conservative management of severe oa knees with the v-vas orthosis
DESCRIPTION
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 ConceptsTRANSCRIPT
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Management of SevereOA Knee
Customised Knee Orthosis
William A Munro, Derek Jones, Martin Buchan
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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
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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
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3 & 4 points ofpressure
Various pad & strapconfigurations
Long lever arms tocreate effective bending
moment
Single UprightDesigns
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DoubleUprightDesigns
3 point pressuresystem
Single segmentadjustments
Within a “fixedframe”
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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™
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Adjustability
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Captured Offloading
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Dynamic Closed Frame
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Adjust Optimal T/F Angle
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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
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Cases
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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
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Clinical Management
•Hyaluronic acid and multiple steroidintra-articular injection providedminimal benefit
•Morphine patches for thoracic pain
•TB chemotherapy
Weight Bearing - No Brace
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Weight Bearing - No Brace Braced
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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
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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?
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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
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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
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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
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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
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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)
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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
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RequiredMeasurements
Via Cast or Scan
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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