L-Code
L5673
Description
ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR
PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING
MECHANISM.
Justification
Working in conjunction with a Locking mechanism (L5671) this is a primary means to holding the prosthesis to
the limb. Suspension of the prosthesis to the limb is critical to maintain fit, comfort and function of an artificial
limb. This liner is worn directly against the skin and dramatically reduces shear forces created by socket
pistoning. Suspension is achieved by the inherent suction capabilities of a silicone material against skin and a
shuttle lock mechanism at the distal end of both liner and socket. The silicone liner is used to provide
suspension. It may be used with a hard socket or with a soft, lined socket depending on the amputee's needs.
(atlas). This system has been well described in the literature (Kapp, Cluitmans, Edwards) and research has shown
improved patient satisfaction and easier donning than with other suspension systems (Gholizadeh). Gel liners
are used to reduce shear on the skin or limb. They are often used with skin conditions and grafts, and they also
protect the limb during high-impact activities. (Fergason)
References
Kapp, Susan, and Donald Cummings. "Transtibial amputation: Prosthetic management." Atlas of limb prosthetics.
St. Louis (MO): Mosby-Year Book, Inc (1992): 453-78.
Boutwell, Erin, et al. "Effect of prosthetic gel liner thickness on gait biomechanics and pressure distribution
within the transtibial socket." J Rehabil Res Dev 49.2 (2012): 227-240.
Kapp, Susan. "Suspension systems for prostheses." Clinical orthopaedics and related research 361 (1999): 55-62.
Cluitmans, J., et al. "Experiences with respect to the ICEROSS system for trans-tibial prostheses." Prosthetics and
orthotics international 18.2 (1994): 78-83.
Gholizadeh, Hossein, et al. "Transtibial prosthetic suspension: Less pistoning versus easy donning and doffing."
Journal of rehabilitation research and development 49.9 (2012): 1321-1330.
Edwards, M. L. "Below knee prosthetic socket designs and suspension systems." Physical medicine and
rehabilitation clinics of North America 11.3 (2000): 585-93.
Fergason J. Clinical application of advanced prosthetic technology: an update. Journal of Trauma. 2007;62(6
Suppl): S6.
Millman Care Guide 18th Edition Lower Limb Prosthesis Guideline: ACG: A-0487 (AC) Last Updated: 2/5/2014
Pp.1
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L-Code
L5624
Description
ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE.
Justification
Use of a test socket (also know as: Check Socket or Diagnostic Socket) has been used since 1973
(Hammontree/Snelson). It has become a standard of practice for determination of appropriate fit and function
of a prosthetic socket (Trower 2006). The use of these sockets (typically a clear thermoplastic) allows the
practitioner to actually “see” the areas of excessive pressure in the absence of other diagnostic techniques, and
helps to assure the proper, long term disbursement of forces within a socket as it applies pressure during use to
the residual limb. (Staats 1985). “The fundamental principals of total contact, uniform pressure distribution,
elimination of shear stress and focal pressures, and restoration of correct limb length have been known for a
long time”. (Trower) The check socket allows for a determination of proper pressure distribution and can help to
avoid skin problems such as Verrucus Hyperplasia, which is associated with lack of prosthesis contact. (Levy)
Test sockets are necessary to evaluate socket fit and ensure a safe, comfortable socket fit. A clear test socket
allows the prosthetist to evaluate and adjust the socket fit to provide maximum comfort and stability for the
patient. A proper fitting socket reduces the risk of limb complications secondary to excessive motion or
improper force distribution in the socket.
References
The Merck Manual Home Health Handbook. Skin Care for Amputees. May 2007.
Millman Care Guide 18th Edition Lower Limb Prosthesis Guideline: ACG: A-0487 (AC) Last Updated: 2/5/2014
Pp.1
Staats, TB. “Advanced Prosthetic Techniques for Below the Knee Amputations.” Orthopedics, 1985 Feb:8(2)24958
Hammontree,S and Snelson, R. “Use of Check Sockets in Lower Limb Prosthetics.” Orthotics and Prosthetics 27.4
(1973): 30-33.
Trower, Ted A. "Changes in lower extremity prosthetic practice." Physical medicine and rehabilitation clinics of
North America 17.1 (2006): 23-30.
Levy SW. Skin Problems of the Amputee. In: Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation
Principles, Smith DG, Michael JW and Bowker JH, eds, 2nd edition, Ch 26, American
Academy of Orthopaedic Surgeons, Rosemont IL, 1992.
Michael, JW. Prosthetic Components. In: Atlas of Amputations and Limb Deficiencies, Surgical Prosthetic and
Rehabilitation Principals, Smith DG, Michael JW and Bowker JH, eds, 3rd edition, Ch 33, pp. 409-410, American
Academy of Orthopaedic Surgeons, Rosemont IL, 2004.
Lusardi MM and Nielsen CC (2007). Orthotics and Prosthetics in Rehabilitation. St. Louis, MO: Saunders/Elsevier.
©2014 O&P Solutions, LLC, 8517 N Dixie Dr Ste 300, Dayton, OH 45414, 937.264.9400, F937.264.9401, OandPSolutions.net
L5624 References (cont.)
Berke, GM. “Lower Limb Prosthetics.” In: Mann’s Surgery of the Foot and Ankle, Coughlin MJ,
Saltzman, CL and Anderson RB eds, 9th edition, vol 2, pp: 15-23, Elsevier Science, 2014.
Reger, S. I., et al. "Applications of transparent sockets." Orthotics and Prosthetics 30.4 (1976): 35-39.
©2014 O&P Solutions, LLC, 8517 N Dixie Dr Ste 300, Dayton, OH 45414, 937.264.9400, F937.264.9401, OandPSolutions.net
L-Code
L5671
Description
ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING MECHANISM (SHUTTLE,
LANYARD OR EQUAL), EXCLUDES SOCKET INSERT.
Justification
Working in conjunction with a socket insert, silicone gel, elastomeric or equal (L5673) this is a primary means to
holding the prosthesis to the limb. Suspension of the prosthesis to the limb is critical to maintain fit, comfort and
function of an artificial limb. This liner is worn directly against the skin and dramatically reduces shear forces
created by socket pistoning. Suspension is achieved by the inherent suction capabilities of a silicone material
against skin and a shuttle lock mechanism at the distal end of both liner and socket. The silicone liner is used to
provide suspension. It may be used with a hard socket or with a soft, lined socket depending on the amputee's
needs. (atlas). This system has been well described in the literature (Kapp, Cluitmans, Edwards, Nieveen) and
research has shown improved patient satisfaction and easier donning than with other suspension systems
(Gholizadeh). The suspension system is critical to further reduce the movement between the socket and residual
limb (Collins)
References
Knapp, Susan and, Cummings, Donald. Transtibial Amputation: Prosthetic Management. In: Atlas of Limb
Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles, Smith DG, Michael JW and Bowker JH, eds, 2nd
edition, Ch 18, American Academy of Orthopaedic Surgeons, Rosemont IL, 1992.
Boutwell, Erin, et al. "Effect of prosthetic gel liner thickness on gait biomechanics and pressure distribution
within the transtibial socket." J Rehabil Res Dev 49.2 (2012): 227-240.
Kapp, Susan. "Suspension systems for prostheses." Clinical orthopaedics and related research 361 (1999): 55-62.
Cluitmans, J., et al. "Experiences with respect to the ICEROSS system for trans-tibial prostheses." Prosthetics and
orthotics international 18.2 (1994): 78-83.
Gholizadeh, Hossein, et al. "Transtibial prosthetic suspension: Less pistoning versus easy donning and doffing."
Journal of rehabilitation research and development 49.9 (2012): 1321-1330.
Edwards, M. L. "Below knee prosthetic socket designs and suspension systems." Physical medicine and
rehabilitation clinics of North America 11.3 (2000): 585-93.
McCurdie, I., R. Hanspal, and R. Nieveen. "ICEROSS—a consensus view: a questionnaire survey of the use of
ICEROSS in the United Kingdom." Prosthetics and orthotics international 21.2 (1997): 124-128.
Collins, Diane M., et al. "Review of research on prosthetic devices for lower extremity amputation." Critical
Reviews™ in Biomedical Engineering 34.5 (2006):379-438..
MIllman Care Guide (MCG) 18th Edition Lower Limb Prosthesis Guideline: ACG: A-0487 (AC) Last Updated:
2/5/2014 Pp.1
©2014 O&P Solutions, LLC, 8517 N Dixie Dr Ste 300, Dayton, OH 45414, 937.264.9400, F937.264.9401, OandPSolutions.net
L-Code
L5910
Description
ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM.
Justification
The use of an alignable system is critical for the continued use and function with a lower extremity prosthetic
device. Multiple studies have shown that the alignment of a prosthetic device (the relationship between the foot
and the socket) can effect function, comfort, energy expenditure skin health and quality as well as the ability to
ambulate (Schmalz, Blumentritt, Kelly, Nelson, Boone, Hannah and Collins). Additional studies have shown that
the alignment can change over time as the patient improves in strength, accommodates to the prosthesis
(whether it is above or below the knee) and improves in confidence (Hafner, Schmalz, Boone, Sjodahl, Gailey),
requiring a change in the alignment allowing for continued protection of the skin, comfort and function.
References
Xiaohong, J., Xiaobing, L., Peng, D., & Ming, Z. (2005). “The Influence of Dynamic Trans-tibial Prosthetic
Alignment on Standing Plantar Foot Pressure.” IEEE Med Biol Soc: Conference Proceeding, 6916-8.
Boone, David A., et al. "Influence of malalignment on socket reaction moments during gait in amputees with
transtibial prostheses." Gait & posture 37.4 (2013): 620-626.
Sjödahl, C., et al. "Kinematic and kinetic gait analysis in the sagittal plane of trans-femoral amputees before and
after special gait re-education." Prosthetics and orthotics international 26.2 (2002): 101-112.
Gailey RS, Clark CR. Physical therapy. In: Atlas of Amputations and Limb Deficiencies Surgical, Prosthetic and
Rehabilitation Principles, Smith DG, Michael JW, Bowker JH, eds. 3rd Ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2004.
Hannah, R. E., J. B. Morrison, and A. E. Chapman. "Prostheses alignment: effect on gait of persons with belowknee amputations." Archives of physical medicine and rehabilitation 65.4 (1984): 159-162.
Collins, DM, Karmarker A, RElich R, Pasquina PF, Cooper RA. “Review of research on prosthetic devices for lower
extremity.” Critical Review in biomedical Engineering 2006:34(5):379-438.
Kelly, Brian M., M. Catherine Spires, and Jose A. Restrepo. "Orthotic and prosthetic prescriptions for today and
tomorrow." Physical medicine and rehabilitation clinics of North America 18.4 (2007): 785-858.
Nelson, Virginia S., et al. "Limb deficiency and prosthetic management. 1. Decision making in prosthetic
prescription and management." Archives of physical medicine and rehabilitation 87.3 (2006): 3-9.
Hafner, Brian J., et al. "Evaluation of function, performance, and preference as transfemoral amputees transition
from mechanical to microprocessor control of the prosthetic knee." Archives of physical medicine and
rehabilitation 88.2 (2007): 207-217.
©2014 O&P Solutions, LLC, 8517 N Dixie Dr Ste 300, Dayton, OH 45414, 937.264.9400, F937.264.9401, OandPSolutions.net
L-Code
L5986
Description
ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL).
Justification
A multiaxial rotation unit is utilized between the socket (human interface) and the foot. It has been shown to
decrease the initial vertical ground reaction force and increases prosthetic foot compliance to uneven surfaces
and have “significant measurable and perceptible effects on gait” (Coleman) Motion is allow in all three planes
with this rotation unit in the form of inversion, eversion, and transverse rotation. Transverse rotation is
important in that it reduces shear forces transmitted to the residual limb and is an alternative to a rotation unit.
(Kapp). The incorporation of a transverse rotation mechanism contributes to both the comfort of the amputee
and the improvement of function and synchrony in walking. (Levens). In a sound limb, rotations occurring in
lower extremity appear to be absorbed in the articulations of the foot and their related ligamentous structures
as well as the knees and hips. (Levens) Further, deviations from normal transverse rotations will, to varying
degrees, modify the synchrony and rhythm of walking and increase discomfort to the patient. A multiaxial
rotation unit mimics natural foot and ankle motion in an attempt to minimize these deviations.
References
Coleman KL, Boone, DA, Smith DG and Czerniecki JM, Effect of Trans-Tibial prosthesis pylon flexibility on ground
reaction forces during gait, Prosthetics Orthotics International, 2001, 25: 195
Peng, Jia Xiaohong Li Xiaobing Dou, and Zhang Ming. The influence of dynamic trans-tibial prosthetic alignment
on standing plantar foot pressure." Engineering in Medicine (2006).
Twiste, Martin, and Shyam Rithalia. "Transverse rotation and longitudinal translation during prosthetic gait-a
literature review." Journal of rehabilitation research and development 40.1 (2003): 9-18.
Buckley, John G., Steven F. Jones, and Karen M. Birch. "Oxygen consumption during ambulation: comparison of
using a prosthesis fitted with and without a tele-torsion device." Archives of physical medicine and rehabilitation
83.4 (2002): 576-580.
Levens, A. S., Verne T. Inman, and J. A. Blosser. "Transverse rotation of the segments of the lower extremity in
locomotion." The Journal of Bone & Joint Surgery 30.4 (1948): 859-872.
Gard, Steven A., and Regina J. Konz. "The effect of a shock-absorbing pylon on the gait of persons with unilateral
transtibial amputation." Journal of rehabilitation research and development 40.2 (2003): 109-124.
Kapp, Susan and, Cummings, Donald. Transtibial Amputation: Prosthetic Management. In: Atlas of Limb
Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles, Smith DG, Michael JW and Bowker JH, eds, 2nd
edition, Ch 18, American Academy of Orthopaedic Surgeons, Rosemont IL, 1992.
©2014 O&P Solutions, LLC, 8517 N Dixie Dr Ste 300, Dayton, OH 45414, 937.264.9400, F937.264.9401, OandPSolutions.net