Thursday, May 19, 2022

Responces re: KO for obese patient

Jim Thelen

Thanks to all who responded to my request. As it turns out the order
was indefinitely postponed because they have decided to do a surgical
repair. The original post and responses follows.
____________________
> I would like to seek advice from the list for bilateral custom KO’s for
> a 500+ lb female. She is diagnosed with OA but knee pain is elicited
> mostly by full forced knee extension. She does not hyperextend.
> Minimally ambulatory at this time due to size and knee pain. Ideal
> orthosis would control genu varus and valgus as well as prevent full
> extension.
>
> Problems to consider are a large thigh and calf with respect to the knee
> circumference (39″proximal thigh, 25″ calf”, 6.5″ ML), difficulty in
> locating actual knee center, short medial thigh due to abdominal
> overhang, difficulty in hip adduction with bilateral rigid ko’s, + + +.
> She is getting physical therapy land her goal is to be able to ambulate
> more at home and possibly in the community without excessive pain.
>
> I’m not stuck on a rigid brace if a neoprene device would be functional
> for her. My best thoughts at this time is a ko with a lateral full
> upright and medial joint that wraps to the lateral side just above and
> below the knee to leave all the medial tissues free to conform. (Lennox
> Hill??)
If you simply want a soft brace for compression and minimal support try
this company http://www.benik.com/ they can make custom soft braces
with hinges. It may not be the solution for her but it is a good
company to know about for special cases.

Director told me that some people are “orthotically
unmanageable” and to use an OTS neoprene knee brace with metal hinges
(medial hinge removed).

Townsend can do the best job with this weight person. I started to use
them over 15 years ago because of an obese person such as this and they
made me a great brace and the person was in water therapy also with the
brace.

I seriously doubt anything can apply the sufficient counterforce to
provide any real relief of symptoms. You will need KAFOs at minimum.

Your proposition is one that used to be known as a circular equation.
There is no knee brace that will successfully control the knee of a 500
pound patient; there is no 500 pound patient who will wear a knee brace
that is trying to control the stress that he/she places on a knee.

I have had a great deal of success with these types of cases by using custom Defiance OA from DonJoy Orthopedics with an anti-migration strap.

You will need a footplate to suspend the orthoses so consider a KAFO
system. Townsend makes nice ones out of Graphite.

Try a lateral knee guard. Used in football to protect the knee from
lateral hits. Good stability and yet no impingment from medial joint.
Straps will be long enough to fasten. Off the self so give it a try be
for you consider custom.

I used the cti OA on a 420# male. We first casted in fiberglass while
applying 3 point unloading during cure of the cast. Before removal of
the cast the pt ambulated a short distance to prove whether or not
unloading had occurred in the cast. In this case it had and the KO was
fabricated. The finished KO did unload. The challenge, as always, was
the patient’s ability the properly don and maintain the position of the KO.

I successfully braced a 450+ lb gentleman using a custom casted V-Vas
KAFO. Anatomical Concepts makes this brace. If you take a cast of her
leg and send it to them they will fashion a nice double upright KAFO and
my patient was able to feel the medial compartment being offloaded. I
don’t know how well it would work for you in stopping the extension, but
he is able to ambulate with his on a regular basis and it does reduce
his knee pain.

Try the V-Vas offloading knee brace by Anatomical Concepts. Talk to Joe Whiteside he can help you.
They can do a large person. Their # is 1800-837-3888.

Really nothing will work, obesity is contraindication to bracing at this
level. I know you have to provide something, I would pick her worst
knee and try one first. Gotta do a KAFO type for migration. I would
try a Townsend single bar KAFO unloader.

I know that Townsend Design has no limitations on size and they can
actually build in varus or valgus correction with the added ability to
continue to unload after you fit the patient. The main question is how
tall is she and will she be able to put them on herself or does she
have help.
Without seeing her my suggestion would cast each leg sitting fully
extended, compress the soft tissue as securley as you would want the
brace to hold her and even correct the angle a bit if you feel
comfortable doing so.
www.townsenddesign.com
Go to Custom OA Full shell
Air townsend
Full figure configuration
4 straps posterior
Optional thigh strap either graphite or strap (same as others) I’m
thinking graphite, the less she has to bend forward the better.
You can actually pick your own length, but the longer the better. She
will rub the shells together but she is most likely already rubbing
legs.

I would suggest a KAFO, for avoidance of suspension issues and to
decrease the need to do the straps up real tight.


Jim Thelen, LPO
Trinidad Medical Consultants
[email protected]
214-340-6200

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