Re: Summary of replies: brace for residual polio with weak quad

Re: Summary of replies: brace for residual polio with weak quad

Donna Rowe

9/30/1999

please remove from mailing list
-----Original Message-----
From: Sun G. Chung < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Date: Thursday, September 30, 1999 1:43 AM
Subject: Summary of replies: brace for residual polio with weak quad


>Dear List members,
>
>Thank you for your kind replies for my previous question as below.
>
>== Previous question ===
>I have a patient with residual poliomyelitis, female 30yo.
>She seems to have destroyed motor neurons of Lumbar 3 and 4 level,
>unilaterally(left). So, she has very weak left hip flexor and knee
extensor,
>nearly one grade of muscle power by MMT.
>She also has valgus deformed left knee. She already uses conventional type
>KAFO with valgus controlling strap and ischial weight bearing function. But
>she complains the weight of the brace and dull pain after long time use.
She
>came to me if there would be any solution for her problems including new
>types of brace.
>===================
>
>The replies can be summarized as below,
>
>1. Change the material to reduce the weight.
> Plastic, thermoplast(for lamination) and carbon graphite(for upright)
>were recommended.
>2. Remove the ischial seat.
>3. Use offset knee joint aligned posterior to the anatomical knee axis: for
>clearance on swing phase
>4. Strong brace is better than light one.
>
>All of the recommendation were very helpful for me. I really appreciate
>their kindness.
>You may find more information from the replies.
>
>
>Sincerely,
>
>---------------------------------------------------
>Sun G. Chung M.D., Ph.D.
>Instructor
>Dept Rehab Medicine
>Seoul National University, College of Medicine
>YeonGeon Dong 28, ChongRo Gu
>Seoul Korea
>
> <Email Address Redacted>
>(T) 82-2-760-3954, 760-2619
>(F) 82-2-743-7473
>----------------------------------------------------
>===================================================================
>I find that an ischial weight bearing KAFO is not needed. One that is high
>enough to provide support should be within 2 finger widths of the ischial
>tuberosity, but not touching it. The weight bearing line from greater
>trochanter, through the knee and then ankle, should be straight- if the
>brace
>has a locked knee . Have the braced leg at least 1/2 inch shorter then the
>contralateral limb with help make swing through clearance easier . I find
>that a plastic KAFO, will provide more support for the valgum and is
lighter
>in weight.
>If the patient had some recurvatum and can ambulate with out a brace, for
>short distances, I would consider a posteriorly offset knee joint and leave
>the knee free for flexion. Letting that leg be 1/2 shorter will still
make
>it easier for her weak hip flexors. Plastic again is a good choice of
>materials. Very important - if you do use a posterior offset knee joint,
>when the KAFO is fabricated, it is important that the mechanical knee axis
>falls posterior to the anotomical knee axis - not in line with it - but
>posteriorly - to provide stability during stance phase.
>I hope this is helpful. Stephanie D. Langdon-Bash, CPO, FAAOP.
>
>
>======================================================================
>Dr. Chung,
> Depending on her present weight and functionality, a thermoplastic KAFO
>with carbon graphite uprights can work. I personally would get rid of the
>ischial weight bearing brim, but that is up to you. At the knee you are
>able
>to have extension assist incorporated to the joints. Depending on the
>degree
>of her valgus and its correctabilty, correction can be addressed in the
>cast.
>Otherwise the strapping system or condylar pad (more comfortable) can be
>utilized.
>
>Depending on the pt's weight you can use 5/32 or
>3/16 copoly plastic, this will cover approx. 3/4 of the pt's thigh. The
>plastic should extend about 5 cm past mid line/uprights (length will vary
>according to pt size). Anteriorly, I incorporate an 1/8 or 1/16
>polyethylene
>tongue attached to the lateral aspect of the proximal shell. This aids in
>comfort as well as control. The theory behind the ischial brim is to
>relieve
>weight from the knee and other areas of the lower extremity. Although,
this
>type of weight bearing was borrowed from prosthetics and does not seem to
>works as intended. In many the genu valgum/varum seems to increase. Plus
>it
>really is an uncomfortable style to wear, it usually hinders more than
help.
>
>
>B.J. Stagner Jr., C.O.
>CEO-Stagner Orthotic Services
>
>========================================================================
>Dr. Chung
> I believe your patient could benefit from a total contact Laminated
>KAFO.The weight of the orthosis can be kept down to 2.5 lbs.. by the use of
>carbon graphite/ kevlar w/ honeycomb inner core for the uprights. By using
a
>total contact technique the negative drop on the limb will be decreased
thus
>taking away the feeling of dragging the orthosis.
>
>The lamination should encompass the hole thigh. Flaps can be cut in to the
>lamination to allow
>easy donning. A proper ischial seat with a quad socket to prevent rotation
>would help. I suggest that you stay about 1.5 - 2 cm below the Ischial to
>floor measurement if she never had a ISCHIAL seat.
>
>Casting : When the cast is almost dry the pat. should stand with normal
>walking base and toe out.
>
>Cast Modifications should be kept tight.
>
>Vincent DeCataldo
>Rinko Orthopedic
>25-09 Broadway
>Fairlawn , New Jersey 07410 USA
>201-796-3121
>
>==========================================================================
>There is a better solution to lower limb support and protection with the
>polio population than using the standard conventional metal and leather
>designs. The keys are joint protection, pressure distribution, and
>alignment using materials which allow better contact and contours.
>Hopefully, there are orthotists in your area that are trained in these
>procedures. If not, please contact me and I will try to provide
>additioal information.
>Mark Taylor
>
>===========================================================================
>Dr. Chung,
>
> Your patient with the weakened quads and a presenting valgum attitude
at
>the knee is probably exhibiting a position of external rotation at the foot
>(or forefoot) and would probably be considered as presenting with an
>Internal
>Rotary Deformity (IRD).
>Because of how the weight-line passes at the knee, the single most
difficult
>obstacle to overcome with your patient is blending a high degree of
strength
>with, of course, the lightest weight possible for the orthosis.
> If you find yourself in conversation with a local practitioner who is
>going to make this patient a suitable orthosis, please do your patient (and
>orthotist) a big favor by backing off of the weight concern (relative to
>strength). There are ways to reduce the weight , i.e utilizing carbon
fiber
>where appropriate, etc.
> You will find that there are numerous approaches in treating this
>patient. It will be interesting to read the replies that you receive, but
I
>would hope that the majority of responses emphasize the overall strength of
>the orthosis as a higher concern than weight.
> An orthosis that fits well and is really light does no one any good if
>it
>fails in six months. Especially when the ability to charge for a stronger
>(more appropriate) orthosis would be undermined by the decision originally
>to
>bill for and build an orthosis that was not up to the task of supporting
her
>during weight-bearing.
> I wish you well and would be glad to discuss the case further, either
>through the internet or via telephone. You need only contact me at
> <Email Address Redacted> or my office # (717) 393-0511 York, PA
>
>===========================================================================
=
>==
>In response to your enquiry on O&P listserv, there are probably three
>different ways in which you could reduce the weight of the KAFO in
question.
>You had mentioned that your patient currently wears a conventional KAFO. In
>transfering her into a plastic KAFO with the plastic sections moulded over
>the side-steels you can improve the inherent strength of the KAFO and
>therefore reduce the gauge of the side steels.
>
>The second solution is probably not as appropriate, Proteor provide carbon
>fibre side steels which can dramatically reduce the overall weight of the
>KAFO. I understand however that these steels do not cope well with M-L
>shaping i.e. to accomodate a valgus knee.
>
>The third solution would be to provide a carbon fibre composite KAFO which
>can be provided by Otto Bok, these devices are extremely light and strong
>but require specialist attention and make take some time to manufacture.
>
>I hope this is of some help.
>
>Peter
>
>Peter Mclachlan
>Lecturer in prosthetics and Orthotics
>University of Strathclyde
>
>e-mail: <Email Address Redacted>
>
>===========================================================================
=
>===========
>Dear Sun G. Chung M.D., Ph.D.
>
>
>We believe we have such a KAFO. We have developed a new orthotic system
>that
>will create a paradigm shift in the future. Only three centers are
>presently
>fitting these new advanced systems. One is in Las Vegas, Nevada, USA the
>second is in Vancouver, BC, Canada and the third is in San Diego,
>California.
>The new systems can control the leg and body so much better. We guarantee
a
>structural outcome, no other system can provide this.
>
>Our new systems are based on very complex principles. The outcomes are
>clearly showing improvements that most of these people dream about and are
>looking for. Our systems can allow for an unlocked knee, even with those
>who
>have zero quads and are presently wearing a locked system. We are
>eliminating or greatly reducing gross body compensations. People can walk
>much more efficiently, with less energy.
>
>We also have systems with energy response capabilities, to add a spring or
>life back in ones step. Our systems can help most lower extremity needs.
>
>Sincerely,
>Marmaduke Loke, C.P.O.
>(858) 268-7000
>
>==================================================
>
>.
>
> ********************
>OANDP-L is a forum for the discussion of topics related to Orthotics and
>Prosthetics.
>Public commercial postings are forbidden. Responses to inquiries of a
>commercial nature should not be sent to the entire oandp-l list. Responses
>should be collected and reposted by the person asking the question.
>Send a message to the list by sending to: <Email Address Redacted> To
unsubscribe,
>send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in
the body of the
>message. All postings related to US-politics must use a subject line
>starting with US-Politics:
>Any questions should be directed to Paul E. Prusakowski, CPO at
> <Email Address Redacted>

                          ********************
OANDP-L is a forum for the discussion of topics related to Orthotics and
Prosthetics.
Public commercial postings are forbidden. Responses to inquiries of a
commercial nature should not be sent to the entire oandp-l list. Responses
should be collected and reposted by the person asking the question.
Send a message to the list by sending to: <Email Address Redacted> To unsubscribe,
send a message to: <Email Address Redacted> with the words UNSUB OANDP-L in the body of the
message. All postings related to US-politics must use a subject line
starting with US-Politics:
Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>