orthotics * prosthetics COPYRIGHT © 1971 BY THE AMERICAN ORTHOTIC AND PROSTHETIC ASSOCIATION, PRINTED IN THE UNITED STATES OF AMERICA, ALL RIGHTS RESERVED orthotics

and prosthetics

THE JOURNAL OF THE

ORTHOTIC AND PROSTHETIC PROFESSION

VOLUME 25

NUMBER 1 Contents

MARCH 1971 1 Seventh Workshop Panel on Lower-Extremity Orthotics of the Subcommittee on Design and Development

32 Orthotic Management of the Problematic Scoliosis Siegfried W. Paul, C.P.O.

42 Blatchford Stabilized Knee A Review Susan Bergholtz, B.S. Editor

Audrey J. Calomino XXVI Classified Advertisements

Orthotics and Prosthetics: The Orthopedic and Pros­ thetic Appliance Journal Is issued in March, June, Sep­ tember and December. Sub­ scription price, payable in advance, is $6.50 a year in the Western Hemisphere rate elsewhere is $7.50 a year. Publication does not consti­ tute official endorsement of opinions presented In articles. The Journal is the official organ of its publisher. The American Orthotic and Pros­ thetic Association. All cor­ respondence should be ad­ dressed to: Editor: Ortho­ tics and Prosthetics, 1440 N St., N.W., Washington, D.C. 20005. Telephone, Area Code 202, 234-8400.

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OFFICERS

President—Roy Snelson, C.P.O. Downey, California President-Elect—Mary S. Dorsch, C.P.O. New York, New York Vice President—Claude J. Lambert, C.P.O. New Orleans, Louisiana Secretary-Treasurer—Durward R. Coon, C.P.O. Detroit, Michigan

Immediate Past President—William L. Barters, CO. Portland, Oregon

REGIONAL DIRECTORS

Region I—Alfred Schnell, C.P.O. Region VII—William M. Brady, CO. Hartford, Connecticut Kansas City, Missouri

Region II—Howard J. Tyo, CP. Region VIII—Harold Prescott, C.P.O. Syracuse, New York San Antonio, Texas

Region III—Phillip N. Pulizzi, CP. Region IX—Patrick J. Marer, C.P.O. Williamsport, Pennsylvania Escondido, California

Region IV—Ben Moss, C.P.O. Region X—Leonard Jay, CP. Winter Park, Florida Salt Lake City, Utah

Region V—Joseph L. Gaskins, CP. Region XI—Dale 0. Butler, Pontiac, Michigan Portland, Oregon

Region VI—Loren D. Jouett, C.P.O. Chicago, Illinois

AMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS AND PROSTHETICS. INC.

President—Robert E. Fannin, CO. Immediate Past President— Columbus, Ohio Samuel E. Hamontree, CP. Downey, California

President-Elect—J. D. Ferguson, C.P.O. Donald F. Colwell, CP. Chapel Hill, North Carolina Panirama City, California

Vice President—Augusto Sarmiento, M.D. Alan G. Smith, M.D. Miami, Flordia Brooklyn, New York

Secretary-Treasurer—Fred J. Eschen, C.P.O. Robert C. Hamilton, M.D. New York, New York Chicago, Illinois

Herbert B. Warburton, Executive Director

Audrey J. Calomino, Asst. Executive Director Index To Advertisers

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Florida Brace Corporation Seventh Workshop Panel on Lower-Extremity Orthotics of the Subcommittee on Design and Development*

FOREWORD brought orthotists to Rancho Los Amigos Hospital to work rather The Subcommittee on Design and than only to sit and think and talk. and Development of the Committee The first part of the workshop was on Prosthetics Research and De­ a session in which 14 orthotists velopment encouraged the planners fitted patients with 19 different low­ of this workshop panel to go "all er-extremity braces. Other persons out" in an attempt to collect in­ were appointed as recorders of the formation on current developments fitting and fabrication procedures. in lower-extremity orthotics because From these people we expected not the Subcommittee felt the emphasis only descriptions of what they saw, should be given to work needed to but some expressions of judgment improve the lot of patients who re­ about the use and design of the ap­ quire braces. This workshop panel pliances. We believe this scheme is considered to be only a start. worked, as the summaries in this The panel meeting was unlike report will attest. anything we have done before. We The patients who were fitted were *Committee on Prosthetics Research analyzed by Drs. Clippinger and and Development, Division of Engi­ McCollough using the biotechnical neering—National Research Council, Na­ tional Academy of Sciences—National analysis form explained in Ap­ Academy of Engineering. pendix A. This permitted CPRD to assist the American Academy of number of below-knee braces in­ Orthopaedic Surgeons in the tended for control of drop-foot be­ procedure for analyzing dysfunc­ cause many of these seemed to be tions that might require bracing. ready for advancement into either Sample forms for some of the pa­ the CPRD evaluation program or tients are shown in Appendix A. into the educational program. With After the fittings were completed, the summaries provided on the drop- the patients wearing the experi­ foot braces in this report, we be­ mental braces were presented be­ lieve we have accomplished an ob­ fore the entire panel and observers. jective. Most are relatively simple This process was a review of the in­ devices, and some possibly can be dividual appliances, the design con­ selected for local trial based on the cepts, and the kinds of patients for information contained here. At the whom the devices were primarily same time all might very well be intended. It was difficult in each in­ studied by a bioengineering labora­ stance to provide exactly the kind tory to delineate the differences of patient for whom the brace was among them, and thus help the edu­ designed, but indications and con­ cational program in offering pre­ traindications of each design were scription guidelines. reviewed and questions raised. Although the meeting became During the third part of the panel hectic at times, particularly when 14 meeting, the panelists discussed each orthotists had to fit 19 braces in one brace. Although it is quite difficult shop, we think much was ac­ to make decisions in large panel complished. The chart shown in the sessions, some decisions were made. report provides a functional analysis What CPRD might do for each of each brace in a concise and conveyablefor m which in itself pro­ brace was of special significance to vides some guidelines for prescrip­ the Subcommittee on Design and tion. As a matter of fact, this anal­ Development at this point because ysis of each brace keys in quite ade­ many of these devices have been in quately with the analysis of disabil­ laboratories for quite long periods ity developed by AAOS. (It should of time. Needed was the review be noted that this same form of achieved at this meeting. Actions analysis is already being used in were recommended. (Appendices B some clinics for prescribing conven­ and C were distributed for the in­ tional braces.) formation of the participants.) It is hoped that it will not be too Some of the panelists might have long before patients can benefit from felt frustrated while experiencing the work that has gone into the de­ the very difficult task we had at this velopment of these devices. meeting, but the Subcommittee on Originally we had intended to Design and Development will be have the workshop panel explore pleased with the resulting compila­ only those devices intended for tion of data about these braces stabilization of the knee. However, under development. The Subcom­ the Subcommittee chose to expand mittee on Evaluation of CPRD can the scope of the panel to include a now make plans for appropriate clinical studies of some of these day. Moreover, although not novel items. by any means, the whole concept of Perhaps of special significance is single-bar bracing can be further the principle of the NYU Insert promulgated by the information Brace. Although limited here to a contained in this report. below-knee brace, the concept of a The Subcommittee on Design and plastic-laminate shoe insert can be Development wishes to thank its applied to nearly all lower-extremity Panel Chairman, Roy Snelson, and braces. It is now well to consider the entire staff at Rancho Los the possibility that conventional Amigos Hospital for accommodating shoe attachments in many cases can this unique workshop; we especially be replaced by the more functional appreciate the use of the Rancho and cosmetic shoe insert. We hope patients and the help of James that the Subcommittee on Evalua­ Blomer in the laboratory. We think tion will consider this very signifi­ an outstanding job was done by all; cant possibility in improving lower- the Subcommittee, on behalf of extremity bracing. The use of syn­ CPRD, is profoundly grateful. thetics, particularly thermoplastics ANTHONY STAROS in below-knee braces such as the IRM Spiral BK Brace, may have Chairman, Subcommittee on significant impacts on bracing to­ Design and Development

Orthotic Analysis Fabrication of Braces of Patients

Group Session For Presentation of Braces 1. SUMMARY OF EACH BRACE plaster cast is taken of the foot in weight-bearing, alignment position A. UC-BL Shoe Insert (Fig. 1) and the shell is laminated over the plaster model. 1. Purpose Developed to control the foot 5. References in the shoe when fitting a leg brace, a. Henderson, W.H., and J.W. Campbell, UC-BL Shoe Insert: its purpose is to hold the foot in Casting and Fabrication, Bulletin of position of function in the shoe. Prosthetics Research, 70:11:215- 2. Description 235, Spring 1969. The shoe insert is a polyester b. Inman, V.T., UC-BL Dual- plastic shell which is contoured to Axis Ankle-Control System and the foot. The insert accomplishes UC-BL Shoe Insert: Biomechanical its purpose by stabilizing the foot in Considerations, Bulletin of Pros­ alignment position. It can be used with or without a brace attached to thetics Research, 70:11:130-145, it. Spring 1969. c. Mereday, C, C.M.E. 3. Prescription Dolan, and R. Lusskin, Evaluation It is indicated for correction of of the UC-BL Shoe Insert in "Flex­ nonrigid varus or valgus deformities ible" Pes Planus, New York Uni­ of the subtalar joint, for painful sub­ versity, September 1969. talar joint motion secondary to arthritic changes, and for inflamma­ B. UC-BL Dual-Axis Ankle Brace tion of the plantar fascia. (Fig. 2) It is contraindicated where 1. Purpose fixed bony deformities exist. To duplicate and control the 4. Fabrication combined motions of the ankle and Reference (a) covers the fab­ subtalar joints, thereby providing rication of the shoe insert in detail. improvement in function and com­ The general procedure is that a fort over single-axis ankle braces.

Fig. 1 Fig. 2 UC-BL Shoe Insert. UC-BL Dual-Axis Ankle Brace. 2. Description Spring 1969. The dual-axis ankle brace has b. Inman, V.T., UC-BL Dual- two mechanical joints—the lower of Axis Ankle-Control System and UC- which attaches to the shoe—with BL Shoe Insert: Biomechanical Con­ one metal upright which attaches to siderations, Bulletin of Prosthetics a calf band. It accomplishes its pur­ Research, 70:11:130-145, Spring pose by alignment of the mechanical 1969. joints to the anatomical ankle and c. Lamoreux, L.W., UC-BL subtalar joints and by using rubber- Dual-Axis Ankle-Control System: band spring assist. Engineering Design, Bulletin of 3. Prescription Prosthetics Research, 70:11:146- 183, Spring 1969. It is indicated for flaccid paral­ ysis of the plantar flexors, dorsiflexors,C. NYU inverter Inserts Braceand/o r (Figeverter. 3)s of the foot. 1. Purpose It combines the advantages of It is contraindicated where the UC-BL Shoe Insert with the pain exists due to increased ankle conventional short-leg brace to sta­ or subtalar joint motions or where bilize the foot in the shoe while pro­ there are rigid deformities of the viding ankle joint motion control. ankle or subtalar joints. Also, in its In addition, it improves cosmesis present configuration, it cannot be and allows easy interchange of used where weight-bearing is neces­ sary. (A weight-bearing design is under development.) 4. Fabrication Reference (a) covers the fab­ rication of the dual-axis ankle brace in detail. The general procedure is to take a plaster cast of the foot and lower leg and very carefully align the mechanical joints to the cast, which is positioned in the shoe. The joints are then attached to the shoe, the calf band is positioned on the cast, and the upright bent and connected to the joints and the calf band. 5. References a. Campbell, J.W., W.H. Henderson, and D. E. Patrick, UC- BL Dual Axis Ankle-Control Sys­ tem: Casting, Alignment, Fabrica­ tion and Fitting, Bulletin of Pros­ Fig. 3 thetics Research, 70:11:184-235, NYU Insert Brace. It is contraindicated where severe spasticity or fixed varus or valgus deformity of the foot exists. 4. Fabrication A plaster cast is taken of the foot according to UC-BL procedures for the shoe insert. The ankle joint is aligned on the plaster model, and the stirrup is laminated into the plastic shell over the model. The ankle joints and metal uprights with a calf band are attached to the stirrup. 5. Reference Dolan, C.M.E., C. Mereday, and G. Hartmann, Evaluation of NYU Insert Brace, New York Uni­ versity, July 1969.

Fig. 4 D. AMBRL Two-Rod Drop-Foot AMBRL Two-Rod Drop-Foot Brace. Brace (Fig. 4) shoes, since the insert brace fits in­ 1. Purpose side the shoe and is not connected It provides a positioning force to it. to hold the foot in a neutral or slightly dorsiflexed position during 2. Description swing phase of gait and provides The insert brace is a conven­ mild resistance to inversion or eversion of the ankle joint. tional short-leg brace with the metal stirrup laminated into a shoe insert. The shoe insert provides foot align­ 2. Description ment in the shoe, the standard ankle Two round fiber glass-epoxy joint provides A-P control of the rods are mounted on the shoe and ankle, and the double uprights with extend to pockets in the calf band. calf band provide M-L stability of The rods are slightly flexible and the ankle. The patient may need a are aligned to provide dorsiflexion slightly larger shoe with this brace assist. The amount of spring force because of the thickness of the can be varied by the diameter and insert and stirrup. alignment of the rods. 3. Prescription 3. Prescription It is indicated for flaccid or It is indicated for drop-foot mildly spastic paralysis of the ankle with mild M-L ankle instability or joint musculature and for nonrigid for mild spasticity. varus or valgus deformities of the It is contraindicated where foot. marked M-L ankle instability or marked spasticity exists. A trial glass-Epoxy Drop-Foot Brace, USA- brace can be temporarily clamped MBRL Technical Report 6910, July to the patient's shoe to aid in pre­ 1969. scription; see reference (c). g. Hill, J.T., and R. W. Stube, 4. Fabrication The USAMBRL Fiberglass Drop- Reference (f) covers the fab­ Foot Brace, Prosthetics Internation­ rication of the AMBRL Two-Rod al, 5:9:25-28, 1969. Drop-Foot Brace in detail. All parts E. VAPC Drop-Foot Brace of the brace can be prefabricated— the metal shoe plate, metal shoe (Fig. 5) adaptors, rods, and calf band. The 1. Purpose shoe plate is installed in the heel of This brace provides the same the shoe and the adaptors with rods function as the AMBRL Posterior- are attached to the plate. The rods Bar Drop-Foot Brace explained be­ are then cut to length and inserted low. into the calf band. 2. Description 5. References It is similar to the AMBRL a. Evaluation: AMBRL Fiber- brace below except that it has a glass-Epoxy Drop-Foot Brace, Bul­ clip which fits on the counter of the letin of Prosthetics Research, 10:9: shoe instead of an insert in the 153-155, Spring 1968. heel, allowing it to be clipped on b. Hancock, R. P., and J. W. any stiff-counter shoes without spe­ Hodge, Structural Analysis and cial attachment. Evaluation of US AMBRL Plastic 3. Prescription Drop-Foot Brace Adaptor, US- AMBRL Technical Report 6913, The indications and contrain- September 1969.

c. Hill, J.T., and A. L. Fenwick, A Clamp-On Fitting Brace for Use in Prescribing the Fiberglass- Epoxy Drop-Foot Brace, US- AMBRL Technical Report 6809, September 1968.

d. Hill, J.T., and A. L. Fenwick, A Fiberglass-Epoxy Drop- Foot Brace, Orthotics and Prosthet­ ics, 22:3:1-8, September 1968.

e. Hill, J.T., and A. L. Fenwick, Fiberglass-Epoxy Drop-Foot Brace, USAMBRL Technical Re­ port 6801, January 1968. f. Hill, J.T., and R. W. Stube, An Improved Manufacturing Tech­ Fig. 5 nique for the USAMBRL Fiber­ VAPC Drop-Foot Brace. dications for use are the same as M-L stability of the ankle during for the AMBRL brace. It has not stance. yet been determined if this brace 2. Description can be used permanently as well as a trial device for aid in prescription. The fiber glass-epoxy posterior bar is attached to the shoe by means 4. Fabrication of a metal insert in the heel and is The posterior strap and calf attached to the calf band by means band are made in similar manner of a slip fit. The bar is slightly flex­ to the AMBRL brace. The clip, ible and is aligned to provide dorsiflexion assist. The amount of force which is still in development, is can be varied by the thickness and presently made of sheet metal alignment of the bar. Because the stamped out and bent to shape. bar is located posterior to the ankle With the current design, large and joint, there is relative motion be­ continuous forces cannot be exerted tween the bar and the leg; this on the clip because it will damage motion is accommodated by the the counter of the shoe. sliding of the bar in the cuff. 5. References None. 3. Prescription It is indicated for drop foot with F. AMBRL Posterior-Bar Drop- some M-L stability and for mild Foot Brace (Fig. 6) spasticity. 1. Purpose It is contraindicated where It provides a positioning force marked M-L ankle instability or to hold the foot in a neutral or marked spasticity exists. slightly dorsiflexed position during 4. Fabrication swing phase of gait and will assist Reference (a) covers the fabri­ cation of the AMBRL Posterior-Bar Drop-Foot Brace in detail. It can be assembled from prefabricated parts—metal heel insert, bar, and calf band. The insert is attached to the heel, the bar is attached to the insert, and the bar cut to length and placed in the slip pocket of the calf band.

5. References

a. Hill, J.T., and A. L. Fenwick, A Contoured, Posterior, Fiber­ glass-Epoxy Drop-Foot Brace, US­ AMBRL Technical Report 6805, May 1968.

Fig. 6 b. Hill, J.T., and R.W. Stube, AMBRL Posterior-Bar Drop-Foot Brace. An Improved Manufacturing Tech- brace position. It is lightweight and cosmetic. 3. Prescription It is indicated for complete flaccidityo f the foot and for mild and moderate spasticity. It is contraindicated for severe spasticity or fixed varus or valgus deformity. 4. Fabrication A plaster cast of the foot and lower leg is taken, the plaster model is modified, and the pre-cut Plexiduri s heated to 275 deg. F. and formed over the model. The nyloplexbrac e is then carefully trimmed for fitting.

5. References Fig. 7 a. Lehneis, H.R., New Con­ IRM Spiral BK Brace. cepts in Lower Extremity Orthotics, nique for the US AMBRL Fiber- Medical Clinics of North America, glass-Epoxy Drop-Foot Brace, 53:3:585-592, May 1969. USAMBRL Technical Report 6910, b. Progress Report, Project July 1969. Number SRS-RD-3129-M, IRM, New York University Medical Cen­ G. IRM Spiral BK Brace (Fig. 7) ter, (New York), June 1969. 1. Purpose To permit controlled plantar flexion, dorsiflexion, eversion, and inversion of the foot while allowing normal transverse rotation of the extremity on the foot. 2. Description The spiral brace is made of a two-piece, contoured, Plexidur (clear thermoplastic) material with three sections—footplate, spiral up­ right, and calf band. The springiness of the material provides the forces for foot control. The calf band sec­ tion has an opening below the fib­ ular head which permits donning; Fig. 8 no straps are required to hold the Rancho Polypropylene Drop-Foot Brace. H. Rancho Polypropylene Drop- Foot Brace (Fig. 8) 1. Purpose To assist dorsiflexion and resist eversion and inversion of the foot. 2. Description The brace is a one-piece unit made of polypropylene—translu­ cent thermoplastic material which has superior fatigue resistance. It is molded to the foot and lower leg and is lightweight and cosmetic. Springiness of the material provides dorsiflexion force. 3. Prescription It is indicated for flaccid or mildly spastic conditions of the foot. It is contraindicated in case of severe spasticity of the foot. Fig. 9 4. Fabrication Teufel Ortholen Drop-Foot Brace. A plaster model is made from foot and lower leg, and elastic a plaster cast of the foot and low­ webbing is used on each side of er leg, a sheet of polypropylene the ankle to provide dorsiflexion material is heated to 400 deg. F. force. Velcro is used to strap the and formed over the model, and the upper portion on the calf. brace is trimmed for fitting. 3. Prescription 5. References It is indicated for flaccid condi­ None. tions of the foot. It is contraindicated for spasti­ 1. Teufel Ortholen Drop-Foot Brace city of the foot. (Fig. 9) 4. Fabrication 1. Purpose A sheet of the material is heated To assist dorsiflexion and re­ to 300 deg. F. and formed over a sist eversion and inversion of the plaster model of the foot and leg. foot. (Ortholen can be cold formed with a hammer for other applications.) 2. Description The brace is trimmed and the elastic The brace is a lightweight and webbing and Velcro attached for cosmetic, one-piece unit made of fitting. Ortholen, a Caucasian-colored thermoplastic material in the poly­ 5. References ethylene family. It is molded to the None. additional strips on the plantar sur­ face of the foot. The nylon stockin­ ette is then impregnated with poly­ ester resin and the brace trimmed for fitting after the resin has cured. A Velcro closure is used on the calf band. 5. Reference Engen, T.J., Progress Report, Project No. SRS-RD-2982-M, Texas Institute for Rehabilitation and Re­ search (Houston), September 1969.

Fig. 10 K. Swedish Knee Cage (Fig. 11) TIRR BK Brace. 1. Purpose J. TIRR BK Brace (Fig. 10) To prevent genu recurvatum while allowing flexion of the knee 1. Purpose for walking. To assist dorsiflexion of the ankle during swing phase without 2. Description conventional shoe attachment. It consists of a plastic-coated aluminum piece which forms up- 2. Description It is a one-piece, molded brace of polyester plastic laminate rein­ forced with strips of polypropylene and formed over a plaster model of the foot and lower leg. The spring­ iness of the material provides the dorsiflexion force. It is a lightweight and cosmetic brace. 3. Prescription It is indicated for a flail foot. It is contraindicated when spasticity and severe deformities are present in the foot-ankle complex. 4. Fabrication After making a plaster model of the foot and lower leg from a plaster cast of the patient, strips of polypropylene are put between layers of nylon stockinette on the model—two strips forming a cross Fig. 11 on the back of the lower leg and Swedish Knee Cage. rights connected posteriorly with a ficial Limbs, 72:2:54-57, Autumn horizontal band. The webbing which 1968. is attached anteriorly to the upper and lower portions and the poster­ L. IRM SK (Supracondylar-Knee) ior padded band at the knee pro­ Brace (Fig. 12) vided a three-point force system to 1. Purpose control hyperextension. Though it has no joint, it protrudes very little To prevent genu recurvatum with knee flexion while sitting. and to provide M-L stability of the knee while allowing flexion for 3. Prescription walking. It is indicated for mild genu recurvatum with some M-L knee 2. Description stability. It is a one-piece brace of poly­ It is contraindicated where ester plastic laminate molded to the marked M-L instability or fixed val­ leg. The unique shape is designed gus or varus deformity of the knee to provide a three-point force sys­ exists. tem for control of hyperextension and to provide M-L stability of the 4. Fabrication knee. The contoured plastic is very The Swedish Knee Cage is cosmetic, though the suprapatellar commercially available in one size, portion does protrude slightly while which will fit left or right sides. It sitting. is being recommended to the manu­ facturer by CPRD that it also be 3. Prescription made in a child size. It is indicated for mild and 5. Reference moderate genu recurvatum with M-L instability of the knee. The Swedish Knee Cage, Arti- It has no effect on a fixed valgus or varus deformity of the knee. There is some question whether the concentrated force on the suprapatellar area is excessive on the quadriceps tendon or the femur at least for some patients.

4. Fabrication A plaster cast is taken of the lower leg and the knee with the knee in slight flexion. After a plaster model has been made and modified, the brace is laminated over the model and carefully trimmed so proper forces are exerted on the patient's leg. The shell has to be Fig. 12 trimmed to permit donning, which IRM SK Brace. is accomplished by putting the foot with a Velcro or taped closure, to permit donning. The high supra­ patellar portion limits hyperexten­ sion and the low popliteal portion allows flexion of the knee. It is cosmetic but does protrude slightly while sitting. 3. Prescription It is indicated for mild genu recurvatum with M-L instability of the knee. It is contraindicated where fixed valgus or varus deformity exists. There is some question whether the concentrated force on the suprapatellar area is excessive on the quadricep tendon or the Fig. 13 femur at least for some individuals. Nitschke PTS Knee Brace. 4. Fabrication through the posterior opening and A plaster cast is taken of the rotating the shell up the leg in place knee and lower leg, the plaster model over the knee. The proximal-medial is modified, and the two halves are and proximal-lateral portions of the made over the model in separate brace are trimmed according to the desired function of controlling valgus or varus deformity. 5. Reference Lehneis, H.R., New Concepts in Lower Extremity Orthotics, Med­ ical Clinics of North America, 53: 3:585-592, May 1969.

M. Nitschke PTS Knee Brace (Fig. 13) 1. Purpose This brace prevents genu re­ curvatum and provides M-L stability of the knee while allowing flexion for walking. 2. Description It is very similar to the upper Fig. 14 part of a PTS below-knee prosthesis University of Michigan Arthritic Knee except that it is made in two halves, Brace. laminations. The halves are cut so rective surgery or who have flexion they overlap and are held together contractures, fixed valgus deform­ by Velcro straps or tape if a thinner ities exceeding 15-20 deg., serious dimension is desired. hip involvement, or poor motivation. 5. Reference 4. Fabrication The brace is constructed of Nitschke, R.O., and K. Marschall, componentThe PTS Knees simila Brace,r to conventionaOrth­ l otics and Prosthetics, 22:3:46-51, long-leg braces. Two points should September 1968. be noted. Tracings are taken with the patient held manually in cor­ N. University of Michigan Arthritic rected position, and considerable ad­ Knee Brace (Fig. 14) justment to fit and alignment is usu­ ally necessary during the early 1. Purpose period of wear. To reduce pain and hence in­ crease ambulatory function of select­ 5. Reference ed patients with unstable arthritic Smith, E.M., R.C. Juvinall, knees. E. Corell, and V.J. Nyboer, Brac­ 2. Description ing the Unstable Arthritic Knee, submitted for publication in Ar­ Though variations are some­ chives of Physical Medicine and times needed, the brace essentially Rehabilitation, 1970. consists of a single lateral upright at­ tached to the shoe with a split stir­ O. Rancho Functional Long-Leg rup, free ankle and knee joints, Brace (Fig. 15) posterior bands at the calf and mid- thigh, anterior cuffs just above and 1. Purpose below the patella, a lateral band at To provide knee stability dur­ the proximal thigh, and a medial ing stance phase while allowing pressure pad at the knee. The brace knee flexion during swing phase and functions in the following manner: to maintain proper alignment of a three-point system produces a the leg. laterally directed force on the knee 2. Description to correct the valgus deformity and The brace has metal uprights a four-point system produces forces with plastic thigh shell, tibial cuff, to prevent anterior displacement of and a shoe insert or a metal stirrup the tibia usually associated with the attached to the shoe. The ankle arthritic knee. joints have a 90-deg. dorsiflexion 3. Prescription stop with no mechanical damping It is indicated for patients with to resist plantar flexion or dorsiflex­ unstable arthritic knees whose pain ion up to 90 deg. The tibial cuff can upon weight bearing can be reduced be fitted anteriorly or posteriorly as by manual correction of M-L or desired for knee A-P stability or A-P instability. prevention of genu recurvatum; it It is contraindicated for those also provides control for valgus or patients who are candidates for cor­ varus of the knee. The knee joints ester plastic laminated over a plaster model from a plaster cast. The thigh shell is made in a similar manner with the plaster cast taken in an above-knee prosthetics casting fix­ ture and the model modified so that the shell will fit looser than an AK socket. The shoe insert is made according to UC-BL procedures but with the stirrup laminated in the insert. Or, if a conventional stirrup is used, it is attached to the shoe. The uprights are bent to a tracing of the patient's leg manually held in alignment position. An aluminum plate is laminated into the thigh Fig. 15 shell and tibial cuff to prevent the Rancho Functional Long-Leg Brace. rivets to the uprights from pulling out. are J-shaped to provide a posterior­ ly offset mechanical knee center for 5. References alignment stability during stance None. phase. The thigh shell is a quad­ rilateral shaped brim, similar to the P. UCLA Functional Long-Leg upper part of an above-knee pros­ Brace (Fig. 16) thetic socket, which bears some 1. Purpose vertical weight but is not designed to be ischial weight bearing. To make it possible for some unilateral lower-extremity paralytics 3. Prescription to walk with a free-swinging knee It is indicated for a unilateral and M-L stability at the knee using flail leg with some hip musculature less energy than required with con­ but requiring alignment stability for ventional long-leg braces. It is stance. As a rule of thumb, the presently being re-designed to make patient should be able to walk a it more practical and to extend its few steps on level floor without a application. brace to successfully wear the 2. Description Rancho Functional Long-Leg Brace. It is contraindicated if the pa­ The brace is made of the fol­ tient has no hip control, if there lowing components: a polyester is severe bilateral involvement, if plastic thigh shell similar to the there is a fixed valgus or varus knee upper part of an AK socket; solid- deformity, or if weight bearing is bar aluminum uprights; ball-bearing required. knee joints with a one-inch posterior offset; a polyester plastic pretibial 4. Fabrication cuff; heavy-duty ankle joints with The tibial cuff is made of poly­ adjustable stops; a hydraulic damper tractures of the knee and/or hip, where ischial weight bearing is re­ quired, or if there are fixed valgus or varus knee deformities. 4. Fabrication Making the UCLA Functional Long-Leg Brace consists of the following steps: making a tracing of the patient's leg held manually in alignment; making the thigh shell from a plaster cast and model us­ ing an AK casting fixture; making the pretibial shell from a plaster cast and model; shaping the foot-ankle section and attaching it to the shoe; Fig. 16 laying out and shaping the uprights; UCLA Functional Long-Leg Brace. and aligning and fitting the brace. The UCLA Prosthetics-Orthotics to provide resistance to ankle dorsi­ Program has an instructional course flexion; and a stainless-steel foot- on this brace. ankle section. It provides knee A-P 5. References stability primarily by the posteriorly positioned knee joint and the knee a. Anderson, M.H., Biomechanical Considerations in the De­ extension torque caused by resist­ sign of a Functional Long Leg ance to dorsiflexion. Knee M-L sta­ Brace, Orthopedic and Prosthetic bility is provided by the alignment Appliance Journal, 75:4:273-280, of the uprights and pretibial cuff. December 1964. The hydraulic damper also provides slight resistance to plantar flexion to b. Anderson, M.H., and J.J. reduce or prevent foot slap. Bray, The UCLA Functional Long The present re-design of this Leg Brace, Clinical Orthopaedics, brace includes a shoe insert in place No. 37:98-109, 1964. of the foot-ankle section and a me­ c. Scott, C.M., Biomechanical chanical damper in place of the Analysis of the UCLA Functional hydraulic one. Long Leg Brace, University of Cali­ 3. Prescription fornia at Los Angeles, September 1, It is indicated for unilateral 1966. lower-extremity paralysis with some hip musculature present. It is im­ Q. VAPC Single-Bar Long-Leg portant to have some active hip Brace (Fig. 17) extension for knee stability. Valgus or varus knee tendency can be con­ 1. Purpose trolled. To stabilize the knee and ankle It is contraindicated for severe in M-L and A-P directions during bilateral involvement, flexion con­ stance phase of gait. It is designed to be a light, modular brace which stops; telescoping uprights that ac­ can be easily fitted. commodate axial and rotational movement; proximal extension of 2. Description uprights to include hip joint; and It is a locked-knee, nonweight- use of free knee if patient is able. bearing brace which provides stabil­ ity of the leg during stance. The 3. Prescription single-bar construction has the ad­ It is indicated for instability of vantage of reducing weight and the knee and ankle with functional bulk. The brace is comprised of the control of the hip. It can be used following components: a half stirrup bilaterally, thereby eliminating both with ankle joint mounted to the medial uprights present on conven­ shoe; a lateral, round, stainless-steel tional long-leg braces. upright; a metal calf cuff which ex­ It is contraindicated where tends upward medially to the tibial there is lack of hip control, fixed condyles; a locked knee joint with deformities of the knee or ankle, posteriorly offset center of rotation; need for weight bearing, or presence and a metal thigh cuff which spirals of marked spasticity. downward medially to encompass 4. Fabrication two-thirds of the thigh. The cuffs are covered with leather and closed It is made similar to a conven­ with Velcro. The modular system tional long-leg brace except that the permits the following functions: thigh and calf cuffs are judiciously various diameter uprights for shaped and fitted to provide appro­ strength; posterior or anterior ankle priate medial reactions normally provided by the medial upright. 5. Reference Evaluation—VAPC Modular Single Bar Braces, Bulletin of Pros­ thetics Research, 70:9:152-153, Spring 1968.

R. Nitschke Single-Bar Long-Leg Brace (Fig. 18) 1. Purpose To support the long bones of the leg in normal weight-bearing position. Through the intricate PTB-like fit of the anterior calf cuff, only small horizontal forces are needed to maintain alignment, pre­ vent knee buckling and recurvatum, and control varus or valgus of the knee. The brace is designed to fit Fig. 17 loosely when sitting and snugly VAPC Single-Bar Long-Leg Brace. when standing. belt is attached at the proximal end of the upright just distal to the greater trochanter, thereby replac­ ing the force normally present at the proximal medial thigh and help­ ing to support the weight of the brace. To control valgus of the knee, a leather strap on the thigh cuff can be used, though patients prefer the help of the Silesian belt. In the absence of M-L hip control, a well-padded disc fitted on the proximal end of the upright over the greater trochanter and the Silesian belt fastened below or above the pad make it possible to control hip abduction or adduction. The dual bar is used when greater Fig. 18 horizontal forces are necessary, Nitschke Single-Bar Long-Leg Brace. such as where a combination of un­ correctable valgus or varus and flex­ 2. Description ion deformities exist. It is a locked-knee, nonweight- 3. Prescription bearing brace which provides stabil­ ity of the leg during stance. The It is indicated for M-L or A-P single-bar construction has the ad­ instability of the knee and will pro­ vantage of reducing weight and vide some M-L control of the hip bulk. The brace has the following if necesary. It can be used bilater­ essential parts: a half stirrup; an ally, thereby eliminating both ankle joint with stops and/or medial uprights present on conven­ springs; a single, flat, metal upright tional long-leg braces. on the lateral side; an anterior It is contraindicated where Polysar X-414 calf cuff; a knee there is a necessity for ischial weight joint with lock; and a posterior bearing. metal thigh cuff. 4. Fabrication The unique features of this The most important aspects of brace are the carefully molded, this brace are the calf cuff and the PTB-shaped calf cuff; the strap pos­ Silesian belt. The calf cuff is made terior to knee which tightens when of Polysar X-414 and is formed on standing and loosens when sitting; the patient, with a high medial or the use of a Silesian belt; and the lateral portion as desired for con­ use of a "dual" or double bar. To trol of valgus or varus, and is rein­ prevent recurvatum, the knee joint forced with a metal band. A strap is set at 5-10 deg. of flexion and of dacron webbing closes the poster­ locked to control buckling. To con­ ior part of the cuff and then runs trol varus of the knee, the Silesian through a loop laterally and up- ward to the side bar to make a three-point attachment which loos­ ens on sitting and tightens on standing; this provides comfort when sitting and control when standing. The Silesian belt goes around the waist and attaches to the lateral bar below or above the trochanter, thus helping to support some weight and to provide desired control.

5. Reference Unpublished case study and summary, by Robert O. Nitschke.

S. IRM SKA (Supracondylar-Knee- Ankle) Brace (Fig. 19)

1. Purpose This brace provides knee M-L stability, prevents genu recurvatum, Fig. 19 and stabilizes the foot and ankle IRM SKA Brace. while allowing knee flexion for walking. 3. Prescription 2. Description It is indicated for a flail leg with hip control. The upper portion is like the It is contraindicated for severe SK Brace described previously, and bilateral involvement, marked spas­ the lower portion is contoured ticity, lack of hip control, presence plastic laminate which extends of knee or hip flexion contractures, down to and around the ankle and or for weight bearing. Some fixed midfoot. The upper portion stabil­ varus or valgus knee deformity can izes the knee in the M-L direction be accommodated but not improved. and prevents genu recurvatum. The lower portion holds the foot in slight 4. Fabrication plantar flexion, thereby preventing A plaster cast is taken of the drop-foot and causing a toe gait foot, lower leg, and knee. The foot which produces a knee extension is positioned with the heel and toes moment to prevent knee buckling. level and the ankle slightly plantar With this design the heel should not flexed. The knee is positioned in touch the ground. The plantar flex­ slight flexion. The plaster model is ion compensates for the difference modified and laminated with poly­ in leg shortening, if any. If there ester plastic reinforced with fiber is no shortening, the sound side glass. The SKA shell is then care­ heel must be built up. fully trimmed to provide the correct biomechanics and to permit don­ brace, offers increased function and ning. usefulness over conventional, shoe- mounted braces. In view of the fact 5. Reference that it has been formally evaluated Lehneis, H.R., New Concepts by NYU, it was recommended that in Lower Extremity Orthotics, Med­ the NYU Insert Brace be concur­ ical Clinics of North America, 53: rently incorporated into education­ 3:585-592, May 1969. al programs and independently evaluated by CPRD under con­ III. RECOMMENDATIONS FOR trolled conditions in various clinics EACH BRACE and that it be included in the com­ A. UC-BL Shoe Insert parative study of the short-leg braces listed below. It was concluded that this device is a valuable addition to D. AMBRL Two-Rod Drop- lower-extremity orthotics. The Foot Brace Spring 1969 issue of the Bulletin of E. VAPC Drop-Foot Brace Prosthetics Research contains the necessary casting and fabrication F. AMBRL Posterior-Bar Drop- procedures, and NYU has eval­ Foot Brace uated it independently on several G. IRM Spiral BK Brace children. No further clinical evalu­ ation is needed. It was recommend­ H. Rancho Polypropylene Drop- ed that the UC-BL Shoe Insert be Foot Brace incorporated into educational pro­ I. Teufel Ortholen Drop-Foot grams and patient usage. Brace B. UC-BL Dual-Axis Ankle J. TIRR BK Brace Brace These seven braces were consid­ It was concluded that this ered together. It was concluded that brace, which is the only one provid­ each offers definite improvement ing subtalar as well as ankle joint over conventional short-leg braces. motion, has existing potential even However, a formal clinical evalua­ though its application appears more tion is not indicated because of the limited than originally anticipated. number and similarity in function To further assess its usefulness, it of these braces. It was therefore was recommended that the UC-BL recommended that each brace be Dual-Axis Brace be evaluated by written up by the developer and CPRD under controlled conditions published in one of the technical in several clinics, and that it be journals for exposure and usage, included in the comparative study and that CPRD undertake a com­ of the short-leg braces listed below. parative study of them along with (B) and (C) above. C. NYU Insert Brace It was concluded that this de­ K. Swedish Knee Cage vice, which combines the benefits It was concluded that since of the shoe insert with the short-leg this device is commercially avail- able, no formal CPRD effort is P. UCLA Functional Long-Leg needed. However, a few improve­ Brace ments were suggested, and it was The UCLA FLLB has been recommended that it be made in taught at UCLA for several years a child size. The Subcommittee on now. The original brace is currently Design and Development will con­ in the final stages of redesign to vey these comments to the manu­ make it more practical and to ex­ facturer. tend its application. L. IRM SK Brace Q. VAPC Single-Bar Long-Leg Brace It was concluded that this This modular brace has been brace offers knee stability with presented to the Subcommittee on greatly enhanced appearance over Evaluation for clinical trial. The conventional braces. To delineate VAPC manual and evaluation pro­ possible medical contraindications tocol are nearly complete. and to study the forces involved in more detail, it was recommended R. Nitschke Single-Bar Long-Leg that more IRM SK Braces be fit in Brace the New York area for further It was concluded that this analysis and follow-up. brace has several interesting fea­ tures such as the Polysar cuff and M. Nitschke PTB Knee Brace the use of a Silesian belt for con­ It was concluded that while trol and unweighting. It was sug­ this device has limited application, gested that the round bar of the it does have potential for success­ VAPC LLB might be used effec­ ful usage. It was recommended that tively on the Nitschke LLB. It was the developer continue fitting and recommended that VAPC provide follow-up study with the help of assistance for the developer to per­ VAPC if necessary. haps combine some of the best ideas of both braces in the further devel­ N. University of Michigan Arth­ opment of the Nitschke LLB. ritic Knee Brace S. IRM SKA Brace This brace is still in design Similar to the SK Brace, it and development. After more refine­ was concluded that this brace offers ments and patient trial fittings, the knee and ankle stability for walking brace will be presented to CPRD and that the one-piece plastic lami­ for recommendations and possible nate contoured construction pro­ clinical evaluation. vides a very aesthetic appearance. However, more needs to be known O. Rancho Functional Long-Leg about indications and contraindica­ Brace tions, and several centers are While the orthotic principles anxious to experiment with it. It are sound, actual fittings of this was recommended that Duke Uni­ brace have been hampered by lack versity and VAPC assist IRM in of necessary hardware. Develop­ further fittings and analysis of the ment is still proceeding at Rancho. SKA Brace. IV. GENERAL RECOMMENDA­ 2. Translatory motion TION Linear arrows horizontally There is need for a further placed below the circle indicate the meeting primarily of orthotists and presence of (abnormal) transla­ manufacturers to consider a few tory motion at one or more of the problems in the design of current six designated levels of the lower hardware and the development of extremity listed on the left side of new hardware for new types of the form. The head of the arrow braces, such as the NYU Insert always points in the direction of dis­ Brace. placement of the distal segment relative to the proximal segment. APPENDIX A Linear arrows vertically placed on Definitions and Rules the right side of the circle indicate (abnormal) translatory motion for along the vertical axis at the site Technical Analysis Form indicated. I. DEFINITIONS A. Translatory Motion—Motion 3. Rotary motion in which all points of the distal Normal ranges of rotary mo­ segment move in the same direction tion about joints are pre-shaded on with the paths of all points being the diagram. Abnormal rotary mo­ exactly alike in shape and distance tion, either as limited or as excess traversed. motion, is indicated by a double B. Rotary Motion—Motion of a headed arrow placed outside and distal segment in which one point concentric to the circle, to indicate in the distal segment or in its the extent of available motion (imaginary) extension always re­ present in the joint on the side (or mains fixed. sides) of the neutral joint position which is affected. The double head­ II. RULES ed arrow thus describes the avail­ A. Rules pertaining to recording able range of motion on the affected motion side (or sides) of the neutral joint 1. The degrees of rotary mo­ position. If one head of the arrow tion or centimeters of translatory fails to reach the pre-shaded margin, motion are to be obtained from limitation of joint motion is denoted. passive manipulation, and are to Conversely, if one head of the arrow reflect passive, not active motion at projects beyond the pre-shaded the site being examined. In addition, margin, excess motion is designated. however, joints are to be observed Numbers in degrees are placed adja­ during weight bearing, and if the cent to the arrows to indicate the degree of joint excursion is greater arc described. In addition, radial under conditions of loading than lines drawn from the center of the by passive manipulation, this figure circle and passing through its per­ is diagramed rather than the small­ imeter at the tips of the double er figure (e.g., recurvatum of the headed arrow are to be used for knee). more graphic representation of the arc of available motion. At sites muscle group strength, not individu­ where rotary motion does not occur, al muscles, is to be placed adjacent (e.g., fracture site, or knee joint in to the skeletal outline at the proper the coronal plane) the presence of location for each muscle group. abnormal rotary motion is similarly Spastic muscle estimates are to be designated by a double headed ar­ made with the patient in the func­ row with adjacent numerical value tional position for the lower extrem­ in degrees. ity, i.e., observation during stand­ ing and walking. The sub-letter 4. Fixed position grades for spastic muscles are as Double radial arrows indicate follows: a fixed joint position, and describe in degrees the deviation from the m indicates a mild degree of neutral joint position. Horizontal or spasticity vertical double arrows indicate a mo indicates a moderate de­ fixed joint position in a translatory gree of spasticity, sufficient sense, and the extent of abnormal for useful holding quality translation is indicated in centi­ s indicates severe spasticity, meters adjacent to the arrow (e.g., obstructive in terms of subluxed tibia in a hemophiliac function knee). C. Rules pertaining to fracture or B. Rules pertaining to muscle bone deformity dysfunction All translatory or rotary mo­ 1. Flaccid muscles tions at the fracture on the shaft of a long bone are diagramed on the Flaccid muscle is designated by circle located at the mid-shaft of the symbol "FL", and its grade by each bone. The actual fracture site sub-letter as indicated in the legend. is indicated by the fracture symbol. The letter grade (e.g., FLp) for All bony deformities such as valgus muscle group strength (e.g., knee angulation of the shaft are likewise extensors), not individual muscles, diagramed on the circle located at is to be placed adjacent to the skel­ the center of the shaft, regardless of etal outline at the proper location the position of the angular de­ for each muscle group. Flaccid formity. The location of the angular muscle strength estimates are ob­ deformity is designated by circling tained by conventional means on the appropriate level of the left hand the examining table, and correspond side of the chart. to the conventional grading system for poliomyelitis. No symbol is used D. Rules pertaining to limb length if muscle strength is normal. Clinical measurements are to 2. Spastic muscle be made and the discrepancy in Spastic muscle is designated by length is to be recorded in the ap­ the symbol "SP", and its grade by propriate space on the front sheet sub-letter as indicated in the legend. for the following: the letter grade (e.g., SPmo) for Ischial tuberosity to sole of heel Ischial tuberosity to medial gait and recorded on the front sheet tibial plateau as follows: Medial tibial plateau to sole of Mild impairment of balance is heel compatible with independent am­ In leg length discrepancies ex­ bulation. ceeding one-half inch, X-ray studies Moderate impairment of bal­ of leg length may be indicated and ance is compatible with ambulation an appropriate space is provided for plus external support. this measurement. Severe impairment of balance E. Rules pertaining to balance necessitates personal assistance for Balance is estimated during ambulation or standing.

APPENDIX B d. The distribution in age of lower-extremity orthotic patients is LOWER-EXTREMITY roughly: ORTHOTIC ESTIMATES FOR FISCAL YEAR 1970 LE deformity— Panel of Lower-Extremity Orthotics 46%—under 21— 679,000 Subcommittee on 41%—21 to 64— 605,000 Design and Development 13%—65 and Committee on Prosthetics over — 192,000 Research and Development 100% 1,476,000 total National Academy of Sciences a. There are about 3,370,000 LE paralysis— orthotic patients in the U.S. as op­ 5%—under 21— 17,000 posed to about 311,000 amputees 52%—21 to 64— 172,000 (10:1 ratio). 43%—65 and b. The distribution in site of over — 143,000 orthotic impairment is approxi­ 100% 332,000 total mately: e. There are 514 Certified Or- 54%—lower thotists and 224 Certified Prosthe- extremity—1,808,000 tists-Orthotists for a total of 738. 29%—upper The ratio of total orthotic patients extremity— 987,000 per CO is therefore 3,370,000:758 17%—spine — 575,000 or 4450:1 (as opposed to 311,- 100% 3,370,000 total 000:648 or 480:1 amputees per CP). c. The distribution in cause of f. More and more research is be­ lower-extremity orthotic impair­ ing directed to lower-extremity ments is approximately: orthotics. During FY 1970, $1,- 82 % —deformity—1,476,000 276,800 ($.71 per patient) is being 18%—paralysis — 332,000 spent on LEO research ($469,000 100% 1,808,000 total on design and development). Appendix C Development of specifications for orthot­ ic components, Bulletin of Prosthetics Selected Bibliography on Research, 265-273, Fall 1967. Lower-Extremity Orthotics Elftman, H., Dynamic structure of the human foot, Artificial Limbs, 49-58, This listing covers references other Spring 1969. than those in the CPOE annotated bibliography of July 1969 on braces, Evans, F. G., Bibliography on the physi­ splints, and assistive devices. Also, ref­ cal properties of the skeletal system, erences to the eighteen different braces Artificial Limbs, 48-66, Autumn 1967. being fitted and reviewed at the meeting Ewing, M. B., Modifications in lower ex­ of the CPRD Panel on Lower-Extremity tremity bracing for specific disability Orthotics at Rancho Los Amigos Hos­ problems, Southern Medical Journal, pital on March 9-12, 1970, will be listed separately in the report of that meeting. October 1969. Fajal, G., and J. M. Paquin, The single Arch supports, Bulletin of Prosthetics tubular splint, Orthopedic and Pros­ Research, 151-152, Spring 1968. thetic Appliance Journal, December Arch supports formed dynamically, Bul­ 1965. letin of Prosthetics Research, 145-146, Foot supports, Bulletin of Prosthetics Re­ Spring 1965. search, 160-164, Fall 1965. AZTRAN, Bulletin of Prosthetics Re­ Formo-ped ortho-inlay shoes, Bulletin of search, 271-272, Fall 1968. Prosthetics Research, 271, Fall 1968. Below-knee weight-bearing brace, Bulle­ Fruedenstein, L., and L. S. Woo, Kine­ tin of Prosthetics Research, 137-141, matics of the human knee joint, IBM Spring 1965. New York Scientific Ctr. Rpt. No. Bobechko, W. P., C. A. McLaurin, and 320-2928, January 1968. W. M. Motloch, Toronto Orthosis for Grynbaum, B. B., J. Sokolow, and H. R. Legg-Perthes disease, Artificial Limbs, Lehneis, Adjustable ischial weight- 36-41, Autumn 1968. bearing brace: preliminary report, Bottomley, A. H., Lower-Limb dynamics, Archives of Physical Medicine and research project studying the knee to Rehabilitation, August 1969. provide criteria for design of optimal Haberman, H., Possibilities of technical knee mechanism, Roehampton, Eng­ orthotic aid for the paralyzed lower land, in progress 1969. extremity, Orthopedic and Prosthetic Bulkeley, P. Z., and C. T. Thompson, Appliance Journal, December 1965. Human knee motion: a preliminary study, Stanford University, September Harris, E. H, E. T. Haslam, and C. A. 9, 1968. Moffatt, An experimental determina­ tion of prosthetic knee moment jor Chalupnik, J. D., G. S. Kirkpatrick, and normal gait, ASME Paper No. 66- J. F. Lehman, Partitioning of am­ WA/BHF-8, 1966. bulatory loads between ischial load- Henderson, W. H, and L. W. Lamoreux, bearing brace and leg, paper presented The orthotic prescription derived from at the Conference on Engineering in a concept of basic orthotic functions, Medicine and Biology, November 18- Bulletin of Prosthetics Research, 21, 1968, Houston, Texas. Spring 1969.

Custom versus stock orthopedic shoes, Hodge, J. W., Outer fiber stresses in long Bulletin of Prosthetics Research, 142- leg brace under static load, USAMBRL 145, Spring 1965. Technical Rpt. 6705, July 1967.

Denver Research Institute, A program Honet, J. C, D. E. Strandness, Jr., W. for the improvement of the below- C. Stolov, and B. C. Simons, Short-leg knee prosthesis with emphasis on bracing for intermittent claudication problems of the joint, Final Rpt, of the calf, Archives of Physical Contract V-100-LM-4089, August Medicine and Rehabilitation, October 1953. 1968. Improvement and innovation: some case Mori ison, J. B., The forces transmitted studies in orthotics, Orthopedic and by the human knee joint during ac­ Prosthetic Appliance Journal, 283- tivity, Ph.D. Thesis, University of 297, September 1963. Strathclyde. Inman, V. T., The influence of the foot- Plastic braces in assorted colors, Re­ ankle complex on the proximal skeletal habilitation Record, 22-23, September- October 1968. structures, Artificial Limbs, 59-65, Spring 1969. Preliminary study on conventional shoe Isman, R. E., and V. T. Inman, An­ wedges, Bulletin of Prosthetics Re­ thropometric studies of the human search, 122-125, Spring 1964. foot and ankle, Bulletin of Prosthetics Robin, G. C, and A. Magora, Dynamic Research, Spring 1969. stress analysis of below-knee drop foot Kay, H. W., and H. Vorchheimer, A braces; studies on patients with paralysis of the lower limb, Medical survey of eight wearers of the Vet­ and Biological Engineering, Vol. 7, erans Administration Prosthetics 1969. Center patellar-tendon-bearing brace, Orthopedic and Prosthetic Appliance Robin, G. C, A. Magora, E. Adler, and Journal, June 1966. J. Saltiel, Dynamic stress analysis of LeBlanc, M. A., Design of a polycentric below-knee drop foot braces, Medical knee joint for a leg brace, Stanford and Biological Engineering, Septem­ University, June 9, 1961. ber 1968. Lehneis, H. R., Orthotic measurement Rodenberger, C. A., A ground contact board for tibial torsion and toe-out, rotational orthotic device, paper pre­ Artificial Limbs, 42-47, Autumn 1967. sented at the Conference on Engi­ Lindahl, O., and A. Movin, The me­ neering in Medicine and Biology, November 18-21, 1968, Houston, chanics of extension of the knee joint, Acta orthop. Scandinav., 38:226-234, Texas. 1967. Saltiel, J., A one-piece laminated knee Measurement of foot parameters, Bulle- locking short leg brace, Orthotics and . tin of Prosthetics Research, 155-164, Prosthetics, June 1969. Spring 1968. Wright, D. G., S. M. Desai, and W. H. Morrison, J. B., Bioengineering analysis Henderson, Action of the subtalar and of force actions transmitted by the ankle joint complex during the stance knee joint, Bio-Medical Engineering, phase of walking, UC-BL Technical Arril 1968. Rpt. 48, June 1962. Orthotic Management of The Problematic Scoliosis*

by Siegfried W. Paul, C.P.O.**

A study of 135 patients under major categories. The idiopathic, treatment with the Milwaukee Or­ paralytic, and juvenile scoliosis. thosis conducted two years ago re­ Problematic cure patterns are most vealed excellent results which are frequently seen in the paralytic and to be expected for the properly juvenile groups. treated case. Missing in my pres­ Problematic idiopathic curves are entation as well as in most known basically related to the following publications was a discussion of the circumstances: A rigid lumbar Problematic Case, i.e., those pa­ curve, severe pelvic obliquity, the, tients which require the fullest at­ high thoracic lordosis observed in tention of all of the members of a conjunction with a narrow A-P di­ "Scoliosis Team." ameter of the chest and the high The Scoliosis Clinic at Newington thoracic curve with rotation of Children's Hospital has seen a most vertebral bodies. dramatic increase in its patient load. Paralytic scoliosis results in the A previous study was based on 135 most severe structural changes patients, we now would have to which are secondary to cerebral discuss over 600 patients in a simi­ palsy, polio, and lower motor neu­ lar paper. ron disturbances. Today, I shall discuss some of The congenital and juvenile these Problematic Cases and our scoliosis cases demand our special concepts of treatment at Newington. attention since problems primarily The initial diagnosis of Scoliosis due to scoliosis easily shadow the will place the patient in one of three spinal problem. Scoliosis is fre­ quently seen secondary to neurofi­ *This Paper was prepared for and bromatosis, amyotonia congenita, presented at the 1970 Assembly of InterborWerni g Hoffmanin Turins , Italydisease. , osteo­ genesis imperfecta, arthrogryposis, **Director, Orthotic and Prosthetic hemivetebra, Marphans syndrome, Department, Newington Children's Hos­ pital, Newington, Connecticut. and Ehlers-Danlos syndrome. liquity. A level pelvis is mandatory for the proper fit of the Milwaukee orthosis and a shoe lift will fre­ quently establish this prerequisite. The high thoracic lordosis in con­ junction with a narrow chest is treated with anterior pressure pads in addition to the routine pressure system. Exercises intended to ex­ pand the chest are also helpful. Fig. 1 High thoracic primary curves with Functional Principle of Spring Loaded Lumbar Pad. severe rotation respond to a shoulder flange. Our basic approaches to these problems can be summarized as fol­ lows: The idiopathic curve is ordinarily treated according to concepts out­ lined by Drs. Schmid, Blount, and Moe. Although the purpose of this presentation is not to discuss the Milwaukee routine, I would like to show the functional Milwaukee or­ thosis as applied at Newington. As you will recall, careful place­ ment of the pressure pads will re­ sult in a three-point pressure sys­ tem aided by the distraction from pelvic and head support. The prob­ lematic curve will require precise arrangement of this pressure sys­ tem. The rigid lumbar curve should be Fig. 2 Spring Loaded Lumbar Pad Applied to first treated with a localizer cast in Patient. an attempt to loosen the structure of the curve. This shoulder ring flange will The Milwaukee orthosis with a actively derotate the veterbral pelvic section fitted tight on the bodies as well as control the high side of the curve and loose on the thoracic curve. Over-correction is opposite side with a functional lum­ possible at this level and application bar pad and pressure coordinating of an L-shaped pad replacing the components will be most effective ring flange will be indicated. in stabalizing and balancing of the The L-shaped pad excludes the curves. shoulder girdle but includes the The Orthotist can do little for scapula, exerting greater lateral the patient with a severe pelvic ob- force than the regular thoracic pad. Fig. 3 Fig. 5 Ring Flange Applied to Patient, Anterior X-Ray Prior to Application of Milwaukee View. Orthosis.

Our primary objective for the severe paralytic scoliosis patient is to achieve a cosmetically acceptable,

Fig. 4 Fig. 6 Ring Flange Applied to Patient, Oblique X-Ray Post Application of Milwaukee Lateral View. Orthosis with Ring Flange. functional correction and to main­ tain this correction. Severe paralytic curves will not stabilize with bony maturity and spinal fusions will be performed once bony maturity has been reached.

THE FOLLOWING CASES WILL DEMONSTRATE THIS APPROACH Fig. 8 Same Patient Posterior View Bending Case No. 1: This is a 17-year- (Note sharp razoring). old boy who was first seen in 1957. He is a post-polio patient.

Fig. 7 Patient Post-Polio after Treatment with Localizer Casts for Two Years (treat­ Fig. 9 ment of choice prior to introduction of X-Ray of This Patient in His Second Milwaukee Orthosis). Orthosis.

His severe curve was treated in The next patient is a twenty-year- localizers for two years. The first old female who was diagnosed as Milwaukee orthosis was applied in amyotonia congenita with secondary 1959. A spinal arthrodesis was per­ scoliosis. This patient is a good ex­ formed in November 1967 and the ample for a case where an error orthosis continued till June 1969. in judgement led us to do too little This patient was fitted with three too late. The patient was ambula­ orthoses during this 10-year period. tory till age seven at which time the His curve was improved and today's scoliosis became decompensated. clinical examination demonstrates a Early holding of the curve was at­ cosmetically acceptable result. tempted with corsets, followed by Fig. 10 Fig. 12 X-Ray of This Patient Post Arthrodesis. X-Ray of Patient in Corset.

an early version of the Milwaukee is now a wheel chair patient who orthosis. A Harrington instrumenta­ is gainfully employed. tion was utilized two years ago. She

Fig. 11 Fig. 13 Initial X-Ray of This Patient Diagnosed Posterior View of Patient Ten Years as Amyotonia Congenita. Post Initial Visit. Fig. 14 Fig. 16 Posterior view of Patient Wearing Mil­ X-Ray of this Patient Post Harrington waukee Orthosis. Rodding.

Our congenital and juvenile to prevent additional deformities. groups benefit from an early treat­ Plastic anterior or posterior body ment which is mandatory in order shells fabricated from vitrathene, a

Fig. 15 Fig. 17 X-Ray of Patient Prior to Harrington Posterior View of Patient PostHarringion Rodding . Rodding. Fig. 18 Fig. 20 Myelomeningocele Patient Wearing An­ Newington Infantile Scoliosis Splint. terior Body Shell, Supine View. neuron disturbed patient will go into polythene plastic, have proven to be extensive orthotic management to most effective. The lower motor become ambulatory.

Fig. 19 Fig. 21 Patient Wearing a Newington Infantile Anterior View of Patient Afflicted with Scoliosis Splint, Anterior View. Marphans Syndrome. Fig. 22 Fig. 24 Posterior View of Patient Afflicted with Most Recent X-Ray of Patient with Mil­ Marphans Syndrome. waukee Orthosis Applied.

Less involved patients will go once tne more mature age of 4 to into the Newington infantile scolio­ 6 years, depending on growth, has sis splint or a spinal corset. A Mil­ been reached. waukee orthosis will be indicated The next patient is a good ex­ ample for this type of treatment. This patient is an 11-year-old boy afflicted with Marphans syndroms. The initial application of a Mil­ waukee orthosis was at age three, which was somewhat early. How­ ever, we have been able to achieve corrections of his curves and have avoided more severe deformity. He is now wearing his fourth Mil­ waukee orthosis. Those patients which demonstrate no hope of future ambulation have benefitted from body jackets molded of vitrathene. Such body jackets have proven to be of help in stabilizing the spine and preventing its collapse. Fig. 23 Anterior View of This Patient with Mil­ The amyotonic case was also able waukee Orthosis Applied. to exercise better respiration and Fig. 25 Fig. 27 Laterial View of Myelomeningocele X-Ray of This Patient With Body Jacket Patient in Body Jacket. Applied.

the retarded child was easier to with Werdnig Hoffmans disease, manage by its custodians. like this patient in a reclining seat­ The same applies to the patients ing device with lateral support.

Fig. 26 Fig. 28 X-Ray of This Patient Without Body Reclining Seating Device for Patient Jacket. with Werdnig Hoffmans Disease. CONCLUSION The examples presented here can knowledge obtained by all of us will only highlight the many problems help to advance our current status posed by scoliosis in its multitude of Orthotic Technology in the treat­ of variations. Only the sharing of ment of scoliosis.

ACKNOWLEDGEMENTS: This paper could not have been sis Clinic Chief, Dr. Walter Bonne, presented without the assistance and Orthopedic Resident, the members cooperation of the staff of the New­ of the Photography Department, ington Children's Hospital. Medical Records, the Radiology De­ My special appreciation is ex­ partment, and the Staff of my De­ tended to Dr. James Hardy, Scolio­ partment. Blatchford Stabilized Knee A Review

Susan Bergholtz, B.S.

The Prosthetics and Orthotics The knee mechanism with its program at New York University belting rotates around the axis has completed a technical and formed by two pivots set on the clinical review of a recently mark­ same horizontal plane. The amount eted knee unit, the Blatchford of friction is determined by the Stabilized Knee (BSK). Its dis­ pressure between the belting and tributors claim the knee provides a the drum. The friction drum is con­ stabilizing effect that "virtually centric with and attached to the eliminates falls, increases confi­ pivots. Swing phase friction is con­ dence, and reduces general fatigue." trolled by the swing phase adjust­ ment wheel. Clockwise rotation Description of Unit raises the friction belting support The new device is a single axis (Figure 2), increasing belt tension knee unit with constant friction and and, in turn, the friction between friction lock. The amounts of swing the drum and the band. phase friction and locking friction Any downward pressure on the are controlled by a continuous teryleneposterior portio brean ofk thbane kned whice bloch kride s on a stationary steel friction drum (as by weight-bearing) stabilizes the (Figure 1). knee. This pressure rotates the unit counterclockwise about an anterior fulcrum, causing the terylene band 1 Assistant Research Scientist, Prosthetics to grip the brake drum and thereby and Orthotics, New York University resist knee flexion. The more weight Post-Graduate Medical School. applied, the more resistance to This study was conducted under the general supervision of Sidney Fishman, flexion. Locking friction is espe­ Ph.D. Appreciation is expressed to Joan cially important during the period E. Edelstein, M.A., Virgil Faulkner, from heel strike to midstance when C.P., and Marshall Kaufman, B.S., for their assistance. a poorly aligned prosthetic knee is LATERAL VIEW OF THE BLATCHFORD STABILIZED KNEE

Figure 1

ANTERIOR VIEW OF SWING PHASE ADJUSTMENT WHEEL WITH FRICTION BELTING

Figure 2 most likely to bend. A single axis axis of knee rotation, the knee re­ knee depends upon alignment and mains flexed during sitting. stump extension force or a positive A leather hyperextension strap lock to keep it extended during the is attached from the knee bolt to first part of stance phase. The the posteroproximal portion of the Blatchford Knee, however, requires shank. As the knee approaches full only the downward force of the am­ extension at the conclusion of putee's body weight. The manu­ swing phase, the strap is tensed, facturer claims that this stabiliza­ thereby reducing terminal impact. tion is achieved if the knee is An external cover contributes cosmesisan d protects the mechanism. loaded in any position between full extension and thirty-five degrees of The knee unit with its wood set­ knee flexion. up and cover weighs 4 1/4 pounds, Two release springs eliminate the as compared with 2 3/4 pounds for stabilizing effect at toe-off. They the Bock Safety Knee 3P23, and are set to counteract the small 2 1/4 pounds for a single axis knee amount of weight still applied by with friction adjustment. the amputee late in stance phase. Clinical Findings Without such counterbalancing springs, even partial weight-bear­ The one test wearer was a sixty- ing would lock the knee. The one year old jazz musician who ac­ springs also enable the amputee to quired a left above-knee amputa­ bend the knee, as when sitting. tion in 1966 as the result of circu­ When the basic knee unit is in­ latory insufficiency. He required corporated into a shank, an ex­ maximum stability in stance, yet tension lever is added. Knee flexion could manage an unlocked knee in stretches an elastic strap located at swing phase if external support the lower end of the extension (such as a cane) were provided. Up lever. The tensed strap prevents ex­ to the time of the study, he had cess heel rise at toe-off and ac­ worn his own prosthesis all day, celerates the shank forward during every day. It was of the following the initial part of swing phase. Be­ design: cause the axis of the lever is Proximal Socket—Quadrilateral Distal Socket—Air chamber posterior to the axis of knee rota­ Socket material—Wood, plastic coated tion, the knee remains flexed during Suspension—Pelvic belt sitting. Knee type—Single axis, manual lock Friction—No adjustable friction When the basic knee unit is in­ Extension aid—None corporated into a shank, an exten­ Shank material—Wood, plastic laminate sion lever is added. Knee flexion finish stretches an elastic strap located at Foot-ankle assembly—SACH the lower end of the extension lever. After the subject was fitted with a The tensed strap prevents excess prosthesis in which a Blatchford heel rise at toe-off and accelerates Stabilized Knee was installed, the the shank forward during the initial following data were gathered: part of swing phase. Because the 1. Prosthetic Considerations axis of the lever is posterior to the a. Installation The attending prosthetist reported requires a major dismantling of the that the time and ease of installation unit. of the Blatchford Stabilized Knee 2. Performance Observations unit was comparable to that re­ a. Initial Evaluation quired in mounting a Bock Safety Ordinarily this amputee am­ Knee or a constant friction single bulates with a manually locked axis knee unit into a new prosthesis. knee unit and a cane. Although he b. Maintenance states that he feels insecure with the One minor adjustment was re­ prosthetic knee unlocked, he can quired during the one-month test walk slowly with the use of a cane. period. When the subject returned For the purposes of functional com­ for the two-week followup, the parison with the BSK, the subject's swing phase friction had decreased gait was studied while he used his slightly. A quarter turn clockwise own prosthesis both with the arti­ of the Swing Phase Adjustment ficial knee locked and with it un­ Wheel returned the unit to the fric­ locked. tion established at the initial fitting. With his conventional prosthesis No decrease in the friction was ap­ and cane, the amputee displayed the parent from the two-week followup following gait deviations whether to the final evaluation four weeks walking with the knee locked or un­ after delivery. locked: (1) lateral trunk bending No further mechanical problems toward the side of the prosthesis; occurred during the test period. (2) ipsilateral arm often rigidly ex­ However, areas of potential diffi­ tended, not swinging reciprocally culty included the following: with the contralateral, sound, leg; (3) circumduction of the prosthesis 1) The BSK mechanism is more when walking with a locked knee; complex than either of the com­ (4) a longer prosthetic step and parable conventional units. In re­ terminal swing impact with an un­ ferring to its installation, the manu­ locked knee and support of a cane. facturer acknowledges "great care The subject took seventy-six steps must be taken at all stages to keep per minute with the locked knee the mechanism clean ... to avoid but slowed to sixty-six steps per having to dismantle it to remove minute when he ambulated with any foreign material." the mechanical knee unlocked. 2) The two release springs on One step stair ascent was un­ the BSK are mounted with plastic affected by the status of the knee. end caps, each of which has a lip When the knee was locked, the covering the end of the spring. This subject descended by the one step lip might be a source of mechanical method. With an unlocked knee, breakdown, for it bears the full however, he was capable of using force of a heavy spring. the step-over-step technique, al­ 3) It might become necessary to though he customarily descended remove the friction belt to clean stairs with a locked knee. dirt that had accumulated between Upon delivery of the experimental the belt and the friction drum. This prosthesis, an effort was made to estimate stance phase stability by Two weeks later he still used a positioning the patient between cane, but had become more profi­ parallel bars, and having him at­ cient in walking, utilizing more of tempt to support most of his weight the features of the test knee. Lateral on the prosthesis with the knee unit trunk bending was still prominent, placed at various angles. In the but the arm on the side of the judgment of the observers, he bore prosthesis was now employed in most of the weight on the prosthesis, reciprocal arm-leg movement and very little on his hands, and none the prosthetic step length was near­ on the sound extremity during the ly that of the sound side. Cadence actual tests. The knee remained increased to seventy-six steps per stable when loaded by a great deal minute, equalling that with the of downward pressure. This test locked knee in his previous pros­ was repeated as the knee flexed at thesis. five degree increments to maximum At the conclusion of the test angulation of thirty-five degrees (a period, one month after delivery, fully extended knee being consid­ the subject's gait was re-evaluated ered to be zero degrees). Stability with his two prostheses. Walking was obtained at all test points, ex­ patterns with the conventional cept the final position, where mod­ prosthesis had not changed since erate weight-bearing caused the the initial evaluation. Performance prosthetic knee to buckle. with the BSK also remained similar Gait on a level surface was ex­ to that displayed at the two-week amined after the terylene belt ten­ follow-up. sion was adjusted to provide mod­ erate swing phase friction. The sub­ 3. Subject's Reactions ject displayed most of the devia­ Initially, the amputee was skepti­ tions found with his conventional cal about the safety of the Blatch­ free swinging prosthesis, namely: ford Stabilized knee. He stated that (1) lateral bending; (2) long pros­ he lacked confidence while am­ thetic step; (3) failure to swing bulating with it. arms reciprocally. Since the BSK At the end of one month, the provides constant friction through­ subject's opinion had altered con­ out swing phase, terminal swing siderably. He said that he would impact was less with the test knee "definitely choose" this prosthesis than with the previous, nonfriction over his previous one, for the fol­ unit. The cadence of sixty-four steps lowing reasons: per minute was similar to that with the conventional unlocked knee. 1) Stability in Stance He climbed stairs one step at a He felt very confident that his time. He could not descend step- knee would not collapse while he over-step because he could not was walking. He stated that he felt transfer enough weight from the safer on curbs and was not as prosthesis to negate the stabilizing "afraid of falling" when someone action of the Blatchford Stabilized bumped into him on the street. The Knee. subject also related that he was beginning to feel more confident duced fatigue when he walked long without the cane. distances. The major difficulty noted 2) More Natural Gait by both the subject and the evaluator was in stair descent. A step-over-stepdescen t could no longer be used because sufficient body The subject claimed he was weight could not be removed from "happy at not walking with a stiff the prosthesis to negate the inherent leg." He felt that the unit had a stability of the knee. definite advantage over his previous one, for it allowed him to feel safe while producing a more natural The additional weight of the unit gait. (approximately one and a half 3) Less Fatigue pounds heavier than his previous The subject stated that he was unit) presented no difficulty to the less tired when using the BSK. Be­ wearer. This subjective reaction cause of its freedom in swing, he may relate to the fact that the BSK did not have to circumduct the was mounted in a prosthesis with prosthesis as he did with his manu­ suction suspension, unlike the ally locked prosthetic knee. The in­ looser socket and pelvic belt on his herent stance stability of the BSK own limb. The more intimate socket obviated the need to extend his fit may have been as responsible for stump at heel strike. the "lighter feeling" as the action The subject was unable to of the test knee. descend stairs by the step-over-step The prosthetist encountered no method. Although he did not find difficulties in installing the knee. this detrimental himself, he con­ He predicted, however, that any in­ jectured that it might limit a more ternal derangement of the mecha­ active individual. nism would require time-consuming dismantling of the entire unit. Summary and On the basis of this study, the Recommendations Blatchford Stabilized Knee appears The Blatchford Stabilized Knee to be a useful addition to the pros­ incorporates a mechanism to resist thetic armamentarium for those knee flexion to thirty-five degrees amputees who require maximum of knee flexion upon downward stability in stance, yet desire a loading. The unit was fitted to an cosmetic swing phase. Further amputee who needed substantial study may answer certain other stability in stance phase, but was questions: also able to utilize an unlocked 1. How durable is the unit over a knee in swing phase if external sup­ prolonged period of wear? port were provided. After wearing 2. How suitable is the mechanism the unit for a month, he stated that for bilateral above-knee am­ he preferred it over the manually putees, feeble geriatric ampu­ locked knee unit in his previous tees, or those with a hip distarticulation? prosthesis. The test unit gave him stance phase stability while offer­ 3. Will the additional weight of ing a more cosmetic gait and re- the unit affect its applicability? ORTHOTICS AND PROSTHETICS

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4Bk If * * I \ * /

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DENIS BROWNE PILLOW & SPLINTS FOR HIP ABDUCTION NIGHT SPLINTS

KNIT-RITE, I NO. 1121 GRAND AVENUE • KANSAS CITY. MISSOURI S4106 PHONE: 816-221-D206 ° NEW...

from Kingsley mfg. co.

The Mortenten Hydra Nu-Matic Knee Control with a new remote-operated locking device which gives security at any angle as the wearer rises from a sitting position.

Now the geriatric amputee can benefit from the smoothness of fluid control, the 1 security of pneumatic extension bias and the safety of a locking knee—all at a reasonable cost!

Adding only six ounces, this lightweight control unit is furnished installed in a conventional-type setup ready to align and finish. No special tools are needed, and no unusual fitting or aligning procedures.

Try one on your next geriatric patient. You will appreciate the simplicity of the unit and ease of installation and training— and your patient will appreciate you and the comfort and security of the hydra nu-matic knee control.

Order by calf circumference or knee width.

1984 PLACENTIA AVENUE • COSTA MESA, CALIFORNIA / \ READY TO FIT HAND, WRIST AND FINGER BRACES, CERVICAL BRACES, TRAINING AIDS AND SPECIAL APPLIANCES - PLUS A COMPLETE LINE OF SPINAL AND LEG BRACES CUSTOM MANUFACTURED TO YOUR MEASUREMENTS. COMPLETE CATALOG AVAILABLE ON REQUEST

C. D. DENISON ORTHOPEDIC APPLIANCE CORP.

220 W. 28th Street - Baltimore, Md. 21211 ^ ' You Just Can't Beat

Our Rover For Brace Work

Look at some of the features of our famous "Brace Shoe"

• Leather Sole & Heel • Long Counter • Extra Strong Steel Shank

You can use this shoe with com- ete confidence.

Sizes 5-13 in varying widths. Extra large size range also available. Colors: Black, Smoke, White, Sage Green Gluv and Antique Brown Crushed Kid. Mismate Service on Black Only. Write For Free Catalog.

w The Irving Drew Corporation Lancaster, Ohio 43130 CORPORATION DREW - DR. HISS - CANTILEVER GROUND GRIPPER

"BecJcfiflL. ADJUSTABLE HYPEREXTENSION BRACE

• Quick release, snap- out attachment • Adjustable, self align­ ing posterior pad • Rotating adjustment for sternal and pubic pads • Vertical and horizon­ tal sliding adjust­ ments • Bi-lateral worm gear traction bands • Plastic water resist­ ant pad covers • Constructed of 24 ST aluminum MODEL L-25 1776 South Woodward • Birmingham. Michigan MANUFACTURERS OF PRECISION-MADE BRACE PARTS 24 Hour Service BECKER ORTHOPEDIC APPLIANCE COMPANY ® The largest, most complete line of

cosmetic restorations available anywhere in the world.

• COSMETIC GLOVES • PASSIVE 8. PARTIAL HANDS • BODY BUILD-UPS and RESTORATION • LEG & FOOT COVERS • ATROPHIED LEG BUILD-UPS • BOW LEG PADS • NOSE, EAR, EYE and FACIAL RESTORATIONS • PARTIAL FEET • COSMETIC FINGERS 8. ARMS • EYEBROWS • BREAST RESTORATIONS • MASKING and STRETCH HOSE

• SUPPLIES

Realastic Industries 1000 - 42nd Street Oakland, Calif. 94608

ORTHOPEDIC and PROSTHETIC LEATHERS

146 Summer Street* Boston, Massachusetts 02110 * 617/542-4112 Do pre-walker shoes rub your little patients the wrong2 1way ?

Sabel introduces a new heel that won't

Rubbing and chafing at the top of the heel has long been a problem to the doctor Now, Sabel has introduced a new elasticized, water repellent insert at the heel that guarantees maxi­ mum comfort to the patient Without reducing the functions of the shoe It's a simple answer to a common and complicated problem Especially in Equino- varus and Surgical type shoes. It's another Sabel first When you're No 1, you're expected to lead and you expect others to follow on the heels of Sabel

SABEL DIVISION The Green Shoe Manufacturing Co. makers of Stride Rite Shoes For information write E J Sabel Co. Benson-East Box 644 Jenkintown, Pa 19046 SERVICE OUR

BYWORD —Exclusively—

LEATHERS FOR THE ORTHOPEDIC and PROSTHETIC TRADE

LIMB & BRACE LEATHERS: HOSPITAL LEATHERS: • Orthopedic Horsehide • Shearlings for Pads • Orthopedic Cowhide • Carving & Tooling • Orthopedic Elkhide • Molding • Glazed & Molding Cowhide • Russet Strap • Calf—Kip—Sheep—Pigskin Satisfied Customers Throughout the United States Since 7924

ORDERS SHIPPED RODEN LEATHER CO., INC. THE SAME DAY 1725 CROOKS ROAD ROYAL OAK, MICH. 48068 Area Code 313-542-7064 THESE TOO (2) WILL BE IMITATED

1. RUHRSTERN ELASTIK PLASTER BANDAGE Sizes 3, 4 and 5 inch. Edges are finished to provide neater appearance. NOT stretched therefore handles easier. Fillauer — first with elastik plaster.

NEW Low PROFILE DETACHABLE DENIS BROWNE NIGHT SPLINT Free, exclusive locking wrench and protractor. Offset Bar permits child to stand without danger. Lengths 4 to 36 inches. Fillauer — first with this new detachable splint.

Surgical Supplies, Inc. Box1678 Established 1914 Chattanooga, Tenn. The 1971 NATIONAL ASSEMBLY of the

AMERICAN ORTHOTIC AND PROSTHETIC ASSOCIATION

will be held

OCTOBER 31 to NOVEMBER 3

at the

SAHARA

LAS VEGAS, NEVADA

For Program Details and Registration Information write to

The American Orthotic and Prosthetic Association

1440 N Street, N.W.

Washington, D. C. 20005

The Assembly is open to all who are interested in the rehabilitation of the orthopedically disabled CLASSIFIED ADVERTISEMENTS Rates: First 35 words, $24.00 (minimum). Additional words $1.00 each. Situations wanted advertisements half rate.Space rate additional: 13x13 picas - $105.00; 13x18 picas - $180.00.

Mail addressed to National Office forwarded unopened at no charge.

Classified Advertisements are to be paid in advance; checks should be made payable to "Orthotics and Prosthetics." Send to: Editor, Orthotics and Prosthetics; 1440 N St., N.W., Washington, D.C. 20005.

CERTIFIED PROSTHETIST Immediate opening available at a lead­ ing orthopedic teaching hospital for an experienced prosthetist. Excellent salary and benefits. Send resume in confidence to Mrs. H. White, Personnel Department

The Hospital for SPECIAL SURGERY 535 E. 70th St. New York, New York 10028 (212) 535-5500

AMERICAN ORTHOTIC AND PROSTHETIC ASSOCIATION 1440 N STREET, N.W. WASHINGTON, D.C. 20005