In Pursuit of Socket Harmony: Optimizing the Transtibial Socket Interface

Glenn M. Street, PhD
Professor Emeritus, St. Cloud State University, Minnesota, USA

Carl A. Caspers
Environmentally Managed Systems, Rice, MN, USA

Kyle B. Miller
Freelance Writing, White Bear Lake, MN, USA

Benjamin C. Noonan, MD
Sanford Orthopedics and Sports Medicine, Fargo, ND, USA

Series: Physical Medicine and Rehabilitation
BISAC: MED065000



Volume 10

Issue 1

Volume 2

Volume 3

Special issue: Resilience in breaking the cycle of children’s environmental health disparities
Edited by I Leslie Rubin, Robert J Geller, Abby Mutic, Benjamin A Gitterman, Nathan Mutic, Wayne Garfinkel, Claire D Coles, Kurt Martinuzzi, and Joav Merrick


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Since the advent of the first modern below-knee prosthesis (joint and lacer) in 1696, the world has seen unprecedented advances in virtually every facet of medical science, yet limb discomfort, pain, and soft tissue breakdown remain a way of life for roughly half of today’s ambulatory, below-knee (transtibial) amputees. These largely avoidable daily struggles are traceable to poorly crafted limbs, ill-designed prostheses, and/or inadequate upkeep of them. Fortunately, the solution to the majority of these struggles is clear-cut and entirely achievable. Primarily, it requires a team effort by surgeons, prosthetists, and amputees: as each has a unique role to play.

Surgeons must employ the latest surgical principles to optimize the limb for prosthetic use (Chapter 2), prosthetists must implement the latest design principles to create a responsive, comfortable, and pain-free socket interface (Chapter 4), and amputees must follow the guidelines to maintain their optimized limb and prosthesis (Chapter 5). However, as discussed in Chapter 2, certainty of a pain-free interface will also require a commitment by researchers to find solutions to the yet unresolved surgical issues (e.g. neuromas and bone spurs). While one can never expect the socket interface to perfectly replace the responsive and pain-free connection lost during amputation, finding solutions to the unresolved surgical issues, and following the latest principles and guidelines discussed in this book unquestionably offers transtibial amputees with their best chance of achieving the active, comfortable, pain-free, and productive lifestyle they deserve.
(Imprint: Nova Medicine and Health)


Chapter 1. Transtibial Amputation History

Chapter 2. Transtibial Amputation

Chapter 3. History of Modern Transtibial Prostheses

Chapter 4. Modern Transtibial Prostheses

Chapter 5. Summary for Amputees & Those Soon to Be




“This chapter on the surgical aspects of transtibial amputation is an excellent discussion of not only amputation wounds and healing, but principles that would be wisely applied to all orthopedic wounds. Healing an amputation wound means working at the critical end of surgical wound management. The amputees usually represent our most compromised patients: those with diabetes, vascular disease, infection, cancer, and trauma. These tissues are the most fragile and/or injured, the patients are the most frail, malnourished, or complicated. Fortunately, the world of prosthetics has advanced tremendously in the 21st century. Our surgical techniques need to keep pace and adapt to these advances by creating a functional residual limb suited to the new prostheses. The authors have provided an excellent roadmap to the optimized residual limb. By tackling the surgery of amputations in depth, the authors instruct and remind us of the critical longstanding and emerging principles of how best to care for these special patients, lessons that we can readily apply to all our patients’ wounds.” - Anthony Brown, MD, Orthopedic Surgeon, Sanford Orthopedics & Sports Medicine

”In Pursuit of Socket Harmony, Optimizing the Transtibial Socket Interface, is an excellent resource for surgeons, prosthetists, and amputees desiring to learn about the optimal transtibial socket design. This optimal transtibial socket design starts in the surgical suite with techniques that have been researched, the science behind the techniques explained, and the technique described in this book. The optimal prosthetic socket design is described in the prosthetic section, where design principles and the logic behind these principles are discussed. Both the surgical and prosthetic sections start with chapters on the history of each discipline regarding transtibial amputation and prosthetic fitting, providing interesting reading on the subjects and giving the reader an understanding of how we have gotten to where we are today. The amputee is the focus in the final section that points out the importance of the role the amputee plays in the success they will have as a lifelong user of prosthetic devices. Amputee education is a vital part for successful fitting of the optimal transtibial socket. Each section of the book can stand alone, but, from a prosthetist’s point of view, I found the entire book interesting to read and picked up valuable information in each section.” - Byron Backus, CP, LP, Clinical Specialist Prosthetics, Ottobock

“This publication is a thorough in-depth explanation of the points that prosthetists and the surgical community have desperately needed to agree on and formally address for years. Historically, from my experience, most attempts of collaboration have resulted in random success due to a lack of consistency. My hope is that this publication will facilitate a much-needed consistent teamwork model. It focuses directly on the source of the issues that have haunted amputees on a daily basis. I appreciate the meticulous effort to break down each factor that plays a part: the surgeon, the prosthetist, the prostheses, and the patient. It describes the symptoms and the sources that have resulted in the “abusive” treatment of the limb while wearing the prosthesis. I believe surgeons and prosthetists alike should utilize this publication as the foundation for achieving successful outcomes in the rehabilitation of patients following limb loss at the transtibial level and sets the patient on a path towards an active lifestyle. Great work!” - Stephen A. Schulte, CP, LP, FAAOP, ProCare Prosthetics & Orthotics, Co-Owner

Bengt Söderberg, CPO, Scandinavian Orthopaedic Laboratory, Owner, Past President of ISPO International - To read the review, click here.

Keywords: Transtibial amputation, below knee amputation, wound healing, neuroma, bone spur, limb length, limb shape, well-crafted limb, limb health, limb volume, socket interface, prosthesis, vacuum suspension, flexible socket

• Vascular, orthopedic and general surgeons out in the field
• Vascular, orthopedic and general surgeons that train medical students
• Vascular, orthopedic and general surgical residents and fellows
• Physical therapists that help amputees rehabilitate from surgery
• Professors that train prosthetic students
• Prosthetic students
• Prosthetists at fitting companies and medical facilities
• Amputees to be or amputees who are contemplating limb revision surgery
• Scientists and engineers that study amputation techniques and transtibial prostheses

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