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This presentation won best paper award at BAPO (British Association of Prosthetics & Orthotics) Conference in 2008. The focus is on conservative management of severe OA knee pain and deformity using the V-VAS Knee orthosis from Anatomical Concepts
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Management of SevereOA Knee
Customised Knee Orthosis
William A Munro, Derek Jones, Martin Buchan
Treatment of OA• NSAID’S
• Narcotics
• Synvisc injections
• Debriedment
• Uni-compartmentresurfacing
• 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 beeasily tolerated
• Designs may not be easily adjusted for optimal comfort
• May not be adequate with severe deformity
3 & 4 points ofpressure
Various pad & strapconfigurations
Long lever arms tocreate effective bending
moment
Single UprightDesigns
DoubleUprightDesigns
3 point pressuresystem
Single segmentadjustments
Within a “fixedframe”
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 orValgum
• Non-Operative Tibial PlateauFixations
• 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 lungresection
• Chronic Renal failure
• Anaemia
• Atypical mycobacteriumpulmonary infection
Clinical Management
•Hyaluronic acid and multiple steroidintra-articular injection providedminimal 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 limitedby respiratory problems ratherthan knee pain
• Issues
• Felt brace heavy and cumbersome
• Tricky to apply until correctapplication taught
• Significant weight fluctuationsinfluenced fitting
Interpretation
• Unbraced XRay - varus axis of 11 degrees
• Braced XRay - varus axis of 11 degrees
• Question
• Does brace work by preventing hingeadduction and compression of the medialjoint?
Mr MD - 44 years
Profile• 1985 left knee arthroscopy and
open medial menisectomy
• 1995 repeat arthroscopyshows complete loss of medialchondral surface
• 2005 right knee arthroscopyshows bone on bone contact
• Both knees have moderatePFJ and lateral compartmentchondral loss.
Without Brace - Stork View
Mr MD
Exam
• Bilateral clinical varus>20 degrees
• Both knees lack 5degrees fullextension
• Moderate effusionright knee only
• Severe pain andswelling right knee
Observations–Too young for jointreplacement–Too severe for chondralresurfacing–Too advanced for high tibialosteotomy–May be suitable for Benjamin’sdouble osteotomy
Mr MD
Following Bracing
• Brace used 2 - 4 hours per day
• Excellent reduction in pain andswelling of right knee
• Weight-bearing Xray
• No brace 11 deg Varus
• With brace 4 deg Varus
Mr ST - 66 years
Profile
• Right knee & left hiposteoarthritis
• Ex marathon runner
• Lateral menisectomy1963
• Knee arthroscopy in1989 showed patella-femoral and lateralcompartment wear
Past History–Coronary bypass grafts (re-stenosed)–Gout–Previous knee brace rejected in2005
Pain medication–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 degreesflexion–Xrays show bone on bonecontact in lateral compartmentsand PFJ–Mild OA medial compartments–Bone on bone hip OA
RequiredMeasurements
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