Thanks to everyone for your advice and suggestions. Following is my original question and the replies. Joan Cestaro, C.P.
Question:
I am seeking advice on yet another very unusual case. I have a 75 year old lady with Rheumatoid Arthritis presenting with 50 degrees of right knee valgus upon weight bearing. This is correctable to about 20 degrees. The left side (not addressing at this time) presents with 20 degrees of knee varus. They both angle to the left. This lady apparently had a stoke affecting the right side about 10 years ago which explains why it is so much worse. I do have photos that I can e-mail anyone with good suggestions. It’s hard to imagine in words a 50 degree knee valgus condition! It’s the worst I’ve seen.
Subject patient has not walked in almost 2 years, so I don’t anticipate much more than transfer assistance and a few steps around the home. A KAFO is just overkill and I also doubt that a true KAFO would be accepted. My initial thoughts are for a KO with posterior straps so that she can don easily for use and remove during non use. She amazingly corrects totally while sitting in her wheelchair, so donning the appliance should be fairly easy. The other concern is that her knee joint itself is very large (RA) and will endure a great amount of pressure for this correction.
Open to any thoughts or suggestions on design. Thanks in advance.
Replies:
I had a similar patient with ra, we did do a kafo, corrected well but was rejected by patient. As you said it was overkill. We finally had success with generation 2 custom unloader with geriatric adaptations. The correction was minimal, but there was enough support to assist in transfers.
If this patient can correct the deformity in her wheelchair it would seem that there isn’t a contracture present, so how about a hip abduction orthosis to influence the knee valgum? Does she have
complications below the knee as well? Just a thought:)
Generation II K.O.
Joan,
Been there, done that, got the t-shirt! There are two big problems with
KO’s: suspension and lack of adequate leverage. I had good results with a lady who resisted the proper orthotic appliance (dbl upright metal KAFO) and started her out with a long post op KO. Of course it bent, rotated, and migrated distally but it made the point and she was able to “graduate” to a proper solution. You may want to look at the Generation II KAFO.
I would suggest a GII Kafo the only reason for the afo section is to support the KO Further if you dont do bilaterals the other knee will be just as bad in no time
I would suggest they try the V.3 with the cast taken in a corrected state – or as much as possible. It is lightweight and with bilateral joints it provides excellent control of valgus/varus deformities. The straps are also posterior as he would like.
Joan, perhaps a G2 unloader with adjustable valgus correction straps would allow her to adjust to her comfort level. Just a thought!!! Good luck
I might consider contacting Bledsoe who has the OA thurster joint that corrects valgus (or varus) upon extension (standing) and reduces it’s correction force in flexion (sitting). They will custom make you one. I have used it on some cases like yours and gotten some success.
Joan, I think a KO will be essentially useless. In my opinion, you need to encapsulate the foot to control as much rotation as possible, and then hope for the best. In this situation, a static knee (no knee joint) locked in full (or as much as possible) extension and with as much valgus correction as is possible is all that you can expect. In short, you can provide a thermoplastic cast.
I had a very similar case about 8 years ago. However, the lady I helped did walk (unbelievably) on a limited basis. It looked painful to watch her walk but she said she was only just starting to experience pain (which is why she came to see me). I fabricated a KAFO for her with a s/s lateral upright, plastic cuffs, and attached the lower cuff to a shoe with free motion. A medial strap helped the cuffs to hold her leg as straight as I could get it. She did quite well in it. She told me that she used it mainly when she knew she’d be doing a lot of walking. I’m not sure that she’d have used it if she only used a wheelchair for ambulation.
I assume that your lady is needing support for transfers? I would make this as simple as possible. I do like lateral uprights for these conditions as they are perceived to be lighter and easier to don. KOs often don’t work due to distal migration if she or her caretakers are unable to don and tighten them adequately.
You don’t mention any problem with the ankle. Does she have an equinovarus tightness? This can complicate things for use of a KAFO. If she doesn’t, I would think a simple KAFO would work best.
