Management of Severe OA Knee Customised Knee Orthosis William A Munro, Derek Jones, Martin Buchan
Treatment of OA • • • • •
NSAID’S Narcotics Synvisc injections Debriedment Uni-compartment resurfacing
• • • • •
Total knee replacement Shoe wedges Hinged knee sleeves Rigid frame KO’s KAFO’s
Orthoses • • • •
Have been successfully used Pressures generated to provide offloading may not be easily tolerated Designs may not be easily adjusted for optimal comfort May not be adequate with severe deformity
Single Upright Designs 3 & 4 points of pressure Various pad & strap configurations Long lever arms to create effective bending moment
Double Upright Designs 3 point pressure system Single segment adjustments Within a “fixed frame�
V-VAS Concept • • • • • •
Total contact cuff Unique self-aligning adjustable joint Adjustable when on the body Femur and tibia - independent adjustment Unique application of corrective forces Made with custom cast or scan
Varum - Valgum Adjustable Stress V-VAS™
Adjustability
Captured Offloading
Dynamic Closed Frame
Adjust Optimal T/F Angle
Successful Applications • • • • • •
Mild to Severe Genu Varum or Valgum Non-Operative Tibial Plateau Fixations Failed Tibial Plateau Reconstructions Osteochondral Defects Post Total-Knee Arthroplasty Tibial and/or Femoral Spacers
Cases
Mr AC - 84 years Profile
• • •
Bilateral knee OA Not fit for total knee Past History
• • • • •
Ischaemic Heart Disease Lung cancer and lung resection Chronic Renal failure Anaemia Atypical mycobacterium pulmonary infection
Clinical Management •Hyaluronic acid and multiple steroid intra-articular injection provided minimal benefit
•Morphine patches for thoracic pain •TB chemotherapy
Weight Bearing - No Brace
Weight Bearing - No Brace
Braced
Mr AC
•
Benefits
• •
•
Pain judged 60-70% improvement Improved walking distance limited by respiratory problems rather than knee pain
Issues
• • •
Felt brace heavy and cumbersome Tricky to apply until correct application taught Significant weight fluctuations influenced fitting
Interpretation • • •
Unbraced XRay - varus axis of 11 degrees Braced XRay - varus axis of 11 degrees Question
•
Does brace work by preventing hinge adduction and compression of the medial joint?
Mr MD - 44 years Profile
• • • •
1985 left knee arthroscopy and open medial menisectomy 1995 repeat arthroscopy shows complete loss of medial chondral surface 2005 right knee arthroscopy shows bone on bone contact Both knees have moderate PFJ and lateral compartment chondral loss.
Without Brace - Stork View
Mr MD Exam
• • • •
Bilateral clinical varus >20 degrees Both knees lack 5 degrees full extension Moderate effusion right knee only Severe pain and swelling right knee
Observations –Too young for joint replacement –Too severe for chondral resurfacing –Too advanced for high tibial osteotomy –May be suitable for Benjamin’s double osteotomy
Mr MD Following Bracing
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Brace used 2 - 4 hours per day Excellent reduction in pain and swelling of right knee Weight-bearing Xray
• •
No brace 11 deg Varus With brace 4 deg Varus
Mr ST - 66 years Past History
Profile
• • • •
Ex marathon runner
–Coronary bypass grafts (restenosed) –Gout –Previous knee brace rejected in 2005
Lateral menisectomy 1963
Pain medication
Right knee & left hip osteoarthritis
Knee arthroscopy in 1989 showed patellafemoral and lateral compartment wear
–Gabapentin –Paracetamol –Tramadol
Mr ST Observations
• • • •
Pain disrupts daily activities Painful and unstable knee Steriod injection in left hip very helpful (December 2007) Steroid injection in right knee not helpful (September 2007)
Mr ST Examination –20 degrees valgus –Correctable to neutral –Full extension to 120 degrees flexion –Xrays show bone on bone contact in lateral compartments and PFJ –Mild OA medial compartments –Bone on bone hip OA
Required Measurements Via Cast or Scan
Benefits • • •
Manageable pain relief Increased tolerance to corrective forces
• •
No contact to knee area itself No need for counterforce strap
Custom fit - Off the Shelf price