prosthetics and orthotics manufacturing guidelines: lower limb orthotics: ankle-foot orthosis
TRANSCRIPT
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 1/31
Physical Rehabilitation Programme
ankle-Foot orthosis
Manufacturing guidelines
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 2/31
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: [email protected]
www.icrc.org
© ICRC, September 2006
All photographs: ICRC/PRP
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 3/31Manufact uring Guid el ines Ankle-Foot Ort hosis
Tae o contents
Foreword 2
Introduction 4
Choosingbetweendierentdesigns 4
Castingandrectication 5
1.FlexibleAFO 6
1.1MouldingoEVA 6
1.2Orthosistrimline 6
1.3Vacuummouldingothepolypropylene 6
1.4Preparationothepolypropyleneshell 7
1.5Preparationothestraps 8
1.6Initialttingandnishing 8
2.RigidAFO 82.1MouldingoEVA 8
2.2Orthosistrimline 9
2.3Plasticreinorcement 12
2.4Vacuummouldingothepolypropylene 13
2.5Preparationothepolypropyleneshell 14
2.6Proximalstrap 14
2.7Distalstrap 15
2.8Instepstrap 16
2.9Initialttingandnishing 183.AFOwithamarackFlexureJointM 18
3.1MouldingoEVA 18
3.2Orthosistrimline 18
3.3Plasticreinorcement 18
3.4InstallationoamarackFlexureJoint M 19
3.5Vacuummouldingothepolypropylene 19
3.6Preparationothepolypropyleneshell 20
3.7Preparationothestraps 22
3.8Initialttingandnishing 224.AFOanti-talus(anteriorshell) 22
4.1MouldingoEVA 22
4.2Orthosistrimline 23
4.3Plasticreinorcement 24
4.4Vacuummouldingothepolypropylene 24
4.5Preparationothepolypropyleneshell 25
4.6Preparationothestraps 26
4.7Initialtting 26
4.8Finishing 26
Listomanuacturingmaterials 27
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 4/31 ICRC P hysical Rehab i l i t at ion P rog ramme
Foreor
Te ICRC poypropyene tecnooy
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuseotechnologythatisappropriatetothespeciccontextsinwhichtheorganizationoperates,i.e.,countriesaectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsothephysicallydisabledinthecountriesconcerned.
Tetechnologyadoptedmustthereorebe:
• durable,comortable,easyorpatientstouseandmaintain;• easyortechnicianstolearn,useandrepair;• standardizedbutcompatiblewiththeclimateindierentregionsotheworld;• low-costbutmodernandconsistentwithinternationallyacceptedstandards;• easilyavailable.
Techoiceotechnologyisogreatimportanceorpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreerredtodevelopitsowntechniqueinsteadobuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.TecostothematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatothematerialsusedinappliancesassembledromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanuacturedlocally.Intheearly1990stheICRCstartedtheprocessostandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,orthesakeoharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityoservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988orthemanuactureoprostheticsockets.Terstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswererstdevelopedinColombiaandgraduallyimproved.Inparallel,adurableoot,madeinitiallyopolypropyleneandEthylVinylAcetate(EVA),andnowopolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberoot.
In1998,aercareulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertoocusonpatientcareandtrainingopersonnelatcountrylevel.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 5/31Manufact uring Guid el ines Ankle-Foot Ort hosis
Ojective o te manas
TeICRC’s“ManuacturingGuidelines”aredesignedtoprovidetheinormationnecessaryorproductionohigh-qualityassistivedevices.
Temainaimsotheseinormativemanualsareasollows:
• opromoteandenhancestandardizationoICRCpolypropylenetechnology;• oprovidesupportortrainingintheuseothistechnology;• opromotegoodpractice.
Tisisanothersteporwardintheeorttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 6/31 ICRC P hysical Rehab i l i t at ion P rog ramme
Coosin eteen ierent esins
Withoutgoingintodetails,someeaturesodierenttypesoAFOaresetoutbelowtoassistinthechoiceodesign.
Feie AFO
• Dorsiexionassistance• Poormedio-lateralstabilizationothesubtalarjoint
Rii AFO
• Blocksanklemovements• Mediolateralstabilizationothesubtalarjoint• Possibilityocontrollingoreootadduction/abduction
AFO it Tamarac Fere Joint TM
• Mediolateralstabilizationothesubtalarjoint• Freeankledorsiexion• Freeorrestrictedankleplantarexion
AFO antitas
• Blocksanklemovements.Particularlyefcientorpreventingankledorsiexion
• Poormediolateralstabilizationothesubtalarjoint
Introction
Teaimothisdocumentistodescribeseveralmethodsormanuacturingankle-foot orthoses
(AFO),workingwiththepolypropylenetechnologyusedattheICRC’sphysicalrehabilitation
centres.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 7/31Manufact uring Guid el ines Ankle-Foot Ort hosis
Castin an rectifcation
Patientassessment,castingandrecticationopositivecastimpressionsareperormedinaccordancewithprostheticandorthotic(P&O)standards.
ForexibleAFO,thecastcanbetakenwith5degreesodorsiexionsoastoprovideapreloadandensuresomespringaction.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 8/31 ICRC P hysical Rehab i l i t at ion P rog ramme
1.1 Moin o EVA
AexibleAFOdoesnotusuallyrequireanyEVA.However,incaseswhereitisnecessarythe
proceduredescribedinsection2.1(page8)shouldbeollowed.
1.2 Ortosis trim ine
oachievethegoaloallowingdorsiexionotheanklewhilepreventingpassiveplantarexion,thereareanumberodesignoptions.
FlExIblE AFO1
4Markthetrimlineasollows:
A Tetopishorizontal,2cmbelowthe
bulahead.
B Attheankle,pass2cmbehindthetipothemalleolitoallowexionothepolypropylene.
C Attheoreoot,leavethesidesothetoesandtheheadothemetatarsuscompletelyclearandpassthetrimlinebelowthem.Tis will allow the
polypropylene to ollow the movement o the metatarso-phalangeal joints.
Pullastockingovertheplastermodel.
1.3 Vacm moin o te poypropyene
Dustthestockingwithtalcumpowder.
Measurementothepolypropylenesheet:
Calcircumerence+10cm. Instepcircumerence+10cm. Legandootlength+10cm.(Seenextpicture.)
Tickness3mm,4mmor5mm,dependingonthepatient’sweight.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 9/31
2
1
3
Manufact uring Guid el ines Ankle-Foot Ort hosis
Heatthepolypropyleneat180°or20to25minutes,dependingonthethicknessothepolypropyleneandtheefciencyotheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
ightenthepolypropylenearoundthesuctionconebymeansoaropeorsomethingsimilar.
Openthevacuumvalve.
4
CutotheexcessPPwithapairoscissorswhileitisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
1.4 Preparation o te poypropyene se
Drawthetrimlineonthepolypropyleneasdescribedinsection1.2(page6).
Followingtheoutline,cuttheorthosiswithanoscillatingsaw.
Removetheplasticshellromtheplastermodel.
RemovethestockingrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 10/31 ICRC P hysical Rehab i l i t at ion P rog ramme
IanEVAhasbeenmoulded,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
1.5 Preparation o te straps
Fortheproximalstrap,ollowtheproceduredescribedinsection2.6(page14).
Adistalstrapmightbeneeded,dependingonthecapacityothepatient’sshoetoholdtheootinsidetheorthosis.Ithisisneeded,ollowtheproceduredescribedinsection2.7(page15).
1.6 Initia fttin an fnisin
IEVAisused,glueitpartiallyinsidetheorthosis.
TeinitialttingisperormedaccordingtoP&Ostandards.
Carryouttherequiredmodicationonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutothesurplusandsmooththetrimline.
RIgId AFO2
2.1 Moin o EVA
EVA(6mm)maybemouldedpriortothedrapingothepolypropylene,ortheollowingreasons:• toimprovecomort;• topreventskinbreakageinpatientswithsensationloss;• ororthosesusedatnight.
Followtheproceduredescribedbelowor,ithecasedoesnotrequireEVA,goontothenextsection.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 11/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Positiontheplastermodelwiththeoreootpointingdownwards.
MeasurementotheEVAsheet:• width,instepcircumerence;• length,thatotheplastermodel
(leg+oot);• thickness,6mm.
HeattheEVAat120°or3to5minutes,dependingontheefciencyotheoven.
DrapetheEVAmanuallyovertheplastermodelandholditinplaceuntilithascooledcompletely.
4Cutotheexcesswithacutterorapairoscissors.
StapletheEVAontotherontotheplastermodel.
2.2 Ortosis trim ine
2.2.1 “Stanar” trim ine
4Markthetrimlineasollows:
A Tetopmustbehorizontal,2cmbelow
thebulahead.
B Attheankle,passtheline1cmanteriortothetipothemalleoli.
C Attheoreoot,leavethesidesothetoesandtheheadothemetatarsuscompletelyclearandpassthetrimlinebelowthem.Tis will allow the
polypropylene to ollow the movement o the metatarso-phalangeal joints.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 12/310 ICRC P hysical Rehab i l i t at ion P rog ramme
2.2.2 Trim ine to correct oreoot action
Foreootadductioniscommonincasesocluboot.
4Markthetrimlineasollows:
A Tetopmustbehorizontal,2cmbelowthebulahead.
B Increasecoverageothelateralmid-oot,passinginrontothecuboid,to enlarge the area o pressure.
C Attheoreoot,thelinemustbeproximaltothe5thmetatarsalhead.
D Decreasecoverageothemedialmid-ootatthenavicular/malleoli,
to acilitate donning.
E Attheoreoot,coverthemedialsideothemetatarsalheadandtoe,to correct
oreoot adduction.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 13/31Manufact uring Guid el ines Ankle-Foot Ort hosis
2.2.3 Trim ine to correct oreoot action
Foreootabductionisoenseenincasesocerebralpalsy.
4Markthetrimlineasollows:
A Tetopmustbehorizontal,2cmbelowthebulahead.
B Decreasecoverageatthelevelothelateralmalleoli,to ease donning.
C Attheoreoot,thelinemustbedistaltothe5thmetatarsalhead,to avoid metatarsus abductus.
D Increasecoverageothemedialmid-ootatthelevelothenavicular,
to increase mid-oot support.
E Attheoreoot,thelinemustbeproximaltothe1stmetatarsalhead.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 14/31 ICRC P hysical Rehab i l i t at ion P rog ramme
2.3 Pastic reinorcement
TeAFOmayneedreinorcement,especiallyatanklelevel.Inecessary,useoneotheollowingmethods;otherwisegoontothenextsection.
2.3.1 doe ayer o poypropyene
4Asecondlayeropolypropylenecoveringtheankleandtheootismouldedatthesametimeasthemainlayer.
Cutapieceopolypropylene:• thickness,3mm;• width,instepcircumerence;
• length,ootlength+10cm
Grindthelast3cmattheproximalendtograduallyreducethethicknessothepolypropylene.
4Tetwolayersareheatedatthesame
time.
Tereinorcementisplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperectsealbetweenthetwo.
A double layer o polypropylene has the disadvantage o reducing exibility o the oreoot in relation tothe metatarso-phalangeal joint.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 15/31Manufact uring Guid el ines Ankle-Foot Ort hosis
2.3.2 Cannes in te poypropyene
Tepresenceochannelsintheplasticsignicantlyimprovesitsstrength.Tereareseveralwaysomakingthesechannels.
4CuttwostripsoEVA:• thickness,6mm;• width,7mm;• length,15cm.
GrindbothdistalandproximalendstograduallyreducethethicknessotheEVA.
Pullastockingovertheplastermodel.
Gluethestriplightlyontothestocking.
Te more anterior the position o the channel, the more the AFO will resist dorsiexion o the ankle.
Reinorcements prolonged along the side o the mid-oot increase the volume o the orthosis so that it may no longer t into the patient’s shoe.
2.4 Vacm moin o te poypropyene
Ithishasnotyetbeendone,pullastockingovertheplastermodel.For maximum eciency, the EVA
used to make channels in the polypropylene must not be covered with a stocking.
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsenceoadoublelayeropolypropylene(section2.3.1,page12).
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 16/31 ICRC P hysical Rehab i l i t at ion P rog ramme
2.6 Proima strap
Useaready-madeVelcrostrap40mmwide,ormakeastrapwithPerlonwebbingorsomeotherstrongmaterial.
4Withalargetubularrivet,xthebeltholdingthelooponthemedialside,1.5cmbelowtheproximaltrimline.
Teloopshouldbeplacedonthepolypropyleneandnotbeincontactwiththepatient’sleg.
2.5 Preparation o te poypropyene se
Drawthetrimlineonthepolypropyleneasdescribedinsection2.2(page9).
Cuttheorthosiswithanoscillatingsaw,ollowingtheoutline.
Removetheplasticshellromtheplastermodel.
RemovethestockingrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IEVAhasbeenmouldedbeorehand,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 17/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperectlyhorizontalbeorexingit.
Coverthesuraceothestrapincontactwiththepatient’slegwith3mmEVA.
4Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperectlyhorizontalbeorexingit.
Coverthesuraceothestrapincontactwiththepatient’slegwith3mmEVA.
2.7 dista strap
Youmustchoosebetweenadistalstrapandaninstepstrap.Telatterhastheadvantageoholdingthecalcaneumrmlyinsidetheorthosis(equinuscorrection).
UseaVelcrostrap25mmwide.
4Withalargetubularrivet,xthebeltholdingthelooponthemedialside,4cmabovethemalleoli.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwiththepatient’sleg.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 18/31 ICRC P hysical Rehab i l i t at ion P rog ramme
2.8 Instep strap
UseaVelcrostrap25mmwide.
wotechniquesarepresented,dependingonwhetherthebackotheootisinaneutralpositionorneedsavalgus/varuscorrection.
2.8.1 Netra position
4Withalargetubularrivet,xthebeltholdingthelooponthemedialside,atanangleo45°passingthroughtheposteriordistaltipothecalcaneum.
Teloopshouldbeplacedoverthepolypropyleneandnotbeincontactwith
thepatient’sleg.
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularriveton
thelateralside,atthesameangleo45°. Coverthesuraceothestrapincontactwiththepatient’slegwith3mmEVA.
2.8.2 Vars/vas correction
Testrapwillpassthroughaslotcutinthepolypropylene.
4Teslotiscutonthelateralsideorvaruscorrectionandonthemedialsideor valguscorrection.
Markthepositionotheslot40mmromthebackotheootandperpendiculartoalinedrawnatanangleo45°passingthroughtheposteriordistaltipothecalcaneum.
Teslotshouldbe30mmlong.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 19/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Makeholesalongtheslotaxiswithadrillttedwitha4mmbit.
4Withacutter,connecttheholeswitheachother.
Finally,smooththetrimlinewithale.
4Teloopisplacedonthemedialsideor varuscorrectionandonthelateralsideorvalguscorrection.
Fixthebeltholdingtheloopwithalargetubularrivet,atanangleo45°passingthroughtheposteriordistaltipothecalcaneum.
Teloopshouldbeplacedoverthepolypropyleneandnotbeincontactwith
thepatient’sleg.
4Insertthebeltthroughtheslotononesideandthroughtheloopontheothersidetomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetjustoutsidetheslot.
Coverthesuraceothestrapincontactwiththepatient’slegwith3mmEVA.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 20/31 ICRC P hysical Rehab i l i t at ion P rog ramme
AFO wITh TAMARACk FlExuRE JO INT TM3
2.9 Initia fttin an fnisin
IEVAoamisused,glueittemporarilyinsidetheorthosis.
TeinitialttingisperormedinaccordancewithP&Ostandards.
Carryouttherequiredmodicationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutothesurplusandsmooththetrimline.
3.1 Moin o EVA
Followtheproceduredescribedinsection2.1(page8),orgoontothenextsectioniEVAisnotrequired.
3.2 Ortosis trim ine
Followtheproceduredescribedinsection2.2.1(page9).
3.3 Pastic reinorcement
Posteriorreinorcementorgreaterplantarexioncontrolisrequiredwhentheorthosisisintendedtopreventplantarexion(notullydescribedbelow).
Followtheproceduredescribedbelow,orgoontothenextsectioniplantarexionisleree.
AsecondlayeropolypropyleneorpositioningatthelevelotheAchillestendonismouldedatthesametimeasthemainlayer.
4Cutapieceopolypropylene:• thickness,5mm;• width,2cm;• length,7cm.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 21/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Firstthereinorcement(heatedatthesametimeasthepolypropylene)isplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperectsealbetweenthetwolayers.
4Usethemouldingdummiestoormasnuglyttingcavityortheamarack
FlexureJointM.
Nailthemverticallyontotheplastermodelsothatthemidpointislocatedontheankleaxis.
3.4 Instaation o Tamarac Fere JointTM
Ontheplastermodel,markthepositionothejointaxis:• laterally,attheapexothemalleoli;• medially,slightlyposteriortothedistaltipothemalleoli.
Makesurethatthejointsareatthesamelevelonbothsides.
3.5 Vacm moin o te poypropyene
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsence
oaposteriorreinorcement(section3.3,page18).
Pullastocking(cottonstockinetistoothick)overtheplastermodel.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 22/310 ICRC P hysical Rehab i l i t at ion P rog ramme
3.6 Preparation o te poypropyene se
Drawthetrimlineonthepolypropyleneasexplainedinsection3.2(page18).
Cutonlythecontourotheorthosiswithanoscillatingsaw.Donotcutalongtheseparationbetweenootsectionandcalsection.
Removetheplasticshellromtheplastermodel.
ExtractthemouldingdummiesandthestockingrominsidetheAFO.
4Drawtheseparationlinebetweentheootsectionandthecalsection:• Markthemiddleothecavitiescreatedbythedummies.
• Drawa“V”anteriortothemidlineo
eachcavity.Ensurethatthe“V”doesnotextendbackwardspastthecentreothecavity.
4ForAFOwith plantar exion control ,
drawahorizontallineposteriortothemarksjoiningthetwosides.
4ForAFOwith ree plantar exion,drawa“V”posteriortothemidlineoeachcavity.Ensurethatthe“V”doesnotextendorwardpastthecentreothecavity.
Correct Incorrect
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 23/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Drillholesatthedimpleslebytheholesinthemouldingdummies:• 5mmorlargesize;• 4.5mmorsmallsize.
4Useathin-bladed saw(1/16’’bladekerorless)toseparatetheootsectionromthecalsection.
Do not use an oscillating saw because toomuch material is lost along a ragged, widecut line.
Smooththetrimlineedgewithahanddeburringtoolorapieceoglass.Do not grind the trim linebecause this will reduce exure coverage and reduce the ability o the cavity to anchor and control the
exure efectively.
4
InserttheamarackFlexureJointM
andsecurewithmetalastenersandanchoringscrews.
Dependingonthethicknessothepolypropylene,itmaybenecessarytoadjustthelengthothescrewsitheendsprotrudeinsidetheAFO.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 24/31 ICRC P hysical Rehab i l i t at ion P rog ramme
3.7 Preparation o te straps
Fortheproximalstrap,ollowtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Iso,ollowtheproceduredescribedinsection2.7(page15).
3.8 Initia fttin an fnisin
IEVAoamisused,glueittemporarilyinsidetheorthosis.
TeinitialttingisperormedinaccordancewithP&Ostandards.
Carryouttherequiredmodicationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutotheexcessandsmooththetrimline.
Gluetheexureanchoringscrewswitharemovablethread-lockingcompound(Loctite).
AFO ANTI-TAluS (ANTERIOR S hEll)4
4.1 Moin o EVA
EVA(6mm)maybemouldedpriortodrapingothepolypropylene:
• toimprovecomort;• topreventskinbreakageorpatientswithsensationloss.
Do not cover the oot, to avoid an increase o volume which may prevent the patient rom wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionithecasedoesnotrequireEVA.
Positiontheplastermodelwiththeoreootpointingupwards.
4CutapieceoEVA:• width,calcircumerence;• length,leglength;• thickness,6mm.
HeattheEVAat120°or3to5minutes,dependingontheefciencyotheoven.
DrapetheEVAovertheplaster
modelmanuallyandholditinplaceuntilithascooledcompletely.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 25/31Manufact uring Guid el ines Ankle-Foot Ort hosis
4Cutotheexcesswithacutterorapairoscissors.
Grindthedistaltrimlinetograduallyreduceitsthickness.
StapletheEVAontothebackotheplastermodel.
4Marktheorthosistrimlineasollows:
A Tetopmustbehorizontal,2cmbelowthetibialtubercle.
B Ontheleg,1cmposteriortothemid-line.
C Ontheankle,atthetopothemalleoli
toacilitatedonning.
D Ontheoreoot,clearthesidesandtopothetoesandtheheadothemetatarsuscompletely,passingbelowthem.Tis will allow the polypropyleneto ollow the movement o the metatarso-
phalangeal joints.
4.2 Ortosis trim ine
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 26/31
2
1
3
ICRC P hysical Rehab i l i t at ion P rog ramme
4.3 Pastic reinorcement
Tepresenceochannelsintheplasticsignicantlyimprovesitsstrength.Tereareseveralwaysomakingthesechannels.
4CuttwostripsoEVA:
• thickness,6mm;• width,10mm;• length,20cm.
Grindbothdistalandproximalendstograduallyreducetheirthickness.
Gluethestripsontotheplastermodel,1cmanteriortothelateralandmediallongitudinalaxes.
Reinorcements prolonged along the side o the
mid-oot increase the volume o the orthosis so that it may no longer t into the patient’s shoe.
4.4 Vacm moin o te poypropyene
Te procedure described below ensures uniorm thickness o the polypropylene all over the orthosis. Donot try to make a single seam on the anterior side, because the creases gathering at the ankle will makeit necessary to stretch the polypropylene too thinly.
Ithishasnotyetbeendone,pullastockingovertheplastermodel.For maximum eciency the EVAused to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementothepolypropylenesheet:
Calcircumerence+10cm. Instepcircumerence+10cm. Legandootlength+10cm.
PPthickness:4mmor5mm,dependingonthepatient’sweight.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 27/31Manufact uring Guid el ines Ankle-Foot Ort hosis
Heatthepolypropyleneat180°or20to25minutes,dependingonthethicknessothepolypropyleneandtheefciencyotheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideandundertheoot.
ightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutotheexcesswithapairoscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
4.5 Preparation o te poypropyene se
Drawthetrimlineonthepolypropyleneasexplainedinsection4.2(page23).
Cuttheorthosiswithanoscillatingsaw,ollowingtheoutline.
Removetheplasticshellromtheplastermodel.
RemovethestockingrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IEVAhasbeenmouldedbeorehand,transerthetrimlinetotheEVAandcutotheexcesswithapairoscissors.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 28/31 ICRC P hysical Rehab i l i t at ion P rog ramme
4.7 Initia fttin
IEVAoamisused,glueittemporarilyinsidetheorthosis.
TeinitialttingisperormedinaccordancewithP&Ostandards.
4Itisoennecessarytoarethepolypropyleneattheposteriorpartotheheelinordertoacilitatedonningandtoavoidpainulcontactwiththeedgeotheplastic.
4.6 Preparation o te straps
Fortheproximalstrap,ollowtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.
Iso,ollowtheproceduredescribedinsection2.7(page15).
4.8 Finisin
Carryouttherequiredmodicationsonthepolypropyleneandsmooththetrimline.
GluetheEVAinsidethepolypropylene,cutothesurplusandsmooththetrimline.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 29/31Manufact uring Guid el ines Ankle-Foot Ort hosis
ICRC Code DescriptionUnit of measure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm cm 70
According to size:• MDREBANDP10• MDREBANDP12• MDREBANDP15
Plaster of Paris bandages10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As required
For EVA and plastic moulding :
If required, according tocolour:• OPLAEVAFERA06• OPLAEVAFLIV06• OPLAEVAFKIN06
EVA 6 mmTerra, olive or beige colour
Each As required
None Nylon stockinet Piece 1
According to colour andthickness:• OPLAPOLYCHOC03• OPLAPOLYCHOC04• OPLAPOLYCHOC05• OPLAPOLYLIV03• OPLAPOLYLIV04• OPLAPOLYLIV05• OPLAPOLYSKIN03• OPLAPOLYSKIN04• OPLAPOLYSKIN05
HomopolymerTerra, olive or beige colour3, 4 or 5 mm thickness
Each As required
For the TAMARACK Flexure JointTM
:According to size:• OCPOSOOTTAL• OCPOSOOTTAS
Large size (740L)Small size (740S)
Piece 1
EHDWGLUEL243 Glue, Loctite 243, blue, threadlock, 50-ml bottle As required 4
For the proximal strap:
OSBOSTRVP440 Strap, Velcro, PVC, with loop, brown, 400 x 40 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO30 Strap, polyester, black, 40 mm cm 25
None Strap, Velcro, 40 mm cm 20
None Loop, 40 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
For distal/instep strap:
OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO24 Strap, Perlon webbing, 25 mm cm 20
None Strap, Velcro, 25 mm cm 15
OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
list o manactrin materias
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 30/31
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral andindependent organization whose exclusively humanitarian mission is to protect thelives and dignity of victims of war and internal violence and to provide them withassistance. It directs and coordinates the international relief activities conductedby the Movement in situations of conict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarianprinciples. Established in 1863, the ICRC is at the origin of the International RedCross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard Matagne
Joel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
8/9/2019 Prosthetics and Orthotics Manufacturing Guidelines: Lower limb Orthotics: Ankle-Foot Orthosis
http://slidepdf.com/reader/full/prosthetics-and-orthotics-manufacturing-guidelines-lower-limb-orthotics-ankle-foot 31/31
9 / 2 0 0
6
2 0 0