[Untitled]

Patricia E. Hazard

8/23/2005

ORIGINAL POSTING

I need recommendations on Central Fabrication service for Graphite Laminated AFO systems. I have preteen patient with CP and hemiparesis who needs light but strong hinged AFO for playing soccer. I want to include a thermoplastic smo in the system.
Patricia Hazard CO

RESPONSES:

     I had a better result with a device with more flexibility ...
used TPE with oklahoma joints this allowed give as the
soccer player planted / kicked etc

***********
Over the years I have successfully fabricated and delivered a number of carbon fiber L.E. orthoses (AFO and KAFO). Carbon fiber has some wonderful properties and advantages, but I believe its main overall advantage for the AFO is its lightweight rigidity. Just realize this rigidity comes with a high price tag.

     One of the main disadvantages is the actual cost of providing this technology verses the reimbursement capabilities. There are no appropriate L-codes to fairly compensate yourself for the efforts and cost of the additional work carbon fiber entails. Therefore in my estimation providing such a service is almost universally done as a labor of love. Hopefully this fact will not detour you if you find it will improve the patient's life in some meaningful and significant way. However you need to consider your options carefully.

     Carbon fiber is extremely rigid and unforgiving, which can work for and against you. The only legitimate adjusting that can and should be done to the finished product is by grinding. Heating and bending breaks the individual carbon fibers and causes delamination and weakening. Because of this, most conscientious prosthetists I know would never consider fitting a definitive carbon fiber socket without first doing a check socket. This due to the inherent lack of the ready adjustability of the finished carbon fiber lamination.

     The same holds true for a carbon fiber orthoses. Unless you are supremely confident you can modify your mold to give your patient a perfect fit without needing post modification adjustments, you will first need to fabricate and fit a check AFO. For this purpose I use the same material employed for check sockets (PETG). This secondary step is necessary and expensive when you consider your total AFO reimbursement capabilities. Just keep in mind there are no applicable orthotic L-code reimbursements for this step of the procedure!

     Also I find the orthotic L-code reimbursement for carbon add on are truly ludicrous and insulting, especially when considering the actual costs plus a necessary profit margin. Medicare reimbursement isn't even a token gesture in light of these facts.

     All that being said, ask yourself this crucial question, how will the additional rigidity aid my patient in this instance? I say that, because there are still several other factors to consider.

     1. Maintenance: I tell my patients if you can't afford to maintain a Mercedes you really can't afford to buy and drive one.

      2. Durability: This is also a factor and unless you have someone highly skilled at laying up your AFO, breakage can still be a considerable problem. If breakage does occur there will be warranty replacement costs and significant time lags without an orthosis (no in house fabrication capabilities) to replace that orthosis.

      3. Replacement frequency: If you are fitting a pre-teen there are almost always above average costs associated with orthotic treatment. This is due to the normal accelerated growth spurts associated with this age group almost always requiring an increased replacement frequency.

      All factors considered, unless the increased rigidity will vastly improve the outcome of this orthosis I personally would stick to polypro. It is reliable, durable, and cost effective. Its application considerations include the obvious, fitting adjustment ease, low initial material or replacement costs, beside the fact that fabrication can be accomplished quickly in yours or almost any lab.

MANUFACTURERS RECOMMENDED or who responded

Tony Wickman RTOP, Freedom Fabrication inc .800.304.3733
************
We are working hard to develop a Central Fabrication Facility which is
unique. We make dynamic prepreg. orthoses. These are made over a reusable
tooling material vs. plaster. The tool (cast is light enough to be sent via.
UPS.
A thermoplastic (or other) SMO is possible if the material will with
stand 250 F during the cure process.
We will some have a silicone insert (SMO concept) soon. Because the
orthoses are dynamic we prefer not to include ankle jts. But this can be
done. When we do this we use Townsend jts.
David Lindsey
British Columbia, Canada
***********
Independent Technical Services Contact Chad at <Email Address Redacted> or 253-435-1770.
They are in Washington state.
************
A great source for this AFO is Kinetic Research
************
Contact Fillauer, they have a great C-Fab with really good turn around and pricing.
The number is 1(800)251-6398 ask for Steve Hughes C-Fab Director
************
Sean Sullivan RTPO, ROF
www.clinicalpando.com
<Email Address Redacted>
************
Custom Composite in Cranston, R.I.
 Web site is www.cc-mfg.com
************
BECKER, OREGON ORTHOTICS,
CLEAN NEAT, AND WELL MADE LAMINATED AFOS.
************
Bader Prosthetics and orthotics in Tampa
813-962-6100.
************
Peter Panuncailman of Windy City Fabricators knows his stuff 866-548-3534

MY THOUGHTS

This is a complex issue. I have only the recommendation of individual practitioners on the above fabrication services. It occurs to that we should have some technical standards for this type of orthotic system based on clinical trial or research.

I am on the fence but considering the idea of using TPE if it will be enough support for medium spacticity with external torsion. Does anyone else have experience in using TPE for this application?

PH