Prosthetic Checkout: Below-Knee PDF

## PROSTHETIC CHECKOUT: BELOW-KNEE ### Patient * Amputation type: ### Date * Initial Checkout ( ) * Pass ( ) * Final Checkout ( ) * Provisional Pass ( ) * Fail ( ) ### If the patient needs further attention, please indicate the type of treatment required: * Medical-Surgical ( ) * Prosthetic ( )...

## PROSTHETIC CHECKOUT: BELOW-KNEE ### Patient * Amputation type: ### Date * Initial Checkout ( ) * Pass ( ) * Final Checkout ( ) * Provisional Pass ( ) * Fail ( ) ### If the patient needs further attention, please indicate the type of treatment required: * Medical-Surgical ( ) * Prosthetic ( ) * Training ( ) * Other ( ) (Vocational, Psychological, etc.) * Recommendations and Comments: ## PROSTHETIC CHECKOUT: BELOW-KNEE 1. Is the prosthesis as prescribed? If a recheck, have previous recommendations been accomplished? 2. Can the patient don the prosthesis easily? 3. Is the patient comfortable while standing with the midlines of the heels not more than 6 inches apart? 4. Is the anteroposterior alignment of the prosthesis satisfactory? (The patient should not feel that his knee is unstable nor should he feel that his knee is being forced backwards.) 5. Is the mediolateral alignment satisfactory? (The shoe should be flat on the floor and there should be no uncomfortable pressure at the lateral or medial brim of the socket.) 6. Is the prosthesis the correct length? 7. Is piston action minimal when the patient raises the prosthesis? 8. Are the anterior, medial, and lateral walls of adequate height? 9. Do the medial and lateral walls contact the epicondyles, and with the patellar tendon-bearing variants, the areas immediately above? ### Thigh Corset 10. Do the uprights conform to the flares above the epicondyles? 11. Are knee joints close to the epicondyles? (about 1/8 to 1/4 inch) 12. Does the thigh corset fit properly, with adequate provision for adjusting corset tension? 13. Do the length and construction of the thigh corset appear to be appropriate for its intended function of weight-bearing or stabilization? ### Check with the Patient Sitting 14. Can the patient sit comfortably with minimal bunching of soft tissues in the popliteal region, when the knees are flexed to 90 degrees? ## PROSTHETIC CHECKOUT: BELOW-KNEE ### Check with the Amputee Walking 15. Is the patient's performance in level walking satisfactory? Indicate below the gait deviations that require attention. 16. Is piston action between the stump and socket minimal? 17. Does the patient go up and down inclines and stairs satisfactorily? 18. Are the socket and suspension system comfortable? 19. Does the knee cuff maintain its position? 20. Is the patient able to kneel satisfactorily? 21. Does the prosthesis function quietly? 22. Are size, contours, and color of the prosthesis approximately the same as those of the sound limb? 23. Does the patient consider the prosthesis satisfactory? ### Check with Prosthesis Off the Amputee 24. Is the patient's stump free from abrasion, discolorations, and excessive perspiration immediately after the prosthesis is removed? 25. Does weight-bearing appear to be distributed over the proper areas of the stump? 26. Is the wedge the correct size? 27. Is the posterior wall of the socket of adequate height? 28. Do the check strap and fork strap have adequate provision for adjustment? 29. Is the general workmanship satisfactory? ## INSTRUCTIONS FOR CHECKOUT OF BELOW-KNEE PROSTHESIS ### Procedures, Standards and Techniques of Checkout 1. Is the prosthesis as prescribed? If a recheck, have previous recommendations been accomplished? The foot-ankle assembly, socket, and suspension should be as specified in the prescription. During fabrication, the prosthetist may sometimes find it necessary to deviate appreciably from the original prescription. When this occurs, the prosthetist should obtain the concurrence of the clinic chief. At the time of checkout the reasons for any deviations from the prescription should be noted. If the prosthesis has been seen previously for checkout and referred back to the prosthetist for alterations, the previous checkout form should be consulted to determine that such recommendations have been executed. 2. Can the patient don the prosthesis easily? A major cause of difficulty in donning is a socket which is too small either in overall circumference, mediolateral dimension, or, less frequently, anteroposterior dimension. Sometimes, the amputee does not don the prosthesis easily because he has not learned the proper technique. In the case of the prosthesis with supracondylar suspension, sharp edges may also impede donning. ### Check with the Patient Standing In checking items 3, 4, 5, and 6, the amputee should stand with good posture with weight evenly distributed on both feet and with his heel centers not more than 6 inches apart, unless otherwise indicated. 3. Is the patient comfortable while standing with the midlines of the heels not more than 6 inches apart? Ask the amputee if he is comfortable. If he reports discomfort, make sure the prosthesis is on correctly. If it is, and discomfort persists, determine the areas affected. If the discomfort is well within the patient's tolerance, it is advantageous to continue with the checkout so that all factors relating to the discomfort may be found, as well as any other items that may need to be corrected. An amputee who is fitted with a patellar tendon-bearing prosthesis for the first time may be aware of increased weight-bearing in the socket if he has not worn a prosthesis of this type before; nevertheless, the amount of pressure borne on the stump should be tolerable. 4. Is the anteroposterior alignment of the prosthesis satisfactory? (The patient should not feel that his knee is unstable nor should he feel that his knee is being forced backwards.) The anterior portion of the heel and the ball of the sole should be flat on the floor, and the amputee should be able to maintain knee stability with minimal muscular effort. The alignment of the patellar tendon-bearing socket is such that the knee will be in slight flexion, but the amputee should be able to control the knee easily. He should not feel that his knee is being forced backward. Check this item both by observation and by questioning the amputee. 5. Is the mediolateral alignment satisfactory? (The shoe should be flat on the floor and there should be no uncomfortable pressure at the lateral or medial brim of the socket.) Look at the shoe to determine whether both the outer and inner borders contact the floor. Examine the lateral and medial brims of the socket to see that there is no gap between the stump and socket. Check the amputee's shoes for uneven wear. If the shoes are in good condition, gapping may be due to the misfit of the socket, malalignment of the prosthesis, or both. 6. Is the prosthesis the correct length? Unless otherwise specified in the prescription, the prosthetic leg should be the same length as the sound leg. To check the length of the prosthesis, ascertain if the pelvis is level by palpating one or more of the following pairs of landmarks: (a) iliac crests, (b) anterior superior iliac spines, (c) posterior superior iliac spines. If the prosthesis is too short, there may be a lumbar convexity towards the side of the prosthesis. Determine whether the scoliosis is due to wearing of the present prosthesis or if it antedated the present prosthesis. Another way to determine leg length difference is to note the attitude of the hip and knee. The pelvis may remain level even if the prosthesis is too short if the amputee flexes his sound leg. Causes of the apparent discrepancy in length may be (a) an excessively plantar flexed or dorsiflexed foot, (b) a stump which is either too far or not far enough into the socket due to poor socket fit or improper donning, as well as (c) a well-flexed hip joint. 7. Is piston action minimal when the patient raises the prosthesis? Inspect the position of the joints to see if they are close to the epicondyles. A space larger than 1/4 inch adds to the width of the prosthesis and tends to interfere with clothing. The joints should not, however, be so close that they press the amputee's flesh. 8. Are the anterior, medial, and lateral walls of adequate height? Adequate height of the socket walls is essential to comfort and stability. The anterior brim of the basic patellar tendon-bearing prosthesis extends to the level of the middle of the patella. A prosthesis with supracondylar/suprapatellar suspension, however, encompasses the entire patella to extend above the superior border. With cuff suspension, the medial and lateral walls should extend to the epicondyles, while with supracondylar and supracondylar/suprapatellar suspension, the side walls should extend above the epicondyles. 9. Do the medial and lateral walls contact the epicondyles, and with the patellar tendon-bearing variants, the areas immediately above? Improper shape will result in inadequate suspension and/or instability. If the prosthesis utilizes supracondylar suspension, the wedge, rather than the wall, should cover the medial epicondyle. 10. Do the uprights conform to the flares above the epicondyles? The uprights should contact the amputee's thigh without causing discomfort. Close fit between the uprights and flesh insures greater stability, more effective suspension, and less bulkiness. 11. Are the knee joints close to the epicondyles? (about 1/8 to 1/4 inch) Inspect the position of the joints to see if they are close to the epicondyles. A space larger than 1/4 inch adds to the width of the prosthesis and tends to interfere with clothing. The joints should not, however, be so close that they press the amputee's flesh. 12. Does the thigh corset fit properly, with adequate provision for adjusting corset tension? The thigh corset should fit closely above the patella and the epicondyles to help suspend the prosthesis. Inspect the upper and lower borders of the corset to see that there is no gapping or flesh rolls. Flesh rolls may be due to obesity, poor corset design or placement, unduly tight lacing, or they may antedate the present prosthesis. If a corset is prescribed for partial weight-bearing, but not full ischial bearing, a flesh roll will develop at the proximal end due to the necessary corset tightness. There should be sufficient distance between the vertical edges of the corset opening to compensate for changes in size of the thigh. 13. Do the length and construction of the thigh corset appear to be appropriate for its intended function of weight-bearing or stabilization? The proximal border of the usual corset designed for some weight-bearing should extend to approximately 2 inches below the perineum. Thigh corsets designed for a high proportion of weight-bearing should extend to the ischial tuberosity to provide ischio-gluteal support and should be molded with posterior reinforcement. If the function of the corset is primarily to control mediolateral and anteroposterior forces applied to the stump, the corset usually need not be higher than 7 inches from the prosthetic knee center. ### Check with the Patient Sitting 14. Can the patient sit comfortably with minimal bunching of soft tissues in the popliteal region, when the knees are flexed to 90 degrees? The amputee should be able to sit comfortably with his feet flat on the floor and his knees flexed to approximately 90 degrees. At other times, as when he is in a bus or theater, it may be necessary for him to sit with his knees bent more than 90 degrees. Ask the patient if he feels discomfort in back of the knee or elsewhere when sitting with his knees flexed to 90 degrees. Inspect the popliteal area to see if the amputee's flesh is forcibly compressed between the posterior brim of the socket and the lower border of the knee cuff or thigh corset. If the amputee finds his prosthesis uncomfortable while sitting, it may indicate: (a) an unduly high posterior brim of the socket or a low trimline of the corset above the popliteal fossa, (b) inadequate hamstring channels, (c) excessive anterior or distal placement of the tabs of the knee cuff. ## PROSTHETIC CHECKOUT: ABOVE-KNEE ### Name of Patient ### Amputation Type ### Date * Initial Checkout ( ) * Pass ( ) * Final Checkout ( ) * Provisional Pass ( ) * Fail ( ) ### If the patient needs further attention, please indicate the type of treatment required: * Medical-Surgical ( ) * Prosthetic ( ) * Training ( ) * Other ( ) (Vocational, Psychological, etc.) * Recommendations and Comments: ## PROSTHETIC CHECKOUT: ABOVE-KNEE ### Fit and Alignment #### Check with the Patient Standing 1. Is the prosthesis as prescribed? If a recheck, have previous recommendations been accomplished? 2. Is the patient comfortable while standing with the midlines of the heels not more than 6 inches apart? 3. Is the adductor longus tendon properly located in its channel and is the patient free from excessive pressure in the antero-medial aspect of the stump? 4. Does the ischial tuberosity rest properly on the ischial seat? 5. Is the prosthesis the correct length? 6. Is the knee stable on weight-bearing? (without the patient using excessive effort in pressing backward with his stump) 7. Is the brim of the posterior wall approximately parallel to the ground? 8. Is the patient free from vertical pressure in the area of the perineum? 9. When the valve of a total-contact socket is removed, does stump tissue protrude slightly into the valve hole and have satisfactory consistency? (approximately that of the thenar eminence) ### Suspension 10. Are the lateral and anterior attachments of the Silesian bandage correctly located? 11. Does the pelvic band accurately fit the contours of the body? 12. Is the center of the pelvic joint set slightly above and ahead of the promontory of the greater trochanter? 13. Is the valve located to facilitate pulling out the stump sock and the manual release of pressure? #### Check with the Patient Sitting 14. Does the socket remain securely on the stump? 15. Does the shank remain in good alignment? 16. Is the center of the knee bolt 1/2 to 3/4 inch above the level of the medial tibial plateau? 17. Can the patient remain seated without a burning sensation in the hamstring area? 18. Can the patient rise to a standing position without objectionable air noise? ### Check with the Prosthesis Off the Patient #### Examination of the Stump 19. Is the patient's performance in level walking satisfactory? Indicate below the gait deviations that require attention. 20. Is suction maintained during walking? 21. With a total-contact socket, does the patient have the sensation of continued contact between the stump and socket in both swing and stance phases? 22. Does the patient go up and down inclines satisfactorily? 23. Does the patient go up and down stairs satisfactorily? (Check these items after the performance evaluation has been done.) 24. Does the ischial tuberosity maintain its position on the ischial seat? 25. Is any flesh roll above the socket minimal? 26. Does the lateral wall of the socket maintain firm and even contact with the lateral aspect of the stump? 27. Does the prosthesis operate quietly? 28. Are the size, contours, and color of the prosthesis approximately the same as those of the sound limb? 29. Does the patient consider the prosthesis satisfactory as to comfort, function, and appearance? ### Check with the Prosthesis Off the Patient #### Examination of the Stump 30. Is the patient's stump free from abrasions, discoloration, and excessive perspiration immediately after the prosthesis is removed? 31. Are the anterior and lateral walls at least 2 inches higher than the posterior wall? 32. Does the inside of the socket have a smooth finish? 33. Is there satisfactory clearance at knee and ankle articulations? 34. Are the posterior surfaces of the thigh and shank shaped so that there is minimal concentration of pressure when the knee is fully flexed? 35. With the prosthesis in the kneeling position, can the thigh piece be brought to at least the vertical position? 36. In the total contact socket, is the bottom of the valve hole at the level of the bottom of the socket? (It may be lower, particularly with a soft insert). 37. Is a back pad attached to the posterior wall of the socket? 38. Is the general workmanship satisfactory? 39. Do the components function properly? ## INSTRUCTIONS FOR CHECKOUT OF ABOVE-KNEE PROSTHESIS ### Procedures, Standards and Techniques of Checkout 1. Is the prosthesis as prescribed? If a recheck, have previous recommendations been accomplished? If the prosthesis is being presented to the clinic for the first time, it should be checked initially against the clinic prescription. All components of the finished prosthesis, such as suspension, socket type, knee unit, foot-ankle assembly, and materials, should be those specified on the prescription form. Any deviations from the prescription should have been approved by the clinic chief. If the prosthesis has been seen previously for Initial Checkout and referred back to the prosthetic shop for alterations, the previous checkout form should be consulted to determine that such recommendations have been carried out. ### Check with Patient Standing Except when instructed to do otherwise during the checkout, the amputee should stand erect, as comfortably as possible, bearing weight equally on both feet, with the heel centers not more than 6 inches apart. The amputee's shoes should match and show no sign of uneven wear. Many of the following check points will prove invalid if these requirements are not met. 2. Is the patient comfortable while standing with the midlines of the heels not more than 6 inches apart? Ask the amputee if he has any pain or discomfort. If he does, question him to find the location and degree of the pain or discomfort. It is suggested that this questioning be done at the beginning of the checkout because it will focus attention on the trouble spots and it will remind the amputee that his comfort is most important to the clinic team. The amputee's responses to these questions should be kept in mind as the checkout procedure continues. If problems of pain or discomfort are noted, the causes of these undesirable conditions will be isolated as each point is examined in turn. 3. Is the adductor longus tendon properly located in its channel, and is the patient free from excessive pressure in the antero-medial aspect of the socket? There should be a well-defined relief to receive the tendons of the adductor longus and gracilis muscles. * a. Improper relief in the anteromedial corner of the socket. There should be a well-defined relief to receive the tendons of the adductor longus and gracilis muscles. * b. Anteroposterior dimension of the medial wall too small. This can crowd the adductors. * c. Mediolateral dimension of the socket too small. This can force the ischium too far medially, crowding the adductors. * d. Downward slant of the ischial seat from lateral to medial side. This may cause the ischium to slide medially, which may compress the adductor longus tendon. 4. Does the ischial tuberosity rest properly on the ischial seat? The ischial tuberosity should rest approximately 1/2 inch behind the inner surface of the rear wall, and 3/4 to 1 inch lateral to the inner surface of the medial wall. In total-contact sockets, however, it is permissible for the ischium to rest slightly anterior to this point. The tuberosity should never be so anterior, however, as to rest on the inner edge of the ischial seat. To check the position of the ischial tuberosity on the ischial seat, stand behind the amputee, ask him to bend forward and take most of his weight off his prosthesis. Provide suitable support while he is bending forward. Probe for the ischial tuberosity with the palmar surface of the index and middle fingers. With older or unstable patients it may be advisable to stand beside and facing the amputee on the side of the prosthesis. This enables the examiner to provide support more readily if the patient should lose his balance. Then ask the amputee to straighten, bear weight on his prosthesis, and relax the muscles of his stump. The examiner's fingers should be squeezed between the ischial tuberosity and the recommended position on the ischial shelf. If there is difficulty in determining the relative position of the ischial tuberosity on the seat, place a mark on the outer surface of the posterior wall indicating the mediolateral placement of the tuberosity, and compare the actual position with the desired position later in the checkout, after the prosthesis has been removed from the patient. With a muscular patient the ischial tuberosity may be slightly above the ischial seat. If the tuberosity is too far posterior, there may be pressure on the hamstring tendons and the gluteal muscles. The patient may complain of a burning sensation in this area or a sensation of tightness at the anteromedial corner of the socket. If the tuberosity is too far inside the socket, the patient may have discomfort in the adductor region where the pubic ramus contacts the medial wall. This condition is caused by too large an antero-posterior dimension, too low an anterior wall, or an insufficient bulge in the Scarpa's triangle area to provide adequate counterpressure. If the tuberosity is displaced medially, this is most likely due to either too small a mediolateral dimension, or a downward slant of the ischial seat from lateral to medial side, or both. Either of these conditions will cause the ischium to slide medially. This will crowd the adductors and create a feeling of tightness or burning in the crotch area. 5. Is the prosthesis the correct length? The prosthetic side should be the same length as the sound leg. To check the length of the prosthesis, compare the heights of the iliac crests. They should be at the same level; an imaginary line across the crests should be parallel to the ground. The anterior and posterior superior iliac spines may also be used as reference points. If the amputee has had previous experience with a prosthesis that was slightly shorter than the new prosthesis, he may feel that the new prosthesis is too long. After a short period of wear, he should adapt to the new prosthesis without difficulty. If the prosthesis is too short, there will be a lumbar scoliosis with the convexity toward the prosthesis. If the prosthesis is too long, the scoliosis will be reversed, with the convexity toward the sound side. 6. Is the knee stable on weight-bearing? (without the patient using excessive effort in pressing backward with his stump) To check stability of the knee, have the amputee stand near parallel bars or other support. His weight should be evenly distributed on both feet. Strike the back of the knee with moderate force. It should give slightly, but should return immediately to full extension. Prosthetic alignment should be such that the amputee does not have to exert significant muscular effort with his stump to prevent the knee from buckling. An additional check for stability is provided by noticing the relative positions of hip, knee, and ankle joints. With stumps of medium length or longer, and normal musculature, the knee bolt should approach the trochanter-ankle reference line closely, but should not be anterior to it. For short stumps or those with weak extensors, the knee bolt should be farther behind the reference line through the greater trochanter and the ankle axis. 7. Is the brim of the posterior wall approximately parallel to the ground? The brim of the posterior wall should be parallel to the ground when the patient is supporting his weight on the prosthesis. If the brim deviates more than 5º from the horizontal, it may cause a poor distribution of weight between the ischium and the gluteal muscles. 8. Is the patient free from vertical pressure in the area of the perineum? Pressure of the inferior ramus against the medial brim of the socket is usually intolerable. Similarly, pressure of the medial brim against an adductor roll is also uncomfortable, as well as being a potential source of skin breakdown. Ask the amputee if he feels pressure in this area. An additional check can be made by having the amputee cross his prosthesis in front of his sound leg and then apply all his weight on the prosthesis. Visual inspection and palpation also help to determine whether or not there is pressure. The most common causes of pressure in the perineum are: * a. insufficient radius on the medial brim of the socket * b. insufficient counterforce from anterior wall * c. anterior pelvic tilt * d. adductor longus not in its channel * e. medial wall too high * f. anteroposterior dimension too great * g. an adductor roll which has not been accommodated in the socket 9. When the valve of a total-contact socket is removed, does the stump tissue protrude slightly into the valve hole and have satisfactory consistency? (approximately that of the thenar eminence) Distal compression of stump tissues should cause the tissues to be forced slightly into the valve hole when the valve is removed. Remove the valve, and determine this visually and by palpation. In stumps of average consistency, the protrusion should be approximately 1/4 inch and should match approximately the firmness of the thenar eminence of the thumb. This indicates sufficient compression of the stump to aid venous return, without creating uncomfortably high pressures on the distal part of the stump. 10. Are the lateral and anterior attachments of the Silesian bandage correctly located? The lateral attachment of the Silesian bandage should be at a point about 1/4 inch above and 1/4 inch posterior to the greater trochanter. A reference point for the anterior attachment is formed by the intersection of: * a. a horizontal line at the level of the ischial seat, and * b. a vertical line that bisects the anterior aspect of the socket. A bifurcated anterior attachment should have attachments approximately equidistant above and below this point. If the anterior attachment does not correspond to the reference point, it does not necessarily mean that it is misplaced. A final decision may have to wait until the patient walks with the prosthesis. Distal placement helps to adduct the prosthesis. Medial or lateral deviation from the reference point tends to rotate the limb around the vertical axis. On the sound side the Silesian bandage should be fit just above or below the iliac crest to prevent it from slipping and make it comfortable for the patient. 11. Does the pelvic band accurately fit the contours of the body? The pelvic band should fit the contours of the pelvis accurately, so that it will stay in the correct position to minimize piston action. For short stumps, the metal of the band should extend anteriorly approximately 1 inch medial to the anterior superior spine and posteriorly to within 1/2 to 1 inch lateral to the posterior superior spine on the amputated side. For longer stumps, the band may be shorter posteriorly, but not anteriorly. If the band extends too far posteriorly, it may irritate the patient's back when he sits. The pelvic belt should pass around the body between the iliac crest and the greater trochanter and should not exert pressure on the anterior superior iliac spine. It should be angled to fit the contour of the pelvis in order to prevent the belt from riding up on the sound side, Check by visual inspection and palpation. 12. Is the center of the pelvic joint set slightly above and ahead of the greater trochanter? The pelvic joint should be set slightly ahead and slightly above the greater trochanter, and parallel to the plane of progression so that the mechanical and anatomic axes are congruent. For a short stump, the joint may be rotated internally slightly (not more than 10°) but the joint axis should remain perpendicular to the ground. Check by visual inspection. 13. Is the valve located to facilitate pulling out the stump sock and for manual release of pressure? The preferred location is on the anteromedial aspect of the prosthesis . In the total-contact socket he valve hole may be located more anteriorly. It should have sufficient vertical inclination (limited by cosmesis and thigh length to minimize friction on the pull sock and to eliminate entrapment of air. In the open-end socket , the valve should be located as far below the end of the stump as the seal will permit. This will minimize the angulation of the sock as it is pulled through the hole and will make it easier to remove. #### Check with the Patient Sitting 14. Does the socket remain securely on the stump? The socket should remain securely on the stump while the patient is seated. Ask the patient to bend to touch his shoe and see if the socket remains on the stump. If the socket changes position, it may be due to: * a. poorly placed pelvic joint. * b. loss of suction because of poor fit of the socket, particularly to see that the lateral wall of the socket fits closely against the stump and that there is no gapping in the rectus femoris or gluteal channels. * c. pressure of socket against abdomen or crotch may force the socket off the stump. * d. excessive thickness of the posterior wall causes the anterior wall to gap with resulting loss of air seal. Ascertain that the anterior brim does not come into contact with the anterior superior spine or the pubis. 15. Does the shank remain in good alignment? The amputee should be able to sit comfortably with his feet flat on the floor and with the shank vertical. If sitting alignment is faulty determine by questioning the amputee and by inspection and palpation whether there is uncomfortable pressure, particularly in the region of the adductors, femoral triangle, and gluteal crease. Inspect the posterior brim of the socket to see that it is flat. Note the effect of pelvic joint placement by loosening the pelvic belt and observing the position the prosthesis assumes. Also check the horizontal alignment of the knee bolt. 16. Is the center of the knee bolt 1/2 to 3/4 inch above the level of the medial tibial plateau? The lengths of the shank and thigh piece of the prosthesis and the sound leg should be equal. If the knee bolt is elevated, the prosthetic knee will project ahead of the sound knee and the thigh piece is too long. If the knee joint is too low, the prosthetic knee is higher than the sound leg and the shank is too long. Since there is no single knee axis in the polycentric knee joints, the relative length of the thigh and shank must be compared. However, the patient with a knee disarticulation or supracondylar amputation requires a longer thigh section if he wishes to avoid the use of external knee joints. With external joints the thighs and shanks of both the prosthesis and sound leg should be equal. 17. Can the patient remain seated without a burning sensation in the hamstring area? The most likely causes of a burning sensation in the hamstring area are: * a. posterior wall too thick, especially at the ischial seat. Even though the ischium rests on the chair, the posterior wall will push the hamstring area strongly if the wall is too thick. * b. insufficient radius at the posterior brim. The inner radius of the ischial seat should be about 1/2 inch . Over the gluteal channel the radius is greater, 3/4 inch or more, depending on the contours of the gluteal musculature. * c. insufficient channel for the hamstring tendons at the posteromedial corner. 18. Can the patient rise to a standing position without objectionable air noise? After the amputee has been seated for a few minutes, ask him to stand quickly. There should be no loud noise due to air escaping from the socket. Noise indicates incorrect socket fit. Check particularly for looseness of the lateral and anterior walls. ### Check with the Patient Walking 19. Is the patient's performance in level walking satisfactory? Indicate below the gait deviations that require attention. This item may have to be omitted at Initial Checkout. If possible have the amputee walk at normal speed, preferably 20 feet or more. Observe him from in front, from behind, and from the side. Note any gait deviations. A deviation usually indicates that the amputee is adapting his gait to compensate for factors that prevent him from walking with a more normal pattern. The clinic team should analyze the deviations to determine what corrective measures, if any, are feasible. 20. Is suction maintained during walking? The suction socket should retain its position on the stump as the patient walks. There should be no piston action. The patient should not have to "pump" his stump to maintain suction, nor should he have to resort to manipulations of the valve or undue muscular activity to retain the socket. Failure to maintain suction can be due to: * a. accumulation of glue, powder, or other foreign material in the threads of the valve * b. an inadequate seal around the edges of the valve * c. flesh obstructing the valve * d. air leakage between the stump and the anterior or lateral brim * e. escape of air through an invaginated scar or skin fold beneath the brim 21. With a total-contact socket, does the patient have the sensation of continued contact between the stump and socket in both swing and stance phases? During walking, there is relatively greater compression between the socket and distal stump tissues during stance phase, and lesser compression during swing phase. If there is piston action , the distal stump loses contact with the socket during swing phase. Negative pressure then becomes very high, which would tend to create edema. Therefore, it is important that continued contact between all portions of the stump and the socket be maintained throughout the gait cycle. Ask the amputee if he experiences continued contact between all areas of the stump and the socket. Later in the checkout, inspect the amputee's stump immediately after the prosthesis is removed for areas of localized edema. 22. Does the patient go up and down inclines satisfactorily? Does the patient go up and down stairs satisfactorily? The amputee's ability to go up and down inclines and stairs should be carefully evaluated at Final Checkout. He may be evaluated at Initial Checkout if he has worn a prosthesis previously; otherwise, these items may be omitted. In evaluating the amputee's performance on inclines and stairs at Initial Checkout, attention should be directed primarily to medical-surgical and prosthetic factors that influence performance unfavorably. The level of performance at Initial Checkout provides indication of the amount and kind of training the amputee requires. His skill must be judged in relation to his total physical condition and age as well as the adequacy of the prosthesis. ## PROSTHETIC CHECKOUT: ABOVE-KNEE In checking out the above-knee prosthesis, the same general pattern is followed that was used in checking out the below-knee prosthesis. The prosthesis is examined with the patient standing, sitting, and walking, and with the prosthesis removed. When a prosthesis with a quadrilateral socket is evaluated, it is especially important that the socket is on the stump correctly. If this is not the case, many of the checkout items cannot be properly judged. The amputee's ability to use the prosthesis warrants special attention in the above-knee checkout. Lack of training or deficiencies in training may prevent the patient from achieving the level of performance of which he is capable, even if there are no prosthetic or medico-surgical problems. At Initial Checkout, attention will be directed to comfort, stability, and effort required. At Final Checkout, in addition to these items, the patient's ability to use the prosthesis effectively should be carefully evaluated. The form on pages 296 through 299 lists specific items to be considered in checking out an above-knee prosthesis. Explanatory comments and suggestions pertaining to each checkout item follow on succeeding pages. In addition to the checkout form, the clinic should have available a yardstick or other straight edge; a set of boards large enough for the amputee's foot, graduated from 1/4 to 1 inch in thickness; parallel bars or a walkerette to provide security; a straight chair; and stairs and a ramp if the patient is expected to climb them. ## PROSTHETIC CHECKOUT: ABOVE-KNEE ### Name of Patient ### Amputation Type ### Date * Initial Checkout ( ) * Pass ( ) * Final Checkout ( ) * Provisional Pass ( ) * Fail ( ) ### If the patient needs further attention, please indicate the type of treatment required: * Medical-Surgical ( ) * Prosthetic ( ) * Training ( ) * Other ( ) (Vocational, Psychological, etc.) * Recommendations and Comments: ## PROSTHETIC CHECKOUT: ABOVE-KNEE ### Fit and Alignment #### Check with the Patient Standing 1. Is the prosthesis as prescribed? If a recheck, have previous recommendations been accomplished? 2. Is the patient comfortable while standing with the midlines of the heels not more than 6 inches apart? 3. Is the adductor longus tendon properly located in its channel and is the patient free from excessive pressure in the antero-medial aspect of the stump? 4. Does the ischial tuberosity rest properly on the ischial seat? 5. Is the prosthesis the correct length? 6. Is the knee stable on weight-bearing? (without the patient using excessive effort in pressing backward with his stump) 7. Is the brim of the posterior wall approximately parallel to the ground? 8. Is the patient free from vertical pressure in the area of the perineum? 9. When the valve of a total-contact socket is removed, does stump tissue protrude slightly into the valve hole and have satisfactory consistency? (approximately that of the thenar eminence) ### Suspension: 10. Are the lateral and anterior attachments of the Silesian bandage correctly located? 11. Does the pelvic band accurately fit the contours of the body? 12. Is the center of