Newton C. Mc Collough, III, M.D
This report was originally distributed as a "Spectator Letter" by Dr. McCollough.
There is little question that the field of Orthotics has taken a back seat to Prosthetics in modern times, and perhaps for good reason. The needs of the amputee are more immediate and obvious, and the wars of the past thirty years have yielded untold numbers of young men in their prime whose productivity depended upon satisfactory functional restoration of their missing limbs. Medicine, engineering, and the prosthetic profession have responded to the needs of the amputee through extensive research and development, widespread educational programs, improved fabrication and fitting techniques, and better delivery of services. The field of Orthotics remains in comparative disarray, with more limited, though no less sophisticated, research activities, few educational endeavors, and little improvement upon local fabrication and delivery services over the past fifty years.
There are no accurate statistics as to the number of persons in this country requiring orthotic services, but when one considers the numbers of spinal cord injuries, stroke victims, congenital neuromuscular disorders, arthritis victims, and post-traumatic neuromusculoskeletal disorders, it is obvious that, in terms of sheer patient volume, there is a much greater need for progress in orthotics than in prosthetics.
Why then have there not been comparable advances in the orthotic field? I believe there are some definite reasons for what I might term the "orthotic lag." There is, first of all, the more obvious and immediate need for replacement of a missing limb as opposed to restoring function to a deranged limb which at least has not parted company with the remainder of the body. Secondly, a missing limb presents in many instances a more straightforward problem--that of replacing the entire missing part, duplicating mechanically as many normal functions as possible. One below-elbow amputee presents the same problem in terms of functional replacement as any other below-elbow amputee. The same cannot be said for an impaired upper extremity. Specific missing functions must be substituted in the presence of intact anatomy, and the variety of functional losses which one encounters means that design criteria must be correspondingly varied and adapted to each individual patient. I find it somewhat discouraging to realize at times that we can replace a missing extremity and secure a better functional result in some cases than we can get in a paralyzed limb with the orthotic options open to us today.
At a recent orthotic seminar (see below) Dr. G. T. Aitken outlined some work currently being done by the American Academy of Orthopaedic Surgeons Committee on Orthotics and Prosthetics. An attempt is being made to devise a technical analysis form wherein one can diagramrrtaticaily plot the biomechanical losses present in an extremity. Once properly identified, these losses can then be matched against specific components or component systems to substitute for the functions lost. In this way, a more rational and scientific approach to bracing will be achieved. It will also serve to identify areas or functions for which satisfactory components are not presently available, and thus become the basis for future design. In addition, it is hoped that such a systematic approach to the problem of bracing will be a valuable teaching tool for physicians and orthotists alike, and serve as a common meeting ground upon which to work out specific problems in bracing. It would also have important repercussions insofar as brace prescription is concerned, requiring that the appliance be prescribed not as a "short-leg brace" or a "long-leg brace" but as a component system to accurately replace the functional loss. This type of basic approach is a small but necessary step in an effort to organize our thinking about the orthotic problem.
Last December, the University of Miami presented a three-day seminar on current concepts and research in orthotics. It was well attended and well received. Interest in this subject is high and additional such seminars are planned.
Milwaukee Brace Modification
At the suggestion of Dr. John Moe and his group in Minneapolis, who originated the idea, we have been using a thermoplastic material as a substitute for leather in making the pelvic girdle of the Milwaukee brace. It has proven so satisfactory that we now regard its use as routine. The chief advantage is the amount of time saved in brace fabrication and a corresponding decrease in cost. This modification is particularly applicable to the young child who will require frequent new braces with growth. It is well tolerated, and we believe a more accurate "total contact" type of fit is obtained, resulting in increased comfort. The material stands up well and retains its shape. The only disadvantage is that it will tend to lose its shape if exposed to extremely hot temperatures. Patients are warned not to leave the brace in the car with the windows rolled up on a hot day while swimming. This disadvantage, however, is more than offset by the advantage of being able to heat the girdle locally to provide simple and quick relief for any pressure areas over bony prominences, without having to replace the entire pelvic portion. The material is commercially available, and is formed over a positive body mold just as the leather girdle is, but with far less time and effort. The completed brace is shown in Fig. 1 and 2 .
Recently we have developed and are using a lightweight single upright brace for protection of the hemophiliac knee. One of the disadvantages of the double-upright long-leg brace in hemophilia is the contusion on the opposite limb, often caused by the medial upright. By using wide thigh and calf cuffs made from plastic laminate and extending the plastic over a considerable distance on the lateral upright, we have been able to impart sufficient strength to this bar and thus eliminate the medial upright (Fig. 3 and 4 ). More recently, we have used a rigid thermoplastic material riveted to the lateral upright instead of plastic laminate. This material makes a lighter brace, is more cosmetic, and has better patient acceptance.
Cartilage Necrosis Following Slipped Capital Femoral Epiphysis
One of the most severe and disabling sequela from slipped capital femoral epiphysis is necrosis or degeneration of the articular cartilage of the hip joint. Its etiology remains obscure. It appears to be more common in the Negro race. It may occur with or without internal fixation of the slipped epiphysis. It is characterized by progressive loss of joint space in the involved hip, and may or may not be associated with aseptic necrosis of the femoral head. The treatment of this condition is nonoperative, and includes removal from weight bearing, traction initially, and physical therapy (Hubbard tank, active assistive exercises). The joint changes are reversible to a degree, and may be completely reversible. A recent case in a 14-year-old Negro male with bilateral cartilage necrosis of the hips of severe degree is illustrated in Fig. 5 . This patient was admitted to the hospital in April, 1969, with severe flexion, abduction and internal rotation limitations of both hips. His treatment involved three months at bed rest with traction, followed by physical therapy. Then he was discharged in bilateral ischial weight-bearing braces. The improvement in the radiological appearance of his hip joints over a four-month period can be noted in Fig. 6 . His range of motion has more than doubled.
The type of ischial weight-bearing braces he is presently wearing (Fig. 7 and 8 ) is of the trilateral socket, single-upright type described originally by Tachdjian and Jouett for the treatment of Legg-Perthes disease. The single upright in abduction eliminates, in part, uncomfortable crotch pressure which would be the case with bilateral conventional ischial weight-bearing braces, and in addition, unloading of the hip joint is more efficient with the trilateral type socket as opposed to the ischial ring. The upright has been reinforced with right-angle steel and by a cable span across the knee joint (Fig. 9 ).
Brace for Recurvatum of the Knee
A great advance in bracing for recurvatum of the knee has resulted from the use of a short-leg brace with a 90-deg. plantar stop and a pre-tibial supracondylar shell. This eliminates the necessity for a long-leg brace in the treatment of this deformity (Fig. 10 , Fig. 11 , and Fig. 12 ). It is extremely effective, even in severe degrees of recurvatum, whether from spastic or flaccid paralysis, and the patient is spared the inconvenience of a knee lock. We claim no originality for the idea. This type of brace has been previously reported by the Rancho Los Amigos group for treatment of recurvatum of the knee in stroke patients.
Mr. H. R. Lehneis at the orthotic facility of New York University originally designed an appliance consisting of only the laminate shell, without the uprights. We have found that in more severe degrees of recurvatum the uprights are necessary.
Newton C. Mc Collough, III, M.D is the Assistant Professor of Orthopaedics at the University of Miami School of Medicine