HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty

HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty
Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

LEARNING OBJECTIVES: Describe the parts of knee-ankle-foot orthosis (KAFO). Determine the different types of knee orthosis (KO). Describe the components of hip-knee- ankle-foot orthosis (HKAFO).

LEARNING OBJECTIVES: Determine the different types of hip orthosis
Differentiate the other types of orthosis for special purposes: Weight- bearing Fracture Pediatric population Search for evidence regarding use of HKAFO, KAFO, hip or knee orthosis

KNEE-ANKLE FOOT ORTHOSIS (KAFO)

KAFO (Knee-Ankle Foot Orthosis)
AFO extended proximally encompassing the knee joint Three (3) types of design: Metal Plastic Plastic-metal

KAFO : METAL DESIGN Components: AFO Two metal uprights
Mechanical knee joint Two thigh bands

KAFO : METAL DESIGN Knee Joints: Single axis Free motion
Unrestricted knee flexion and extension Hyperextension stop Recurvatum or mediolateral instability Free motion knee joint is indicated for individuals who have sufficient muscle power to control the knee during weight bearing and walking but has a tendency toward recurvatum or mediolateral instability.

KAFO : METAL DESIGN Knee Joints: Offset Axis is posterior to uprights
Knee stability Allows knee to bend during swing phase Allows sitting NOT used in knee or hip flexion contracture and AFO with plantarflexion stop Because of the position of the mechanical axis (posterior), the knee assumes an extended position early in the stance phase (becomes more posterior in relation to ground reaction forces during walking Show a picture na lang for this. Hence, the knee is relatively stable without a lock. But the knee is still free to bend during swing phase and allows sitting without manipulating the locks.

KAFO : METAL DESIGN Knee Locks: Drop-ring Most common Control flexion
Attached to both uprights Simple, effective sturdy May bind in knee flexion contracture or spasticity When the uprights are fully extended, the rings drop over the joints by gravity or with manual assistance.

KAFO : METAL DESIGN Knee Locks:
Drop-ring variant: spring-loaded retention button For occasional locking Prevent rings from dropping accidentally Can be used patients who can walk with a free knee but wish to lock it occasionally. Retention button assists sitting as well since the patient can raise one lock above the button and still have adequate stability to grasp the chair with one hand while raising the lock with the free hand.

KAFO : METAL DESIGN Knee Locks:
Drop-ring variant: spring-loaded pull rod Extend to mid-thigh level Convenient locking/ unlocking without bending Used only for a unilateral upright

KAFO : METAL DESIGN Knee Locks: Pawl lock
Easier to release with a flexion force Lever arm (bail) attached to the pawl for release  pull upward French or Swiss lock Here, the pawl is spring loaded. When the knee joint is fully extended, the pawl fits into the recess and spring maintains the pawl in the recess, thereby locking the knee in extension. to release, just pull upward on the bail or by catching the bail on the edge of a chair. In the absence of springs, a french or swiss lock is used where the elastic webbing is attached from the bail to the calf band.

KAFO : METAL DESIGN Knee Locks: Adjustable
Conditions where changes in knee ROM is desired Gradual stretching of knee flexion contracture

KAFO : METAL DESIGN Knee Locks: Adjustable: Fan lock
Has a drop ring lock to maintain desired knee position The drop ring lock maintains the desired knee position in standing and walking but which can be unlocked to permit full knee flexion when sitting

KAFO : METAL DESIGN Knee Locks: Adjustable: Serrated
Permits locking in almost any degree of flexion at 6° intervals Proximal component: drop ring lock Distal component: outer ring with internal serrations matching external serration of inner disc

KAFO : METAL DESIGN Accessory Pads Knee cap
In front of the knee & secured to the uprights with straps Reduce discomfort between knee and orthotic cuffs during stance phase During stance phase when knee assumes a slightly flexed position

KAFO : METAL DESIGN Accessory Straps: Extend from knee cap
Medial or lateral Genu varum and valgum Buckles around one upright to pull the knee If medially located, the strap is buckled around lateral upright to correct genu valgum; If laterall located, buckled around medial upright to correct genu varum? – check this in other books or at internet?

KAFO : METAL DESIGN Variants of metal design: Single upright orthosis
Lacks medial upright Has plastic molded thigh and pretibial cuffs

KAFO : METAL DESIGN Variants of metal design: Scott-Craig orthosis
For patients with SCI Orthotic stability of knee, ankle and foot, passive ligament stability at hip Key design factor: ankle in 10° dorsiflexion To help patients with SCI stand and walk passive ligament stability at hip is achieved without any orthotic component at hip Parts: Double uprights One posterior thigh band Hinged pretibial band for donning and doffing Ankle joint with adjustable pin stops (anterior and posterior) Cushion heel T-shaped foot plate- embedded in the sole of the shoe from the heel to the metatarsal head . Young cross bar of “T” lies at the metatarsal head area to provide mediolateral stability. The alignment of 10 degrees dorsiflexion at the foot forces the limb to lean slightly forward. Balance is achieved by compensatory hip hyperextension so that COG is posterior to the hip and anterior to knee and ankle joints.

KAFO : PLASTIC DESIGN Supracondylar KAFO Very durable
Resists recurvatum Provides mediolateral stability Distal postion: limits subtalar motion and places the ankle in slight plantarflexion Indicated for knee extensor weakness Very durable because of its unitary construction and absence of mechanical parts. The ankle is positioned in slight plantarflexion to create a kee-extension moment when the forefoot contacts the ground. In knee-extensor weakness, the knee stabilizing principles of the orthosis eliminate the need for mechanical knee lock during stance and permits knee flexion during swing phase.

KAFO : PLASTIC DESIGN Supracondylar KAFO Drawbacks:
Proximal portion protrudes in sitting NOT for bilateral use Variant: includes conventional metal knee joints & uprights Proximal portion protrudes in sitting, if the height of this segment is lowered to address this problem, excessive force concentration may result Because the ankle component is positioned in slight plantarflexion, if both lower limbs are donned with this orthosis, anteroposterior stability will be compromised. Because of these problems, a variant was made which includes conventional metal knee joints & uprights allowing the orthosis to flex at the knee in sitting

KAFO : PLASTIC-METAL DESIGN
Accommodate longitudinal and circumferential growth Components: AFO Plastic shells Metal uprights attached by screws or rivets Knee joint Straps Accommodate longitudinal growth by changing relations of metal uprights with the thigh and calf bands. Circumferential growth is accommodated by spot heating and reshaping thermoplast.

KAFO : PLASTIC-METAL DESIGN
Quadrilateral shape of proximal thigh shell control rotation Can incorporate ischial seat for weight-bearing INSERT PICS OF TWO TYPES OF PLASTIC-METAL AFO PAGE 144 IN NYU. Extensive thigh shell provide greater support and control. Also the forward rotation of the proximally hinged segment provides clearance for the foot to pass through the thigh shell during donning of orthosis.

KAFO : PLASTIC and PLASTIC-METAL DESIGN
Perform the same functions of the metal orthoses Light weight Improved cosmesis Nonabsorbent Indicated for: Close fit Precise control of pressure Maximum foot control

QUESTION: You have a 4 year-old patient with a ® sided plantarflexion spasticity. Also, the ® knee is kept in a flexed position. Upon assessment, the ® ankle and knee can be manipulated to neutral position. Which of the following orthotic devices will BEST address the child’s problems? A metal KAFO with a drop ring lock on (B) uprights A plastic –metal KAFO utilizing a pawl lock on each upright A KAFO that has an adjustable knee lock. Letter B. no need for adjustable knee lock since the knee can be extended to neutral position already.

KNEE ORTHOSIS (KO)

KO (Knee Orthosis) For support and control of knee only Indications:
Patellofemoral disorders Abnormal angulation Axial rotation/ instability

KO: PATELLOFEMORAL DISORDERS
Infrapatellar strap Foam padded Encircles the knee below the patella Worn during activity

KO: PATELLOFEMORAL DISORDERS
Palumbo: Elastic sleeve with patella cutout Two (2) circumferential rubber straps  dynamic tension to patellar pad One counterforce strap  maintain pad position & avoid axial rotation

KO: ANGULAR MOTION CONTROL (FRONTAL & SAGITTAL PLANE)
Components of typical KO: Thigh and calf cuffs joined by sidebars Flexion-extension joint Pressure pad (medial or lateral) Primarily protects knee from mediolateral forces Flexion –extension control through hyperextension stop or drop lock Pressure pads may be provided to apply medial or lateral force to the knee.

Components of typical KO: May incorporate polycentric joint Follow natural motion of anatomical knee joint Two (2) basic designs: Two meshing gears: fixed Plate with two pivots (genucentric): adapts Gear type: fixed path of rotation Genucentric: path adapts to the changing center of motion of the anatomic knee

Variants of typical KO: Miami Thermoformed plastic More accurate force application and distribution Medial suspension wedge prevent downward slippage Side bars and polycentric joints are incorporated into the polypropylene thigh and calf shells which cover the anterior limb surface. Downward slippage is a common problem in knee orthoses.

Variants of typical KO: CARS-UBC Consists of 2 plastic cuffs connected by telescoping rod  placed laterally (valgum) or medially (varum) Third point of force: pad placed Medially (valgum) or laterally (varum NO control of axial rotation CARS-UBC: canadian arthritis and rheumatism society-university of british columbia) Knee flexion is permitted by telescoping of the rod Problems with this is related to cosmesis, interference with clothing and difficulty in donnning.

Recurvatum (hyperextension) Swedish knee cage Restricts hyperextension Not much mediolateral stability Three-way knee stabilizer More cosmetic because of pivotal strap attachment Lateral and medial uprights  slight mediolateral stability Both have two anterior straps and one posterior strap which are held in position by metal frame Both allows almost complete knee flexion.

Supracondylar KO: More control of recurvatum Firm mediolateral stabilization Does not interfere with knee flexion Rigid support Suprapatellat portion protrudes in sitting

KO: AXIAL ROTATION CONTROL
Also provides angular control in frontal and sagittal planes Types: Lennox Hill Derotation orthosis Lerman multi-ligamentous knee control orthosis

KO: AXIAL ROTATION CONTROL
Both has elastic straps that exert forces to provide rotation stability Lerman: condylar pads to control mediolateral stability of patella Both are used in prevention and management of knee injuries (sports).

QUESTION: You have a female patient diagnosed with RA of (B) knees. She exhibits genu valgum on the (L) knee. Your assessment revealed that the hip and ankle joints are in proper alignment. you would consider prescribing which of the following knee orthosis to BEST address the deformity? Standard knee orthosis with a medial knee strap attached to the knee cap Three-way knee stabilizer CARS-UBC with a medially placed telescoping rod Answer is letter A.

HIP-KNEE-ANKLE-FOOT ORTHOSIS (HKAFO)

HKAFO (Hip-Knee-ankle-foot Orthosis)
Extension of the KAFO to the hip to gain selected control of hip motions Additional components: Hip joint Pelvic band attached to lateral upright of KAFO

Hip joints and locks: Single axis Permits flexion and extension All prevent ABD, ADD and rotation

Hip Joints and Locks Adjustable hyperextension stop
Pawl or drop ring lock to restrict flexion-extension

Hip Joints and Locks Double axis joints are used if there is no need to control abduction and adduction. Only has adjustable stops for abd-add if these motions need to be limited. Double axis joint has flexion-extension axis which is free or locked & adjustable stops for abd- add. Two-position hip locks fix hip at full extension or 90° hip flexion

Pelvic bands: Provide stabilization to hip joint Intimate contact with pelvis Usually bilateral, unilateral is rare Usually bilateral because conditions that use HKAFO has bilateral affectation of lower limbs such as spina bifida and SCI

Pelvic bands: Unilateral band: Metal Encompass pelvis on involved side Between iliac crest and greater trochanter Fastened to the body by a flexible belt

Pelvic bands: Bilateral band Just anterior to lateral midline of pelvis Curves posteriorly and downward to contact most prominent part of buttock then slightly upward to overlie sacrum Padding & flexible belt

Pelvic bands: Double (hessing) or pelvic girdle: Maximum control Hessing: metal Girdle: increased comfort and grasp Attached to single orthosis: maximal unilateral control

Pelvic bands: Silesian belt: No metal joint or rigid band Does not control motion in sagittal plane Mild resistance to rotational and abduction-adduction forces KAFO attachment: lateral upright Quadrilateral brim Quadrilateral brim: attaches slightly posterior and superior to the apex of greater trochanter, encircles pelvis and terminate at the ischial level on the anterior midline.

Spinal attachments: For SCI, polio, spina bifida, muscular dystrophy To control trunk motions Modify spinal alignment Reduce loads on the spine Reduce load on spine by increasing intracavitary pressure

Spinal attachments: Types: Lumbosacral flexion- extension-lateral flexion control (Knight) Thoracolumbosacral flexion-extension-lateral flexion control (Knight- Taylor)

HIP ORTHOSIS (HO)

HO (Hip Orthosis) Selected control of hip motions only.
Incorporates the same hip joints and pelvic bands Additional component: Lower bar attaching hip joint to thigh cuff

HO (Hip Orthosis) Most commonly used to control adductor spasticity
Distal extension of the thigh cuff to medial condyle of femur – additional resistance to ADD and IR Can also be used for elderly patients post-THA Scan illustration in page 154 of HO to control adduction spasticity – the hip joints include a two-position lock (full extension and 90-degree hip flexion) and an adjustable adduction stop. Used in patients post-THA to control hip position during convalescence

SPECIAL-PURPOSE ORTHOSIS

Special-Purpose Orthosis
Three (3) subdivisions: Weight-bearing devices Fracture orthosis Pediatric population

Special-Purpose Orthosis: Weight-bearing Devices
To reduce weight transmission through the lower limb Types: Patellar-tendon-bearing Ischial weight-bearing Patten bottom

Special-Purpose Orthosis: Weight Bearing Devices
Patellar-tendon-bearing Reduction of weight through the mid or distal tibia, ankle & foot PTB-type brim replaces the calf band Little or no motion at ankle joint Cushion heel or rocker bar Since there is little or no motion at ankle joint, cushion heel or rocker bar should be added to the shoe for a smoother gait pattern

Ischial weight bearing Impaired femur or knee Quadrilateral rim or ischial ring Ischial ring: less effective but more comfortable Ischial ring is more comfortable since it distributes forces over less area and does not have the stabilizing effect of the anterior wall. But is sufficient if minimal weight relief is desired

Patten bottom: Complete weight reduction through the limbs No ankle joint, uprights terminate in a floor pad which extends distal to the shoe Shoe lift on other leg Weight is directly transmitted from the ischial tuberosity or patellar-tendon areas through the uprights to the floor pad with the foot being suspended freely in midair. Shoe lift needs to be done on the other side to equalize the legs

Special-Purpose Orthosis: Fracture Orthosis
Allows movement of adjacent joints and early weight bearing Maintains bone reduction Provides circumferential compression of surrounding tissues

Tibial orthosis Four (4) weeks post- fracture Thermoplast Plastic-cable ankle joint  allows ankle motion Plastic thigh section  tibial plateau fracture stability Thermoplast is preferred because it is more comfortable and light weight than plaster cast Plastic-cable ankle joint is connected to a plastic heel insert

Tibial orthosis: variant Bivalve shell which pivot at proximal end Veclro strap ensures adequate compression Distal trimlines determine ankle motion Bivalve shell: anterior and posterior shell The more distal the trimlines are, the less motion permitted at the ankle.

Femoral orthosis Fracture at mid or distal third of femur Applied if with (+) callus formation and pain free Same design features with tibial orthosis Quadrilateral proximally for rotational stability Not indicated for fracture of proximal third of the bone because of the difficulty in controlling varus angulation.

QUESTION: A patient 10 mo.post-tibial plateau fracture was referred for PT management. X-ray findings revealed nonunion of the fracture site. Which of the following statements is TRUE regarding orthotic management of this patient? The patient will need to wear the tibial orthosis longer because the fracture is not yet healing. The patient will need a plastic –metal KAFO with a quadrilateral rim to reduce axial loading. The anwer is letter B. because the bone involved requires to be deloaded to promote union and at the same time, other joints need to be mobile to preserve muscle and joint integrity. Aside from this, the orthosis should have a knee lock, correction strap if with valgum/varum deformity, solid AFO for maximum stability.

Special-Purpose Orthosis: Pediatric Orthosis
Indications: Angular and rotational deformities Congenital hip dislocation and dysplasia LCPD (Legg-Calve-Perthes Disease) Severe paralytic disorder

Pediatric Orthosis: Angular & Rotational Deformities
Denis Browne splint Spreader bar Adjustable foot plates  rotation Varus-valgus positioning Used in rotational & angular deformities – clubfoot, pronated foot, abnormal tibial torsion Spreader bar can be of various length Foot plates are located at either end and. Shoes are attached here. Valgus-varus positioning of the foot is done by bending the spreader bar

“A”-frame orthosis Adjustable components Same purpose as Denis-Browne splint Calf & thigh bands and pressure pads are added for proximal abnormalities Components are adjustable to accommodate growth

Torsion-shaft orthosis Consists of tightly coiled spring Spring tension apply rotary force distally  screw Mild scissor gait, spastic hemiplegia, abnormal toeing Problem: excessive rotary force Proximal end connected to pelvic band; Distal end connected to shoe Degree of rotary force is controlled by controlling the spring tension through the screw

Hip-rotation control straps Two straps for control internal and external rotation Allows reciprocal gait pattern and sitting Light-weight and easy to don Cosmetic

Internal rotation control strap Consists of a waist belt Posterior tapes are taut at standing  hip ER Tapes slackens during sitting

External rotation control strap No belt Single anterior strap Strap shorten  hip IR

Pediatric Orthosis: Congenital Hip Dislocation/ Dysplasia
Maintain the femoral head within the acetabulum Hold the hip in flexion and abduction Types: Von Rosen Ilfeld Pavlik harness

Von Rosen Plastic frame Easily conformed to child’s body Vertical straps hold thigh in position Above shoulder: superior part of the frame Thigh area: inferior part of the frame Picture: modern von rosen in which vertical straps and horizontal straps are eliminated already. Sturdiness of the frame is enough to hold splint in position.

Ilfeld splint Two thigh bands holds the limb in abduction Length of cross bar adjusts the degree of abduction Waist band is used to secure the splint Crossbar is connected the two thigh bands.

Pavlik harness Chest strap Shoulder harness Anterior and posterior straps Permits greatest activity Frejka pillow Anterior and posterior straps that extend from the chest strap to bootees tha hold the feet securely.

Pediatric Orthosis: Legg-Calve-Perthes Disease
Maintain femoral head in acetabulum Position hip in abduction Types: Trilateral orthosis Toronto orthosis Scottish rite orthosis

Trilateral orthosis Rotates femur internally Lateral wall of plastic brim is cut away to reduce ABD forces Usually unilateral Internal rotation of femur aids containment of femoral head

Toronto orthosis Rotates femur internally single vertical tube connected to thigh cuffs Spreader bar Angled shoe blocks attached to high-top shoes maintain foot ankle alignment

Scottish Rite orthosis Maintains hip flexion and abduction Horizontal telescoping spreader bar Lightest and least restrictive Does not hold hip in IR Proper alignment of subtalar joint is not achieved

Pediatric Orthosis: Severe Paralytic Disorder
Detachable hip joint Allows easy donning and doffing of spinal orthosis For children with high level lesions

Standing frame orthosis To train standing balance and swing-through gait pattern Worn over clothing

Parapodium Worn over clothing Allows standing without crutches Permits child to sit and stand Child is able to sit and stand because it has hip and knee joints

Reciprocation-gait orthosis Extends from thorax to the feet Provides lower limb support Allows reciprocal walking Permits sitting Can be used by adults

SEARCHING FOR EVIDENCE ……

SAMPLE CASE You are considering to prescribe a denis-browne splint to your 2 year old patient with talipes equinovarus on (B) LE. You want to know the effective of the splint in correcting this foot deformity in children at this age. What type of clinical question are you faced with? A question on effects of intervention.

When searching for evidence on effects of intervention…….
What type of evidence should you look for? What are the key terms you will use for searching? Which of the key terms is likely to be uniquely answered by the studies of your interest? What are the alternative terms of your key terms? Ask them to write their answers on a piece of paper. #1: systematic review or randomized clinical trial #2: denis-browne splint, talipes equinovarus, children #3: denis-browne splint #4: ankle orthosis, foot orthosis, clubfoot, congenital clubfoot, kids, toddlers

When searching for evidence on effects of intervention…….
What are the alternative terms of your key terms? What database/s will you best find the studies of your interest? Ask them to write their answers on a piece of paper. #4: ankle orthosis, foot orthosis, clubfoot, congenital clubfoot, kids, toddlers #5: PEDDRo and Cochrane Library- because they contain a lot of systematic reviews and RCTs

REFERENCES Herbert, R., Jamtvedt, G., Mead, J., & Hagen, K. (2005). Practical evidence-based physiotherapy. China: Elsevier Limited. New York University(1986). Lower Limb Orthotics. Staff prosthetics and orthotics.

THANK YOU FOR LISTENING!!!!!!!!!
“To LEARN, you must WANT TO BE TAUGHT...” Proverbs 12 1

HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty

Similar presentations

Presentation on theme: "HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty

Similar presentations

Presentation on theme: "HIP AND KNEE ORTHOSES Minerva Zaniebeth A. Gomez, PTRP Faculty"— Presentation transcript:

Similar presentations

About project

Feedback