Klenow T D, Schulz J
Martin Bionics Clinical Care, Fort Myers, Florida, USA.
Martin Bionics Innovations, Oklahoma City, Oklahoma, USA.
Can Prosthet Orthot J. 2021 Sep 21;4(2):35208. doi: 10.33137/cpoj.v4i2.35208. eCollection 2021.
The prosthetic socket is commonly considered to be the most important part of the prosthesis and lack of fit can lead to skin breakdown, reduction in wear, reduction in activity, and consequential deleterious health effects. Furthermore, approximately 90% of amputations are due to a vascular etiology, which affect fluid retention regularity, and even small limb volume fluctuations can lead to lack of fit. Adjustability in the socket volume has been suggested as a potential solution to common fit issues but has lacked market penetration mostly due to lack of reimbursement. Despite this there are several adjustable-volume sockets emerging on the market today including prefabricated, modular, custom with adjustable-volume component, custom with adjustable-volume feature, and adjustable-hybrid sockets. Prefabricated sockets are mass produced in common sizes and fit directly to the patient by a prosthetist using pad kits, BOA dials, or straps. Modular sockets are assembled to a patient or model with panels or struts attached to an adjustable base. Custom sockets with adjustable-volume elements are traditionally-fabricated sockets made to a model of a patient's limb with a volume-adjustable component added or volume-adjustable feature built in. Custom-hybrid sockets are made custom to a model of the patient's limb and incorporate several aspects of the previous socket types and include some radically-unique design aspects which cannot be limited to one category. These adjustable-volume sockets offer several advantages to traditional rigid-volume sockets for the patient, prosthetist, and providing clinic. The micro-adjustability for the patient allows them to alter fit without removing the socket, maintaining a more intimate fit throughout the day than traditional sockets. The macro-adjustability for the prosthetist allows for increased options for fit customization including the ability to reverse or undo changes without necessarily re-making the socket. This allows for the most optimal fit for the patient. Adjustable volume also present efficiencies in the fitting process by simplifying or eliminating steps including residual limb shape capture, form modification, diagnostic fabrication, iterative alteration, and definitive fabrication with the different socket types affecting different steps. Due to these factors, adjustable-volume sockets have disrupted the market to the point where reimbursement reform is needed including additional L-codes in the United States and fee-for-service or fee-for-outcome associated with prosthetic follow-up care. Prosthetic care should also be separated from durable medical equipment to allow for alternative reimbursement models. As reimbursement adapts prosthetists must adapt correspondingly to differentiate their skillset from other allied health providers including incorporating more objective methods to show superior care outcomes. This adaptation should include a continued push for state and municipal licensure of prosthetists.
假肢接受腔通常被认为是假肢最重要的部分，贴合不佳会导致皮肤破损、穿戴时间减少、活动量降低，进而对健康产生有害影响。此外，约90%的截肢是由血管病因引起的，这会影响液体潴留规律，即使肢体体积的微小波动也可能导致贴合不佳。有人提出接受腔容积的可调节性是解决常见贴合问题的潜在方案，但由于缺乏报销，其市场渗透率一直较低。尽管如此，如今市场上仍出现了几种可调节容积的接受腔，包括预制的、模块化的、带有可调节容积组件的定制型、带有可调节容积功能的定制型以及可调节混合型接受腔。预制接受腔以常见尺寸批量生产，假肢师使用衬垫套件、BOA旋钮或绑带将其直接适配到患者身上。模块化接受腔通过将面板或支柱连接到可调节底座上，组装到患者或模型上。带有可调节容积元件的定制接受腔是根据患者肢体模型传统制作的接受腔，添加了容积可调节组件或内置了容积可调节功能。定制混合型接受腔是根据患者肢体模型定制的，融合了前几种接受腔类型的多个方面，还包括一些根本独特的设计方面，无法局限于某一类别。这些可调节容积的接受腔为患者、假肢师和提供诊疗的机构带来了相较于传统固定容积接受腔的诸多优势。对患者而言，微调节性使他们无需取下接受腔就能改变贴合度，一整天都能保持比传统接受腔更紧密的贴合。对假肢师来说，宏观可调节性增加了贴合定制的选项，包括能够在不一定重新制作接受腔的情况下反转或撤销更改。这能为患者实现最优化的贴合。可调节容积还通过简化或消除一些步骤提高了适配过程的效率，这些步骤包括残肢形状获取、形状修改、诊断性制作、反复更改以及使用不同接受腔类型进行最终制作，不同的接受腔类型影响不同的步骤。由于这些因素，可调节容积的接受腔已经对市场造成了冲击，以至于需要进行报销改革，包括在美国增加L编码以及与假肢后续护理相关的服务收费或按结果收费。假肢护理也应与耐用医疗设备分开，以允许采用替代报销模式。随着报销政策的调整，假肢师必须相应地进行调整，以使他们的技能与其他联合健康服务提供者区分开来，包括采用更客观的方法来展示卓越的护理效果。这种调整应包括持续推动对假肢师进行州和市一级的执照许可。
