Prosthetics And Orthotics Orthotics: branch of mechanical and medical science that deals with the support and bracing of weak or ineffective joints or muscles by developing and fitting surgical devices Orthosis: (orthoses-p)An orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. Orthotist :A medical Practioner who prescribes the orthoses

Prosthetics And Orthotics Prosthetics: branch of mechanical and medical science that deals with developing artificial replacements (Prosthesis) for body parts Prosthesis: an artificial substitute or replacement of a part of the body such as a tooth, eye, a facial bone, the palate, a hip, a knee or another joint, the leg, an arm, etc. A prosthesis is designed for functional or cosmetic reasons or both. Prosthetist: A medical Practioner who prescribes the prosthesis

Types Of Orthoses and prosthesis 1)Lower limb orthoses 2) Upper limb orthoses 3) Spinal orthoses Prostheses: 1)Upper limb Prostheses 2) Lower limb Prostheses

Lower limb Orthoses These devices are used for supporting the lower limbs Materials: For many years metal components were used in lower limb orthoses. The last decade has seen a marked increase in the use of plastics. No of designs have been developed to include both metal and plastics. Metal components: Aluminum-light wt, Stainless steel-durable Plastic Components: thermoplastic materials(polypropelene,polyethylene)

Materials Compared to metal plastic orthoses are more cosmetic. They also are lighter and offer greater flexibility in design They can also be readily formed over a plastic model of body part Plastic permits a closer fit and more precise control of pressure distribution. The design of these orthoses depend upon the structural and functional characteristics desired

Lower limb Orthoses Types: 1) Ankle Foot Orthosis 2) Knee Ankle Foot Orthosis 3) Hip Knee Ankle Foot Orthosis 4)Knee Orthosis 5)Hip Orthosis

Lower limb Orthoses Ankle Foot Orthoses: The primary function of all AFO’s is to control the alignment and motion of the joints of foot and ankle. Users: Common users of these devices include children with Cerebral Palsy, or other neuromuscular problems. Stroke victims, and many other people with various pathologies also often benefit from the use of an AFO. Metal and Metal Plastic design: These orthoses consist of two metal uprights whose proximal ends are connected to a leather covered metal or plastic calf bands and distal ends are the proximal part of the ankle joint mechanism. The shoe and foot attachment completes the mechanical ankle and anchors the orthoses distally .

Metal AFO Calf band Metal uprights Ankle joint stirrup Shoe attachment

Metal AFO Shoe attachments: A sturdy shoe is prerequisite for orthoses which attach to the shoe by means of a stirrup Stirrup: The most commonly used method of attachment is the stirrup riveted directly to the sole of the shoe under the anterior section of heel. The stirrup encompasses the shoe like a U and provides permanent attachment between the uprights and shoe. this component can be employed with nearly any standard ankle and permits a fairly accurate alignment of mechanical joint with the ankle, an alternative may be a split stirrup

Metal AFO Caliper: A round tube placed in the shoe receives the caliper. The caliper permits easy shoe interchangeability, is of minimal wt and allows economy of construction. The disadvantage is that the mechanical jt is at the level of shoe heel, distal to anatomical ankle. Shoe Insert: Instead of attachment the stirrup is incorporated in a shoe insert, shaped to the contour of the patients foot that fits into the shoe. This component provides max support and control of the foot, also the mechanical and anatomical ankle are congruent,also there is no problem in interchanging shoes

Metal AFO A single metal upright is used when there is a mild dorsiflexion weakness. The single upright may be located medially laterally or posteriorly Calf bands: Metal or plastic bands add rigidity to the orthoses, maintain alignment of the upright also secures the orthoses to the limb

Metal AFO Ankle joints: Most mechanical ankles are single axis joints used to control 1) mediolateral motion. 2)dorsiflexion and planter flexion Ankle stops: limit stops may be set in the ankle to allow for any predetermined range of motion. A PF stop is often used when there is DF weakness or excessive PF,restricts PF but allows unlimited DF Restriction of movement in both directions is both accomplished by limited motion stop.

Metal AFO When no restrain of the ankle joint is required a free motion ankle joint is used. This provides full dorsiflexion and full planter flexion Ankle assist devices: contrary to the stops which prevent motion ,assists in the form of springs are used to assist motion. With the DF assist spring is compressed after heel strike (in stance phase )which helps to control planter flexion. The recoil of the spring aids dorsiflexion for clearance during swing phase a second spring is utilized in DF-PF assist .The anterior string is compressed during mid stance and it’s recoil helps to PF the ankle during rollover.

Dorsiflexion Assist Ankle Foot Orthoses

Dorsiflexion Assist Ankle Foot Orthoses This Ankle Foot Orthoses combines the simplicity of the short leg AFO with a hinge at the ankle that allows for dorsiflexion. This AFO is widely used in cases of moderate foot drop, as the simple hinge will work to increase dorsiflexion enough to restore normal gait that had been disrupted

Plantarflexion Stop Ankle Foot Orthosis This AFO is rigid at the base as to prevent cases of plantarflexion. Plantarflexion is less commonly associated with cases of foot drop, but nonetheless can develop. A hinge is built in to assist with dorsiflexion as in the Dorsiflexion assist AFO. The Plantarflexion Stop Ankle Foot Orthoses is bulkier than the two previous models as the entire base of the foot must be held in place to completely negate and plantarflexion

Varus Valgus Correction Although the uprights and attachments provide some mediolateral control at the ankle there still may be a tendency of the foot to deviate laterally or medially within the shoe In such cases additional support is provided by a varus and valgus correction strap that attaches to the shoe and buckles around the opposite upright. Varus-inversion(inner margin raised, sole pointing inwards) Valgus-Eversion(outer margin raised, sole pointing outwards)

Plastic AFO Plastics are readily formed over modified plaster model of a body part, thus permitting a closer fit and precise control of pressure distribution The extend to which motions are controlled depends upon 1)Chemical composition 2)thickness 3)Shape The plastic AFO’s are formed from a single piece of thermoplastic They contain three components: calf band , calf shell and shoe insert The most common application of this orthoses is to compensate for weak DF by resisting Pf at heel strike and during swing period

Posterior leaf spring AFO Posterior leaf spring: this is a most common AFO characterized by a narrow calf shell Movement of orthosis at the ankle derives from it’s narrow width at the junction of shell and shoe insert These orthoses are fabricated from a sheet or a preformed thermoplastic blank which are available in different sizes Calf band Calf shell Shoe insert

Patellar Tendon Bearing AFO When reduction of weight transmission through the middle or distal tibia ,ankle or foot is indicated a PTB type brim will replace the calf band of the orthosis.The brim is designed to support wt on the patellar tendon, the load in turn transmitted to the shoe by the means of an upright When fabricated correctly this orthosis can unload as much as 90% of the load typically borne the distal tibia, talus and heel

The Solid Ankle Foot Orthosis The Solid Ankle Foot Orthoses is the most basic form of an ankle foot orthoses. This AFO simply wraps around the calf, ankle, and foot and holds them in place disrupting both dorsiflexion and plantarflexion. The Solid AFO is useful in cases of severe footdrop, as the abnormal adaptation to gait is controlled entirely. This does not however restore normal gait as no true dorsiflexion or plantarflexion take place

Spiral Orthoses The spiral design consist of 1)shoe insert 2)A spiral that originates at the medial distal aspect passing around the leg posteriorly continuing across the anterior aspect of the leg A calf band with a lateral opening is attached to the upper end of the spiral This upright is designed to permit the leg to rotate in a transverse plane controlling DF,PF,inversion & eversion

Knee Ankle Foot Orthoses A knee ankle foot orthoses extends from thigh to foot and may be used to control motion and alignment of the knee and ankle and provide support for femur and tibia. It is very beneficial for individuals with valgus (knock knees), varus (bow legs) or hyperextension deformities in combination with neuromuscular problems in the lower legs. People who suffer from pathologies such as spinal cord injuries, post polio, etc benefit from the use of a KAFO. These devices control the knee and foot enough to aid standing and walking for some clients, while others use them to maintain stability for transfers to and from their wheel chair. KAFO has two uprights that extend up to the thigh ,include a mechanical knee joint and are held together by two thigh bands. The distal components are same as in ankle foot orthoses discussed earlier.

Knee Ankle Foot Orthoses Thigh bands Knee joint Calf bands Metal uprights Shoe attachment Ankle joint stirrup

Knee Ankle Foot Orthoses A KAFO is more difficult to don and doff than an AFO, so it is not recommended for patients who have moderate-to-severe cognitive dysfunction. This orthoses can be made of metal-leather and metal-plastic or plastic and plastic-metal. The metal design includes double upright metal KAFO (most common), single upright metal KAFO (lateral upright only), and Scott-Craig metal KAFO. The plastic designs are indicated for closer fit and maximum control of the foot, including supracondylar plastic KAFO, supracondylar plastic-metal KAFO, and plastic shells with metal uprights KAFO.

Knee joints Knee joints: The mechanical knee joint can be polycentric or single axis. Polycentric is used for significant knee motion, and a single axis is more common and is used for knee stabilization. Single axis knee joints include the following:

Free Motion Knee joints Free motion knee joint: This joint has unrestricted knee flexion and extension with a stop to prevent hyperextension. The free motion knee joint is used for patients with recurvatum but good strength of the quadriceps to control knee motion.

Genu Recurvatum Genu Recurvatum:The backward curvature of the knee; hyperextension of the knee.

Offset Knee joints Offset knee joint: The hinge is located posterior to the knee joint and ground reaction force; thus, it extends the knee and provides great stability during early stance phase of the gait cycle. This joint flexes the knee freely during swing phase and is contraindicated with knee or hip flexion contracture and ankle plantar flexion stop.

Knee locks Drop ring lock knee joint: Some KAFOs may have drop locks at the knee joint (See Figure 4). A drop lock allows the knee to be kept in extension or straight while walking can be unlocked for sitting Drop locks would be used for someone with severe knee instability feel more secure with both medial and lateral drop locks.

Knee locks A spring loaded pull rod extending to the mid-thigh level may be added to the ring so the wearer need not bend to lock or unlock the joint

Knee locks Pawl lock with bail release knee joint: The semicircular bail attaches to the knee joint posteriorly, and it can unlock both joints easily by pulling up the bail or backing up to sit down in a chair. A major drawback is the accidental unlocking while the patient is bumping into a chair. Adjustable knee lock joint (dial lock): The serrated adjustable knee joint allows knee locking at different degrees of flexion. This type of knee joint is used in patients with knee flexion contractures that are improving gradually with stretching.

Types of KAFO (condyle-A rounded prominence at the end of a bone, most often for articulation with another bone) Supracondylar -Situated above a condyle or condyles

Types of KAFO The supracondylar plastic orthoses uses immobilized ankle in slight plantar flexion to produce a knee extension moment in stance to help eliminate the need for a mechanical knee lock. This orthosis also resists genu recurvatum and provides mediolateral knee stability

Types of KAFO A plastic shell and metal upright orthoses consists of a posterior leaf spring AFO with double metal uprights extending up to a plastic shell in the thigh with an intervening knee joint.

Types of KAFO A Scott-Craig orthosis consists of a cushioned heel with a T-shaped foot plate for mediolateral stability, ankle joint with anterior and posterior adjustable stops, double uprights, a pretibial band, a posterior thigh band, and knee joint with pawl locks and bail control. With 10° of ankle dorsiflexion alignment, it allows a swing-to or swing-through gait with crutches. This orthosis is used for standing and ambulation in patients with paraplegia due to spinal cord injury (SCI).

While sitting, position the thigh and the leg inside the KAFO instructions are for putting on a basic plastic KAFO with metal uprights: While sitting, position the thigh and the leg inside the KAFO

Position the heel completely back into the plastic of the KAFO

Secure the Velcro strap across the instep Continue fastening the Velcro straps up the leg and the thigh The foot can then be inserted into the shoe. If necessary, the insole of the shoe can be removed to allow for more room for the foot portion of the KAFO

Wearing Schedule On the first day you receive the brace, begin by wearing for only 1 hour. After 1 hour, remove the brace and check your skin for red marks. Some small, light red marks may be noticed on the skin that should go away in 20 to 30 minutes after removing the brace. Slight redness is common over the instep and under the ball of the foot. If the red marks do not go away in 20 to 30 minutes or if you notice any scratching, bruising, or blistering, do not put the brace back on. Call immediately to schedule an appointment with your orthotist. If the skin is ok, wait at least 1 hour and then put the brace back on for 1 hour at a time for the rest of the first day, checking the skin after each hour. On the second day, put the brace on for 2 hours. After 2 hours, remove the brace and check the skin. If the skin is ok, put the brace back on for 2 hours at a time for the rest of the day, checking the skin after every 2 hours. If your skin is ok, gradually increase wearing time by 1 hour each day, checking the skin after each wearing time.

Knee Orthoses Patients who require support and control of knee ,but not the foot and ankle may benefit from a knee orthoses Knee Orthoses are used for any knee ligament instability or cartilage damage. The brace will support and protect the joint capsule during activities. Often the damage is the result of an acute injury incurred while participating in a sport. Osteoarthritis in the knee joint is another common problem leading to the need for a knee orthosis

Types Of Knee Orthoses Traditional knee orthosis:these orthosis incorporate a leather thigh and calf cuffs and metal side bars A pressure pad may be applied to generate medial or lateral forces Nowadays these orthsis are made up of thermoformed plastic molded over plaster model of the limb so that forces can be applied more accurately

Types Of Knee Orthoses Dynamic patellar orthosis: It consist of an elastic sleeve with a patellar cutout , two circumferentially wrapped rubber straps that apply dynamic tension to a patellar pad and axial rotation of the device. Its purpose is to avoid the dislocation of the patella

Types Of Knee Orthoses Swedish knee cage: An effective Orthosis used in the management of knee hyperextension Quick and easy to fit 2 anterior pads and an adjustable posterior pressure pad, at the attachment to the upright, allows for an individual fit Straps are lined with a strong elastic for a firm grip of the leg Permits flexion at knee Indications: Provides management of genu recurvatum Unstable knee due to laxity of ligaments

The CAR-UBC orthosis helps to provide knee stabilization against varus and valgus It consist of two plastic cuffs one on the thigh and one on the leg connected by a telescoping rod The rod is placed on the medial side of the limb for for genu valgum,and lateral side for genu varus

Types Of Knee Orthoses Lenox-Hill derotation orthosis: knee orthosis designed for control of knee axial rotation (in addition to anterio-posterior and mediolateral planes control). It utilizes elastic straps that encircle the leg and thigh and exert forces designed to provide rotation control Used in prevention and management of sports injuries to the knee (e.g., ACL injuries).

Hip Knee Ankle foot orthoses Hip joint and pelvic band attached to the lateral upright of a KAFO converts it to a HKAFO. Indications Hip flexion/extension instability Hip adduction/abduction weakness Hip internal rotation/external rotation instability

Hip Knee Ankle foot orthoses

Hip joints and locks Single axis hip joint :permitting flexion and extension and include and adjustable stop to limit hyperextension. By the nature of their design these joints also resist abduction ,adduction and rotation. The flexion extension capacity can be restricted by including a pawl or a drop lock similar to that used for a knee joint. Two position hip locks : provide locking for full extension and 90° hip flexion, are of limited use for children which have difficulty in maintaining the sitting position.

Hip joints and locks Double axis hip joint: If there is no need to block both abduction and adduction a double axis joint may be used. The flexion extension axis must be free or locked as required while the adduction, abduction axis include adjustable stops to place limit on these motions as needed.

Pelvic Bands To enable the hip joint to accomplish its function of motion control, it's upper arm must be stabilized by attachment by intimate contact with the pelvis The types of pelvic bands utilized depends upon the degree of control required and whether one or both hip joints are involved.

Pelvic Bands Unilateral pelvic band: Occasionally a unilateral pelvic band is used. It encompasses the pelvis involved on the side between that of iliac crust and the greater trochanter.A flexible belt that encompasses the band then encircles the entire pelvis Bilateral pelvic band: The ends of this band lie anterior to lateral midline of pelvis. The band then curves posteriorly and downwards and continues slightly upwards to overlie the sacrum

Pelvic Bands Silesian belt: A Silesian belt also referred to as a silesian bandage is a flexible band hat encircles the pelvis and helps stabilize the orthoses on the wearer. since it has no metal joint or rigid band it cannot control motion of the sagittal plane .It van however offer mild resistance to rotational and abduction ,adduction forces at the hip

Hip Orthoses The most common function of such an orthoses is to resist femoral adduction produced by the mildly spastic adductor musculature of individuals with cerebral palsy. An HO designed to accomplished this purpose has a two position lock (full extension and flexion and 95 hip flexion) and an adjustable adduction stop. This type of orthoses is used for selected elderly patients who have had total hip joint replacement to control hip position