Friday, May 20, 2022

Responses: Help on Difficult KAFO case

Ryan

Thank you to everyone who responded so quickly to my query. I think I am going to get an Ortho consult to look at the PF contracture before anything else. Unfortunately, the Physiatrist whom I would normally be working with left on vacation and won’t be back for 3 weeks and the “back-up” physician has no experience with this type of thing so it is up to myself and the PTs to get this patient the care he needs.

Here are the responses:

1) What kind of range at the ankle? That 30 degrees is it ? If that’s the case, I would concentrate on that, as ambulation with a KAFO (for which the needs are obvious), would cause you to deal with tremendous leg length discrepancies and does the patient really want to deal with lifts and so on ? If you can stretch out that angle to maybe minus 15, then I would attach an articulating AFO, well stabilized in all planes of course, to a KAFO with may a set of Ultraflex ADR knee joints. I didn’t see that you mentioned any range limitations at the knee and if this is just for weakness why lock him up completely ?

2) Yea that seems like a tough case. I am thinking his goal is just for standing and transfers? Or does he want to do more? The contracture is the first issue. If they plan to release it, then I’d either wait to do the kafo until that’s done or use an adjustable articulated joint to match the joint correction.
At the knee, a ball retainer or bail droplock to use for knee control where it can be easily release for sitting. With the hip weakness I can see there is going to be a hard time advancing the hip. Maybe an RGO type of top or a walkabout inner thigh hip attachment to help control them? Not sure what abilities and goals he has. Maybe he just plans to swing his hips through and use forearm crutches? Let me know how this works out.

3) no quads no hamstrings why do anything beside alocking knee joint?a basic kafo with solid nakle afo with a cam ankle joint so u acn correct as they get better

4) Hi Ryan,

That sounds really tough. The only thing that really sticks out in my mind is trying to correct the pf’n – If the patient’s contracture is from surgical opening of the calf then the contracture is scarred and will not respond to stretching. If there was no surgery in the calf then the muscle fibres may still stretch over time. I had a similar case where the patient had huge pfn contracture post-op and the Doctor was determined to stretch her so they kept asking me to reduce the heel height – this resulted in massive pain and after several weeks there was no change – after researching the web I found an article on how scarred muscle will not stretch. Once I fully accommodated the pfn she was happy.

I am not sure if this helps – I wish you luck with this!

5) Ryan,

Have you thought about a ground reaction AFO? Is there any chance of motor nerve return? How old is the injury? How long has the foot been in a dorsiflexed position? Can you take video of the patient standing and walking in parallel bars? If so take video and talk with Marmaduke Loke, CPO, he has done some amazing things with many different pathologies by staying below the knee. Check out his website: http://dynamicbracingsolutions.net. I am working on a young lady that had a stroke has non-spastic (flaccid) hemiplegia, has genu recurvatum, MMT is almost identical to your patient and I am going to be fitting her with a carbon ground reaction AFO using Marmaduke’s methods.

Either way would you let me know what you decided to do and how it turned out?

Thanks and good luck,

6) Wow, looks like my weird disease magnet worked its’ way north.

With the 2/5 hip, weight is the critical issue. And how does PT feel about long term prognosis?

Gonna be interesting to see what other inputs you get on this, I’m almost at head scratch phase myself.

As for final design, how is the overall strength of the patient, given the EtOh abuse? And does he have sufficient drive to want to walk again? Patient height and weight?

Given the poor grade at the hips and essentially flail distally, you may want to consider laminated carboe graphite shells proximally and distally for strength and weight reduction, but the metal componentry is the big issue. Goes back to height/weight and general physical condition.

Definitely need drop locks for knee stability, the plantar flexion ctx, is the main issue I can see, provided PT is working that out, any style of adjustable plantar flexion stop ankle joint should work.

Good luck with this one.

7) Hi Ryan,

He needs surgical correction on contracture, no ankle joint. Reinforce solid ankle and you may be able to use offset knee joints. I’d probably lock the knee initially. Give him a heel lift on contralateral to aid in toe clearance on affected side.

8) #1 AFO on ASAP to prevent further contracture. That means today or tomorrow. He probably has a overall strong body design that contractures very fast.
KAFO design can be numerous. The best is tough. Make the AFO so you attach the upper to it. Or throw a CTI brace on him, cast over it and attach the AFO. That way it can be complete in a few hours and work awesome and look awesome. Now if you need a locking knee, that makes it more difficult. I am off to the lake have fun.

9) would start with a custom night stretch AFO and maybe do it turbo style to keep the foot aligned. Get him within 10 degrees of 90 before thinking about the KAFO. The KAFO will need to be ischial weight bearing. Good luck.

Ryan Cochrane C.P.O.(c)
Lethbridge Orthotic-Prosthetic Services Ltd.
Tel: (403) 328-1144
Fax: (403) 328-1137
[email protected]

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