Carl A. Paulsen, M.D. Richard R. la Torre, CO. Klaus H. Lohmann, CP.
Conventional metal and leather braces for lower-extremity stabilization and/ or support have been used for centuries. The excessive weight, poor appearance, and soiling tendencies of these devices have been objectionable for as long. Recently, the search for improved orthoses for lower-extremity stabilization has benefited by the adoption of techniques long applied in prosthetics. In September 1967, Simons et al, described a plastic short-leg brace of distinctly new design.3 This brace incorporated a molded plastic shell with a foot portion integral with the shank section of the brace. A Velcro strap provided anterior closure proximally (Fig. 1 ). The rigid ankle construction provided plantar and dorsiflexion control as well as mediolateral stability. A lightweight calf-length stocking or elastic hose was worn under the brace and the usual stocking was worn over it. To lessen the impact at heel strike a soft rubber heel wedge was used and a Blucher-type shoe was recommended.
The Simons article stimulated the Schenectady group to explore the use of laminated braces for the solution of various lower-extremity bracing problems. The first modifications tried were directed toward eliminating the anterior Velcro closure used in the brace described by Simons and the replacement of long-leg by short-leg braces whenever practical. With experience in the fabrication of these braces, confidence increased and applications to a wider range of problems were attempted. Other centers have had similar experiences which have been documented in the prosthetics/orthotics and medical literature.1,2 The use of these laminated leg braces in selected cases is briefly described in this paper.
First Used on Hemiplegic Patients
At first the laminated braces were used only on hemiplegic patients who had suffered cerebrovascular accidents. For these patients return of dorsiflexion function was regarded as improbable and ankle motion was not considered necessary for satisfactory ambulation. In these cases a laminated infrapatellar anterior transverse portion was used in place of the anterior Velcro strap closure and proved to be quite effective (Fig. 2 ). An unexpected bonus was a diminution in the problem with edema.
The first variation was utilized for an adult patient with myelodysplasia who had had three unsuccessful attempts at foot stabilization by panarthrodesis of the ankle. A single surgical procedure on the opposite extremity had produced a somewhat stable foot and ankle. Three sets of molded-leather and steel-reinforced braces had been fabricated for this patient over a period of four years. These devices had provided only partial stabilization, especially on the limb with fibrous ankylosis and all had produced decubiti in insensitive areas and rather severe shoe damage because of instability and breakage of the molded supports. For this patient a laminated plastic brace with high medial and lateral walls was fabricated in order to obtain additional support from the femoral condylar region to stabilize the ankles (Fig. 3 ). Again edema was significantly decreased by these orthoses. In addition, the stability produced could be provided previously only by bilateral double-upright long-leg braces, and thus the total volume and weight of the supports were significantly reduced.
Control of Recurvatum
The next variation was required for a patient who was 10 years postcerebro-vascular accident and had developed a 20-deg. recurvatum of the knee. In this case also, only long-leg bracing could heretofore have satisfactorily stabilized this knee in an acceptable position. However, a laminated short-leg brace with a suprapatellar bridge successfully controlled the recurvatum plus the small amount of mediolateral instability (Fig. 4 ).
The final variation was for a patient with chronic osteomyelitis of the tibia with rather severe lateral tibial bowing and an associated genu varus. Here again, only long-leg bracing would previously have satisfactorily supported the tibia and knee. However, a laminated brace with a high medial extension in the femoral condyle region provided good support for the tibia, and control of the varus deformity (Fig. 5 ). For this patient ease of cleansing of the orthosis was of considerable value.
We have attempted to illustrate the wide variety of uses which are possible with laminated leg braces. They have the obvious advantage of improved appearance compared to conventional metal and leather braces. In addition, ordinary shoes without stirrups are possible and a reasonable variety of shoes may be utilized by the patient. The ease of cleansing the brace for the patient is probably one of the great advances. In many instances females may wear hose over the brace.
Techniques from the field of prosthetics have been adapted to support and stabilize the lower extremities. Illustrated cases have been presented as representative of modifications possible for a myriad of lower-extremity brace problems.
Children's Amputee Clinic, Sunnyview Rehabilitation Center Schenectady, New York
1. Jebsen, R. H., et al., Clinical experience with a plastic short leg brace, Arch. Phys. Med., 51:114-119, Feb. 1970.
2. Saltiel, J., A one-piece laminated knee locking short leg brace, Orth. and Pros., 23: 2:68-75, 1969.
3. Simons, B. C., R. H. Jebsen, and L. E. Wildman, Plastic short leg brace fabrication, Orth, and Pros., 21:3:215 218, 1967.