Re: GRAFOs for Spina Bifida
Martin Faulkner
Description
Collection
Title:
Re: GRAFOs for Spina Bifida
Creator:
Martin Faulkner
Date:
4/18/2006
Text:
Here are the responses regarding GRAFOS for spina bifida.
Thanks to all who replied.
I cast in dorsiflexion in the end to reduce forefoot loading and stuck
to the original design so as to test this change in isolation.
A few of you mentioned lack of GR force with knee flexion contractures -
true, but they work - maybe I should call them very rigid AFOs. At the
least they will lessen the knee flexion moment.
Original post:
>Has anyone got any suggestions for GRAFO design for an 18yo man with
spina >bifida?
>
>He has approx. 25 deg knee flexion contractures and currently wears
>bilateral rear entry GRAFOS with reinforced sole plates, The trimlines
are >behind the met heads to allow bending at the met heads but this
leads to >breakage from constant weight bearing on the forefoot.
>
>I could always replace them as they are but breakage is not an ideal
end to >an ideal orthotic design (?)
------------------------------------------------------------------------
We have the same kind of patient and found that we had to do a rear
entry that was laminated with carbon braiding. THIS HAS WORKED THE BEST
TRIM LINES AT THE SIULCUS. yOU NEED TO CAST IN DORSIFLEXION TO
COMPENSATE FOR THE KNEE FLEXION CONTRACTURE.
------------------------------------------------------------------------
--
Do the GRAFOs have only an anterior band or do they extend the entire
length of the tibia and over the dorsum to the mets?
I have had great success with the following particular design: Open
posterior, anterior plastic that extends from the knee all the way down
the tibia over the dorsum of the foot. The design is kind of like a
solid posterior AFO--only it covers the dorsum of the foot to the met
heads. This makes the whole desgin much more stable and much harder to
break or bend. For comfort--add padding down the entire device. It
is critical to have a good neutral mold and a measurement of the dorsum
height and width of the foot at the mets. If you do not make the
opening for the foot wide enough, you will have a very difficult time
donning the device. If you make the device well, it will work
beautifully...or at least it does for me.
Good luck. Emial if you have other questions or you are interested in
this type of device.
------------------------------------------------------------------------
--
It is important for him to take his weight along the entire plantar
surface of his foot and the GRAFO. Bring the floor up to him,
especially through his calcanei, by posting the GRAFO enough to balance
out knees/hips/low back.
------------------------------------------------------------------------
--
You didn't specify exactly where the fracture is occurring, but maybe
you can try a full length foot plate with an appropriate degree of toe
spring.
This may help distribute the loading forces on the distal trim line.
------------------------------------------------------------------------
--
If the trim lines are behind the met-heads what kind of ground reaction
could he possibly be having? I do think he needs a knee control joint
billateral hinges, with a ROM stops, like a ratchet. I would control
the foot and ankle in neutral with whatever design you want; anterior or
posterior trims. A company here in the US and elsewhere have a variety
of ROM knees, with many configurations. There is a recent joint made by
a company called Ultra-Flex. It has a knee control with a locking
rachet for leg extending to stance. It also has a free mode for a
locked KNEE while you can still have 0-30 degrees of freedom in knee
flexsion for ambulation. In order to make life simple I would probably
use the double action Otto-Bock joints at the ankle for a 150 degree
adjustment if you go conventional, or the molded in plastic double
action from otto bock for the plastic footplates; but they only adjust
up 35-40 degrees. Better check with Bock regarding these
specifications.
Good Luck, Rick/CPO
Oh, by the way. The KAFO'S I mentioned perhaps could be worn as night
braces if botox injections were thought to be of any value; or to help
with future releases.
------------------------------------------------------------------------
--
We usually fabricate a two-part Ground reaction for the larger crouch
walkers (spina bifida) because of their insensate foot and constant
breakdown.
The inner boot is a Supramalleolar design, with a full flexible toe
plate to control the foot in good anatomical alignment and prevent
breakdown (DAFO design). We use polyethylene.
The outer section is more of a traditional GRAFO- reinforced at the
ankle with Carbon reinforcements and although it is entered into
posteriorly, the trimlines of the foot section mimic that of a
traditional Solid AFO
The AFO is donned first then the SMO is donned and the SMO snaps
securely into the posterior section.
Alot of control, flexible forefoot, good alignment, and no need to
replace often.
Hope this helps! If you need any more information, feel free to contact
me.
------------------------------------------------------------------------
--
How about just adding a CG rigid sole plate in the shoes to
significantly reduce the stress on your GRAFO sole plates, which should
allow you to go back to full-foot length?
Personally I would not recommend a GRAFO for a 25 degree knee flexion
contracture. At that much knee flexion your ground reaction force is
probably limited anyway.
------------------------------------------------------------------------
--
What I have done for these young adults is to use 3/8 polypropylene. I
also use a full toe plate that is dorsiflexed to allow roll over (third
rocker). I feel that the full toe plate is necessary to protect the
insensate toes from getting curled under while donning shoes. The 3/8
polypropylene is heavy and bulky, but I have not had anyone break one
yet, so the trade off seems worthwhile.
Extend the footplate and allow for contractures if you can't get the
anterior tib. at 90. Just make sure they are going to fall backwards or
post heels to accomidate. Use copoly with polypro combined 3/16 and
3/16, very stiff!
Consider riveting 1/8 copolymer for toe section and cover on bottom with
1 1/2 dacron tape at seam and on top with leather or EVA foam-replace
as needed.. A lot less expensive than making new AFO's over and over. I
learned this from polio patients.
------------------------------------------------------------------------
--
If breakage is a problem at the met heads and you want bending there we
manufacture a polyprop insert on the cast initially, remove and trim it,
replace on the cast and then laminate the GRAFO over the top. You can
then trim the laminate back to the met heads but have polyprop bending
instead.
We do this for a few very active polio clients. Contact if you want any
more info.
------------------------------------------------------------------------
--
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related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Thanks to all who replied.
I cast in dorsiflexion in the end to reduce forefoot loading and stuck
to the original design so as to test this change in isolation.
A few of you mentioned lack of GR force with knee flexion contractures -
true, but they work - maybe I should call them very rigid AFOs. At the
least they will lessen the knee flexion moment.
Original post:
>Has anyone got any suggestions for GRAFO design for an 18yo man with
spina >bifida?
>
>He has approx. 25 deg knee flexion contractures and currently wears
>bilateral rear entry GRAFOS with reinforced sole plates, The trimlines
are >behind the met heads to allow bending at the met heads but this
leads to >breakage from constant weight bearing on the forefoot.
>
>I could always replace them as they are but breakage is not an ideal
end to >an ideal orthotic design (?)
------------------------------------------------------------------------
We have the same kind of patient and found that we had to do a rear
entry that was laminated with carbon braiding. THIS HAS WORKED THE BEST
TRIM LINES AT THE SIULCUS. yOU NEED TO CAST IN DORSIFLEXION TO
COMPENSATE FOR THE KNEE FLEXION CONTRACTURE.
------------------------------------------------------------------------
--
Do the GRAFOs have only an anterior band or do they extend the entire
length of the tibia and over the dorsum to the mets?
I have had great success with the following particular design: Open
posterior, anterior plastic that extends from the knee all the way down
the tibia over the dorsum of the foot. The design is kind of like a
solid posterior AFO--only it covers the dorsum of the foot to the met
heads. This makes the whole desgin much more stable and much harder to
break or bend. For comfort--add padding down the entire device. It
is critical to have a good neutral mold and a measurement of the dorsum
height and width of the foot at the mets. If you do not make the
opening for the foot wide enough, you will have a very difficult time
donning the device. If you make the device well, it will work
beautifully...or at least it does for me.
Good luck. Emial if you have other questions or you are interested in
this type of device.
------------------------------------------------------------------------
--
It is important for him to take his weight along the entire plantar
surface of his foot and the GRAFO. Bring the floor up to him,
especially through his calcanei, by posting the GRAFO enough to balance
out knees/hips/low back.
------------------------------------------------------------------------
--
You didn't specify exactly where the fracture is occurring, but maybe
you can try a full length foot plate with an appropriate degree of toe
spring.
This may help distribute the loading forces on the distal trim line.
------------------------------------------------------------------------
--
If the trim lines are behind the met-heads what kind of ground reaction
could he possibly be having? I do think he needs a knee control joint
billateral hinges, with a ROM stops, like a ratchet. I would control
the foot and ankle in neutral with whatever design you want; anterior or
posterior trims. A company here in the US and elsewhere have a variety
of ROM knees, with many configurations. There is a recent joint made by
a company called Ultra-Flex. It has a knee control with a locking
rachet for leg extending to stance. It also has a free mode for a
locked KNEE while you can still have 0-30 degrees of freedom in knee
flexsion for ambulation. In order to make life simple I would probably
use the double action Otto-Bock joints at the ankle for a 150 degree
adjustment if you go conventional, or the molded in plastic double
action from otto bock for the plastic footplates; but they only adjust
up 35-40 degrees. Better check with Bock regarding these
specifications.
Good Luck, Rick/CPO
Oh, by the way. The KAFO'S I mentioned perhaps could be worn as night
braces if botox injections were thought to be of any value; or to help
with future releases.
------------------------------------------------------------------------
--
We usually fabricate a two-part Ground reaction for the larger crouch
walkers (spina bifida) because of their insensate foot and constant
breakdown.
The inner boot is a Supramalleolar design, with a full flexible toe
plate to control the foot in good anatomical alignment and prevent
breakdown (DAFO design). We use polyethylene.
The outer section is more of a traditional GRAFO- reinforced at the
ankle with Carbon reinforcements and although it is entered into
posteriorly, the trimlines of the foot section mimic that of a
traditional Solid AFO
The AFO is donned first then the SMO is donned and the SMO snaps
securely into the posterior section.
Alot of control, flexible forefoot, good alignment, and no need to
replace often.
Hope this helps! If you need any more information, feel free to contact
me.
------------------------------------------------------------------------
--
How about just adding a CG rigid sole plate in the shoes to
significantly reduce the stress on your GRAFO sole plates, which should
allow you to go back to full-foot length?
Personally I would not recommend a GRAFO for a 25 degree knee flexion
contracture. At that much knee flexion your ground reaction force is
probably limited anyway.
------------------------------------------------------------------------
--
What I have done for these young adults is to use 3/8 polypropylene. I
also use a full toe plate that is dorsiflexed to allow roll over (third
rocker). I feel that the full toe plate is necessary to protect the
insensate toes from getting curled under while donning shoes. The 3/8
polypropylene is heavy and bulky, but I have not had anyone break one
yet, so the trade off seems worthwhile.
Extend the footplate and allow for contractures if you can't get the
anterior tib. at 90. Just make sure they are going to fall backwards or
post heels to accomidate. Use copoly with polypro combined 3/16 and
3/16, very stiff!
Consider riveting 1/8 copolymer for toe section and cover on bottom with
1 1/2 dacron tape at seam and on top with leather or EVA foam-replace
as needed.. A lot less expensive than making new AFO's over and over. I
learned this from polio patients.
------------------------------------------------------------------------
--
If breakage is a problem at the met heads and you want bending there we
manufacture a polyprop insert on the cast initially, remove and trim it,
replace on the cast and then laminate the GRAFO over the top. You can
then trim the laminate back to the met heads but have polyprop bending
instead.
We do this for a few very active polio clients. Contact if you want any
more info.
------------------------------------------------------------------------
--
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
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
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Martin Faulkner, “Re: GRAFOs for Spina Bifida,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/226633.
