Methods: The guideline is based upon the best available evidence as it relates to socket design, interface, and suspension of definitive transtibial prostheses. Where possible, recommendations are drawn from systematic review and meta-analysis. Where this standard is unavailable, alternate academic literature has been used to support individual recommendations. 

Results: Recommendation 1: The static and dynamic pressure distribution of the residual limb within the socket are essential considerations in patient comfort, function and well-being. Recommendation 2: Total surface bearing sockets are indicated to decrease fitting times and enable higher activity levels. Recommendation 3: Compared to traditional foam-based interfaces, viscoelastic interface liners are indicated to decrease dependence on walking aides, improve suspension, improve load distribution, decrease pain and increase comfort. Recommendation 4: Among modern suspension options, vacuum assisted suspension (VAS) sockets permits the least amount of pistoning within the socket, followed by suction suspension and then pin-lock suspension. The traditional suspension options of supracondylar, cuff and sleeve suspension provide comparatively compromised suspension. Recommendation 5: VAS sockets are indicated to decrease daily limb volume changes of the limb in the socket while facilitating more favorable pressure distribution during gait. Recommendation 6: VAS sockets require both awareness and compliance on the part of the end user and are not universally indicated. 

Conclusions: These clinical practice guidelines summarize the available evidence related to the socket design, interface, and suspension of definitive transitibial prostheses. The noted clinical practice guidelines are meant to serve on as “guides.” They may not apply to all patients and clinical situations. (J Prosthet Orthot. 2019;31:172–178)