’s weight and activity level. For
a heavy duty user, or a user with a long limb length where more torque may be
applied to the Lateral Struts, it is advisable to extend the Rabbit Ear Lamination
more proximally up the two Lateral Struts to provide added system strength.
30
The Multi-Hole Cross Connectors
can be swapped for the Single
Hole Cross Connectors for a
cleaner cosmetic appearance,
although either can be used
definitively. Both types of Cross
Connectors have numbered
hole positions. Simply drill out
the corresponding mounting
holes on the Single Hole Cross
Connector as is used in the final
fitting with the Multi-Hole Cross
Connectors, and cut to length.
Replace all Thumb Screws for
the male end of the Truss Nuts or
other connection types before
delivering to the patient. Ensure
that the Truss Nuts male and female ends are fully seated together when
tightened, and still allow the connected component freedom to swivel.
Be sure to apply Loctite 242 removable thread locking compound to all Truss
Nuts and connectors’ threads, as the fabrication kit does not come with Loctite
pre-applied. Any provided Truss Nuts can be replaced with other connection
methods as you determine best fit considering your patient’s weight and activity
level. Periodically check the soundness of the fasteners to make sure none have
backed out - a loose fastener could cause a subcomponent to become
disconnected, which may result in injury.
THINK FORWARD:
The end user’s weight and activity level should be
considered when fitting and fabricating the Socket-less Socket™ to ensure
sufficient strength and durability, just as in fitting conventional sockets. This
includes, but isn't limited to, the layup and length of the Rabbit Ear Lamination
with respect to length of the Lateral Struts, the mounting method of the Rabbit
Ear Lamination to the Lateral Struts, the mounting methods of the brim
components, the types of connectors used (such as for connecting the
Ratchet Buckles or Z-Straps), and other such fabrication considerations.
31
The Swing Webbing can be trimmed to length, and a hole can be burned in the
end of the Swing Webbing to hard mount to the socket, and eliminate the 3-Bar
Buckles. A stronger end mounting can be obtained by folding over the end of
the webbing, sewing it together, and then burn a hole in its end, just as is
conventionally done in mounting webbing onto a socket.
SwingBrim™ Retrofit Instructions:
Just like the full Socket-less Socket™
configuration, the SwingBrim™ has various
configuration options to optimize its use for
various users. The SwingBrim™ offers the
same brim conformity and comfort of a full
Socket-less Socket™, but can be integrated
into an existing conventional socket. This
allows a practitioner to literally replace an
existing socket brim with the Socket-less
Socket™ SwingBrim™ materials.
This
eliminates point specific ischial loading and
provides more dynamic comfort to the brim.
In most cases, the
SwingBrim™ still supports
the limb within the socket
functionally similar to their
existing socket, but does
so with much more
conformity, and hence
comfort.
Its the
difference of sitting on a
hard chair versus into a
soft hammock. Both can
support the same person,
but the conforming
hammock is significantly more comfortable. Watch this SwingBrim™ video to
see some of its various configuration options and fabrication details.
https://
vimeo.com/
165377468
To integrate the SwingBrim™, begin by simply modifying the brim trim lines of an
existing conventional socket. The conventional socket’s frame is trimmed down
considerably lower than normal, following the trim lines shown in this SwingBrim™
video. In general, the ischial seat area of the frame should be trimmed to
32
between 1” and 1.5” below the ischial seat swing webbing connection point.
The anterior scarpas trim line area should be about the same distance below
the attachment point of where we will mount the anterior Swivel.
If you desire to keep the existing flexible inner socket
as-is, the Swing Webbing can be attached to the
trimmed frame over the intact flexible inner socket,
as is pictured to the left.
The Swing Webbing is connected at the scarpas
area anteriorly, and the proximal posterior aspect of
the frame laterally, putting the connection points
about 180 degrees apart. Both locations will use a
provided 3-Bar Buckle for initial mounting, so that
the Swing Webbing span can first be adjusted
before hard mounting the webbing in place.
The Swing Webbing will also connect to the
included Strutsert which is mounted to the frame at
the ischial seat area. This Strutsert is flexible and
merely holds positioning of the Swing Webbing, but
does not support loading by itself.
Rather, the
support comes through the span of the Swing
Webbing between the two end mounting points,
and acts like a hammock to support the user’s
weight.
On the anterior side, the Z-Strap is connected
between the scarpas area and the anterior lateral
corner of the frame, which provides additional
anterior support, and volume adjustability. This ZStrap is often beneficial but may be able to be left
off in some fittings.
Trimming both the flexible inner socket and frame,
and replacing them altogether with the full
SwingBrim™ not only eliminates a rigid ischial seat
but also eliminates a static brim shape. This is a
great solution for a user who wants to remain in their
existing conventional socket, but would like a more
comfortable brim that fits like sitting into an ultra-
33
comfortable climbing har ness or
hammock. Make sure the trim lines of
the flexible inner socket are not below
the position of where the final Swing
Webbing and pad will sit, to prevent
pinching.
Begin by adding the Swing Webbing,
similar to the prior example, using the
same mounting locations. Also mount
the Swing Webbing to the Strutsert
through the existing flexible inner socket,
using a Truss Nut or rivet.
On the
scarpas area of the existing flexible
inner socket, mount the velcro-backed
Swivel using a Truss Nut or rivet. Be sure
the Swivel can still swivel. This will be
used to attach to the Arch Pad.
And finally, attach the Arch Pad to the Swing Webbing using the Velcro Dots
provided. It is typically easier to place the brim’s Arch Pad beginning with the
anterior Swivel first, and laying it onto the Swing Webbing toward the back. The
Arch Pad height can be adjusted with respect to the Swing Webbing, and can
be trimmed as needed. Since it is mounted with velcro, it can easily be
removed for washing as needed.
The Strutsert can be trimmed to
desired length distally, and is
mounted to the frame using at least
two mounting holes to prevent
rotation. It will also be mounted
proximally through the existing flexible
inner socket and into the Swing
Webbing.
The Swing Webbing is mounted to the
Strutsert through the existing flexible
inner socket. Make sure the flexible
inner socket’s trim lines are not below
the Arch Pad, as it could lead to
pinching if trimmed too low.
34
When mounting the Swivel, be sure that either the Truss Nuts or rivets used are at
the correct full length to allow swiveling rotation.
The Z-Strap and anterior end of the Swing Webbing will share a common
connection point onto the frame in the scarpas area. In some cases, the Z-Strap
can be eliminated. The Swing will initially be mounted with the included 3-Bar
Buckles, which will ultimately be removed once final Swing Webbing length is
determined.
The posterior side of the Swing Webbing is mounted at the
proximal lateral aspect of the frame, typically as high as possible.
The Arch Pad will span from the anterior Swivel to the posterior Swing Webbing.
Looking down into the socket with the integrated swing brim should largely
resemble the socket’s original trim lines and shape.
Socket-less Socket™ Coding:
Medicare has approved coding for the Socket-less Socket™. A reference can
be found at: http://www.medicarenhic.com/viewdoc.aspx?id=3346. The Socket-less Socket can use whatever form of suspension you choose for your
patient including suction/vacuum, pin/lanyard, or velcro. As such you will bill
according to the socket design you make for your patient, using existing coding.
Watch this video to see the various configurations of the Socket-less Socket:
https://vimeo.com/164781960
SwingBrim™ Coding:
To bill the retrofit of the SwingBrim™ within an existing socket: If the patient is no
longer able to tolerate their existing brim due to anatomical changes, we
suggest billing for time and materials as a repair code.
Socket-less Socket™ Trouble Shooting:
Inadequate lateral stability: The Socket-less Socket™ should be every bit as
stable as a conventional socket. If the patient is experiencing inadequate
lateral stability, A. make sure that the Lateral Struts are effectively capturing the
distal lateral femur, B. make sure that the proximal end of the Lateral Struts are at
least 2/3 the anterior/posterior dimension of the limb at the trochanter level, C.
make sure that the distal lateral femur is effectively posted as applicable, and D.
make sure that the Rabbit Ear Lamination is not too flexible, if already in the
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definitive stage. Any flex in the Rabbit Ear Lamination will cause bowing and loss
of lateral control.
The Maximizing Femoral Control video (https://vimeo.com/165508597) explains
more details about each of the above. If lateral stability issues still persist,
consider the socket configuration path. Integrating a more effective method of
suspension or a thermoplastic inner socket can solidify the limb tissue, similar to
how it would be managed in a conventional socket, and hence provide
greater residual limb control within the socket. Likewise, additional socket
configuration methods may be integrated, as described in further detail in this
video: Limit-less Configurations (https://vimeo.com/164781960).
Patient feels discomfort on distal end of limb during weight bearing:
It is
important to contain the limb tissue within the Socket-less Socket™. If the tissue
is not contained, it will tend to balloon out between the struts in weight bearing.
This results in the femur pressing into the distal end of the residual limb tissue and
can become sensitive. Containing the limb tissue creates the effect of a
hydrostatic fit of the tissue within the socket, and can help to maintain tissue
control and hence more comfort.
The Ladder Straps are roping into the soft tissue: Simply add a strip of velcro to
back of the Ladder Strap and fit a section of the Lateral Foam Pad to the back
of the Ladder Strap to post the tissue. The Z-Straps are also velcro compatible
on their backside. Use a double sided hook Velcro Dot to connect the two, to
further post the tissue as needed.
Patient has trouble donning the socket the same every time: If there is not a
thermoplastic inner socket within the Socket-less Socket™ configuration, the
Medial Panel’s position will be quite flexible. Most users can quickly learn how to
donn the socket the same every time. If a user has cognitive challenges
preventing consistent donning capabilities, a thermoplastic inner socket can be
integrated and affixed to all four struts. This solidifies the position of the Medial
Panel and provides a consistent ‘stop’ at the end of the socket to help in
consistent donning position.
The end of the limb is contacting the Blue Laminating Plate: If you have ‘short
socketed’ the patient, simply loosen the Blue Pylons within the Through Hole
Tube Clamps and lengthen the distance between the two Lateral Struts and the
Blue Laminating Plate. Similarly, if you have integrated a thermoplastic inner
socket, and if the patient is bottoming out in that socket, simply un-velcro the
thermoplastic inner socket from the four struts, and reposition it lower onto the
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four struts to provide more room between the brim and the end of the
thermoplastic inner socket.
For Knee Disarticulation users, is the distal build height taller than in conventional
sockets? No, the distal build height of the Socket-less Socket™ is no greater
than in conventional socket fabrication methods - and in many cases even less.
The distal Rabbit Ear Lamination uses a single stage lamination with laminating
plate, which is ultra-low-profile. Some knee disarticulation users also do not
need to utilize a thermoplastic inner socket, which eliminates some of the bulk at
the distal end.
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