replies: 50 degree knee valgus

replies: 50 degree knee valgus

Joan Cestaro

2/2/2002

Thanks to everyone for your advice and suggestions. Following is my
original question and the replies.
Joan Cestaro, C.P.

Question:
I am seeking advice on yet another very unusual case. I have a 75 year
old lady with Rheumatoid Arthritis presenting with 50 degrees of right
knee valgus upon weight bearing. This is correctable to about 20
degrees. The left side (not addressing at this time) presents with 20
degrees of knee varus. They both angle to the left. This lady
apparently had a stoke affecting the right side about 10 years ago which
explains why it is so much worse. I do have photos that I can e-mail
anyone with good suggestions. It's hard to imagine in words a 50 degree
knee valgus condition! It's the worst I've seen.

Subject patient has not walked in almost 2 years, so I don't anticipate
much more than transfer assistance and a few steps around the home. A
KAFO is just overkill and I also doubt that a true KAFO would be
accepted. My initial thoughts are for a KO with posterior straps so
that she can don easily for use and remove during non use. She
amazingly corrects totally while sitting in her wheelchair, so donning
the appliance should be fairly easy. The other concern is that her knee
joint itself is very large (RA) and will endure a great amount of
pressure for this correction.

Open to any thoughts or suggestions on design. Thanks in advance.

Replies:
I had a similar patient with ra, we did do a kafo, corrected well but
was rejected by patient. As you said it was overkill. We finally had
success with generation 2 custom unloader with geriatric adaptations.
The correction was minimal, but there was enough support to assist in
transfers.

If this patient can correct the deformity in her wheelchair it would
seem that there isn't a contracture present, so how about a hip
abduction orthosis to influence the knee valgum? Does she have
complications below the knee as well? Just a thought:)

Generation II K.O.

Joan,
Been there, done that, got the t-shirt! There are two big problems with
KO's: suspension and lack of adequate leverage. I had good results
with a lady who resisted the proper orthotic appliance (dbl upright
metal KAFO) and started her out with a long post op KO. Of course it
bent, rotated, and migrated distally but it made the point and she was
able to graduate to a proper solution. You may want to look at the
Generation II KAFO.

I would suggest a GII Kafo the only reason for the afo section is to
support the KO
Further if you dont do bilaterals the other knee will be just as bad in
no time

I would suggest they try the V.3 with the cast taken in a corrected
state - or as much as possible. It is lightweight and with bilateral
joints it provides excellent control of valgus/varus deformities. The
straps are also posterior as he would like.

Joan, perhaps a G2 unloader with adjustable valgus correction straps
would
allow her to adjust to her comfort level. Just a thought!!! Good luck

I might consider contacting Bledsoe who has the OA thurster joint that
corrects valgus (or varus) upon extension (standing) and reduces it's
correction force in flexion (sitting). They will custom make you one. I
have used it on some cases like yours and gotten some success.

Joan, I think a KO will be essentially useless. In my opinion, you
need to
encapsulate the foot to control as much rotation as possible, and then
hope
for the best. In this situation, a static knee (no knee joint) locked
in
full (or as much as possible) extension and with as much valgus
correction as
is possible is all that you can expect. In short, you can provide a
thermoplastic cast.

I had a very similar case about 8 years ago. However, the lady I helped
did walk (unbelievably) on a limited basis. It looked painful to watch
her walk but she said she was only just starting to experience pain
(which is why she came to see me). I fabricated a KAFO for her with a
s/s lateral upright, plastic cuffs, and attached the lower cuff to a
shoe with free motion. A medial strap helped the cuffs to hold her leg
as straight as I could get it. She did quite well in it. She told me
that she used it mainly when she knew she'd be doing a lot of walking.
I'm not sure that she'd have used it if she only used a wheelchair for
ambulation.

I assume that your lady is needing support for transfers? I would make
this as simple as possible. I do like lateral uprights for these
conditions as they are perceived to be lighter and easier to don. KOs
often don't work due to distal migration if she or her caretakers are
unable to don and tighten them adequately.

You don't mention any problem with the ankle. Does she have an
equinovarus tightness? This can complicate things for use of a KAFO.
If she doesn't, I would think a simple KAFO would work best.