Fairbank's changes
-  Fairbanks disease
-  Fat embolism
-  Femoral fracture
-  Femoral head ostectomy
-  Fibrocartilage callus
-  Fibrocartilage
-  Fibrosarcoma
-  Fibrous dysplasia of bone
-  Fibrous joint
-  Fibular fracture
-  Ficat classification
-  Finkelstein's test
-  Fixation (surgical)
-  Flat bone
-  Flat feet
-  Flexion teardrop fracture
-  Foot drop
-  Foot fracture
-  Forearm fracture
-  Frankel's sign
-  Freiberg disease
-  Froment's sign
-  Frykman classification


Gaenslen's test
-  Galeazzi fracture
-  Galeazzi test
-  Gamekeeper's thumb
-  Garden classification
-  Garre's sclerosing osteomyelitis
-  Gartland classification
-  Genu recurvatum
-  Genu valgum
-  Genu varum
-  Gerber's test
-  Gerdy's tubercle
-  Geriatric trauma
-  Giant-cell tumor of bone
-  Gigli saw
-  Gilula's Lines
-  Girdlestone's Procedure
-  Gorham's disease
-  Gosselin fracture
-  Greenstick fracture
-  Grosse-Kempf nail
-  Gruen zone
-  Gustilo open fracture classification
-  Guyon's Canal


Haglund's deformity
-  Hajdu–Cheney syndrome
-  Hallux rigidus
-  Hallux valgus
-  Hallux varus
-  Hammer toe
-  Hand deformity
-  Hand fracture
-  Hand of benediction
-  Hand surgery
-  Hangman's fracture
-  Haruguchi classification
-  Hardinge lateral approach to the hip
-  Harrington rod
-  Harris Hip Score
-  Harris lines
-  Harrison's groove
-  Haversian canal
-  Hawkin's classification
-  Hawkins-Kennedy test
-  Heberden's node
-  Hemarthrosis
-  Hematoma
-  Hemimelia
-  Herbert classification
-  Herbert screw
-  Herscovici classification
-  High ankle sprain
-  High tibial osteotomy
-  Hilgenreiner's line
-  Hill–Sachs lesion
-  Hip dysplasia (human)
-  Hip examination
-  Hip fracture
-  Hip replacement
-  Hip resurfacing
-  Hip spica cast
-  Hoffa fracture
-  Holdsworth fracture
-  Holstein–Lewis fracture
-  Hubscher's maneuver
-  Hueter-Volkmann law
-  Human musculoskeletal system
-  Hume fracture
-  Hume fracture
-  Humerus fracture
-  Humphrey's ligament
-  Hyaline cartilage
-  Hydroxylapatite
-  Hyperostosis
-  Hypertrophic pulmonary osteoarthropathy


Ideberg classification
-  Ilizarov apparatus
-  Infantile cortical hyperostosis
-  Injury Severity Score
-  Internal fixation
-  Intervertebral disc annuloplasty
-  Intervertebral disc arthroplasty
-  Intramedullary rod
-  Intramembranous ossification
-  Involucrum
-  Irregular bone
-  Iselin's disease


Jansen's metaphyseal chondrodysplasia
-  Jefferson fracture
-  Jobe's test
-  Joint dislocation
-  Joint locking (symptom)
-  Joint replacement
-  Joint replacement registry
-  Joint stiffness
-  Joint
-  Jones fracture
-  Juvenile osteoporosis


Kanavel's cardinal signs
-  Kapandji score
-  Kashin–Beck disease
-  Keller procedure
-  Kellgren-Lawrence grading scale
-  Khyphoplasty
-  Kienbock's disease
-  Kirschner wire
-  Klein's line
-  Klippel–Feil syndrome
-  Klippel–Trénaunay–Weber syndrome
-  Knee cartilage replacement therapy
-  Knee examination
-  Knee replacement
-  Kniest dysplasia
-  Kocher criteria
-  Kocher manoeuvre
-  Köhler disease
-  Krukenberg procedure
-  Kuntscher nail


Lachman test
-  Larrey's sign
-  Larsen syndrome
-  Lasègue's sign
-  Latarjet procedure
-  Lauge-Hansen classification
-  Legg–Calvé–Perthes syndrome
-  Ligamentous laxity
-  Limb lengthening methods
-  Lisfranc fracture
-  Lisfranc joint
-  Lisfranc ligament
-  List of orthopedic implants
-  Lister's tubercle
-  Lobstein syndrome
-  Loder classification
-  Long bone
-  Loosers zone
-  Lunotriquetral shear test
-  Luxating patella


Madelung's deformity
-  Maffucci syndrome
-  Maisonneuve fracture
-  Major trauma
-  Malgaigne's fracture
-  Malunion
-  March fracture
-  Marfan syndrome
-  Marie-Strümpell disease
-  Marshall syndrome
-  Marshall–Smith syndrome
-  Martin-Gruber Anastomosis
-  Mayfield classification
-  McCune–Albright syndrome
-  McMurray test
-  Medullary cavity
-  Melnick–Needles syndrome
-  Melorheostosis
-  Mesenchymal chondrosarcoma
-  Metaphysis
-  Metatarsophalangeal joint sprain
-  Microfracture surgery
-  Milch classification
-  Mirel's Score
-  Monostotic fibrous dysplasia
-  Monteggia fracture
-  Moore or Southern posterior approach to the hip
-  Moore's fracture
-  Moore's pin
-  Morton's neuroma
-  Morton's toe
-  Mulder's sign
-  Müller AO Classification of fractures
-  Multiple epiphyseal dysplasia
-  Mumford procedure
-  Musculoskeletal injury
-  Myxoid chondrosarcoma


National hip fracture database
-  Neer classification
-  Neer impingement sign
-  Neer's prosthesis
-  Nonossifying fibroma
-  Nonunion
-  Nonunion of fracture
-  Nursemaid's elbow


O'Brien's test
-  Ober's test
-  Oligodactyly
-  Ollier disease
-  Orthopaedic pathology
-  Orthopaedic procedure
-  Orthopedic cast
-  Orthopedic plaster casts
-  Orthopedic plates
-  Orthopedic surgery
-  Orthotics
-  Ortolani test
-  Ortolani test
-  Osgood–Schlatter disease
-  Osseointegration
-  Osseous tissue
-  Ossification center
-  Ossification
-  Ostectomy
-  Osteitis fibrosa cystica
-  Osteitis
-  Osteoarthritis
-  Osteoblast
-  Osteoblastoma
-  Osteochondritis dissecans
-  Osteochondritis
-  Osteochondrodysplasia
-  Osteochondroma
-  Osteochondromatosis
-  Osteochondrosis
-  Osteoclast
-  Osteocyte
-  Osteofibrous dysplasia
-  Osteogenesis imperfecta
-  Osteoid osteoma
-  Osteoid
-  Osteolysis
-  Osteoma
-  Osteomalacia
-  Osteomyelitis
-  Osteon
-  Osteopetrosis
-  Osteophyte
-  Osteoporosis
-  Osteosarcoma
-  Osteosclerosis
-  Osteostimulation
-  Osteotomy


Paget's disease of bone
-  Panner disease
-  Patella alta
-  Patella baja
-  Patella fracture
-  Patellar dislocation
-  Patellar tendon rupture
-  Pathologic fracture
-  Patrick's test
-  Patrick's test
-  Pauwel's angle
-  Pauwel's classification
-  Pectus carinatum
-  Pectus excavatum
-  Pediatric trauma
-  Pelvic fracture
-  Penetrating trauma
-  Perichondrium
-  Periosteal reaction
-  Periosteum
-  Periostitis
-  Perkin's line
-  Perthes Lesion
-  Pes cavus
-  Phalen maneuver
-  Phocomelia
-  Physical therapy
-  Pigeon toe
-  Pigmented villonodular synovitis
-  Pilon fracture
-  Pipkin classification
-  Pipkin fracture-dislocation
-  Pivot-shift test
-  Plafond fracture
-  Polydactyly
-  Polyostotic fibrous dysplasia
-  Polytrauma
-  Ponseti method
-  Porotic hyperostosis
-  Pott's fracture
-  Preiser disease
-  Proteus syndrome
-  Protrusio acetabuli
-  Pseudarthrosis
-  Pulled hamstring
-  Pycnodysostosis
-  Pyogenic osteomyelitis


Quadriceps tendon rupture


Radius fracture
-  Rapadilino syndrome
-  Reduction (orthopedic surgery)
-  Resuscitation
-  Resuscitative thoracotomy
-  Rett syndrome
-  Revised Trauma Score
-  Rib fracture
-  Rickets
-  Rocker bottom foot
-  Rolando fracture
-  Rotationplasty
-  Rotator cuff tear
-  Rowe Score
-  Rubinstein–Taybi syndrome
-  Ruedi-Allgower classification
-  Rush nail


Sacralization of the fifth lumbar vertebra
-  Salter–Harris fracture
-  Sanders classification
-  Sarcoma
-  Scaphoid fracture
-  Scapular fracture
-  Schenck classification
-  Scheuermann's disease
-  Schmorl's nodes
-  Schober's test
-  Schwartz–Jampel syndrome
-  Scoliosis
-  Seddon classification
-  Segond fracture
-  Seidel nail
-  Seinsheimer classification
-  Separated shoulder
-  Sequestrum
-  Sesamoid bone
-  Sesamoiditis
-  Sever's disease
-  Shenton's Line
-  Shepherd's fracture
-  Shin splints
-  Short bone
-  Shoulder examination
-  Shoulder fracture
-  Shoulder replacement
-  Shoulder surgery
-  Silver–Russell syndrome
-  Simmonds' test
-  Skeletal fluorosis
-  SLAP tear
-  Slipped capital femoral epiphysis
-  Slipped Upper Femoral Epiphysis
-  Smith Peterson nail
-  Smith-Petersen anterior approach to the hip
-  Smith's fracture
-  Soft tissue injury
-  Southwick angle
-  Speed's test
-  Spina bifida occulta
-  Spinal curvature
-  Spinal fracture
-  Spinal fusion
-  Spiral fracture
-  Splint (medicine)
-  Spondylolisthesis
-  Sports injury
-  Sprained ankle
-  Sprengel's deformity
-  Steinmann pin
-  Stener lesion
-  Sternal fracture
-  Stieda fracture
-  Straight leg raise
-  Stress fracture
-  Subacromial bursitis
-  Sudeck's atrophy
-  Sulcoplasty
-  Supracondylar fracture
-  Swan neck deformity
-  Swanson prosthesis
-  Swanson's arthroplasty
-  Symphysis
-  Synchondrosis
-  Syndactyly
-  Syndesmosis
-  Synovectomy
-  Synovial fluid
-  Synovial joint


Talipes equinovarus
-  Talwalkar nail
-  Taylor Spatial Frame
-  Tear of meniscus
-  Teisen classification
-  Tendon transfer
-  Tension band wiring
-  Teunissen–Cremers syndrome
-  Thomas test
-  Thompson and Epstein classification
-  Thompson test
-  Thurstan Holland sign
-  Tibia fracture
-  Tibial plateau fracture
-  Tietze syndrome
-  Tile classification
-  Tillaux-Chaput avulsion fracture
-  Tinel sign
-  Toddler's fracture
-  Tommy John surgery
-  Trabecula
-  Traction (orthopedics)
-  Traction splint
-  Trauma center
-  Trauma surgery
-  Trauma team
-  Traumatology
-  Trendelenburg gait
-  Trendelenburg's sign
-  Trethowan's sign
-  Trevor's disease
-  Triage
-  Trimalleolar fracture
-  Triple arthrodesis
-  Tscherne classification
-  Tumoral calcinosis


Ulnar fracture
-  Unhappy triad
-  Unicompartmental knee arthroplasty
-  Upington disease


Valgus deformity
-  Valgus stress test
-  Vancouver classification
-  Varus deformity
-  Vertebral osteomyelitis
-  Villonodular synovitis
-  Volkmann's canals
-  Volkmann's contracture
-  Volkmann avulsion fracture


Waddell's signs
-  Wagstaffe-Le Fort avulsion fracture
-  Wallis–Zieff–Goldblatt syndrome
-  Wassel classification
-  Watson-Jones anterolateral approach to the hip
-  Watson's test
-  Weaver–Dunn procedure
-  Webbed toes
-  Wedge fracture
-  Weil's osteotomy
-  Wilson test
-  Winged scapula
-  Wolff's law
-  WOMAC
-  Wound healing
-  Wrist drop
-  Wrist osteoarthritis


Yergason's test
-  Young-Burgess classification


Zadek's procedure


James H-C. Wang  is a Chinese American orthopedic biomechanist and  academic . Currently, he is a  Professor  at the Departments of  Orthopaedic Surgery ,  Bioengineering , and PM&R at the  University of Pittsburgh . [ 1 ]  In addition, he is a Faculty Member at the  McGowan Institute for Regenerative Medicine . [ 2 ]


Wang is most known for his work on tissue biomechanics,  tissue engineering , and cell  mechanobiology . [ 3 ]


Wang is a Fellow of the International Orthopaedic Research (FIOR), and  American Institute for Medical and Biological Engineering  (AIMBE). [ 4 ]


Wang completed his  Bachelor of Science  in Engineering Mechanics in 1982 and  Master of Science  in Experimental Biomechanics in 1989 from  Tongji University . Later in 1996, he obtained  PhD  in  Bioengineering  from the  University of Cincinnati  in the US. [ 1 ]


In 1982, Wang joined Tongji University as an Assistant Instructor in the Department of Engineering Mechanics. After moving to USA, he finished his PhD at the University of Cincinnati and later completed postdoctoral training in  Biomedical Engineering  at  Johns Hopkins School of Medicine  and  Washington University in St. Louis . After his postdoctoral training, he joined the  University of Pittsburgh  in 1998, where he was  Assistant Professor  at the Department of Orthopaedic Surgery from 1998 to 2005. Subsequently, he held the position of tenured  Associate Professor  at the Department of Orthopaedic Surgery and associate professor at the Departments of Bioengineering,  Mechanical Engineering  and  Materials Science , and PM&R between 2005 and 2012. Since 2012, he has been serving as Professor at the Department of Orthopaedic Surgery and also Professor at the Departments of Bioengineering and PM&R. [ 1 ] [ 2 ]


In 2017, he was appointed  Vice Chair  of Research at the Department of Orthopaedic Surgery at the University of Pittsburgh. Since 2004, he has been the Director of the MechanoBiology Laboratory in the same department. [ 2 ]


At the University of Pittsburgh, Wang has developed a research program in cell mechanobiology, which particularly focuses on the role of tendon cells in the development of  tendinopathy . He has been consistently receiving substantial funding support from  NIH  and  NSF . Additionally, he has been awarded research grants from DOD for several projects that aim to develop practical and clinically actionable strategies for the prevention and treatment of tendinopathy. He has authored numerous publications spanning the areas of tissue biomechanics, tissue engineering, and cell mechanobiology. [ 3 ]


To understand the inflammatory and degenerative responses of tendon due to overuse injury, Wang's group has established a validated animal model of tendinopathy by using mouse treadmill running that mimic human tendinopathy development. Additionally, his work emphasized the role of HMGB1 as a pivotal molecule in mechanically induced tendinopathy and proposed glycyrrhizin and metformin as potential therapeutic agents to inhibit HMGB1 activity, thereby offering preventive and treatment options for tendinopathy. [ 5 ] [ 6 ]


Wang's research team has also worked on the identification and characterization of tendon stem cells (TSCs) in humans, mice, rats, and rabbits. [ 7 ]  Wang's tendon stem cell research has focused on the effects of different mechanical loading conditions on TSC growth and differentiation. [ 8 ]  Focusing on TSCs, his work highlighted the role of  TSC mechanobiology in tendon homeostasis as well as the development of degenerative tendinopathy. [ 8 ] [ 9 ]  His group showed that in normal conditions, the multi-differentiation potential of TSCs allows these stem cells to differentiate into tenocytes; however, under high stress and injurious conditions TSCs can undergo aberrant differentiation into adipocytes, chondrocytes, and osteocytes. Wang's team has established the beneficial effects of modest exercise on tendons via moderate treadmill running by the virtue of its effect in enhancing the function of TSCs resulting in the formation of normal-like tendon tissue at the site of injury. [ 10 ] [ 11 ]  In their examination of treatment options for tendon injuries, [ 12 ]  his group has provided insights into the application of biologics such as PRP [ 13 ]  for the effective treatment of tendon injuries. [ 14 ]


Wang also focuses his research on tissue engineering. His approach to regenerate tendons after injury includes the use of PRP. His group showed that PRP with minimal leukocytes, known as pure-PRP (P-PRP), induces TSC differentiation into active tenocytes. These tenocytes produce abundant collagens, enabling P-PRP to effectively repair tendon injuries. His team demonstrated that the combined application of kartogenin and PRP effectively enhanced the formation of a fibrocartilage region connecting the tendon graft and bone interface, thereby improving the biomechanical strength of the tendon-bone junction. [ 15 ]


The  management of scoliosis  is complex and is determined primarily by the type of scoliosis encountered: syndromic, congenital, neuromuscular, or idiopathic. [ 1 ]  Treatment options for idiopathic scoliosis are determined in part by the severity of the curvature and  skeletal maturity , which together help predict the likelihood of progression. Non-surgical treatment (conservative treatment) should be pro-active with intervention performed early as "Best results were obtained in 10-25 degrees scoliosis which is a good indication to start therapy before more structural changes within the spine establish." [ 2 ]  Treatment options have historically been categorized under the following types:


For adults, treatment usually focuses on relieving any pain, [ 3 ] [ 4 ]  while physiotherapy and braces usually play only a minor role. [ 5 ]


Treatment for idiopathic  scoliosis  also depends upon the severity of the curvature, the spine’s potential for further growth, and the risk that the curvature will progress.


Mild scoliosis (less than 30 degrees deviation) has traditionally been treated through observation only. [ 7 ]  However, the progression of adolescent idiopathic scoliosis has been linked to rapid growth, [ 8 ]  suggesting that observation alone is inadequate as progression can rapidly occur during the pubertal growth spurt. Another study has further shown that the peak rate of growth during puberty can actually be higher in individuals with scoliosis than those without, further exacerbating the issue of rapid worsening of the scoliosis curves. [ 8 ]  Moderately severe scoliosis (30–45 degrees) in a child who is still growing requires bracing. A 2013 study by Weinstein et al. [ 9 ]  found that rigid bracing significantly reduces worsening of curves in the 20-45 degree range and found that 58% of children receiving "observation only" progressed to surgical range. Recent guidelines [ 10 ]  published by the Scientific Society of Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) in 2016 state that “the use of a brace is recommended in patients with evolutive idiopathic scoliosis above 25º during growth” based on a review of current scientific literature. Severe curvatures that rapidly progress may be treated surgically with spinal rod placement. Thus, early detection and early intervention prior to the pubertal growth spurt provides the greatest correction and prevention of progression to surgical range. [ 11 ]  In all cases, early intervention offers the best results. A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. [ 12 ]


Physical therapists  and  occupational therapists  help those who have experienced an injury or illness regain or maintain the ability to participate in everyday activities. For those with scoliosis, a physical therapist and/or occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition. This helps them manage physical symptoms and/or use compensatory techniques so that they can participate in  daily activities  like self-care, productivity, and leisure.


One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. [ 13 ]  Studies demonstrate that preventing force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, [ 14 ]  while other studies have also shown that braces can be used by individuals with scoliosis during physical activities. [ 15 ]  It is important to note that scoliosis is not merely a lateral or sideways deformity, but occurs in three dimensions [ 16 ]  as a rotational component is often present.


Other interventions include postural strategies, such as posture training in sitting, standing, and sleeping positions, and in using positioning supports such as pillows, wedges, rolls, and corsets. [ 17 ]


Adaptive and compensatory strategies are also employed to help facilitate individuals to returning daily activities.


Scoliosis specific exercises have been found to improve treatment outcomes when utilized in addition to bracing and other standards of care. [ 18 ]  Scoliosis specific exercises include methods such as Schroth [ 19 ]  which specifically aim to correct aesthetic differences and strengthened muscles and connective tissue that may have atrophied as a result of scoliosis and asymmetric posture. Schroth exercises and other scoliosis specific exercises should be utilized in conjunction with bracing and other standards of care, [ 20 ]  and be performed under the guidance of a trained professional to ensure the exercises are effective and target the individual's curve pattern so that the correct muscles are strengthened. Strengthening spinal  muscles  is a crucial preventive measure. This is because the muscles in the back are essential when it comes to supporting the  spinal column  and maintaining the spine's proper shape.  Exercises  that will help improve the strength of the muscles in the back include rows and leg and arm extensions. [ 21 ]  Elastic  resistance exercise  may also be able to sustain the progression of  spinal curvature . [ 22 ]  This type of exercise is able to sustain progression by equalizing the strength of the torso muscles found on each side of the body.


Disability caused by scoliosis, as well as physical limitations during recovery from treatment-related surgery, often affects an individual’s ability to perform  self-care  activities. [ 23 ]  One of the first treatments of scoliosis is the attempt to prevent further curvature of the spine. Depending on the size of the curvature, this is typically done in one of three ways: bracing, surgery, or postural positioning through customized cushioning. [ 23 ] [ 24 ] [ 25 ]  Stopping the progression of the scoliosis can prevent the loss of function in many  activities of daily living  by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting.


Occupational therapists  are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms. [ 23 ]


For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of  occupational therapy  treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. [ 26 ]   For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist self-dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes.


Productive activities include paid or  unpaid work , household chores, school, and play. [ 27 ]  Recent studies in healthcare have led to the development of a variety of treatments to assist in the management of scoliosis thereby maximizing productivity for people of all ages.  Assistive technology  has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. [ 28 ]  As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life. [ 27 ]


A common assistive technology intervention is specialized seating and postural control. For children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. [ 29 ]  A child's well-being in a productive sense involves the ability to participate in classroom and play activities. [ 27 ]  Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with  muscular dystrophy . [ 30 ]


With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position 20° forward (toward the thighs), seating pressure is significantly redistributed, so sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward-sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. An open hip angle can benefit the used lung volume and respiration. [ 31 ] [ 32 ]


For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces.


Physical symptoms such as chest pains, back pains, shortness of breath, and limited spinal movement can hamper or preclude participation in leisure activities of a physical nature. The occupational therapist's role is to facilitate participation by helping the patient manage these symptoms.


Bracing is a common strategy recommended by an occupational therapist, in particular, for individuals engaging in sports and exercise. [ 15 ]  An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace.


To help a person manage heart and lung symptoms, such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. [ 26 ]  This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy.  Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. [ 26 ]  Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An occupational therapist and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing.


Bracing is most effective when the patient has bone growth remaining (is skeletally immature) and should aim to both prevent progression of the curve (prevent progression to surgery), as well as reduce the scoliosis curve. Reduction of the curve is important as the natural history of idiopathic scoliosis suggests it can continue to progress at a rate ~1 degree per year in adulthood, [ 33 ]  while the treatment results of bracing have been shown to hold over >15 years. [ 34 ]  In some cases with juveniles, bracing has reduced curves significantly, going from a 40 degrees (of the curve, mentioned in length above.) out of the brace to 18 degrees in it. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers the torso; in some cases, it extends to the neck. The most commonly used brace is a  TLSO , such as a  Cheneau type brace , a  corset -like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is worn upwards of 18–23 hours a day, depending on the doctor's prescription, and applies pressure on the curves in the spine. The effectiveness of the brace depends not only on brace design and  orthotist  skill; patient compliance; and amount of wear per day, but also the "stiffness" of the spine resulting from a shortened spinal cord [ 35 ] [ 36 ]  and/or nerve tension. [ 37 ]  as evidence by the force necessary (mean force ~121 lbs) to physically correct scoliosis during spinal surgery [ 38 ]
The typical use of braces for idiopathic scoliosis is to prevent progression to surgical range as well as reduce the scoliotic curve of the spine as spinal fusion surgery can reduce mobility due to fusion of the vertebrate while potentially increasing pain long term. [ 39 ]  For non-idiopathic scoliosis (ie. neuromuscular, congenital, etc.) and those with additional comorbidities (ie.  Marfans Syndrome ) spinal surgery may be required due to structural changes in the spine.


Indications for Scoliosis Bracing:  Scoliosis professionals determine the proper bracing method for a patient after a complete clinical evaluation. The patient’s growth potential, age, maturity, and scoliosis (Cobb angle, rotation, and sagittal profile) are also considered. Immature patients who present with Cobb angles less than 20 degrees should be closely monitored and proactively treated based on their risk of progression [ 40 ]  as surgery can be prevented with early intervention of conservative treatment. [ 41 ]  Immature patients who present with Cobb angles of 20 degrees to 29 degrees should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. Immature patients who present with Cobb angles greater than 30 degrees should be braced. However, these are guidelines and not every patient will fit into this table. For example, an immature patient with a 17-degree Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29-degree Cobb angle and a Risser sign three or four might not need to be braced because there is reduced potential for progression. [ 42 ]


Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45 degrees to 50 degrees [ 10 ]  and by the Scoliosis Research Society (SRS) at a Cobb angle of 45 degrees. [ 43 ]  SOSORT uses the 45-degree to 50-degree threshold as a result of the well-documented, plus or minus five degrees measurement error that can occur while measuring Cobb angles.


Scoliosis braces are usually comfortable for the patient, especially when it is well designed and fit; also after the 7- to 10-day break-in period.  A well fit and functioning scoliosis brace provides comfort when it is supporting the deformity and redirecting the body into a more corrected and normal physiological position. [ 44 ]


The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°,  Risser sign  0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. [ 45 ]


Progressive scolioses exceeding 25° Cobb angle in the pubertal growth spurt should be treated with a pattern-specific brace like the Chêneau brace and its derivatives, with an average brace-wearing time of 16 hours/day (23 hours/day assures the best possible result).


The latest standard of brace construction is with CAD/CAM technology. With the help of this technology, it has been possible to standardize the pattern-specific brace treatment. Severe mistakes in brace construction are largely ruled out with the help of these systems. This technology also eliminates the need to make a plaster cast for brace construction. The measurements can be taken in any place and are simple (and not comparable to plastering). Available CAD/CAM braces include the Regnier-Chêneau brace, the Rigo-System-Chêneau-brace (RSC brace), the Silicon Valley Brace, and the Gensingen brace; braces can and should be customized to fit the individual's curve pattern and reduce the curve as much as possible as immediate in-brace correction has been shown to be associated with better treatment outcomes. [ 46 ] [ 47 ]  Many patients prefer the "Chêneau light" brace as it has good in-brace corrections reported in international literature and is easier to wear than other braces in use today. [ 48 ] [ 49 ]  However, this brace is not available for all curve patterns.


Prior to 2013 the efficacy of bracing has not been definitively demonstrated in randomised clinical studies, with more limited studies giving inconsistent conclusions. [ 50 ]  In 2013 the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST) published results establishing benefits of bracing in adolescents with idiopathic scoliosis. In the randomized cohort, 72% in the group instructed to wear a brace for 18 hours per day against 48% in the observation group sustained curve progression to under 50 degrees, the proxy used for not requiring surgery. Additionally results suggested that the more a patient wore the brace, the better the result. [ 51 ] [ 52 ]


In progressive infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible [ 53 ]  to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and work with their growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. [ 54 ]  EDF casting is now the only clinically known nonsurgical method of complete correction in progressive infantile scoliosis. Complete correction may be obtained for curves less than 50° if the treatment begins before the second year of life. [ 55 ] [ 56 ]


Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45 to 50° of magnitude), curves that would be cosmetically unacceptable as an adult, curves in patients with  spina bifida  and  cerebral palsy  that interfere with sitting and care, and curves that affect physiological functions such as breathing. [ citation needed ]


Surgery for scoliosis is performed by a  surgeon  specializing in spine surgery. For various reasons, [ specify ]  it is usually impossible to completely straighten a scoliotic spine, but in most cases, significant corrections are achieved. [ citation needed ]


The two main types of surgery are:


One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, takes four to eight hours. A Cochrane review could not draw conclusions on how effective surgical interventions were when compared to non-surgical interventions in patients with adolescent idiopathic scoliosis. [ 57 ]


Spinal fusion  is the most widely performed surgery for scoliosis. In this procedure, bone [either harvested from elsewhere in the body ( autograft ) or from a donor ( allograft )] is  grafted  to the vertebrae so when they heal, they form one solid bone mass and the  vertebral column  becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the  thoracic  or  abdominal  cavities, or more commonly, performed from the back (posterior). A combination may be used in more severe cases, though the modern pedicle screw system has largely negated the need for this. [ 50 ]


In recent years all-screw systems have become the gold-standard technique for adolescent idiopathic scoliosis.  Pedicle  screws achieve better fixation of the  vertebral column  and have better biomechanical properties than previous techniques, so enabling greater correction of the curve in all planes. [ 50 ]


Pedicle screw-only  posterior spinal fusion  may improve major curve correction at two years among patients with adolescent idiopathic scoliosis (AIS) [ 50 ]  as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a  retrospective, matched-cohort study . [ 58 ]  The prospective cohorts were matched to the retrospective cohorts according to patient age, fusion levels, Lenke curve type, and operative method. The two groups were not significantly different in regard to age, Lenke AIS curve type, or Riser grade. The numbers of fused vertebrae were significantly different (11.7±1.6 for pedicle screw versus 13.0±1.2 for hybrid group). This study's results may be biased due to the pedicle screw group's being analyzed prospectively versus retrospective analysis of the hybrid instrumentation group.


In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. However a systematic review of  PubMed  papers in 2008 concluded "Scoliosis surgery has a varying but high rate of complications", although the non-standardised data on complications was difficult to assess and was incomplete. [ 59 ]  Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age. [ 60 ]


A complementary surgical procedure a surgeon may recommend is called thoracoplasty (also called costoplasty). This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve. A rib hump is evidence of some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery, entirely.


Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back straight.


Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10–15% is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is the surgeon might inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity,  hemothorax  or  pneumothorax , respectively. [ 61 ]


Implants that aim to delay spinal fusion and to allow more spinal growth in young children is the gold standard for surgical treatment of early onset scoliosis. Surgery without fusion can be divided into three principles: distraction of the entire spine, compression of the short segment of spine, and guided-growth techniques. Distraction-based systems include Vertical, Expandable Prosthetic Titanium Ribs (VEPTR) & growing rods. The concept uses distraction to create additional soft-tissue space in-between the vertebrae, for the bone to later grow into. Its universal application was thrusted through the use of traditional growth rods which required repeated invasive surgeries every 6–12 months for the sustenance of growth, via distraction. Nowadays developed countries only use MAGEC (MAGnetic Expansion Control) rods to non-invasively lengthen the spine. In contrast, developing and under-developed countries still use traditional growing rods, which require invasive surgery every 6–12 months, because of high initial cost associated with procurement of MAGEC rods. Compression-based system include tethering using a flexible rope-like implant and are relatively new to receive FDA approval. Guided-growth technique include SHILLA (named after a hotel in Korea, where the concept was initiated). SHILLA has the advantage of being one-time surgery and is technologically less demanding compared with MAGEC rod. However, there are still two major disadvantages of using SHILLA: loss of correction and need for osteotomies. [ 62 ] [ 63 ]


The failure of most of these standalone techniques has shown that the concept of “one size fits all” is not applicable for the surgical management of EOS. Therefore, newer concepts employing two or more of the above philosophies, i.e. various combinations of distraction-based, guided-growth, and compression-based approaches might be more suitable and biomechanically-speaking, a more optimal surgical intervention. One such combination currently used for surgery includes  active apex correction (APC) . It is a hybrid of guided-growth and compression-based management of deformity. The technique simply consists of replacing the apical fusion (of traditional SHILLA) with unilateral compression (via pedicle screws or any other means) on the convex side. The latest clinical results presented by spine researchers  Aakash Agarwal  and Alaaedldin Azmi Ahmad on APC shows good clinical results with no economic barrier to use the technology. [ 62 ] [ 64 ] [ 65 ]


The risk of undergoing surgery for scoliosis was estimated in 2008 to be varying, but with a high rate of complications. Possible complications may be inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding and nerve injuries. It is not yet clear what to expect from spine surgery in the long term. [ 66 ] [ 67 ]  Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains primarily a cosmetic indication [ dubious  –  discuss ] , only especially in patients with adolescent idiopathic scoliosis, the most common form of scoliosis never exceeding 80°. [ 66 ] [ 68 ]  However, the cosmetic effects of surgery are not necessarily stable. [ 66 ]


For spinal fusion surgery on AIS cases, with instrumentation attached using pedicle screws, complication rates were reported in 2011 as transient neurological injuries between 0% to 1.5%, a pedicle fracture rate of 0.24%, screw malposition assessed by radiography at 1.5%, 6% when assessed by CT scans though these patients were asymptomatic not requiring screw revision, and screw loosening noted in 0.76% of patients. [ 50 ]


For surgery without fusion in growing children, substantial percentage of patients undergoing SHILLA technique experience loss of correction via crankshafting or adding-on (eg, distal migration). In addition, the need for osteotomies on the concave side has the potential of severe complications. For MAGEC rods, higher distraction magnitude resulted in the generation of higher distraction forces, and this in combination with off-axis loading (exemplified by “growth marks”) result in wear and breakage of MAGEC rod’s components. [ 69 ] [ 70 ]


In the event of surgery to correct scoliosis, pain medications and  anesthesia  will be administered. Before the surgery, the patient will receive anesthesia. With adults, the anesthesia will be administered through an IV in the antecubital region of the arm. With young children, however, the child will be asked to breathe in  nitrous oxide , or laughing gas. Because needles can be frightening for a young child, the nitrous oxide will put them to sleep so the  anesthesiologist  can then insert the IV in order to give them the anesthesia. After the surgery, the patient will most likely be given  morphine . Until the patient is ready to take the medicine by mouth, an IV will be giving them their medication. Morphine is the most common pain medicine used after scoliosis surgery, and is often administered through a  patient-controlled analgesia  (PCA) system.  The PCA system allows the patient to push a button when they are feeling pain, and the PCA will emit the drugs into the IV and then into the body.  To prevent overdoses, there is a limit on the number of times a patient can push the button. If a patient pushes the button too much at once, the PCA will reject the request. [ 71 ]


For the patient's bladder control, a  catheter  will be inserted so that a patient can urinate without having to move. A catheter is inserted because the patient will not have much free movement to be able to get up and walk to the bathroom. The most common type of catheter used after major surgeries is an indwelling  Foley catheter . The indwelling Foley catheter is most often put in the  urethra , with a tube leading into a drainage bag. Once the catheter is inserted into the urethra, a balloon is blown up inside the bladder in order to keep it from falling out. The balloon allows the catheter to remain inside the urethra until the patient is able to get up and go to the bathroom on their own. [ 72 ]  The drainage bag is connected to the side of the bed, and must be changed or emptied out once it is full.


Bowel control can vary from patient to patient. The combination of no food, very little fluids, and a lot of  prescription drugs  has the potential to cause many patients to become constipated. The body is used to a normal diet, and used to excreting waste in a system. Interrupting the system can cause bowel problems. This  constipation  can be resolved in a couple of ways. The first way, and the most common way, is to administer a  rectal suppository . A rectal suppository is administered through the  anus , and into the  rectum . They are bullet-shaped and contain medicine that will help the patient's bowels get back on track. Once the suppository is inserted, it is designed to melt off the wax-like case, and put the medicine in the body. [ 73 ]  If the suppository does not work, a laxative may be continued at home to keep the bowels in full function.


When first returning home after surgery, a nutritional diet is necessary in order to keep the body operating correctly. Junk food is not a good idea, as the grease and sugar can irregulate the bowels. Fruit, vegetables, and juices will be a vital part in the diet. [ 74 ]  Food and drink will be limited for the patient after surgery. Because the bowels are not fully active because of anesthetic, clear water and ice may be the only acceptable thing to ingest. After the digestive tract is back up to speed, soft food and drink like pudding, soup broth, and orange juice are acceptable. [ 75 ]  Very dark urine with a strong odor means that the person is most likely dehydrated and needs more fluids. In order for the urine to become a pale or clear color, the patient will need to drink a lot of water. Juices such as prune juice are a healthy option and prune juice also helps with constipation, a common factor after surgery. When it comes to food, whole grains should be added into the diet. Whole grains can be broken down easily by the body whereas processed grains and flour cannot be broken down easily. Processed grains and flour also add to  constipation . [ 76 ]


In 1962,  Paul Harrington  introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The original (now obsolete)  Harrington rod  operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. The Harrington rod represented a major advance in the field, as it obviated the need for prolonged casting, allowing patients greater mobility in the postoperative period and significantly reducing the quality of life burden of fusion surgery. Additionally, as the first system to apply instrumentation directly to the spine, the Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming of the Harrington method was it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early-onset arthritis, disc degeneration, muscular stiffness, and pain with eventual reliance on painkillers, further surgery, inability to work full-time, and disability.  "Flatback"  became the medical name for a related complication, especially for those who had lumbar scoliosis. [ 77 ]


In the 1960s, the gold standard for idiopathic scoliosis was a posterior approach using a single Harrington rod. Post-operative recovery involved bed rest, casts, and braces. Poor results became apparent over time. [ 78 ]


In the 1970s, an improved technique was developed using two rods and wires attached at each level of the spine. This segmented instrumentation system allowed patients to become mobile soon after surgery. [ 78 ]


In the 1980s,  Cotrel-Dubousset instrumentation  improved fixation and addressed  sagittal  imbalance and rotational defects unresolved by the Harrington rod system. This technique used multiple hooks with rods to give stronger fixation in three dimensions, usually eliminating the need for post-operative bracing. [ 78 ]


Orthopaedic Nurse, Certified  (ONC) is the designation for an  orthopaedic nurse  who has earned  nursing board certification  from the Orthopaedic Nurses Certification Board (ONCB)


ONBC supports the advancement of health of orthopaedic patients by administering a certificate to the Orthopaedic nurse that improves their knowledge and practice to support patients with orthopaedic conditions or injuries. [ 1 ]


An Orthopaedic nurse is responsible for assessing new patients, monitoring the condition of their current patients, and providing treatments and medication. As part of this role, the nurse also monitors vital signs, assess the surgical sight, provide dressing changes, and notifies the doctor of any changes in the patient's condition. Finally, the Orthopaedic nurse also performs general nursing techniques, such as changing bedpans, assisting the patient with ambulation, maintaining care plans, providing IV medication, and informing and supporting the patient and their families.


The optimal goal for the Orthopaedic nurse is to keep the patient comfortable, which may require turning the patient and providing pain relievers as needed.


The Orthopaedic certification exam contains 150 questions, 135 of which are scored while the other 15 do not affect the test score. 97/135 is needed to pass the exam. Results are hosted by AMP, which is ONCB's test vendor. The ONCB then distributes the results directly to the new certified holder. The ONCB does not distribute the results to individual agencies. [ 2 ]  The exam is usually given in the Fall and Spring and is offered around the United States. To take the certification exam the nurse has to be licensed and have at least 2 years experience but doesn't need a bachelor's degree. Nurses must have 1000 hours of Orthopaedic patient care within the last 3 years. Certification lasts for 5 years, after which recertification or continuing education is required. [ 3 ]


Recertification in Orthopeadic Nursing requires 1000 practice hours logged in an applicant's past 5 years and 100 hours of education: 70 hours in Orthopaedics and 30 hours in general nursing. The application can take 8 weeks to process. Paper applications should be mailed with a return receipt. [ 4 ]


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The  Orthopaedic Research Society  ( ORS ) is a professional, scientific, and medical organization focused on  orthopaedic  research. [ 1 ] [ 2 ]  The stated mission of the ORS is to advance orthopaedic research through education, collaboration, communication, and advocacy. [ 3 ] [ 4 ]  The ORS aims to raise resources for orthopaedic research and increase the awareness of the impact of such research on patients and the public. Annual meetings are held across the US to discuss current research, with a number of  awards  available to further career trajectories of members.


In 1940, the Research Committee of the  American Academy of Orthopaedic Surgeons , chaired by  Alfred R. Shands , [ 5 ]  conducted a survey of its members which indicated that over 180 members were conducting some type of research. [ 6 ]  This finding prompted several  musculoskeletal  investigators to express the desire for having a forum to present and share their work. [ 7 ]   Philip D. Wilson Jr. , a member of the Academy, along with several others, met in San Francisco and proposed the idea of starting an organization focused solely on musculoskeletal research. This idea gained unanimous support from the  American Academy of Orthopaedic Surgeons  at their Annual Meeting in 1951. [ 6 ]


In 1952, the first meeting of the founding members of the ORS took place. At this first meeting,  Philip D. Wilson Jr.  created a draft constitution and set of by-laws for the fledgling society. [ 8 ]   It was determined that the purpose of the society was to "encourage and coordinate investigation and research in basic principles or clinical problems related to the special field of Orthopaedic Surgery." [ 7 ]    Due to the unexpected death of  Dallas B. Phemister , who had agreed to take on the role of chairman, the formal organization of the society was delayed. [ 6 ]


1954 marked the first official meeting of the group at the Palmer House in Chicago under the Chairmanship of Wilson. [ 8 ]   At this first meeting there were twenty-nine people in attendance.  Cultivating the relationship between clinicians and scientists while providing them with opportunities to come together and share ideas was the driving factor in establishing the society. "The close relationship of between clinicians and basic scientists would help ensure the prominent role of orthopaedic surgeons in delivering care to patients with injuries and diseases of the  musculoskeletal system ," explained Eugene R. Mindell, [ 9 ]  MD who served as president of the ORS from 1972–1973. [ 8 ]


As of June 2018 [update] , membership had grown to more than 4,100 members from across the globe. [ 10 ]   Once a role only held by surgeons, in 1982 the ORS elected  Van C. Mow  as the first PhD president.  Currently, Presidents are elected from each of the three disciplines represented in the membership: clinicians, biologists, and engineers.


Past presidents of the ORS have included  Farshid Guilak  and  Marjolein C. van der Meulen .


Members of the ORS conduct cutting-edge research on the full range of musculoskeletal tissues :  bone ,  tendon ,  cartilage  &  synovium ,  meniscus ,  skeletal muscle , and the  intervertebral disc . Researchers focus on all aspects of these tissues, including  development , structure and function, mechanics, diagnostics, injury and healing, and potential therapeutics. Special emphasis is given to pathologies that cause significant morbidity in patients, such as  osteoarthritis ,  osteoporosis ,  osteopenia ,  rheumatoid arthritis ,  fracture healing ,  ACL tears ,  tendinopathies , and  meniscus tears .


More recently a number of research subsections have been formed, starting with the Spine Section in 2015. These small communities bring together like-minded researchers with a focus on a specific topic of research. Since then, the number of sections has expanded to include: International Section of Fracture Repair, Meniscus Section, Orthopaedic Implants Section, Preclinical Models Section, Strategies in Clinical Research Section, and the Tendon Section. Each of these meets annually at the regular meeting, and some have added satellite meetings to create more opportunity for collaboration in their respective field.


The  Journal of Orthopaedic Research  is a peer-reviewed journal that is published in cooperation with  John Wiley & Sons, Inc . [ 11 ]  The journal provides an essential forum for the orthopaedic community to share and communicate new information in the different research areas of orthopaedics, including  life sciences ,  engineering ,  translational  and  clinical studies . [ 11 ]


JOR Spine  is a fully open access and peer-reviewed journal that was established by the ORS. [ 12 ]  The journal provides a platform to share original and innovative information focusing on basic and translational research of the spine. Publications in this journal include the following topics in spine research:  ageing ,  biomaterials ,  biomechanics ,  bioreactors ,  degeneration ,  genetics ,  inflammation ,  pain , remodeling,  tissue engineering , etc.


Coordinated by the ORS Basic Science Education Committee,  On the Horizon  presents brief articles discussing current scientific investigations that may have future orthopaedic clinical applications.
This feature was previously presented quarterly in the  Journal of the American Academy of Orthopaedic Surgeons  (January, April, July, and October), where archived articles remain available.


The ORS is invested in developing partnerships and collaborations dedicated to research, outreach and education worldwide:


LearnORS  is an online platform that offers courses suited for PhD candidates, medical students, postdoctoral fellows, orthopaedic residents, orthopaedic fellows, and industry researchers interested in learning more about orthopaedic research. Courses include those geared towards improving grant writing, basic musculoskeletal science, and clinical research, among others. [ 13 ]


The  Musculoskeletal Knowledge Portal (MSK-KP)  is currently in development by a team of scientists and software engineers at the  Broad Institute  in collaboration with the International Federation of Musculoskeletal Research Societies (IFMRS). The site enables browsing, searching, and analysis of human genomic information associated with musculoskeletal traits and pathology.


ORS Open Door is an outreach activity aimed at communicating orthopaedic/musculoskeletal science to the general public, and takes place during the annual meeting in the local community. Open Door 2023’s target audience was middle school- and high school-aged students from the Dallas area, with the goal of sharing potential careers and topics in musculoskeletal science to under-represented minorities and first-generation students in STEM (science, technology, engineering, mathematics) fields.


Open Door 2024 will be held in Long Beach CA just prior to the annual meeting.


Orthopaedic Studio  is an application designed to help  orthopaedic  specialists perform several common quantitative hip examinations that are based on standard  x-ray images .


The application is implemented as a plugin for the medical image viewer  OsiriX  and thereby only runs on  Mac OS X .


Orthopaedic Studio evaluates four different types of hip  radiographs  (standing anteroposterior, Von Rosen, false profile and frog). On such images a number of standardized angles, offsets and ratios can be measured, including: [ 1 ]


The following visual scores can also be registered:


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OrthoPediatrics  is an American  bio-science  company engaged in designing, developing, manufacturing, and distributing orthopedic  implants  and  instruments  for  pediatric  issues. [ 1 ]  It is based in  Warsaw, Indiana . [ 2 ]


Founded in 2006, OrthoPediatrics is an orthopedic company focused on providing  product offerings to the pediatric  orthopedic  market to improve the lives of children with  orthopedic conditions . [ 3 ] [ 4 ]  They currently market 24 surgical systems spanning trauma and deformity,  scoliosis  and sports medicine among others. [ 3 ] [ 4 ] [ 5 ]  They hold exclusive rights to the Hamann-Todd Human Osteological Collection at the  Cleveland Museum of Natural History . [ 6 ]  The company is dedicated to clinical research and education and licensed its name to establish a  501(c)(3)  public charity focused on advancements in the field of pediatric orthopedics. [ 7 ]


In October 2017, they went public with a common stock of 4,000,000 shares and raised $52 M with $13 per share. [ 8 ] [ 9 ] [ 10 ]


OrthoPediatrics has partnerships with 31 independent distributors selling products to children's hospital in the United States and 34 countries globally.


They signed a license agreement with the Sydney Children's Hospitals Network in 2016 and a partnership agreement with Mighty Oak Medical for FIREFLY Technology in 2017. [ 11 ] [ 12 ]


OrthoPediatrics holds nine patents for bottom loaded pedicle screw, bone screw, graft fixation, bone screw, surgical connectors and instrumentation, pediatric long bone support or fixation plate, pediatric intramedullary nail, compression bone fragment wire, convertible threaded compression device and its method of use. [ 13 ]


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Orthotics  ( Greek :  Ορθός ,  romanized :  ortho ,  lit.   'to straighten, to align') is a  medical specialty  that focuses on the design and application of  orthoses , sometimes known as braces, calipers, or splints. [ 1 ]  An  orthosis  is "an externally applied device used to influence the structural and functional characteristics of the  neuromuscular  and  skeletal systems ." [ 2 ]   Orthotists  are medical professionals who specialize in designing orthotic devices such as braces or foot orthoses.


Orthotic devices are classified into four areas of the body according to the international classification system (ICS): [ 2 ]  orthotics of the  lower extremities , orthotics of the  upper extremities , orthotics for the  trunk , and orthotics for the head. Orthoses are also classified by function: paralysis orthoses and relief orthoses. [ 3 ]


Under the  International Standard  terminology, orthoses are classified by an acronym describing the anatomical joints they support. [ 2 ]  Some examples include KAFO, or knee-ankle-foot orthoses, which span the knee, ankle, and foot; TLSO, or thoracic-lumbar-sacral orthoses, supporting the  thoracic ,  lumbar  and   sacral  regions of the  spine . The use of the International Standard is promoted to reduce the widespread variation in the description of orthoses, which is often a barrier to interpreting research studies. [ 4 ]


The transition from an orthosis to a  prosthesis  can be fluid. An example is compensating for a leg length discrepancy, equivalent to replacing a missing part of a limb. Another example is the replacement of the forefoot after a forefoot  amputation . This treatment is often made from a combination of a prosthesis to replace the forefoot and an orthosis to replace the lost muscular function (ortho prosthesis). [ citation needed ]


An orthotist is a specialist responsible for the customising, manufacture, and repair of orthotic devices (orthoses). [ 5 ]  The manufacture of modern orthoses requires both artistic skills in modeling body shapes and manual skills in processing traditional and innovative materials—  CAD / CAM ,  CNC machines  and  3D printing  are involved in orthotic manufacture. [ 6 ]  Orthotics also combines knowledge of anatomy and physiology,  pathophysiology ,  biomechanics  and engineering. [ 7 ]


In the United States, while orthotists require a prescription from a licensed healthcare provider, physical therapists are not legally authorized to prescribe orthoses. In the U.K., orthotists will often accept referrals from doctors or other healthcare professionals for orthotic assessment without requiring a prescription. [ 8 ]


Orthoses are offered as:


Both custom-fabricated products and semi-finished products are used in long-term care and are manufactured or adapted by the orthotist or by trained orthopedic technicians according to the prescription. In many countries the physician or clinician defines the functional deviations in his prescription, e.g. paralysis ( paresis ) of the calf muscles ( M. Triceps Surae ) and derives the indication from this, e.g. orthotic to restore safety when standing and walking after a  stroke . The orthotist creates another detailed physical examination and compares it with the prescription from the physician. The orthotist describes the configuration of the orthosis, which shows which orthotic functions are required to compensate for the functional deviation of the neuromuscular or skeletal system and which functional elements must be integrated into the orthosis for this. Ideally, the necessary orthotic functions and the functional elements to be integrated are discussed in an interdisciplinary team between physician,  physical therapist , orthotist and patient.


All orthoses that affect the foot, the ankle joint, the lower leg, the knee joint, the thigh or the hip joint belong to the category of orthoses for the lower extremities. [ 2 ]


Paralysis  orthoses are used for partial or complete paralysis, as well as complete functional failure of muscles or muscle groups, or incomplete paralysis ( paresis ). They are intended to correct or improve functional limitations or to replace functions that have been lost as a result of the paralysis. Functional leg length differences caused by paralysis can be compensated for by using orthosis. [ 9 ]


For the quality and function of a paralysis orthosis, it is important that the orthotic shell is in total-contact  with the patient's leg to create an optimal fit, which is why a custom-made orthotic is often preferred. As reducing the weight of an orthosis significantly lessens the energy needed to walk with it, the use of light weight and highly resilient materials such as  carbon fiber ,  titanium  and  aluminum  is indispensable for the manufacture of a custom-made orthosis. [ 10 ]


The production of a custom-made orthotic also allows the integration of orthotic joints, which means the dynamics of the orthotic can be matched exactly with the pivot points of the patient's anatomical joints. As a result, the dynamics of the orthosis take place exactly where dictated by the patient's anatomy. Since the dynamics of the orthosis are executed via the orthotic joints, it is possible to manufacture the orthotic shells as stable and torsion-resistant, which is necessary for the quality and function of the orthosis. The orthosis thus offers the necessary stability to regain the security that has been lost due to paralysis when standing and walking. [ 11 ]


In addition, an orthosis can be individually configured through the use of orthosis joints. In this way, the combination of the orthotic joints and the adjustability of the functional elements can be adjusted to compensate for any existing functional deviations that have resulted from the muscle weakness. [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ]  The goal of a high-quality orthotic fitting is to adjust the functional elements so precisely that the orthosis provides the necessary support while restricting the dynamics of the lower extremities as little as possible to preserve the remaining functionality of the muscles. [ 11 ]


In the case of paralysis due to disease or injury to the spinal/peripheral nervous system, a  physical examination  is needed to determine the strength levels of the affected leg's six major muscle groups and the orthosis's necessary functions.


According to Vladimir Janda, a muscle function test is carried out to determine strength levels. [ 18 ]  The degree of paralysis is given for each muscle group on a scale from 0 to 5, with the value 0 indicating complete paralysis (0%) and the value 5 indicating normal strength (100%). The values between 0 and 5 indicate a percentage reduction in muscle function. All strength levels below five are called  muscle weakness .


The combination of strength levels of the muscle groups determines the type of orthosis (AFO or KAFO) and the functional elements necessary to compensate for restrictions caused by the reduced muscular strength levels. [ medical citation needed ]


Paralysis may be caused by injury to the spinal or peripheral nervous system after  spinal cord injury , or by diseases such as  spina bifida ,  poliomyelitis  and  Charcot-Marie-Tooth disease . In these patients, knowledge of the strength levels of the large muscle groups is necessary to configure the orthotic  for the necessary functions. [ medical citation needed ]


Paralysis caused by diseases or injuries to the central nervous system (e.g.  cerebral palsy ,  traumatic brain injury ,  stroke , and  multiple sclerosis ) can cause incorrect motor impulses that often result in clearly visible deviations in gait. [ 19 ] [ 20 ]  The usefulness of muscle strength tests is therefore limited, as even with high degrees of strength, disturbances to the gait pattern can occur due to the incorrect control of the central nervous system.


In  ambulatory  patients with paralysis due to  cerebral palsy  or  traumatic brain injury ,  the gait pattern is analysed as part of the  physical examination  in order to determine the necessary functions of an orthosis. [ 21 ] [ 22 ]


One way of classifying gait is according to the "Amsterdam Gait Classification", which describes five gait types. To assess the gait pattern, the patient is viewed directly, or via a video recording, from the side of the leg being assessed. At the point when the leg is   mid-stance  the knee angle and the contact of the foot with the ground are assessed. [ 21 ]  The five gait types are:


Patients with paralysis due to cerebral palsy or traumatic brain injury are usually treated with an ankle-foot orthosis (AFO). Although in these patients the muscles are not paralyzed but being sent the wrong impulses from the brain, the functional elements used in the orthotics are the same for both groups. The compensatory gait is an unconscious reaction to the lack of security when standing or walking that usually worsens with increasing age; [ 20 ]  if the right functional elements are integrated into the orthosis to counter this, and maintain physiological mobility, the right motor impulses are sent to create new cerebral connections. [ 23 ]  The goal of an orthotic is the best possible approximation of the physiological gait pattern. [ 24 ]


In the case of paralysis after a  stroke , rapid care with an orthosis is necessary. Often areas of the brain are affected that contain "programs" for controlling the musculoskeletal system. [ 25 ] [ 26 ] [ 27 ]  With the help of an orthosis, physiological standing and walking can be relearned, preventing long term health consequences caused by an abnormal gait pattern. [ 28 ]  According to Vladimir Janda, when configuring the orthotic it is important to understand that the muscle groups are not paralyzed, but are controlled by the brain with wrong impulses, and this is why a muscle function test can lead to incorrect results when assessing the ability to stand and walk. [ citation needed ]


An important basic requirement for regaining the ability to walk is that the patient trains early on to stand on both legs safely and well balanced. An orthosis with functional elements to support balance and safety when standing and walking can be integrated into physical therapy from the first standing exercises, and this makes the work of mobilizing the patient at an early stage easier. With the right functional elements that maintain physiological mobility and provide security when standing and walking, the necessary motor impulses to create new cerebral connections can occur. [ 23 ]  Clinical studies confirm the importance of orthoses in stroke rehabilitation. [ 29 ]


Patients with paralysis after a stroke are often treated with an ankle-foot orthosis (AFO), as after a stroke stumbling can occur if only the  dorsiflexors  are supplied with incorrect impulses from the central nervous system. This can lead to insufficient foot lifting during swing phase of walking, and in these cases, an orthosis that only has functional elements to support the dorsiflexors can be helpful. Such an orthosis is also called drop foot orthosis. When configuring a foot lifter orthosis, adjustable functional elements for setting the resistance can be included, which make it possible to adapt the passive lowering of the forefoot (plantar flexion) to the  eccentric work  of the dorsal flexors during loading response. [ 12 ] [ 13 ]


In cases where the muscle group of the  plantar flexors  is supplied with wrong impulses from the central nervous system, which leads to uncertainty when standing and walking, an unconscious compensatory gait can occur. [ 20 ]  When configuring an orthosis functional elements that can restore safety when standing and walking must be used in these cases; a foot lifter orthosis is not suitable as it only compensates for the functional deviations caused by weakness of the dorsiflexors.


Patients with paralysis after stroke who are able to walk have the option of analysing the gait pattern in order to determine the optimal function of an orthosis. One way of assessing is the classification according to the "N.A.P. Gait Classification", which is a physiotherapeutic treatment concept. [ 30 ]  According to this classification, the gait pattern is assessed in the mid-stance phase and described as one of four possible gait types.


This assessment is a two step process; in the first step, the patient is viewed from the side of the leg to be assessed, either directly or via a video recording. In gait type 1 the knee angle is hyperextended, while in type 2, the knee angle is flexed. In the second step, the patient is viewed from the front to determine if the foot is  inverted , if it is the letter "a" is added to the gait. This is associated with a  varus deformity  of the knee. If instead the patient stands on the inner edge of the foot (eversion), which is associated with a  valgus deformity  of the knee, the letter "b" is added to the gait type. Patients are thus classified as gait types 1a, 1b, 2a or 2b. The goal of orthotic fitting for patients who are able to walk is the best possible approximation of the physiological gait pattern. [ medical citation needed ]


In the case of paralysis due to  multiple sclerosis , the degree of strength of the six major muscle groups of the affected leg should be determined as part of the  physical examination  in order to determine the necessary functions of an orthosis, just as in the case of diseases or injuries to the spinal/peripheral nervous system. However, patients with multiple sclerosis may experience muscular fatigue as well. The fatigue can be more or less pronounced and, depending on the severity, can lead to considerable restrictions in everyday life. Persistent stress, such as from walking, causes a deterioration in muscle function and has a significant effect on the spatial and temporal parameters of walking, for example by significantly reducing the cadence and walking speed. [ 31 ] [ 32 ] [ 33 ]  Fatigue can be measured as  muscle weakness . When determining the strength levels of the six major muscle groups as part of the patient's medical history, fatigue can be taken into account by using a standardized six-minute walking test. [ 34 ]  According to Vladimir Janda the muscle function test is carried out in combination with the six-minute walk test in the following steps:


This sequence of muscle function test and six-minute walk test is used to determine whether muscular fatigue can be induced. If the test reveals muscular fatigue, the strength levels and measured fatigue should be included in the planning of an orthosis, and when determining the functional elements. [ medical citation needed ]


Paralysis of the dorsiflexors  –  weakness  of the  dorsiflexors  results in a  drop foot . The patient's foot cannot be sufficiently lifted during the swing phase while walking, as the necessary concentric work of the dorsiflexors can not be activated. [ 35 ]  There is a risk of stumbling, and the patient cannot influence the shock absorption when walking (gait phase, loading response), as the  eccentric work  of the dorsiflexors is limited. [ 35 ]  After initial heel contact the forefoot either slaps too quickly on the floor via the heel rocker, which creates an audible noise, or the foot does touch the floor with forefoot first, which disrupts gait development. [ 36 ] : 178–181  [ 37 ] : 44–45, 50–54 and 126  [ 38 ]


Paralysis of the plantar flexors  – If the  plantar flexors  are weak, the muscles of the forefoot lever are either inadequately activated or not activated at all. The patient has no balance when standing and has to support themself with aids such as  crutches . The forefoot lever required for energy-saving walking in the gait phases from mid-stance to pre-swing cannot be activated by the plantar flexors. This leads to excessive dorsiflexion in the ankle joint in terminal stance and a loss of energy while walking. The center of gravity of the body lowers towards the end of the stance phase and the knee of the contralateral leg is flexed excessively. With each step, the center of gravity must be raised above the leg by straightening the excessively flexed knee. Since the plantar flexors originate above the knee joint, they also have a knee-extension effect in the stance phase. [ 36 ] : 177–210  [ 37 ] : 72  [ 38 ]


Paralysis of the knee extensors  – if the  knee extensors  are weak, there is an increased risk of falling when walking, as between loading response to the mid-stance the knee extensors control knee flexion inadequately, or not at all. To control the knee, the patient develops compensatory mechanisms that lead to an incorrect gait pattern, for example by exaggerated activation of the plantar flexors, leading into hyperextension of the knee, or when initial contact is with the forefoot and not the heel in order to prevent the knee-flexing effect of the heel rocker. [ 36 ] : 222, 226  [ 37 ] : 132, 143, 148–149  [ 38 ]


Paralysis of the knee flexors  – if the knee flexors are weak, it is more difficult to flex the knee in pre-swing. [ 36 ] : 220  [ 37 ] : 154  [ 38 ]


Paralysis of the hip flexors  – if the hip flexors are weak, it is more difficult to flex the knee in pre-swing. [ 36 ] : 221  [ 37 ] : 154  [ 38 ]


Paralysis of the hip extensors  – the  hip extensors  help control of the knee against unwanted flexion when walking between loading response and mid-stance. [ 36 ] : 216–17  [ 37 ] : 45–46  [ 38 ]


The functional elements of an orthosis ensure the flexion and extension movements of the ankle, knee and  hip joints. They correct and control the movements and secure the joints against undesired incorrect movements, and help avoid falls when standing or walking. [ citation needed ]


Functional elements in paralysis of the dorsiflexors  – if the  dorsiflexors  are weak, an orthosis should lift the forefoot during the swing phase in order to reduce the risk of the patient stumbling. An orthosis that has only one functional element for lifting the forefoot in order to compensate for a weakness in the dorsiflexors is also known as a drop foot orthosis. An AFO of the drop foot orthosis type is therefore not suitable for the care of patients with weakness in other muscle groups, as these patients require additional functional elements to be taken into account. Initial contact with the heel should be achieved by lifting the foot through the orthosis, and if the dorsiflexors are very weak, control of the rapid drop of the forefoot should be taken over by dynamic functional elements that allow for adjustable resistance of  plantar flexion . Orthoses should be adapted to the functional deviation of the dorsiflexors in order to correct the shock absorption of the heel rocker lever during loading response, but should not block plantar flexion of the ankle joint as this leads to excessive flexion in the knee and hip and an increase in the energy needed for walking. This is why static functional elements are not recommended when there are newer technical alternatives. [ 12 ] [ 36 ] : 105  [ 37 ] : 134  [ 38 ]


Functional elements in paralysis of the plantar flexors  – in order to compensate for a  weakness  of the  plantar flexors , the orthosis has to transfer large forces that the strong muscle group would otherwise take over. These forces are transmitted in a similar way to a ski boot during downhill skiing via the functional elements of the foot part, ankle joint and lower leg shell. Dynamic functional elements are preferable for the ankle joint as static functional elements would completely block the dorsiflexion, which would have to be compensated for by the upper body, resulting in an increased energy cost when walking. [ 15 ]  The functional element's resistance to protect against unwanted dorsiflexion should be able to be adapted according to the weakness of the plantar flexors. In the case of very weak plantar flexors, the functional element's resistance against undesired dorsiflexion must be very high in order to compensate for the functional deviations this causes. [ 39 ] [ 16 ]  Adjustable functional elements allow the resistance to be adjusted exactly to the weakness of the muscle, and scientific studies recommend adjustable resistance in patients with paralysis or weakness of the plantar flexors. [ 13 ] [ 14 ]


Functional elements in paralysis of knee extensors and hip extensors  – in the case of weak  knee extensors  or  hip extensors , the orthosis must take over the stability and stance phase control when walking. Different knee-securing functional elements are needed depending on the weakness of these muscles. In order to compensate for functional deviations with slightly weakness of these muscle groups, a free moving mechanical knee joint with the mechanical pivot point behind the anatomical knee pivot point can be sufficient. In the case of significant weakness, knee flexion when walking must be controlled by functional elements that mechanically secure the knee joint during the early stance phases between loading response and mid stance. Stance phase control knee joints which lock the knee in the early stance phases and release it for knee flexion during the swing phase can be used here, with these joints, a natural gait pattern can be achieved despite mechanically securing against unwanted knee flexion. In these cases, locked knee joints are often used, and while they have a good safety function, the knee joint remains mechanically locked during the swing phase while walking. Patients with locked knee joints have to manage the swing phase with a stiff leg, which only works if the patient develops compensatory mechanisms, such as by raising the body's center of gravity in the swing phase ( Duchenne  limping) or by swinging the orthotic leg to the side ( circumduction ). Stance phase control knee joints and locked joints can both be mechanically "unlocked" so the knee can be flexed to sit down. [ 17 ]


AFO is the abbreviation for ankle-foot orthoses, which is the English name for an orthosis that spans the ankle and foot. [ 2 ]  In the treatment of paralyzed patients, they are mainly used when there is a  weakness  of the  dorsiflexors  or  plantar flexors . [ 40 ] [ 41 ]


Through the use of modern materials, such as carbon fibers and  aramid  fibers, and new knowledge about processing these materials into composite materials, the weight of orthotics has been reduced significantly. In addition to the weight reduction, these materials and technologies have created the possibility of making some areas of an orthosis so rigid that it can take over the forces of the weakened muscles (e.g. the connection from the ankle joint to the frontal contact surface on the shin), while at the same time leaving areas requiring less support very flexible (e.g. the flexible part of the forefoot). [ 42 ]


It is now possible to combine the required rigidity of the orthotic shells with the dynamics in the ankle, [ 43 ]  with this, other new technologies, and the possibility of producing lightweight but rigid orthoses, new demands have been made of orthotics: [ 44 ] [ 45 ]


A custom-made AFO can compensate for functional deviations of muscle groups, it should be configured according to the patient data through a function and load calculation so that it meets the functional and load requirements. In calculating or configuring an AFO, variants are optimally matched to individual requirements for the functional elements of the ankle joint, for the stiffness of the foot shell, and for the shape of the lower leg shell. The size of these components is selected by matching their resilience to the load data. [ medical citation needed ]


An ankle joint based on new technology is the connection between the foot shell and the lower leg shell and at the same time contains all the necessary adjustable functional elements of an AFO. [ clarification needed ]


Depending on the combination of the degree of paralysis of the  dorsiflexors  or  plantar flexors , different functional elements to compensate for their weakness can be integrated into the ankle joint; if both muscle groups are affected, the elements should be integrated into one orthotic joint. The necessary dynamics and resistance to movements in the ankle can be adapted via adjustable functional elements in the ankle joint of the orthosis, which allows it to compensate for muscle weaknesses, provide safety when standing and walking, and still allow as much mobility as possible. For example, adjustable spring units with pre-compression can enable an exact adaptation of both static and dynamic resistance to the measured degree of muscle weakness. Studies show the positive effects of these new technologies. [ 12 ] [ 14 ] [ 15 ] [ 39 ] [ 16 ]  It is of great advantage if the resistances for these two functional elements can be set separately. [ 13 ]


An AFO with functional elements to compensate for a weakness of the  plantar flexors  can also be used for slight weakness of the knee-securing muscle groups, the  knee extensors  and the  hip extensors . [ medical citation needed ]


A drop foot orthosis is an AFO that only has one functional element for lifting the forefoot in order to compensate for a weakness in the dorsiflexors. [ 46 ]  If other muscle groups, such as the plantar flexors, are weak, additional functional elements must be taken into account, making a drop foot orthosis unsuitable for patients with weakness in other muscle groups.


In 2006, before these new technologies were available, the  International Committee of the Red Cross  published in its 2006 Manufacturing Guidelines for Ankle-Foot Orthoses, with the aim of providing people with disabilities worldwide standardized processes for the production of high-quality, modern, durable and economical devices. [ 47 ]


Because new technologies are not widely used, AFOs are often made from polypropylene-based plastic, mostly in the shape of a continuous "L" shape, with the upright part behind the calf and the lower part under the foot, however, this only offers the rigidity of the material. AFOs made of polypropylene are still called "DAFO" (dynamic ankle-foot orthosis), "SAFO" (solid ankle-foot orthosis) or "Hinged AFO". DAFOs are not stable enough to transfer the high forces required to balance the weak plantar flexors when standing and walking, and SAFOs block the mobility of the ankle joint. A "Hinged AFO"  only allowed for the compensation that could be achieved with the orthotic joints of the time, for example, they commonly block plantar flexion, as the joints cannot simultaneously transmit the large forces that are required to compensate for muscle deviations while also  offering the necessary dynamics. [ medical citation needed ]


While there was a multitude of AFOs with differing designs in clinical practice, there was also a clear lack of details regarding the design and the materials used for manufacture, leading Eddison and  Chockalingam  to call for a new standardization of the terminology. [ 48 ] [ 49 ]  With a focus on caring for children with cerebral palsy there is a recommendation to investigate the potential for gait pattern improvement via the design and manufacture of orthotics made of polypropylene. [ 50 ]  On the other hand, integrating orthotic joints with modern functional elements into the  production of older technologies using polypropylene is unusual because the orthotic shells made of polypropylene either could not transfer the high forces or would be too soft. [ medical citation needed ]


New studies now show the better possibilities for improving the gait pattern through the new technologies. [ 12 ] [ 15 ] [ 39 ] [ 16 ] [ 13 ]


The International Committee of the Red Cross published its manufacturing guidelines for ankle–foot orthoses in 2006, and, unfortunately, today's terminologies are still based those guidelines and therefore require a particularly high level of explanation. [ 47 ]  The intent was to provide standardized procedures for the manufacture of high-quality modern, durable and economical devices to people with disabilities throughout the world. However, with the new technologies available, the main types mentioned are in need of revision today.


plus the body parts included in the orthosis fitting: ankle and foot, English abbreviation: AFO for ankle-foot orthoses


"SAFO"


Rigid AFO [ 47 ]


"DAFO"


Flexible AFO [ 47 ]


"Hinged-AFO"


"Hinged" simply means a flexible connection between the two parts of the orthosis. The joint itself does not offer any further functional elements.


AFO with Tamarack Flexure Joint


"Posterior Leaf Spring"


Spring made from flexible material behind (posterior) the ankle


A DAFO often also known as "Posterior Leaf Spring"


FR for Floor reaction


"FRAFO"


Designation is misleading as other orthoses also have this function


Plus further descriptions, such as:
 - ventral shell with torsionally rigid reinforcement to focus the dynamics on the ankle joint
 - dynamic ankle joint with precompressed spring elements to control plantarflexion and dorsiflexion


KAFO is the abbreviation for knee-ankle-foot orthoses, which spans the knee, ankle and foot. [ 51 ]  In the treatment of paralyzed patients, a KAFO is used when there is a  weakness  of the knee  or hip extensors. [ 17 ] [ 40 ] [ 41 ]  They have two orthotic joints: an ankle joint between the foot and lower leg shells and a knee joint between the lower leg and thigh shells. [ citation needed ]


KAFOs can be roughly divided into three variants, depending on whether the mechanical knee joint is: locked, unlocked or locked and unlocked. [ medical citation needed ]


KAFO with locked knee joint -  The mechanical knee joint is locked both when standing and also when walking (in both the stance and swing phases) in order to achieve the necessary stability. To sit, the user can unlock the knee joint. When walking with a locked knee joint it is difficult for the user to swing the leg forward and, in order to not stumble, the leg must be swung forward and out in a circular arc (circumduction) or the hip must be raised unnaturally to swing the stiff leg. Each of these incorrect gait patterns can lead to secondary diseases in the bone and muscle system, and such compensatory movement patterns lead to increased energy consumption when walking. The film  Forrest Gump  impressively shows how the main character  Forrest Gump  is additionally hindered in his urge to move by such orthoses. [ relevant? ]  For centuries, KAFOs were built with mechanical knee joints that stiffened the knee of the paralyzed leg, and even today, such orthotic fittings are still common. Typical designations for a KAFO with a locked knee joint include "KAFO with Swiss lock" or "KAFO with drop lock lock". [ medical citation needed ]


KAFO with unlocked knee joint -  An unlocked knee joint can move freely both when standing and when walking, both in the stance phase and in the swing phase. In order for the leg to swing through without stumbling, knee flexion of approximately 60° is allowed; the user does not need to unlock the knee joint to sit. As a KAFO with an unlocked knee joint can provide only minor compensation for paralysis-related issues while standing and walking, an orthotic knee joint with a rearward displacement of the pivot point can be installed in order to increase safety. However, even with this, a KAFO with a non-locked knee joint should only be used in cases of minor paralysis of the knee and hip extensors. With more severe paralysis and low levels of strength in these muscle groups, there is a significant risk of falling. A typical designation for a KAFO with a unlocked knee joint is, among other things, "KAFO with knee joint for movement control". [ medical citation needed ]


KAFO with locked and unlocked knee joint -  The mechanical knee joint of a KAFO with locked and unlocked knee joint is locked when walking in the stance phase, [ 52 ]  providing the necessary stability and security for the user. The knee joint is then automatically unlocked in the swing phase, allowing the leg to be swung through without stumbling. In order to be able to walk efficiently, without stumbling, and without compensating mechanisms, the joint should allow  knee flexion of approximately 60° in the swing phase. The first promising developments of automatic knee joints, or stance phase locking knee joints, emerged in the 1990s. In the beginning there were automatic mechanical constructions that took over the locking and unlocking, now [ when? ]  automatic electromechanical and automatic  electrohydraulic  systems are available that make standing and walking safer and more comfortable. Various terms are used for a KAFO with a locked and unlocked knee joint. Typical designations are "KAFO with automatic knee joint" or "KAFO with stance phase control knee joint". In scientific articles, the English term Stance Control Orthoses SCO is often used, but as this term differs from the ICS classification, one of the first two terms is preferable.


Different functional elements to compensate for weakness of the  dorsiflexors  or  plantar flexors  can be integrated into the ankle joint of the orthosis depending on the degree of paralysis of the two muscle groups. It is of great advantage if the resistances for these two functional elements can be set separately. [ 13 ]  The functional elements to compensate for paralysis of the knee-securing muscle groups of the  knee  and  hip extensors  are integrated into the knee joint of the orthosis via knee-securing functional elements. A KAFO can use a variety of combinations of different variants in the stiffness of the foot shell, the different variants of the functional elements of a dynamic ankle joint, the variants in the shape of the lower leg shell, and the functional elements of a knee joint to compensate for the user's limitations. [ 41 ]


HKAFO is the abbreviation for hip-knee-ankle-foot orthoses; which is the English name for an orthosis that spans the hip, the knee, the ankle and the foot. [ 51 ]  In the treatment of paralyzed patients, a HKAFO is used when there is a  weakness  of the pelvic stabilizing trunk muscles. [ 41 ]


Relief Orthoses are used when there is degeneration to a joint (from "wear and tear" for example) or after an injury such as a torn ligament. [ 53 ]  Relief orthoses are also used after operations such as operations on the joint ligaments, other bony, muscular structures, or after a complete replacement of a joint. [ 54 ] [ 55 ]


Relief orthosis may also be used to: [ citation needed ]


A custom-made ankle/foot orthosis can be used for the treatment of patients with foot ulcers, it is a rigid L-shaped support member with a rigid anterior support shell on an articulated hinge. The plantar portion of the L-shaped member has at least one ulcer-protecting hollow to allow the user to transfer their weight away from the ulcer to facilitate treatment. The anterior support shell is designed with a lateral hinged attachment to take advantage of the medial tibial flare structure to enhance the weight-bearing properties of the orthosis. A flexible, polyethylene hinge attaches the support shell to the L-shaped member and straps securely attach the anterior support shell to the user's lower leg. [ 56 ]


Foot orthoses (commonly called  orthotics ) are devices inserted into shoes to provide support for the foot by redistributing  ground reaction forces  acting on the foot joints while standing, walking or running. They may be either pre-moulded (also called pre-fabricated) or custom made according to a cast or impression of the foot. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue conditions. Foot orthoses are effective at reducing pain for people with painful  high-arched feet , and may be effective for people with  rheumatoid arthritis ,  plantar fasciitis , first  metatarsophalangeal  (MTP) joint pain [ 57 ]  or  hallux valgus  (bunions). For children with  juvenile idiopathic arthritis  (JIA) custom-made and pre-fabricated foot orthoses may also reduce foot pain. [ 58 ]  Foot orthoses may also be used in conjunction with properly fitted orthopedic footwear in the prevention of  diabetic foot ulcers . [ 59 ] [ 60 ]  A real-time weight bearing orthotic can be created using a neutral position casting device and the Vertical Foot Alignment System VFAS. [ citation needed ]


An AFO can also be used to immobilize the ankle and lower leg in the presence of arthritis or a fracture. Ankle–foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States. [ 61 ]  According to a review of Medicare payments from 2001 to 2006, the base cost of an AFO was about $500 to $700. [ 62 ]


A knee orthosis (KO) or knee brace extends above and below the knee joint and is generally worn to support or align the knee. In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion, extension, or instability of the knee. If the ligaments or cartilage of the knee are affected, a KO can provide stabilization to the knee by replacing their functions. For instance, knee braces can be used to relieve pressure from diseases such as  arthritis  or  osteoarthritis  by realigning the knee joint. In this way a KO may help reduce osteoarthritis pain, [ 63 ]  however, there is no clear evidence about the most effective orthosis or the best approach to rehabilitation. [ 64 ]  A knee brace is not meant to treat an injury or disease on its own, but is used as a component of treatment along with drugs, physical therapy and possibly surgery. When used properly, a knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain. [ medical citation needed ]


Prophylactic braces are used primarily by athletes participating in contact sports. Evidence indicates that prophylactic knee braces, like the ones football linemen wear that are often rigid with a knee hinge, are ineffective in reducing anterior cruciate ligament tears, but may be helpful in resisting medial and lateral collateral ligament tears. [ 65 ]


Functional braces are designed for use by people who have already experienced a knee injury and need support while recovering from it, or to help people who have pain associated with arthritis. They are intended to reduce the rotation of the knee, support stability, reduce the chance of hyperextension, and increase the agility and strength of the knee. The majority of these are made of elastic. They are the least expensive of all braces and are easily found in a variety of sizes. [ medical citation needed ]


Rehabilitation braces are used to limit the movement of the knee in both medial and lateral directions, these braces often have an adjustable range of motion, and can be used to limit flexion and extension following ACL reconstruction. They are primarily used after injury or surgery to immobilize the leg and are larger in size than other braces, due to their function.