My first absolute rejection of elevated vacuum was a recent Syme patient. I know that others have worked out well, but this man could not get past the application, fitting and removal of the liner.

He is a large 70 year old gentleman with vascular insufficiency.  In designing his prosthesis,  I had to consider that, when sitting, he is not able to bend sufficiently to touch his shoe or lower half of his Syme prosthesis (therefore a window with a sleeve ovet it was out of the question). Currently he uses a system with a window which slips into a ledge distally and fastens with a strap proximally. For elevated vacuum I decided to try a custom gel liner  which is built up proximal to the malleoli so that he can slip it into a solid outer socket and seal it with a proximal sleeve. Alas, he was unable to don the liner in the normal way, by reflecting it back on itself, due to his limited range of motion. He could apply it with lotion and it was very comfortable. But then he could not remove the liner independently.  After several liner designs and several socket designs, we are abandoning elevated vacuum for him. This does not mean that I would not fit elevated vacuum to the next Syme patient I see, but it means that it is not for everyone.