1、AK Quadrilateral Socket Design and Applications of Biomechanics大腿假肢接受腔设计及生物力学原理Dr. Winson Leehtwinsonpolyu.edu.hk,Socket shape - posterior wall接受腔形状 后壁,解剖学Gluteus maximus (臀大肌)Hamstrings (腿筋肌肉)Ischial tuberosity (坐骨结节),Socket shape - posterior wall接受腔形状 后壁,Functions 功能Posterior wall provides a major
2、 weight bearing area后壁提供了一个主要负重区Ischial tuberosity medially坐骨结节内侧Gluteus maximus laterally 臀大肌外侧,Socket shape - posterior wall接受腔形状 后壁,Shape形状Height (高度)Distance from the IT to the floor从坐骨结节至地面的距离Contours (轮廓)Posterior brim (ischial seat) should be parallel to the floor when in correction adduction
3、/flexion在正确内收/屈曲角度，后缘（坐骨座位）应平行于地面,Socket shape - posterior wall接受腔形状 后壁,Posterior wall is at an angle of 97 to medial wall (90-112 )后壁与内墙成97 角(90-112 )Relief for hamstrings in posterior medial corner腿筋肌肉在后内侧角缓解Contour for gluteals in posterior laterally area臀肌肉在后外侧区的轮廓Relatively flat posterior wall,
4、 avoid undercuts后壁较平坦,Socket shape - posterior wall接受腔形状 后壁,Problems and possible solutions存在的问题及可能的原因Pain on ischial tuberosity 坐骨结节疼痛AP dimension too large. IT sliding over radius of posterior wall前后尺寸过大。坐骨结节滑过后壁角落Inadequate radius on inner edge of brim内半径不足Patient not used to ischial support病人不习惯
5、坐骨支持,Socket shape - posterior wall接受腔形状 后壁,IT not properly positioned 坐骨结节没有正确定位IT too posteriorly AP too tight坐骨结节太后前后尺寸太紧IT too medial Sloping posterior wall坐骨结节太内后壁倾斜Painful/cramping hamstrings 腿筋肌肉疼痛Socket undercut接受腔凹陷Socket too tight接受腔太紧,Socket shape - anterior wall接受腔形状 - 前壁,肌肉接触Adductor lon
6、gus (内收肌长肌腱)Rectus femoris (股直肌)Sartorius (缝匠肌)Tensor Fasciae latae (阔筋膜张肌)Pubis (耻骨)ASIS (髂前上棘),Socket shape - anterior wall接受腔形状 - 前壁,Functions(功能)To maintain proper placement of the ischial tuberosity on the posterior brim为了保持对坐骨结节后缘的妥善位置Provide sitting comfort提供坐時的舒适,Socket shape - anterior wall
7、接受腔形状 - 前壁,Shape(形状)Height(高度)Proximally 4-6cm higher than posterior wall(近端高于后壁4 - 6cm)Correct when it doesnt limit hip flexion(正确时，髋关节屈曲不受限制)Medial third - Scarpas triangle (内侧三分之一 :股骨三角)Located over Scarpas triangle 坐落在股骨三角Apex at level is posterior wall 水平的顶点是后壁Gradual pressure 渐进式压力Lateral thir
8、d 外侧三分之一 Rectus femoris containment height 20mm more superficial than apex of Scarpas triangle包含股直肌高度比股骨三角的顶点浅20mm,Socket shape - anterior wall接受腔形状 - 前壁,Problems and possible reasons存在的问题及可能的原因Pressure on pubic ramus(耻骨支压力)Insufficient flaring(展開不足)Impinging on the ASIS(撞击髂前上棘)Anterior wall too hig
9、h(前壁过高)Loss of suction because the socket is pushed up吸力损失，因为接受腔被推高,Socket shape - anterior wall接受腔形状 - 前壁,Pressure on ASIS in sitting 坐時在髂前上棘的压力Anterior brim is too high in this area前緣在這一領域太高Numbness of residual limb 殘肢麻木Scarpers pillow is excessive (股骨三角太深)Causing localized presure on the femoral
10、artery造成股动脉局部的压力Proximal brim is too low (近端太低)Causing narrow band of tightness over the anterior region造成前区窄带的紧束,The medial wall内侧墙,Muscles in contact(肌肉接触):Adductor longus(内收长肌)Adductor magnus(大收肌)Hamstrings(腘绳肌)Pubic and ischial ramus (耻骨支和坐骨支),The medial wall内侧墙,Functions(功能) Contain medial tiss
11、ues and prevent “roll” of adductor tissue包含内侧组织和防止内收组织肉辊Represents the line of progression, parallel to the sagittal plane代表着进展线(line of progression)，平行于矢状面Relieve adductor longus tendon and hamstrings as they exit the socket缓解收肌长肌肌腱和腿筋肌肉Part of mediolateral stability内外侧稳定的一部分,The medial wall内侧墙,Sha
12、pe(形状)Height5mm lower than ischium (variations)高度低于坐骨5mm (可以变化的）Influence of pelvit tilt(骨盆倾斜的影响)low medial wall would lead to adductor roll 内侧墙过低会导致内收组织肉辊Internal length of medial wall(内部长度内侧壁)Adductor longus tendon to IT in sitting坐时坐骨结节至内收长肌肌腱的长度,The medial wall内侧墙,Corners(角落)Relief for Adductor
13、longus and hamstring tendons缓解收肌长肌肌腱和腿筋肌肉Contours(轮廓)Medial wall is flat内侧墙是平的 Outward flare向外展開,The medial wall内侧墙,Problems and possible reasons存在的问题及可能的原因Tightness of adductor longus tendon内收肌长肌腱太紧diomfortInsufficient relief(没有足够的缓解)Improper relief in the anteriomedial corner不当的前内侧角缓解AP too small前
14、后尺寸太小Proximal brim of the posterior wall slopes downward from lateral to medial近端的后壁由外侧向下斜至内侧,The medial wall内侧墙,Pubic ramus experience too much pressure- usually with burning sensation耻骨支太大的压力，通常出现灼热感Medial wall too long (AP too large)内侧墙太长（前后尺寸太大）Medial wall too high内侧墙过高Adductor roll (内收肌组织肉卷)Med
15、ial brim too low内侧墙太低ML too tight內外尺寸太紧Sometimes several weeks of discomfort must be tolerated to reduce the pain due to adductor roll有时几个星期的不适必须忍受，以减少由于内收肌组织肉卷的痛楚,Socket shape - lateral wall接受腔形状 外壁,肌肉接触Tensor fascia lata (阔筋膜张肌)Vastus lateralis (股外侧肌)Gluteus maximus (臀大肌)骨结构的接触Greater trochanter (
16、大转子)shaft of femur (股骨),Socket shape - lateral wall接受腔形状 外壁,Functions(功能) Provide mediolateral stability in conjunction with medial wall提供外内壁与内壁结合的稳定性Try to keep the femur in adducted alignment尽量保持股骨内收Relief for end of remnant femur缓解殘肢股骨远端残,Socket shape - lateral wall接受腔形状 外壁,Shape(形状)Height 高度Simi
17、lar to anterior wall 类似前壁Typically just above greater trochanter, but can be higher通常略高于大转子，但是可以更高Contours轮廓Symmetrical about the sagittal mid-line对称矢状中线Typically flat from greater trochanter to just above remnant bone end通常由大转子至略高于残骨远端是平的,Socket shape - lateral wall接受腔形状 外壁,May be concave above bon
18、e end可能在骨末对上是凹Contours above greater trochanter大转子至上轮廓Smooth radius into both the anterior and posterior walls,Socket shape - lateral wall接受腔形状 外壁,Problems and possible solutions存在的问题及可能的原因Pain on bone end(骨末疼痛)Insufficient support of femur above bone end - contour of stump shape股骨骨端支持不足 残肢轮廓Imprope
19、r adduction内收不当 Excessive mediolateral socket dimension at brim接受腔外内侧尺寸过度Pain at proximal brim(疼痛近端)Insufficient relief of greater trochanter大转子没有足够的缓解,Modification of plaster model for quadrilateral socket四边形接受腔石膏模型的修形,Know what the common problems are知道什么是常见的问题,Brim impinges on the symphysis pubis
20、口型圈令耻骨联合不适Brim too square in posterior lateral corner口型圈后外侧太方,Know what the common problems are知道什么是常见的问题,Ischial seat of brim is often too narrow坐骨的座位往往过于狭窄as can be flares on anterior and medial walls因为前内侧壁可以展开Prominent greater trochanter can leave a gap in lateral wall突出大转子可以留下一个在侧壁的差距Residual li
21、mb shape残肢形状 short residuums(短残肢) achieving desired angle of residual limb(实现理想的残肢角),石膏模型的修改,Step步骤1. Reduce medial and posterior overhands 减少内侧和后侧悬垂Medial 内侧:Reduce the overhands above the medial brim to about 18mm减少内侧上方至约18毫米的悬垂部分Make medial overhang parallel to line of progression/perineum令内侧的悬垂部
22、分平行于进展线悬/会阴,石膏模型的修改,Posterior后侧: Reduce the overhands above the posterior brim to about 15mm减少后上方至约15毫米的悬垂部分Make medial overhang perpendicular to the medial wall令内侧悬与侧壁垂直,Step步骤2. Smooth out irregularities over the whole model 平滑整个模型上不规则地方Do not smoothen the model at pressure sensitive areas不要在压力敏感的
23、地区理顺模型,石膏模型的修改,Step步骤3. Round off square corners 弄圆方形角落Round off square corners postero-medially and antero-medially弄圆后内侧和前内侧的方形角落,石膏模型的修改,Step步骤4. Flatten medial wall 弄平内侧墙Remove the unwanted bumps from proximal portion删除近端突起不需要的部分Step步骤5. Slightly remove plaster at the area between greater troncha
24、nter and femoral end 稍稍删除大转子和股骨远端之間的石膏Obtain the contour of the femur获取的股骨轮廓 Relieve pressure from bone end during abduction.缓解骨外展时压力,See slides 40 and 41 for modification of scapas triangle, if using hand casting technique.,石膏模型的修改,Step步骤6. Make measurements 进行测量Measure the circumference at perinea
25、l level and at each of the 50mm intervals marked on the model在会阴部的水平测量的周长和在该模型每间隔50毫米的周长Make sure the measurement is parallel to the ischial seat确保测量平行于坐骨座位,石膏模型的修改,Measure the length 测量长度From perineum at the level of IT to the distal end of the residual limb在坐骨结节水平，由会阴到残肢末端Measure the AP测量前后尺寸from
26、the deepest point of the Scarpas triangle to where the ischium sits从股骨三角最深点至坐骨Measure the adduction and flexion angles测量内收和屈曲角度,石膏模型的修改,Step步骤7.1 Your goal modifications 你的修改目标Goal residual limb length as measured on patient目标残肢长度度量病人的残肢If the model length is 9mm or more longer than the measured res
27、idual limb length, add 6mm to the residual limb length如果模型的长度较残肢测量长度长9毫米或以上的，从实测值加6毫米Goal AP reduce 12mm from the measurment目标前后尺寸测量的尺寸减少12毫米,石膏模型的修改,Goal medial wall length as measured on patient目标内侧墙长度从病人测量得到的Goal adduction as measured on patient目标内收从病人测量得到的Add/remove plaster at the posterior shel
28、f for adjustment在后壁添加/删除石膏作调整Goal flexion as measured on patient + 5目标弯曲角度从病人测量得到的+ 5 Add/remove plaster at the medial brim for adjustment在內壁添加/删除石膏作调整,石膏模型的修改,Step(步骤)7.2 Your goal modifications你的目标修改Goal circumferences (decrease from the measured value) at the perineal level在会阴水平的目标圍长(从实测值減少) Firm
29、坚硬 Average平均 Soft软Long长 25mm31mm 37mmMedium中 25mm31mm 37mm Short短 31mm37mm 44mm50mm below perineal level reduce by 18mm会阴水平以下50毫米圍长减少18毫米 All other levels reduce by 6mm from the measurement所有其他水平:圍长减少6毫米 Smoothen irregularities first, then lateral side of the model.,石膏模型的修改,Step 8. Sand the model fo
30、r smoothness步骤8.平滑模型,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,40,From a point 25mm lateral to the anterior me
31、dial 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,41,Socket biomechanics接受腔生物力学,接受腔墙壁体重承受Support of bod
32、y weight by socket wall,Forces are applied to the residual limb by socket walls (f1,f2,f3,f4,f5,f6);接受腔墙壁施以压力於残肢(f1,f2,f3,f4,f5,f6);Only the vertical components of these forces will be effective in opposing the body weight (W);只有這些力的垂直组件将有效地反对体重（W）;,接受腔墙壁体重承受Support of body weight by socket wall,The
33、refore, f1+f2+f3+f4+f5+f6 should be much greater than W;因此，F1 + F2+ F3+ F4+ F5+ F6应该比W大;Large forces applied onto the residual limb can cause soft tissue problem.过大压力施到残肢可能会导致软组织问题,Support of body weight by a horizontal surface由一个水平的表面承受体重,If forces acted on the residual limb is a horizontal surface
34、, f1+f2+f3+f4+f5+f6 = W如果压力於一个水平面施到残肢，为F1 + F2+ F3+ F4+ F5+ F6 = WDistal end potential provides a horizontal surface末端提供一个水平面However, most trans-femoral amputations cannot tolerate load at the distal end然而，大多数大腿截肢不能忍受在远端负载压力,Support of body weight by a horizontal surface由一个水平的表面承受体重,The posterior br
35、im of the quadrilateral socket provide a horizontal shelf, which load against the ischial tuberosity四边形接受腔后边提供一个水平面，令坐骨粗隆负荷压力This reduce the supporting forces supplied by the socket walls.这减少了由接受腔墙壁作出的支持力,Anterior wall of the socket接受腔的前壁,Weight line AB passes anterior to the ischial seat重量线AB通过坐骨座位
36、的前方Pelvis tends to rotate downward and forward盆骨趋于向下和向前旋转Ischial tuberosity tends to slide off坐骨结节趋于滑落A posteriorly directed force is necessary to stop this tendency一向后定向力是必要的，以制止这种趋势,Anterior wall of the socket接受腔的前壁,The anterior wall should be high (5-6cm higher than the posterior wall)前壁应该是高(比后壁高
37、5 - 6cm)To maintain the ischial tuberosity on the seat为了保持坐骨粗隆在座位上However, the anterior wall should not be so high that affects hip flexion of slightly more than 90 degrees during sitting然而，前壁不应太高，以至在坐时影响髋关节稍多于90度弯曲The convex bulge of the anterior wall in the area of Scarps triangle provides a more
38、effective stabilizing force前壁在股骨三角区的凸隆提供了更加有效的稳定力量Due to softness of the soft tissue, it would not be enough for the anterior wall just matches the shape of the residual limb由于软组织柔软，前壁只是匹配残肢形状将是不够的,Action of hip abductors髋关节外展肌肌肉行动,Non-amputees 截肢者:During swing phase, the pelvis tends to drop on the
39、 unsupported side;在摆动期，骨盆往往砸不支持的一方;This tendency is opposed by the action of hip abductors;这种倾向是由髋关节外展肌的行动抗拒;W x Dw = Fg x Df,Action of hip abductors髋关节外展肌肌肉行动,Trans-femoral amputees 大腿截肢者:During swing phase, the pelvis tends to drop on the unsupported side;在摆动期，骨盆往往砸不支持的一方;This tendency is opposed
40、by the action of hip abductors;这种倾向是由髋关节外展肌的行动抗拒;,Action of hip abductors髋关节外展肌肌肉行动,The lateral wall has to be well shaped to provide counterforce on the lateral aspect of the residual limb侧壁要有良好形状以提供在残肢侧面的反作用力A slight relief at the lateral distal end is usually needed在外侧远端轻微缓解通常需要的W x Dw = FL x Df,Action of hip abductors髋关节外展肌肌肉行动,Trans-femoral amputees大腿截肢者：If the residual limb is too short, the amputee may have some lateral bending of the trunk toward the prosthetic side during stance phase如果残肢是太短，截肢者在站立时期躯干可能会有一些侧向義肢To shorten Dw为了缩短Dw,
