Alpha DESIGN® BK Liners Order Form Important Casting & Marking Guidelines This form will allow you to order an Alpha DESIGN® Liner with custom modifications for either a "Standard" shaped BK limb or for a "Symes" shaped BK limb. Below are diagrams that explain what the custom profile of each type will be. For greater control over the design ask WillowWood about the OMEGA® Scanner 3D and the Alpha DESIGN Liner wizard. Maximum of 25 mm thickness. ForFor a astandard standard Alpha Alpha DESIGN BK BK Liner Liner ForFor aa SymesSymes AlphaAlpha DESIGN DESIGN BK BK Liner Liner from a cast, fromfrom a acast, cast thethe standardprofile will base be: gel would be: thefrom standard a cast the base profile gel will would be: be: • 6*6 mm mm basebase thickness •*3 3 mmmm base base thickness thickness • 9*9 mm mm distal distal thicknessthickness over thethe distal distal fibula fibula and and tibia tibia •*3 3 mmmm of of proximally proximally above above the the socket socket • 3*3 mm mm proximally proximally above thethe socket socket •*3 3 mm posteriorly posteriorly behind behind the the patella patella • 3*3 mm mm posteriorly posteriorly behind the the patella patella •*Up Up toto 2525 mm mm to to fill fill the the necking necking area area above above the the malleolus. malleolos • 9*9 mm mm over over thethe fibulafibula head This area willwill be filledfilled to to create create a morea more cylindrical cylindrical shaped shaped limb. limb •*6 6 mm over over fibula fibula head head

3 mm 3 mm Patella

Please wrap Please wrap plaster 5" (12 cm) plaster 5" (12 cm) above MPT above MPT

9 mm (Fib Head) 9 mm6 mm (Fib Head)

Additional thickness to 25 mm 6 mm

9 mm This is defined as the distal end. 3 mm Base This is defined as the distal end.

Proximal View See the diagram below for the marks that must be indicated on the cast. Missing marks may result in no additional gel at theProximal location andView may delay the order. Patella Distal FibulaPatella See the examples for the marks that Patella Fibula Head must be indicated MPT on the cast. MPT Distal Fibula Missing marks MPT Bar may result in no Distal Tibia additional gel at the location and may delay the order. Distal Tibia Fibula Head Distal Tibia Fibula Head Lateral Malleolus

Please Note: • For bilateral amputees, please use separate forms for each residual limb for best socket/liner accuracy. • When casting, please cast patient at least 4” to 5” above the knee. • Please make sure to include the patient ID on the cast.

PN-1773-Y 17 NOVEMBER 2015