Ischial ramal containment (IRC) socket design IRC 接受腔设计

1. Ischial ramal containment (IRC) socket design IRC接受腔设计 Dr. Winson Lee htwinson@polyu.edu.hk

3. Ischial-containment (IC) socketIC接受腔 • Newer design than the quadrilateral sockets; • 比四边形接受腔较新的设计 • Has different names有不同的名称: • IRC (Ischial ramal containment) • CAT-CAM (Contoured Adducted Trochanteric-Controlled Alignment Method) • NSNA (Normal Shape-Normal Alignment) • Narrow ML • The basic idea is the same其基本思想是相同的 • to stabilize the pelvis and femur by controlling the ischium and the femur. • 通过控制坐骨和股骨來稳定盆骨和股骨

4. Problems with quadrilateral sockets四边形接受腔的问题 • As early as 1969, people were questioning the quadrilateral socket design! • 早在1969年，人们质疑四边形接受腔设计！ • The ML dimension is too large内外侧尺寸过大 • Several inches away from the femur except at the most distal point • 除了在最远端点，远离股骨几英寸 • Most above knee amputees walk with a wide base and laterally bend to the amputated side; • 大部分大腿截肢者走路，基础广泛和横向弯曲到截肢一侧; • We looked at 100 x-rays of above knee amputees in standing in their prosthesis and found 92 of the 100 tend to abduct the residual limb; • 我们研究了100个大腿截肢者站立在假肢的X光片，发现92个倾向于外展残肢; • The ischial tuberosity is a couple of inches above the posterior seat in most fittings • 在坐骨结节是在后座上面几英寸

5. In weight bearing在负重時 • The body weight (W) produces a tendency of trunk bending towards the sound side • 体重（W）生产趋势令躯干向健侧弯曲 • To stabilize the pelvic • 为了稳定骨盆 • Abductors at the amputated side have to contract • 在切除侧，外展肌肉需要收缩 • The socket should give enough stabilization • 接受腔给予足够的稳定

6. Quadrilateral sockets (ML too wide) may not give enough lateral stabilization: • 四边形接受腔（內外則尺寸太宽）可能无法提供足够的侧向稳定： • During weight bearing在负重時 • The femur can abduct股骨可以外展 • Lateral distal end pushing towards socket • 外侧远端推往接受腔 • Socket shifts laterally接受腔横向转移 • Higher pressure at proximal medial area • 在内侧近端压力较高 • Pain疼痛 • Decreased stability of the pelvis • 盆骨稳定性下降

7. To reduce pain and to give pelvic stability为了减少疼痛，并给予骨盆稳定 • Lateral trunk lean towards the amputated side横向弯曲到截肢一侧 • Reduce tendency to fall to the sound side减少跌向健侧的趋势 • Move medial tissue away from brim移动内侧组织远离边缘 • Reduce requirement of gluteus medius减少臀中肌的需求 • To forces pushing bone end into lateral wall of socket为了推骨末端入接受腔侧壁 • These lead to abducted base • 这些导致外展的基步

8. Summary of the problems综述问题 Poor femoral adduction In weight bearing… Femur abducts股骨外展 Socket moves laterally 接受腔横向移动 IT moves medially 坐骨结节向内侧移动 End result… Pain疼痛 Abducted base外展的基步 Poor pelvic stability不良的骨盆稳定 Lateral trunk lean躯干倾向假肢侧

9. The solution解决方案 • John Sabolich, in 1981, sponsored a workshop to look for alternatives to the quadrilateral socket. • 1981年， John Sabolich举办了研讨会，寻找四边形接受腔的替代品。 • Sabolich prosthetics made over 900 non-quadrilateral sockets to come up with the CAT-CAM socket • Sabolich假肢做了900个非四边形接受腔来得出CAT – CAM的接受腔 • The CAT-CAM socket was later classified as IC (Ischial containment) sockets • CAT – CAM接受腔，后来列为IC(坐骨遏制)接受腔

10. The solution解决方案 CAT-CAM CAT Contour Adducted Trochanteric – CAM Controlled Alignment Method

11. The solution解决方案 CAT-CAM • Holds femur in adduction using a ‘bony lock’ • 使用‘骨锁‘維持股骨内收 • Ischium and ischial ramus are contained 包含坐骨和坐骨支 • Sub-trochanteric contour 大转子下轮廓 • Snug, natural M-L dimension 舒适，自然的內外尺寸

12. The solution解决方案 • CAT-CAM • Reduces lateral trunk leaning • 降低躯干侧倾斜 • The base of support is held in adduction underneath the hip joint, as in non-amputees • 支持的基地在髋关节下維持内收，如像非截肢者一樣 • Long’s line

13. The socket shape接受腔形状 • Medial wall内侧墙 • Ischium and ischial ramus contained • 包含坐骨和坐骨支 • Exit for pubis • 耻骨出口 • ‘V’ shape concept for pubic exit • V字形状耻骨出口的概念 • Height of encapsulation • 封装高度

14. The socket shape接受腔形状 • Medial wall内侧墙 • 3D pocket or channel that contains the ischium and ischial ramus • 三维口袋或通道，它包含坐骨和坐骨支 • Channel follows through the medial wall where pubic ramus and pubis can exit • 通道通过内侧墙壁，亦是耻骨支和耻骨可以離開的地方

15. The socket shape接受腔形状 • Medial wall内侧墙 • 3D pocket or channel that contains the ischium an ischial ramus • 三维口袋或通道，它包含坐骨和坐骨支 • Loading under ischium can vary depending on tissue types • 坐骨以下受力清況可以取决于组织类型

16. The socket shape接受腔形状 • Influence of pelvic shape on medial wall • 盆腔形状對内侧壁的影响 • Ischial diameter坐骨直径

17. The socket shape接受腔形状 • Influence of pelvic shape on medial wall • 盆腔形状對内侧壁的影响 • Pubic arch angle耻骨弓角度

18. The socket shape接受腔形状 • Influence of pelvic shape on medial wall • 盆腔形状對内侧壁的影响

19. The socket shape接受腔形状 • Lateral wall 外侧壁 • Contours to shape of femur • 轮廓以迎合股骨形状 • provide support and keep femur in adduction • 提供支持和保持股骨内收 • More closely undercuts sub-trochanteric region, creating a snug fit in this area • 更加紧密地凹陷大转子以下地区，在这方面创造一个舒适合身

20. The socket shape接受腔形状 • Lateral wall 外侧壁 • Socket fits snugly over trochanter • 接受腔正好符合了大转子 • Iliofemoral angle髂股角

21. The socket shape接受腔形状 • Medio-lateral dimensions内外侧尺寸 • Function is to create a ‘bony lock’ between femoral shaft and ischium and ischial ramus • 功能是在股骨与坐骨和坐骨支之間创造一个”骨锁” • Snug M-L, keeps the ischium on the sloping contour of the ischial containment area • 内外则舒适贴身，保持对坐骨在坐骨遏制地区倾斜轮廓上

22. The socket shape接受腔形状 • Medio-lateral dimensions内外侧尺寸 • Skeletal M-L骨骼肌内外侧尺寸 • Dimension between medial ischium and femur, just distal to GT • 股骨与坐骨内侧之间尺寸，刚刚在大转子远端 • Measure with a calliper • 用游标卡尺测量 • Distance is smaller in females than males • 女性距离是比男性较小

23. The socket shape接受腔形状 • Anterior wall前壁 • Original designs without Scarpa’s triangle • 没有股骨三角的原始设计 • Height of anterior trim line • 前方修剪線的高度 • Shape similar to quad • 形状类似四方型

24. The socket shape接受腔形状 • Posterior wall后壁 • 4mm above the ischial tuberosity • 4mm高於座骨 • Makes anterior wall look low • 使前壁看起来低 • Posterior wall height determined by medial wall height • 后壁高度由的內侧壁高度決定 • Posterior wall cups around back of ischium • 后壁包围着坐骨后方

25. The shape comparison形状比较 • Quadrilateral vs. ischial containment shape • 四边形形状vs坐骨遏制形状 • ML, AP dimension • 内外侧，前后侧尺寸 • Femur relationship to lateral wall • 股骨和外侧壁关系

26. The shape comparison形状比较 • Quadrilateral vs. ischial containment shape • 四边形形状vs坐骨遏制形状 • Change in shape and height of medial wall • 改变形状及內侧壁高度 • Change in shape and height of posterior wall • 改变形状和后壁高度 • Anterior wall remains basically unchanged • 前壁保持基本不变 • Lateral wall is more snug in sub-trochanteric area • 外侧壁在下大轉子区更合身 • Height of lateral wall over GT • 外侧壁高过大转子 • More rounded anatomical shape • 更圆解剖形状

27. The shape comparison形状比较 • Advantages优势 • Better control更好地控制 • Feeling of more security感觉更安全 • Improved femoral adduction angles股骨内收角度改进 • Reduced Lateral trunk leaning减少横向主干倾斜 • Improved comfort on bone end and medial groin • 改进对骨端和腹股沟内侧舒适 • Energy expenditure reductions? • 减少能源支出？ • Tissue interface pressures • 组织界面压力 • Bilateral TF amputees • 双边大腿者截肢 • Short residuums • 短殘肢

28. The shape comparison形状比较 • Disadvantages缺点 • More time to fabricate更多的时间来制作 • More materials – check socket, flexible brims and supporting frames/sockets • 更多材料 - 检查接受腔，灵活口班圈和支持接受腔 • More expensive socket • 较昂贵的接受腔 • Tolerating containment • 容忍遏制 • Problems occur more easily when fit changes • 合身有变化時，问题更容易出现 • More difficult to manufacture/fit • 更难以制造/合身 • More experience needed to get reliable, consistent results • 需要得到更多的经验，以得到一致，可靠的结果

29. Casting for IC socketsIC接受腔取模

30. Examination of residual limb残肢的检查 • Any painful site 任何痛苦的位置 • Musculature 肌肉 • … • Measurement量度 • The distance between the medial aspect of the ischial tuberosity to the greater trochanter • 大转子内侧和坐骨结节之间的距离 • Medial arm of the gauge is parallel to line of progression • 规内侧，平行於进展线 • Ischial tuberosity to adductor longus • 坐骨结节至内收长肌 • Lateral AP: distance from rectus femoris to gluteal fold • 外侧前后尺寸：由距离股直肌至臀倍

31. Residual limb length残肢长度 • Perineum (touching the pubic ramus) to the distal end • 会阴（接触耻骨支）到末端 • Hip adduction angle • 髋关节内收角度 • Amount of hip extension • 髋关节伸展角 • Sound side’s ischial tuberosity to the floor, when standing • 站立时，健侧的坐骨结节至地面 • Sound side’s mid-patellar tendon to the floor with shoe off • 健侧髌腱至地面（没有着鞋） • Shoe size, heel height, calf, ankle and thigh circumferences • 鞋的大小，鞋跟的高度，小腿，脚踝和大腿周长

32. Familiar with the anatomical structures of the patient • 熟悉病人的解剖结构 • Make sure the ischial tuberosity and ramus are easily palpable • 确保坐骨结节和坐骨支容易触诊 • Put a casting garment on the patient • 替病人穿上取模服  • Worn like a pair of short pants像一个短裤子 • Snug合身的 • The seam is located along the perineum • 缝线位于沿会阴

33. Marking标记 • Inguinal crease (approximately 10cm proximal to the greater trochanter) • 腹股沟抗皱（约10厘米近端大转子） • Greater trochanter大转子  • Apex, superior and inferior borders • 顶点，上方和下方的边界 • ASIS髂前上棘 • Lateral distal femur外侧远端股骨 • Ischial tuberosity坐骨结节 • Adductor longus内收长肌 • Any sensitive areas任何敏感地区

34. Hand casting approach手取模方法 • Wrap tightly 1 layer of plaster bandage around the waist (ASIS level) • 紧紧裹1层石膏带在腰上（髂前上棘水平） • Continue to wrap the residual limb: • 继续包裹残肢： • Ischial tuberosity at least 5cm inside the wrap • 坐骨结节内至少在包裹內5公分 • Minimal layers should be applied at perineum without sacrifice of strength • 最小层应适用于无会阴，但沒有牺牲强度 • Difficult to palpate the bony structures if too thick • 如果太厚，很难触诊的骨性结构

35. Reinforce the post-trochanteric region using 4-layer of region plaster splints • 使用层4石膏带，加固后股骨粗隆部地区 • Reinforce using two layers of rigid plaster bandage • 使用两层刚性石膏绷带加强 • Pull over the perineal to improve contact with the pubic ramus • 在会阴拉一拉，改善与耻骨支接触 • Using hands to define the ischial tuberosity, pubic ramus, and greater trochanter • 用双手来定义坐骨结节，耻骨支，和大转子

36. Two prosthetists are required for shaping the plaster cast • 需要两个义肢師來取模 • The first prosthetist (in front)第一义肢師（前方）： • Do the following with one hand用一只手做以下 • The index and middle fingers firmly press against the medial aspect of the ischial tuberosity and ramus, • 食指和中指用力地按住坐骨结节和坐骨支内侧 • The web of thumb conforms to the contour of the perineum • 拇指网络顺应了会阴轮廓 • Spread the 4th and 5th fingers as they compress the adductor tissues distal to the ischium • 分开第四和第五的手指，因为他们压在坐骨远端的内收肌组织

37. The other hand compress against the later femur • 另一只手压着股骨下方 • Between greater trochanter and distal end of femur • 大转子及股骨远端之间 • Use the hand to help extend the residual limb • 使用手来帮助延长残肢 • Active extension causes ischial tuberosity difficult to be located • 主动伸展令坐骨结节难以定位 • While maintaining one hand on the ischium, apply a counter fore with the other force against an area inferior to the greater trochanter • 在一手保持在坐骨，在大转子以下区域施加与对一个反作用力 • This is to accurately capture the distance between the ischium and the greater trochanter • 这是为了准确地捕捉大转子和坐骨之间的距离

38. The second prosthetist/assistant (behind)第二义肢師（後方）： • Compress the plaster immediately behind the greater trochanter, to the contour of the fossa, • 按压紧跟大转子后方石膏，到窝的轮廓 • Locate the apex of the trochanter • 找到了转子顶点 • Identify the inferior border of the ischium • 确定的坐骨下缘 • When the plaster begins to set, moderately compress the lateral aspect of the femur (between greater trochanter and distal end) • 当石膏开始设置，适度压缩之间的大转子与股骨远端（侧面） • Cut the plaster around the waist, and remove the plaster when it sets • 切腰部石膏，石膏时并删除它设置 • Check ML dimension at the ischial level, length, general contours • 检查在坐骨水平外内侧尺寸，长度，一般轮廓 • Draw anterior plumb line with the cast placed in desired adduction angle • 放置模具至所需内收角度，并画前铅垂线 • Draw lateral plumb line with the cast in desired flexion • 放置模具至所需屈曲角度，并画外铅垂线

39. Cast modification石膏模修改 • Reduce medial and posterior overhands • 减少内侧和后侧悬垂 • Smooth out irregularities over the whole model • 平滑整个模型上不规则地方 • Measure the model and compare with previous measurement • 量度石膏模与以往的尺寸比较 • Length长度 • Circumference- every 2.5cm for short and 5cm for medium to long residual limbs below the ischial level • 在坐骨水平以下，短残肢每2.5厘米圆周，中型至长残肢每5厘米圆周 • Modify ML dimension修改内外侧尺寸 • Measure the distance between the medial aspect of the ischium and the greater trochanter • 量度坐骨内侧和大转子之间的距离 • Remove the plaster to achieve the measured distance • 取去石膏，以达到测量距离 • Avoid plaster remove at cut end • 避免在殘肢末取去石膏

40. Proximal shapes近端形状 • Medial wall内侧墙 • Slightly convex outward, following adductor musculature • 略向外凸，跟著内收肌肌肉 • Anteromedial wall should have sufficient radius to prevent excessive impingement on the adductor longus tendon and the neuro vascular region • 前内侧墙应该有足够的半径，防止过度内收肌长肌腱和神经血管区的冲击 • Posterior wall后壁 • Narrow, semi-circular contour • 窄，半圆形轮廓 • Anterior wall前壁 • Semi-circular contour • 半圆形轮廓 • Lateral wall侧壁 • Well contoured to the shaft of the femur • 股骨骨干良好轮廓到

41. Femoral triangle股骨三角 • Draw an ischial line at the level of ischium • 在坐骨水平画一条坐骨线 • Divide the anterior aspect of the line into thirds and perpendicular to the ischial line • 垂直於坐骨线，在前方划分三分 • Draw a lateral third line proximally 5cm • 在外方近端5厘米，画一条线

42. From a point 25mm lateral to the anterior medial corner and at ischial level, draw a line 8 cm distal and perpendicular to the ischial line • 从坐骨水平外内侧角落向外25毫米1点，划一条线8厘米远端于和垂直于坐骨线 • Connect the end points of the perpendicular lines • 连接的垂直线的终点 • Shaping for smooth contour within the boundaries • 为边界内，塑造轮廓

43. Trim lines修剪线 • Anterior前 • Just proximal to the inguinal crease • 腹股沟折痕近端 • Lateral外侧 • About 7.5 cm above the apex of the trochanter • 约在大转子顶点以上7.5厘米 • Posterior后 • At least 2.5cm above the level of inferior border of the ischial tuberosity • 在坐骨结节下缘水平以上至少有2.5厘米 • Medial内侧 • V-shape, vertex of the “V” located at the point where pubic ramus crosses the medial wall • V型，“V”形顶点位置于耻骨支的穿过墙壁内侧的点

44. Re-measure the circumferences • 重新测量周长 • Remove plaster in the posteriolateral and posterior regions to obtain the goal circumference • 删除后外侧，后地区的石膏获取目标周长 • Use reduction values table to determine the goal circumference • 使用减少值表来确定目标的周长