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LOWER LIMB ORTHOSISByDr. Aliaa El-HadyMD. Rheumatology & Rehabilitation

An orthosis (orthotics) is a device that is applied externally to a part of the body.

The word is derived from ortho, meaning straight.

Brace: is a device that corrects irregularities.

Splint: usually used after surgery and restrict movements.

The orthotist is the person who designs, fabricates and repair the orthotic device.

Indications for recommending orthotic devices:

To relief pain.To limit motion (immobilization after surgery, after traumatic injury, Compression # management & Kinesthetic reminder to avoid certain movements).To correct deformity e.g. Scoliosis management To relieve symptoms of a disease by supporting or assisting the MSk & neural systems.To reduce axial loading, mechanical unloading To improve function in a certain segment of the body. Assist and improve movement and functionReduce muscle tone.Protect against injury.Provide proprioceptive feedback.Provide rest.

Design characteristics of an orthotic device: Most important features include the following: Weight of the orthosis Adjustability Functional use Cosmoses Cost Durability Material Ability to fit various sizes of patients Ease of putting on (donning) and taking off (doffing) Access to tracheostomy site, peg tube, or other drains Access to surgical sites for wound care Aeration to avoid skin maceration from moisture

Duration of orthotic use:

It is determined by the individual situation.

In situations where instability is not an issue, recommend use of an orthosis until the patient can tolerate discomfort without the brace.

When used for stabilization after surgery or acute fractures, allow 6-12 weeks to permit ligaments and bones to heal.

Effects of the orthosis may lead to:Decrease pain Increase strength Improve function Increase proprioception Improve posture Correct of spinal curve deformity Protect against spinal instability Minimize complications Assist healing of ligaments and bones

Associated drawbacks of the use of an orthotic device:Discomfort Local pain Skin breakdown Nerve compression Muscle atrophy with prolonged use Decreased pulmonary capacity Increased energy expenditure with ambulation Difficulty donning and doffing orthosis Difficulty with transfers Psychological and physical dependency Increased segmental motion at ends of the orthosis Poor patient compliance

Benefits of orthosis:Improve function.Save energy.Increase endurance.

Disadvantages & limitations of orthoses:Limit mobility and ROM of the joint.Restrict rotation around a joint.Movement is usually limited to certain direction.Weakness of other muscles in opposite direction.The device is exposing to wear and tear. It needs maintenance, care, cleaning, repairing, and frequent changing of shoes.

Principles and consideration for orthoses:Orthosis should :

provide support and stability to the hip, knee and ankle joints.be designed to permit safe and effective ambulation by patients.Provide the need and requirements of the patient to support or to mobilize.Correlate to the findings of tests & measurements.Correlate with pateint personality and the impact of device upon him.

Principles and consideration for orthosis (cont.):

Prevent the development of deformity and require modifications in design.

Orthosis is only one component of the treatment and is not the whole treatment.

Conserve the time and energy of the patient.

The materials used should be light, sturdy and resistance to wear.

Maintenance of orthosis:Patient should be taught for:Cleaning the leather.Oiling the joints.Wash the orthosis if possible.

Types of orthosisTemporarily orthosis: Used for certain time after injury or operation.Permanent orthosis: Used for ever when there is muscle weakness, paralysis or deformity cannot be corrected.Static orthosis: does not allow movement.Dynamic orthosis : allows movement.

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MATERIALSAn orthosis can be constructed from metal, plastic, leather, synthetic fabrics, or any combination. Plastic materials, such as thermosetting and thermoplastics, are the materials most commonly used in the orthotic industry.

Lower limb orthoses

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THE SHOE

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Functions of the shoesTo minimize pressure on sensitive, deformed structuresTo redistribute weight towards pain-free areasTo serve as foundation of an orthosis

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Sole

Heel

Upper

LiningReinforcementsComponents of a Shoe

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Lies under the anatomic heelThe higher the heel, the more weight is shifted to the forefootLeg length discrepancy < 2.5 inches - internal heel elevation > 2.5 inches - external heel sole elevation HEEL

Spring (1/8)

Cuban (12/8)

Military (10/8)

Oxford (6/8 8/8)TYPES OF HEEL HEIGHTS

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Outer SoleContacts the floorResilient outer sole to cushion impact

Inner SoleLies under the footFiller: separates the inner from the outer sole

Midsole for athletic shoes

SOLE

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VampQuarters

UPPERS

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Tongue

ThroatEyelets

Lace stay

AgletsVamp

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Helps keep feet inside the shoe

Adjustable versus non-adjustableClosures

Zippers

Elastic Webbing InsertNon-adjustable Closures

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Adjustable ClosuresCotton laces

Elastic shoe laces

Velcro Flaps

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HighQUARTERSLow

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CounterToe BoxShank PieceReinforcements

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Reinforced Toe Box

Balls

Breasts

Tongue

Throat

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Model over which the shoe is madeLasts

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StraightInflaredOutflaredTypes of Lasts

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Transfer forces from sensitive to tolerant areasReduce friction and shear on sensitive areasModify weight transfer patternsCorrect flexible deformitiesAccommodate fixed deformitiesLimit motion of painful, inflamed or unstable joints

Internal versus ExternalShoe Modifications

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disadvantageadvantageShoe Modifications

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External Shoe ModificationsHeel Modifications

Sole Modifications

Combination Heel and Sole

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1-Cushion HeelHeel Modifications

Is made of resilient material to absorb shock at heel strike, because it provides slight planter flexion

It is indicating when the patient wears an orthosis with a rigid ankle, it reduces the knee flexion moment by allowing a more rapid ankle plantar flexion.

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Heel Modifications

2-Heel Flare

A medial flare is used to resist hind foot eversion A lateral flare is used to resist inversion.Both flares are used to provide heel stability.

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Heel Modifications3-External Heel Wedge

Medial wedge: Is used to promote hind foot inversion.Incorporated in Thomas heel, intended for flexible pes valgus. The ant. border of Thomas heel extended formed on the medial side to augment the effect of medial wedge to support the longtudinal arch.Lateral wedge: Is used to promote hind foot eversion.Shifts wt. bearing to the medial side of forefoot. It compensates for fixed forefoot valgus, allowing the entire forefoot to contact the floor.The exact elevation of the wedge is determined by the height needed to place the calcaneus in near- vertical position.

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Extended (Thomas) HeelReversed Extended (Thomas) HeelHeel Modifications

4- Extended heel (Thomas heel): a wedge with an extended anterior medial border used to support the longitudinal arch and correct for flexible pes valgus (pronated foot) Reverse Thomas heel: It projects anteriorly on the lateral side to provide stability to the lateral longtudinal arch.

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5- Heel ElevationHeel Modifications

A shoe lift is used to compansate for fixed equinus deformity or for any leg-length discrepancy of less than inch

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Sole Modifications

Rocker Bar1- Rocker Bar

Is a convex structure placed posterior to the metatarsal head to metatarsal shaft to avoid irritation of ulcers along a metatarsal head in patients with DM.

It also decreases demands on the plantar flexors.

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Rocker bottomIt builds up the sole over the metatarsal heads and improves push off in weak or inflexible feet. May also be used with insensitive feet

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Sole Modifications

2- Metatarsal BarMetatarsal Bar

Is a flat leather bar placed across the sole posterior to metatarsal head.It is used to relieve the pressure from the metatarsal heads.

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3-Sole WedgeSole Modifications

This alters mediolateral metatarsal alignmentA medial wedge is used to promote forefoot supination.A lateral wedge is used to provide pronation.

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Sole Modifications4- Sole Flare

A medial flare is used to resist eversion.A lateral flare is used to resist inversion.Both flares promote great stability.

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5- Steel sole barInserted between the inner and outer solesApproximately 0.2 cm thick, 1.5 cm wide, and extends from a point 1cm anterior to the posterior edge of the heel counter to 1 cm posterior to the anterior edge of the toe boxPrevents motion of the anterior portion of the sole reduce stress on the phalanges and metatarsals in the presence of fractures.Used with a rocker bar to assisst rolloverSole Modifications

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6- Combination of sole and heel modificationsShoe lifts and wedges can be combined in both the heel & sole

Heel Modifications Sole Modifications Foot Orthoses (inserts/inlays)Internal Shoe Modifications

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Internal Heel Modifications

1- Heel Cushion Relief:

A soft pad with excavation which may be filled by a compressible material is placed under the painful point of the heel.

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2- Heel Wedge

Internal Heel Modifications

A medial heel wedge can rotate a flexible hind foot into inversion.A lateral wedge can evert a flexible hind foot to avoid pressure on the cuboid.It also increases the weight bearing area and can be used in fixed pes varus.

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1-Inner Sole ExcavationA soft pad with excavation which may be filled by a compressible material is placed under one or more painful metatarsal heads.Excavation is cushioned to protect tender bony prominenceInternal Sole Modifications

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2- Metatarsal Pad Internal Sole Modifications

A domed pad is designed to reduce the stress from metatarsal heads by transferring the load to metatarsal shafts in metatarsalgia.

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Internal Sole Modifications3- Toe Crest

A crescent-shaped pad is placed behind the 2-4 phalanges to fill the void under the proximal phalanges and reduces the stress.

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Internal Sole Modifications4- Scaphoid pad:A rubber, cork or plastic foam wedge is extended from posterior to the 1st metatarsal head to the ant. tubercle of the calcaneus.The apex of the scaphoid pad is between the talonavicular jt. & the navicular tuberosity.The scaphoid pad is used for medial arch support & prevents depression of the subtalar joint.

Foot Orthoses (inserts/inlays)UCBL (University of California at Berkeley Laboratory)insert.Heel cup.Sesamoid insert.Longtudinal arch insert.A foot orthosis is a rigid, semi-rigid, or flexible insert into the shoe and surrounds the foot medially & laterally below the ankle.It is used to provide support under the arch, the metatarsals, &/or the heel to prevent, correct or accommodate foot deformities that improves overall function of the foot.

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Foot Orthoses (inserts/inlays)

This insert is made of rigid plastic, fabricated over a cast of the foot held in maximal manual correction.It extends from the post. border of the foot to a point just post. to the metatarsal heads.It encompasses the heel & mid-foot & has rigid medial, lateral, & post. walls.It is used to accommodate a flexible abnormal foot to help restore more normalized lower limb biomechanics.1- UCBL (University of California at Berkeley Laboratory)insert.

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2- Heel Seat/Heel CupFoot Orthoses (inserts/inlays)

Is a rigid plastic insert that covers the plantar surface of the heel and extends posteriorly, medially and laterally up the side of the heel.It is used to prevent lateral calcaneal shift in the flexible flat foot.

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3-Sesamoid Platform insertIs an insert amounting to length with an extension under the hallux Stabilizes the first metatarsalReduces excessive pressure on the head of the first metatarsal by transferring some of the load to the MT shafts

Foot Orthoses (inserts/inlays)

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4- Longtudinal arch support

Foot Orthoses (inserts/inlays)This can be applied medially to support the medial longtudinal arch or laterally to support the lateral longtudinal arch.Prevent depression of the subtalar joint and correct for pes planus (flat foot)

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ANKLE-FOOT ORTHOTICSAFO

AFOAn AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexion, plantar flexion, inversion, and eversion to enhance toe pickup during the swing phase, simulate push-off and provide mediolateral stability during the stance phase.

AFOs are used to prevent or correct deformities and reduce weight bearing.

An AFO has been shown to reduce the energy cost of ambulation in a wide variety of conditions, such as spastic diplegia in CP, LMNL weakness of poliomyelitis, and spastic hemiplegia in cerebral infarction.

As the position of the ankle indirectly affects the stability of the knee, the best selected orthosis is the one that can balance the floor reaction force to the patients advantage by reducing deforming forces & allowing a normal gait.

AFO

Controls the alignment & motion of the foot & ankleApplies a three-point pressure system

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AFO

These devices are plastic molded AFOs, consisting of the following 3 parts: a shoe insert, a calf shell,a calf strap attached proximally. The rigidity depends on the thickness and composition of the plastic, as well as the trim line and shape. Thermoplastic AFOs are contraindicated in cases of fluctuating edema and insensation & inadequate hip & knee strength. Thermoplastic AFOs

The Trim line:Is the border of the orthosis, the location of which is a factor in determining the level of support or flexibility available.

1- Posterior leaf spring (PLS): The PLS is the most common form of AFO with a narrow calf shell and a narrow ankle trim line behind the malleoli. The PLS is used for compensating for weak ankle dorsiflexors.During early stance, the narrow part resists ankle plantar flexion and bends slightly backwards then during the swing phase it recoils to lift the foot into nuteral position.The orthosis has no mediolateral control. Thermoplastic AFOs

Swedish AFOA moulded polyethylene splint providing dorsiflexion assistance for the full length of the foot.Indications for Use: Flaccid drop foot-Post stroke patientsFeatures and Benefits:Made of durable plasticEncourages improved toe clearance in normal gait

2-Spiral AFO: This AFO consists of a shoe insert, a spiral that starts medially, passes around the leg posteriorly, then passes anteriorly to terminate at the medial tibial flare where a calf band is attached. The spiral AFO allows for limited rotation in the transverse plane while controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion. These orthosis are indicated in the presence of weal ankle dorsiflexors or plantar flexors with moderate mediolateral instability & mild weakness of knee extensors.They are contraindicated in pronounced imbalance of forces acting on the foot-ankle complex, moderate to severe spasticity, severe mediolateral instability & fixed ankle deformity.Thermoplastic AFOs

3- Hemispiral AFO: This AFO consists of a shoe insert with a spiral starting on the lateral side of the shoe insert, passing up the posterior leg, and terminating at the medial tibial flare where the calf band is attached. This design is used for achieving better control of equinovarus than the spiral AFO can. Thermoplastic AFOs

4- Solid AFO: The solid AFO has a wider calf shell with trim line anterior to the malleoli. This AFO prevents ankle dorsiflexion and plantar flexion, as well as varus and valgus deviation. Thermoplastic AFOs

5- AFO with flange: This AFO has an extension (flange) that projects from the calf shell medially for maximum valgus control and laterally for maximum varus control. Thermoplastic AFOs

6- Articulated or Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion. Thermoplastic AFOs

Thermoplastic AFOs

Thermoplastic AFOs7- Ground-reaction AFO: This orthosis is molded to fit around the front of the leg and foot.Straps on the back of the leg (lower & upper parts) hold the heel & leg in place.These straps & the ant. shell limit the forward promoting knee extension.

This orthosis is used in the presence of correctible knee flexion contractures or flexible ankle dorsiflexion contracture and contraindicated when these contractures are fixed7- Ground-reaction AFO:

8- Tone-reducing AFO (TRAFO): The broad footplate is used to provide support around most of the foot, extending distally under the toes and up over the foot medially and laterally to maintain the subtalar joint in neutral foot position and hyperextending the toes.

The TRAFO is indicated for patients with spastic hemiplegia.Thermoplastic AFOs

Specialized AFOsPatellar-tendon-bearing brim: allows for weight distribution on the patellar shelf similar to patellar-tendon-bearing prosthetic socket; reduces weight bearing forces through the foot.PTB, specific weight bearing or total surface bearing, TSB (inverted cone with lace closure) to unweight the ankle foot using prosthetic principles

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Immobilizing AFO- Cam walkersCommonly used with a lower extremity deficiency when ankle immobilization is desired distal tibia/ fibula fracture foot bone fractures tendocalcaneus rupture Diabetic Foot (Charcot Foot)

Specialized AFOs

Other AFOsFabric, Air, Leather and Gel Supports

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Leather & metal AFO

Stirrup: These are steel plates bent in a U shape that anchors the uprights to the shoes between the sole and the heel, with the upper part forming part of the ankle joint.A solid stirrup is riveted to the shoe, while a split stirrup, placed in the heel of the shoe, allows for easy detachability of the uprights.

Leather & metal AFO

Foot Plate: a molded plastic shoe insert; allows application of the brace before insertion into the shoe, ease of changing shoes of same heel height.

This type of AFO consists of a shoe or foot attachment, ankle joint, 2 metal uprights (medial and lateral), with a calf band (application of force) connected proximally. The stirrup anchors the uprights to the shoes between the sole and the heel. A molded shoe insert is another alternative to fit the stirrup into the shoe, which also allows maximum control of the foot and aligns the anatomic and mechanical ankles.Metal & metal plastic AFOs

The axis of the mechanical ankle jt. should be aligned at the same level with the axis of anatomical joint that runs through the malleoli.

The mechanical ankle joints can control or assist ankle dorsiflexion or plantar flexion by means of stops (pins) or assists (springs).

The mechanical ankle joint also controls mediolateral stability.

Knee extension moment is promoted by ankle plantar flexion, and knee flexion moment is promoted by ankle dorsiflexion. Ankle joints: Leather & metal AFO

1- Free motion ankle joint: The stirrup has a completely circular top, which allows free ankle motion and provides only mediolateral stability.

Ankle joints & controls

2-Plantar flexion ankle joint stop: This joint stop restricts plantar flexion but allows unlimited dorsiflexion.It is produced by :1-a pin inserted in the posterior channel of the ankle joint 2-or by flattening the posterior lip of the stirrup's circular stop. 3- or by a posterior angulation at the top of the stirrup It promotes knee flexion moment at heel strike. Adjusting the stop in 5 plantar flexion attenuates the duration and magnitude of this moment.This design is used in patients with weakness of dorsiflexion (foot drop) during swing phase and flexible pes equinus.

Ankle joints & controls

3- Dorsiflexion ankle joint stop: The stirrup has a pin inserted in the anterior channel of the ankle joint or by flattening the anterior lip of the stirrup's circular stop. The dorsiflexion stop has an anterior angulation at the top of the stirrup that restricts dorsiflexion but allows unlimited plantar flexion and promotes a knee extension moment in the meantime. This design is used in patients with weakness of plantar flexion during late stance.

Ankle joints & controls

4- Limited motion ankle joint stop: This ankle joint stop has anterior and posterior angulations at the top of the stirrup with restricted dorsiflexion and plantar flexion ankle motion. The limited motion ankle joint stop has a pin in the anterior and the posterior channel, and it is used in ankle weakness affecting all muscle groups.

Ankle joints & controls

Ankle joints & controls

Double stop

Ankle joints & controls

Ankle joints & controls

5- Dorsiflexion assist spring joint (Klenzak joint):This joint has a coil spring in the posterior channel of the stirrup to counteract plantar flexion and aid dorsiflexion during the swing phase.It is indicated when muscle function allows a normal range of plantar and dorsiflexion, but dorsiflexor muscles are inadequate.Flexion moment at the knee is less than that of a posterior stop.

Ankle joints & controls

Ankle joints & controls

6- Varus or valgus correction straps (T-straps): A T-strap attached medially and circling the ankle until buckling on the outside of the lateral upright is used for valgus correction. A T-strap attached laterally and buckling around the medial upright is used for varus correction.

Ankle joints & controls

Valgus-Varus Correction StrapsLateral T-strapVarus correction strapMedial T-strapValgus correction strap

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Leather and Metal AFOs Problems Foot drop/ pawing/ scuffing of the toebox

Calcaneal gait

Knee buckling

Severe recurvatum

Extensor spasticity (circumducting gait)

Flexor spasticity

Appropriate Type of Stop

PF stop preset at 0 degreesDF stop preset at 0 degreesPF stop preset at 5 degrees of PF DF stop preset at 5 degrees of DF PF stop preset at 5 degrees of DF

DF stop preset at 5 degrees of PF

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Uprights and attachmentsConventional AFOs have metal uprights (aluminum, carbon graphite or steel) and a hinged ankle joint allowing plantarflexion and dorsiflexion. Provides maximum support if the patients condition is changing (e.g. peripheral edema), conventional metal AFOs may be easier to alter to accommodate changes than molded AFOs.

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Double metal uprights extend upwards from the ankle on both sides of the leg and attach to a calf band.Conventional AFO, calf band (metal with leather lining or plastic); provides proximal stabilization on leg; anterior opening and buckle or velcro closure. Calf bands

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Indicated when lesser devices are biomechanically insufficient; combines KO & AFOConsists of a shoe attachment, ankle control, uprights, knee control, and bands or shells for the calf and thighKnee-ankle-foot orthosis (KAFO)

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KAFOKAFO can be used in quadriceps paralysis or weakness to maintain knee stability and control flexible genu valgum or varum.These orthosis can be made of metal-leather and metal-plastic or plastic and plastic-metal.The metal designs include double upright metal KAFO (most common), single upright metal KAFO (lateral upright only), and Scott-Craig metal KAFO.The plastic designs are indicated for closer fit and maximum control of the foot, including supracondylar plastic KAFO, supracondylar plastic-metal KAFO and plastic shells with metal uprights KAFO.A KAFO is more difficult to don & doff than an AFO, so it is not recommended for patients who have moderate-to-severe cognitive dysfunction.

This is an AFO with two/single metal uprights extending proximally to the thigh to control knee motion & alignment.This orthosis consists of mechanical knee joint and 2 thigh bands between 2 uprights.

Single/Double Bar KAFOKAFO

This design is intended for standing & ambulation of paraplegic adults based on eliminating unnecessary structural elements to make it more functional and easier to don & doff.

It consists of a cushioned heel with a T-shaped foot plate for mediolateral stability, ankle joint with anterior and posterior adjustable stops, double uprights, a pretibial band, a posterior thigh band and knee joint with pawl locks and bail control.Scott-Craig orthosisKAFO

Hyperextension of the hip allows the center of gravity falling behind the hip joint and in front of the locked knee and ankle joint.With 10 of ankle dorsiflexion alignment, it allows a swing-to-or swing-through gait with crutches.

Scott-Craig orthosisKAFO

Oregon orthotic system: a combination of plastic and metal components allows for triplanar control in three plans of motion(sagittal, frontal, and transverse)KAFO

KAFOSupracondylar plastic orthosisResists hyperextension at the knee without hindering flexion, thus is used to eliminate the need for a mechanical knee lock.It also resists genu recurvatum and provides mediolateral knee stability.

KAFOPlastic shell & metal upright orthosis:Consists of a posterior leaf spring AFO with double metal uprights extending up to a plastic shell in the thigh with an intervening knee joint

KAFOBilateral KAFO:Typically used 2ry to spinal cord injury when paraplegia or paraparesis is present.A spreader bar can be added to lock a pair of KAFOs together.The functional use of this orthosis entails training in the swing-to & swing-through type of ambulation.

Fracture braces: a KAFO device with a calf or thigh shell that encompasses the fracture site and provides support.More customizable - Better load distribution.Includes Sarmiento Style Fracture Bracing.

Total Contact KAFO- fracture brace:KAFO

Ischial containment or Quadrilateral style brims with high trimlines. Generally used with paralytic limbs. Not as effective with larger or obese individuals.

Ischial Weight Bearing (unweighting) KAFOKAFO

Functional electrical stimulation (FES) orthosis:

Orthotic use and functional ambulation is facilitated by the addition of electrical stimulation to specific muscles; the pattern and sequence of muscle activation by portable stimulators is controlled by an externally worn miniaturized computer pack; requires full passive range of motion good functionalKAFO

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Functional electrical stimulation (FES) orthosis:

KAFOKnee cap & strap:

The knee cap can be placed in front of the knee in the orthosis to prevent flexion of the knee.A medial strap is used for genu valgum and a lateral strap is used for genu varum.These buckles wrap around the upright on the opposite side.

KAFOKnee ControlsHinge joints provides mediolateral and hyperextension control while allowing for flexion and extension.

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1-Free motion knee joint: This joint has unrestricted knee flexion and extension with a stop to prevent hyperextension. The free motion knee joint is used for patients with recurvatum but good strength of the quadriceps to control knee motion.

KAFO- Knee Controls

2-Offset knee joint: The hinge is located posterior to the knee joint and ground reaction force; thus, it extends the knee and provides great stability during early stance phase of the gait cycle. This joint flexes the knee freely during swing phase and is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop.

KAFO- Knee Controls

3-Drop ring lock knee joint: The drop ring lock is the most commonly used knee lock to control knee flexion. The rings drop to unlock over the knee joint while the knee is in extension by gravity or manual assistance. This type of joint is stable, but gait is stiff without knee motion.A ball bearing on a spring can be added just above the drop lock to keep it from slipping up as the patient ambulates.Patients over 120 pounds usually feel more secure with both medial and lateral drop locks.

KAFO- Knee Controls

4-Pawl lock with bail release knee joint: The semicircular bail attaches to the knee joint posteriorly, and it can unlock both joints easily by pulling up the bail or backing up to sit down in a chair. A major drawback is the accidental unlocking while the patient is pulling his or her pants up or bumping into a chair.

KAFO- Knee Controls

5-Adjustable knee lock joint (dial lock): The serrated adjustable knee joint allows knee locking at different degrees of flexion. This type of knee joint is used in patients with knee flexion contractures that are improving gradually with stretching.

KAFO- Knee Controls

6-Spring assist knee joint- Ratchet lock:

The ratchet knee joints lock automatically while standing as long as the lock mechanism is engaged (catching mechanism). Start standing with knee extension knee flexion is achieved by pressing down the released lever. Prevents unstabilities or flexion movements of knee and keep gain towards extension.KAFO- Knee Controls

7- The polycentric knee joint:It uses a double-axis system to simulate the flexion-extension movements of the femur and tibia at the knee joint. Although this concept is theoretically sound, the polycentric knee joint has not proved to be advantageous over the straight-set knee joint, and it is less commonly used. It also adds bulk to the orthosis.It is most frequently used in sport knee orthoses.KAFO- Knee Controls

HKAFO Hip Knee Ankle Foot Orthosis

Very restrictive and laborious to swing-to or through in gait

Hip Knee Ankle Foot Orthosis (HKAFO)

Hip joint: typically a metal hinge jointControls for abduction, adduction and rotationControls for hip flexion when locked, typically with a drop ring lock; a locked hip restricts gait pattern to either a swing to or swing through gaitPelvic attachmentsA leather covered, metal pelvic band; attaches the HKAFO to the pelvis between the greater trochanter and iliac crest; adds to difficulty in donning and doffing; adds weight and increases overall energy expenditure during ambulation.HKAFO

Specialized HKAFO

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Standing FramesAllows standing without crutch support may be stationary or attached to a wheeled mobility base

ParapodiumAllows for standing without crutch support; also allows for ease in sitting with the addition of hip and knee joints that can be unlocked can be used on children with myelodysplasia

THKAFO & Parawalker

Utilizes plastic molded solid ankle orthoses with locked knees, plastic thigh shell, a hip joint with pelvic and trunk bands; the hips are connected by steel cables which allow for a reciprocal gait pattern (either 4point or 2point); when the patient leans on the supporting hip, it forces it into extension while the opposite leg is pushed into flexion allowing limb advancement

Reciprocating Gait Orthosis (RGO)

Contains a trunk band added to a HKAFO

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The RGO is appropriate for children who have used the standing frame, developed good trunk control and coordination, can safely stand and are mentally prepared for ambulation. Good upper limb strength, trunk balance and active hip flexion are important positive variables. Commonly used in cases of spina bifida and spinal cord injury.

Reciprocating Gait Orthosis (RGO)

Patten Bottom

Knee Orthoses (KO)

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1- Knee orthosis for patellofemoral disorders:These orthosis are used to supply mediolateral knee stability & to control tracking of the patella during knee flexion & extension.

These orthoses include the :-Infrapatellar strap KO-Patellar stabilizer brace (Palumbo KO)

Infrapatellar strap KO

Patellar stabilizing braces (Palumbo KO)Improve patellar tracking; maintain alignmentLateral buttress or strap positions patella mediallyA Central Patellar cutout may help positioning and minimizes compression

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2- Knee orthosis for knee control in the sagittal plane:These orthosis are used to control genu recurvatum, which occurs due to tight calf muscles or weak knee extensors with minimal mediolateral stabilization.

These orthoses include the :-Swedish knee cage-Three way knee stabilizer

Swedish Knee Cage Used to control minor to moderate genu recurvatum due to ligamentous or capsular laxity. The articulated version of the orthosis allows full knee flexion and prevents hyperextension.

Swedish Knee Cage It uses a three point system with two bands placed anterior to the knee axis (one above and one below the knee) and a third band posterior to the knee joint in the popliteal area. It also has a thigh band with longer uprights to obtain better leverage at the knee joint.

Three-way knee stabilizer:

Three-way knee stabilizer:

Three-way knee stabilizer:

3- Knee orthosis for knee control in the frontal plane:These orthosis consist of thigh and calf cuffs joined by sidebars with mechanical knee joints.The knee joint is usually polycentric that closely mimics the anatomic joint motion.

These orthoses include the :-Traditional metal-leather KO-Supracondylar KO

Traditional metal-leather knee orthosis with leather thigh and caffs and metal side bars

Supracondylar knee orthosisResists hyperextension at the knee without hindering flexion, thus is used to eliminate the need for a mechanical knee lock.It also resists genu recurvatum and provides mediolateral knee stability.

4- Knee orthosis for axial rotation control:These orthosis can provide angular control of sagittal (flexion-extension) & frontal (mediolateral) planes in addition to controlling axial rotation.This orthosis is used mostly in management of sports injuries of the knee.

These orthoses include the :Articulated hinged knee orthosis

Articulated hinged KO: control knee motion and provide added stability.Post surgery KO protects repaired ligaments from overloadFunctional KO is worn long-term during selected activitiesExamples include: Lenox Hill, Pro-Am, Can-Am, Don Joy

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Lenox HillDonjoy

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Nylon coated rubber materialProvide compression, protection and proprioceptive feedbackProvide little stabilization unless metal or plastic hinges are addedRetains body heat which may increase local circulationA central cut out minimizes patellar compressionCan be used in other areas of the body such as the elbow and thigh etc

Neoprene sleeves

Specialized KO

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Knee Immobilizers KOSpecialized KO

Hip Orthosis (HO)Hip Abduction OrthosisStanding Walking And Sitting Orthosis (SWASH)Some Orthoses can intervene at the hip without crossing the hip.

Hip Abduction OrthosisCommonly used post-operatively to position the femoral head optimally within the acetabulum. Hip Abduction orthoses can be an HO only or can have a KAFO extension.

Specific Case Hip Orthosis (HO):S.W.A.S.H OrthosisStanding Walking And Sitting Hip OrthosisMaintains femoral abduction in standing, walking and sitting hip dislocation rate in CP, scissoring gait, sitting balancePlastic pelvic section and malleable cuffs. 115 or 123 uprights.

Dennis Brown Bars

static correction off shelf straight or reverse last boots bar maintains external rotationAluminium crossbar with rotation adjustable end plates.

Designed to provide adjustable abduction and adduction control.Nylon ball and socket joints duplicate the anatomical motion of the hip. Breathable neoprene liners discourage limb migration during gait training or limited ambulation.Indications in Post-surgical hip conditions, or Legg Perthes Disease.Hip ABDUCTION BARS

Hip control orthosisInternal rotation control strapsExternal rotation control straps

Special purpose orthosis-Angular & rotational deformities-Congenital hip dysplasia-Legge-Calve-Perthes Disease-Spinal cord injury levels

Congenital Talipes Equinovarus (CTEV)1:1000 live births, male:female 2:1, 50% bilateralhindfoot equinus, Subtalar varus/inversion, cavus, forefoot adduction

Angular & rotational deformities

Newborn -> 3/12, 85%-95% success, application criticalsafe zone (100-110 flexion, 60-80 abduction) allows movement within rangeno place for double nappies

Developmental Hip Dysplasia (DDH)

RHINO BRACEFunction:To hold hips in the correct abduction position, but flexible enough to allow walking.Description: A moulded plastic orthosis with foam lining. Anterior velcro closures strap around the abdomen and thigh shells.Indications:Hip Dysplasia.

VON ROSEN SPLINTFunction: To rigidly maintain the hips in flexion and abduction.Indications:Congenital dislocation of the hip

PAVLIK HARNESSFunction: To maintain hips in desired degree of flexion and abduction, whilst encouraging active motion.Description: The harness fits over the torso and straps embrace the legs. Pelite booties and chest strap are perforated for ventilation. Leg straps are adjustable.Indications: Congenital dislocation or subluxation of the hip.

Legg-Calve-Perthes Disease Orthosis

Legg-Calve-Perthes Disease OrthosisAtlanta Orthosis

Legg-Calve-Perthes Disease Orthosis

Scottish Rite orthosis

Custom made for Perthes disease, this brace holds the hips in a determined degree of abduction whilst permitting flexion and thus mobility. Used also following surgical procedures to maintain the hips in the desired degree of abduction during the healing phase. Hip joints are now available which permit selection of abduction.