Dear List,
Thank you for your great responses to my query.
ORIGINAL POST WAS AS FOLLOWS:
I saw a patient today who has about 35 degree of valgus at knee upon weight
bearing. She is 65years old and an household ambulator. The etiology is
unknown. Her recent condition is the cause of negligence over last 10-15 years,
now at a point of no return and is slowly getting worse. According to
physician she is not a surgical candidate. Her main goal is to control the
valgus and reduce some of the knee pain.
During standing I can barely correct approx. 8-10 degrees. Upon non weight
bearing the valgus is reduced to about 20 degree( A 15 degree of correction).
She does have Osteo Arthritis. That is all the info I have on the patient.
I know that Townsend and GII do make custom and off the shelf braces. I am
asking the list of their experience in treating their patients for similar
conditions in off the shelf braces, KO Vs KAFO’s
What has been your analogy in design consideration and brace selection, keeping
patient compliance in mind.
Thanks for your help. I will compile the answers and post.
Aman Raj CPO, FAAOP
RESPONSES FROM THE LIST
My experience with that much Valgum is that the stock knee braces do not
offer the leverage needed to do the correction job with any comfort. Less
distance from the force, increases the force. The stock knee braces are
just too short. I would go custom. More bulky, bigger, but will be more
comfortable. At 65 years old, for around the house, I don’t think she would
mind trading bulk for comfort
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For the patient you described, I’d use a KAFO. The forces need to correct
her knee will be so great she may not tolerate them. You only hope is to
lengthen the lever arms as much as possible.
My experience has been to use a KAFO. The footplate does not necessarily have to have functional purposes–it helps with suspension and provides a better lever arm. With the amount of valgus you are describing you need as long of a lever arm as possible. I have had very good luck with Townsend on things such as this. Good luck.
Based on past experience, I would guess this woman also has a moderate — severe Pes Planus with an Internal Rotary Pattern (IRP). It is hard for us to assess this persons true needs without video. I would recommend a well molded rigid (graphite) ground reaction KAFO with pretibial shell, utilizing IRP rotational control with maximum correction of the knee valgum. Foot correction and placement is critical for success in addition to multiple three point pressure systems to control this limb in all three dimensions. I believe this knee can be corrected further in time provided the corrective forces are maintained. The pressures on the limb will decrease as the knee corrects. This woman should be advised not to stand and walk barefoot once a viable orthosis has been fit and tolerated. Please let me know if you need any assistance or advice how to obtain your goal. These are fun challenges
Related to this patient, GII custom knee brace is the most ideal one. I have had a similar situation with one of my patient and GII helped significantly.
It has been my experience that for severe angulation problems of the knee the best results in providing support as well as maximizing overall comfort has been achieved using a K.A.F.O. instead of a K.O. Spreading corrective pressure over the greatest area (i.e. high on lateral thigh, wide over medial knee, and anchoring at the shoe) will probably make the patient more comfortable. Be sure the patient has the dexterity and motivation to don/doff the orthosis though, as sometimes this can prove to be overwhelming for some geriatric and OA patients.
You have a very diffficult situation to treat. I advise a KAFO. A KO will rotate or migrate distally (or probably do both!) Interview the patient very carefully to see if she is willing to wear a KAFO. If she doesn’t, then I would offer her a long wraparound neoprene Knee Orthosis with hinges that have substantial sidebars. Let me know if you need more details.
Rigid KAFO with valgus side pull strap, Free ankle rigid joints that will not torque. As long as the brace prevents pt from hitting that 35% end point, you have succeeded. Try to get 10% correction if possible. Pt will likely over power a K.O. If the brace reduces her pain then she will comply with use. When she is standing and you correct with your hands, does she get relief? If yes, you should be able to get that result with a KAFO. If it still hurts then she may refuse the brace
you can use newperen knee cage with lateral bar and medial pad if you can not succeful add shoes with ankle joint.
I would cast her non weight bearing and reduce the valgus and have townsend
make the k.o with lateral extension…this suspends the ko without digging
into the condyles…ask for a “Check socket” to fitt to make sure the
correction isn’t too much… use the unloader mechanism to gradually move
her if it is…does she buckle?? Use the cable trigger lock
Treated multiple patients with that presentation. KAFO only way to go.
My experience with that much Valgum is that the stock knee braces do not
offer the leverage needed to do the correction job with any comfort. Less
distance from the force, increases the force. The stock knee braces are
just too short. I would go custom. More bulky, bigger, but will be more
comfortable. At 65 years old, for around the house, I don’t think she would
mind trading bulk for comfort
I am sure you have now the same patient I have worked with regularly up
until about a month ago. Almost the exact some clinical picture. I
first fit her with a Bledsoe Unloader KO, this was a complete failure.
I then took an impression of her leg for a KAFO–obtaining as much
correction as possible. Back at the lab we even increased the degree of
correction another 7 degree trying to anticipate “soft tissue
migration”.
The KAFO was also a failure. It did correct some of the valgus at the
knee and ankle but it augmented the external rotation and severely
limited her knee flexion during swing causing her to drag her foot.
Quite frankly I didn’t and still don’t know how to orthotically treat
the lady’s deteriorating condition.. I have asked a few colleagues and
the consensus was that it might be beyond the scope of orthotic
intervention.
When you deal with extreme valgus or varus you have to consider rotation of the leg. That becomes a problem with a ko. you need to consider a kafo for that reason alone.Be sure and correct the leg as much as possible when casting. Remember the longer the brace the more pressure the patient can tolerate
That seems like a lot of force to spread over the contact area of a a simple
KO. Seems like you might get better control with a well fit thermoplastic
KAFO. I think I remember seeing a similar example in a lecture by John
Michael (whomever it was they had success with this method).
FORGET A KNEE ORTHOSIS IT ISNT GOING TO BE WELL TOLERATED ——CONSIDER A SINGLE UPRIGHT KAFO WITH A PADDED PRE TIBIAL SHELL— FREE MOTION ANKLE JOINT—OFFSET KNEE JOINTS WITH DROP LOCK AND BAA STOP—–THERE IS A STRAP THAT STARTS DISTAL TO THE DISTAL EDGE OF THE PRE TIB SHELL —-THIS STRAP GOES THROUGH A ONE INCH LOOP THAT IS ATTACHED TO THE MEDIAL BORDER OF PRE TIB SHELL—-THE STRAP THEN CROSSES THE POPITEAL AREA AND GOES THROUGH ANOTHER ONE INCH LOOP THAT HAS BEEN ATTACHED TO THE LATERAL ABOVE KNEE UPRIGHT ABOUT SEVEN INCHES ABOVE KNEE CENTER —THE STRAP IS ONE INCH NYLON WITH VELCRO ——IF YOU LIKE I CAN SEND YOU A DIAGRAM—-THIS ORTHOSIS WAS DESIGN BY A MAN NAMED ROBERT NITSHKI AND KNOWN AS THE ((NITSHKI BRACE )))))I HAVE USED THIS ORTHOSIS MANY TIMES OVER THE YEARS AND WORKS WELL
What is her height and weight? Why do you not want to consider a custom
brace.
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Thanks once again to all.
Aman Raj, CPO, FAAOP
