Reply summary: orthosis for difficult knee

Reply summary: orthosis for difficult knee

Ted A. Trower

9/8/1999

The response to my request for ideas on the challenging client was quick and
very diverse. I would be pleased to receive any additional thoughts you
might have as I've not really decided just what I'm going to do yet.

My original post was as follows:

I had a visit the other day with a young lady who has a very difficult knee
problem. She presents with an unstable knee following an MVA. Her ACL is
ruptured and unrepaired, I suspect several other structures are also damaged
or destroyed as she frequently dislocates the femur anteriorly on the tibia.
When this happens she falls, often upon the knee itself. The instability is
complicated by an anterior inclination of the tibial plateau secondary to
severe lower extremity trauma with multiple fractures bilaterally. She has
had well over a dozen surgeries and is not willing to under go any more so
please don't tell me that surgery is what she really needs. I already know
it and so does she.

What I'm looking for is a knee orthosis which might help stabilize her knee
and prevent dislocations. She currently is wearing a Townsend with fair
results. She has rejected a Donjoy Defiance ACL as inadequate. My best
idea so far has been the Donjoy Defiance combined instability model with the
motocross kneecap. She is overweight and her tissue is very soft. The
minimal surface area coverage of the Donjoy design appears to be one of the
reasons for her rejecting it previously as it dug into her thigh. Any other
thoughts or suggestions?





>ted, I don't want to tout my product, but I feel that you as the practitioner
>should create the devise to your own specs. I developed Ultra-G, and one our
>first applications was in custom knee bracing. Becker sells our Ultra-G
>Knee Spike Kit for about $180 just add plaster, some time, and resin....
>don't forget the allignment kit, but you can create whatever design you want,
>and I think you will be very pleased with the results....
>
>you make it, you choose the trim lines.... there is more than enough
>graphite in the kit to cover you....
>
>Wade Bader, LCPO

-------------------------------------------

>Ted, How is her patella and tendon? Does this add to the instability? What
>about spandex bike shorts to control the soft tissue? Would she wear a
>carbon fiber laminated kafo with a pretibial shell and Bock 22 mm offset
>knee joints, bical ankles, and you could add the extension assist knee
>rubbers they offer to control motion. I did one that weighed 3 lbs for a 200
>lb gal. Will a ko control the instability? It sounds like no. I think
>T-Send is my first choice but a longer solid lever may behelpful. Is she to
>vain for a KAFO/
>
>
>Does the femur slide forward? With an ACL injury the tib does.
>Bruce Russell CO

-------------------------------------------
>
>I have used several of the defiance knee braces with good success. They
>have also recently come out with a new knee brace. It is a cross
>between a legend and definace, much lighter than defiance, aluminum
>frame. You could try this with teir chamosi liner and air condyle
>pads. This brace comes in about five sizes and since it is an off-shelf
>can be returned. Anoer advantage may be the aluminum frame is
>contourable.
>
>Unfourtuantley the name escapes me, however it is an acl or combined
>instability type brace. I just received a coulple I will email you
>names tomorrow evening.
>
>good luck
>
>Mickey Howard, C.O.
-------------------------------------------
>You are proably not going to like this suggestion, but, I have had good
>results using the old fashion Lennox Hill Derotation knee orthosis for
>overweight patients with alot of exta soft tissue(soft not firm musculature).
>From your description, it sounded like the patient was larger then normal.
>This orthosis seems to control the over weight leg using its alum. frame and
>elastic straps, better then the laminate type. The major difficulty with it
>is, the asthetics when compared to the newer, hi tech orthoses. Also, the
>strapping can be confusing.
>FYI, the only time I ever use the Lenox Hill orthosis is when presented with
>a fleshy overweight leg that needs alot of external stability.
>
>Have fun,
>Sy Rosen, C.O.
-------------------------------------------
>Interesting situation with your knee patient. First off, let me preface by
>saying I am a DonJoy sales rep, but (in my humble opinion) a quite
>knowledgeable one. Your initial thought of using the Defiance would be mine
>as well, but with the ACL configuration (unless she has no PCL as well).
>This setup would provide greater resistance to anterior tibial translation,
>and thereby (hopefully) increase her stability. As for the soft tissue
>compression issue, try either a neoprene or cotton undersleve (you get
>either one free with the Defiance if you ask for it, BTW). Patients
>complain that sleeves make the brace too hot, but it sounds like your
>patient is running out of options!
>
>If that does not work, I would suggest the most comfortable shell-type
>brace that encompasses as much of the thigh and calf as possible. Flex-Tech
>has a few that look comfortable enough, but they are my competition and not
>my forte'!
>
>Just my two cents worth! Please keep me posted on how the Defiance works!
>
>Sincerely,
>
>J. Todd Griffin MS, ATC
----------
MY reply to Todd was as follows:

Todd,

Thanks for your reply. She already has the Donjoy ACL and it does not work
for her. Her femur moves ANTERIORLY on her Tibia due to the inclination of
the tibial plateau. I suspect but have no confirmation that both the ACL
and the PCL are ruptured. My guess is that the quad tendon and the joint
capsule are all that she has left.
I did consider having her Defiance ACL retrofitted into a combined with the
kneecap. Any reason this could not be done?

----------
>Sorry, my misunderstanding. Here is what I would suggest:
>
>1. Yes, that Defiance can be retrofitted. Call Customer Care with the
>brace number (or patient name) and ask for Jason Gregg, our product support
>specialist. Tell him you need the anterior thigh strap, strap pad, and
>D-rings to convert that brace to a CI version. He should be able to arrange
>that with no problems. Also, ask them to send you a CI version instruction
>manual AND a PCL version instruction manual.
>
>2. Once you get the parts, all you have to do is loosen the screws on the
>inside of the frame that hold the caps on the sides where the D-rings
>attach. You should see the empty groove where the anterior D-rings fit
>right in. (If there are no extra grooves, you will need new caps, so look
>before you order or ask Jason if it is supposed to. I am 99% sure they are
>already there.) Once the D-rings are in place, tighten the screws back and
>velcro in the strap and strap pad.
>
>3. Now, when fitting the patient I have 3 different strapping
>configurations for you to try. First is the PCL configuration, where you
>would not tighten the posterior thigh strap (strap #3 on ACL version) or the
>anterior tibial strap (strap #4 on ACL version). This will give the
>opposite dynamic force from the ACL version.
>
>4. Regardless of that effectiveness, also try the brace as above, but also
>tighten the anterior tibial strap. Do that strap last, after the PCL
>protocol is complete. This would provide more tibial stabilization while
>still resisting anterior femoral translation.
>
>5. Lastly, try the CI version as listed in the manual.
>
>
>With the instability you are describing, I think the PCL version could be
>quite helpful! This type of instability is so unusual in the functional
>bracing population that most orthotists are not familiar with the way PCL
>braces from DonJoy work, but I have had many success stories with them!
>
>Todd
>
>P.S. Another tip: If you need to generate more dynamic force on the femur,
>you can order a pneumatic pad (either a condyle pad or part of a pneumatic
>liner kit, I would reccomend a pneumatic condyle pad or even two if she is
>really large) and use it in place of the strap pad on the anterior thigh
>strap. With that in place, once the brace is applied, the pads are inflated
>to tolerance to provide additional force to resist that femoral translation.
> Good luck, and keep me posted!
>

>
>Sorry, I forgot to mention that the patella cup idea is a good one, but I am
>not sure how much increased stabilization it would provide. Worth a try
>though!
>
>Todd

-------------------------------------------

>On two occasions I have used Flex-Tech to fabricate a combined instability KO
>with what I call a Patella Stabilizer. They use rubber tubing configured in a
>4-pull design that is connected to a rubber donut. This will help track the
>knee for you, but it may not solve all your concerns. If needed, they can add
>an AFO for additional stability.
>
>If you need a contact, let me know.
>
>Good Luck.
>
>Jon Naft, CP

-------------------------------------------

>Have you considered a floor reaction type of AFO? I have used an
articulated AFO with
>dorsi-stop to control an unstable knee. The advantage was that the patient
was willing to
>wear it because it was easy to wear. The disadvantage was that it could
not control the knee
>from buckling 100% of the time.
>
>This system would help an ACL type injury, however, what you describe
(femur dislocates
>anteriorly on tibia) would be a PCL deficiency. If she doesn't dislocate
in the ACL
>direction, you could use just a posterior stop.
>
>You could also incorporate this into a knee brace or just make a KAFO.
>
>I'd be interested in hearing how you solve the problem.
>
>Good luck.
>
>Matt Bailey, CPO - Florida
>

-------------------------------------------
>Have you tried the custom CTi. I had a pt. that wore one in which his femur
>only contacted the anterior third portion of his tibial plateau. He used a
>loftstrand crutch as well. He was bilateral and opted for no surgery for
>correction due to his age. I'm not sure with the lower extremity
>complications if a KO would be appropriate as you need a vehicle for
>attachment in the lower leg. Good Luck.
>Terese Hurin C.O.
>
-------------------------------------------
>Ted,
> There are two that come to mind. The LH2 has always worked well for me,
>in your case you may want cast over (tightly) a compression sleeve. This in
>itself will keep the articulation taut and the LH2 will provide the
>stability. If you are going to use a motocross design, go with the CTi2,
>they make one that gives complete control in all planes with good
>adjustability. If it were me, I would probably go with the CTi2.
>If I can help at all, feel free to reply with more information on your pt.
>Respectfully,
>B.J. Stagner Jr., C.O.
-------------------------------------------
>Ted - have you considered the MKS II that was designed by Stuart Marquette CO
>-- it is now being fabricated (it's custom) out of New Hampshire. It is a
>good brace forcontrolling all around A-P-M-L Rotation instabilities.
>
-------------------------------------------
>just a couple questions? how far out is she from her last knee surgical
>procedure?
>
>what kind of physical therapy is she getting?
>
>if she is heavy set, how are you suspending the KO to locate the knee
>joints?
>
>what kind of activities are you hoping to correct?
>
>Ramona M. Okumura, CP

--------

My reply to Ramona's questions:
>just a couple questions? how far out is she from her last knee surgical
>procedure?
>

No surgery in the last few years.


>what kind of physical therapy is she getting?
>

none at this time


>if she is heavy set, how are you suspending the KO to locate the knee
>joints?
>

Have to admit I hadn't given it a thought. Her existing KO's are straight
out of the box. (Townsend and Donjoy Defiance.)


>what kind of activities are you hoping to correct?
>

Just walking without falling down. In the MVA she also suffered a severe
TBI. Comatose for several weeks, pretty functional now but terrified of
striking her head in any fall due to the knee.


Ted A. Trower C.P.O.

<Email Address Redacted>