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.


A soft brace, sometimes called soft support or a bandage, belong to the field of orthoses and are supposed to protect the joints from excessive loads.
Soft braces are also classified according to regions of the body. In sport, bandages are used to protect bones and joints, and prevent and protect injuries. [ 66 ]  Bandages should also allow  proprioception . They mostly consist of textiles, some of which have supportive elements. The supporting functions are low compared to paralysis and relief orthoses, though they are sometimes used  prophylactically  or to optimize performance in sport. [ 67 ]  At present, the scientific literature does not provide sufficient high quality research to allow for strong conclusions on their effectiveness and cost-effectiveness. [ 68 ]


Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices applied externally to the arm, or segments of it, in order to restore or improve function or structural characteristics of the arm segments enclosed in the device. In general, musculoskeletal problems that may be alleviated by the use of upper limb orthoses include those resulting from trauma [ 69 ]  or disease (arthritis for example). They may also benefit individuals who have a neurological impairment from a stroke, spinal cord injury, or peripheral neuropathy. [ citation needed ]


Scoliosis , a condition describing an abnormal curvature of the spine, may in certain cases be treated with spinal orthoses, [ 70 ]  such as the  Milwaukee brace ,  Boston brace ,  Charleston bending brace , or  Providence brace . As scoliosis most commonly develops in adolescent females who are undergoing their  adolescent growth spurt , compliance is hampered by patient concerns about appearance and movement restrictions caused by the brace. [ citation needed ]


Spinal orthoses may also be used in the treatment of spinal fractures. A Jewett brace, for instance, may be used to aid healing of an anterior  wedge fracture  involving the T10 to L3 vertebrae, and a body jacket may be used to stabilize more involved fractures of the spine. There are several types of orthoses for managing cervical spine pathology. [ 71 ]  The halo brace is the most restrictive cervical thoracic orthosis in use; it is used to immobilize the cervical spine, usually following fracture, and was developed by Vernon L. Nickel at  Rancho Los Amigos National Rehabilitation Center  in 1955. [ 72 ]


Helmets  such as a cranial molding orthoses is an example of orthoses for the head. [ 73 ]  These devices are often suggested for infants with  positional plagiocephaly . [ 74 ] [ 75 ]


An  orthotist  is a healthcare professional who specializes in the provision of  orthoses . An orthotist has an overall responsibly of  orthotics  treatment, who can supervise and mentor the practice of other personnel. [ 1 ]  They are clinicians trained to assess the needs of the user, prescribe treatment, determine the precise technical specifications of orthotic devices, take measurements and image of body segments, prepare model of the evaluation, fit devices and evaluate treatment outcome. [ 1 ]  In the United States, orthotists work by prescription from a licensed healthcare provider. Physical therapists are not legally authorized to prescribe orthoses in the U.S. In the U.K., orthotists will often accept open referrals for orthotic assessment without a specific prescription from doctors or other healthcare professionals. [ 2 ]


The scope of an orthotist includes the design and application of  orthoses  (braces or  orthotic devices ). The definition of an orthosis is an “externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system”. [ 3 ]


In Canada, a Certified Orthotist CO(c) provides clinical assessment, treatment plan development, patient management, technical design, and fabrication of custom orthoses to maximize patient outcomes. To become CBCPO certified through Orthotics Prosthetics Canada (OPC) an applicant must successfully meet the following requirements:


Upon successful completion of the national certification exams, candidates are conferred the designation of Canadian Certified Orthotist CO(c). [ 4 ]


In the UK orthotists assess patients, and where appropriate design and fit orthoses for any part of the body. Registration is with the  Health and Care Professions Council  and BAPO - the British Association of Prosthetists and Orthotists. The training is a B.Sc.(Hons) in Prosthetics and Orthotics at either the  University of Salford  or  University of Strathclyde . New graduates are therefore eligible to work as an orthotist and/or  prosthetist .


Podiatrists are the other profession involved with foot orthotic provision. [ 5 ]  They are also registered with the  Health and Care Professions Council  . Podiatrists assess gait to provide orthotics to improve foot function and alignment or may use orthoses to redistribute stress on pressure areas for those with diabetes or rheumatoid arthritis.


A licensed orthotist is an orthotist who is recognized by the particular state in which they are licensed to have met basic standards of proficiency, as determined by examination and experience to adequately and safely contribute to the health of the residents of that state. An American Board of Certification certified orthotist has met certain standards; these include a degree in orthotics, completion of a one-year residency at an approved clinical site, and passing a rigorous three-part exam. [ 6 ]  A certified orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics, Prosthetics and Pedorthics. Other credentialing bodies who are involved in orthotics include the Board for Orthotic Certification, the pharmaceutical industry, the Pedorthic Footcare Association, and various of the professional associations who work with athletic trainers, physical and occupational therapists, and orthopedic technologists/cast technicians.


Four universities including the  Iran University of Medical Science ,  Isfahan University of Medical Science ,  University of Social Welfare and Rehabilitation Sciences  and Iran Red Crescent University confer bachelor of science in the Prosthetics and Orthotics. Three universities including Isfahan University of Medical Science, the Iran University of Medical Science and University of Social Welfare and Rehabilitation Science also confer  M.Sc.  and  Ph.D . New bachelor graduates are eligible to work as an orthotist and  prosthetist  after registration in the  Medical Council of Iran . [ citation needed ]


Lars Peterson  (born 1936 in  Vansbro ,  Sweden ) is an  orthopedist , known as "the father of autologous cell implantation". [ 1 ]


Beginning in 1987, Peterson co-pioneered, with colleague  Mats Brittberg  and others,  autologous chondrocyte implantation , a method of repairing  cartilage  using a patient's own cartilage cells. [ 2 ]  He was honored for his work at  Genzyme  in 2009. [ 3 ]


He is also a professor and sports physician, and has been a Swedish national league football and ice hockey player, active in both  Örgryte IS  and  Frölunda HC .


Peterson's sports career started early in most sports, ending up playing in the Swedish National League in both soccer and hockey with Örgryte IS, ending on fourth place and  Västra Frölunda IF , ending first place, respectively. Along with playing soccer and football, he studied medicine at the  University of Gothenburg  and graduated in 1966.
He served his Residency in General Surgery in Kungälvs Hospital, his orthopaedic residency in  Sahlgrenska University Hospital  from 1967 to 1974, and became specialist in General Surgery 1972 and in Orthopaedic Surgery 1974. In 1974, Peterson defended his doctoral thesis: Fracture of the Neck of the Talus, An Experimental and Clinical Study.


In 1980, Peterson was approved associate professor of Orthopaedic Surgery at the University of Gothenburg and in 2000, appointed professor of Orthopaedic Surgery. Peterson had a long and broad experience in treating athletes in his University practice and as team physician in soccer and ice hockey and since 1987 in his clinic, Gothenburg Medical Center. He has served as head physician of the Swedish National Team in ice hockey and in soccer


For over 25 years, Peterson has been a member of the Sports Medical Committee of  FIFA , The International Football Federation and a founding member of F-Marc (FIFA Medical Assessment and Research Center). He has served as a Medical Officer at six World Cups in Football.
Peterson has been President of the  Swedish Society of Sports Medicine  and is an honorary member. He was president and one of the founding members of the  International Society of Cartilage Repair  (ICRS). He has served as Godfather for ICRS Traveling Fellows in 2001. He also has served as Goodfather in the Herodicus Society.


In 2010, Peterson received “The Duke of Edinburgh Prize“ for “Outstanding contribution to international education in Sports Medicine”. In 2010 awarded “Doctor Honoris Causa” at the  University of Helsinki , Finland. In 2011, he was awarded “Doctor Honoris Causa” at  Universidad Católica San Antonio de Murcia , Spain.


Peterson has lectured extensively, nationally and internationally and served as visiting professor several times. His publication list includes more than 200 originals, reviews books, book chapters in the fields of Orthopaedic Surgery, Sports Traumatology and Sports Medicine, Biomechanics, and Rehabilitation.


This Swedish biographical article is a  stub . You can help Wikipedia by  expanding it .


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Prosthetic joint infection  (PJI), also known as  peri-prosthetic joint infection , is an acute, sub-acute or chronic infection of a  prosthetic joint . It may occur in the period after the joint replacement or many years later. It usually presents as joint pain,  erythema  (redness of the joint or adjacent area),  joint swelling  and sometimes formation of a  sinus tract  ( a tract connecting the joint space to the outer environment). PJI is estimated to occur in approximately 2% of hip and knee replacements, and up to 4% of revision hip or knee replacements. Other estimates indicate that 1.4-2.5% of all joint replacements worldwide are complicated by PJIs. [ 1 ]  The incidence is expected to rise significantly in the future as  hip replacements  and  knee replacements  become more common. It is usually caused by  aerobic   gram positive  bacteria, such as  Staph epidermidis  or  Staphylococcus aureus  but  enterococcus  species,  gram negative  organisms and  Cutibacterium  are also known causes with  fungal  infections being a rare culprit. The definitive diagnosis is isolation of the causative organism from the  synovial fluid  (joint fluid), but signs of inflammation in the joint fluid and imaging may also aid in the diagnosis. The treatment is a combination of systemic  antibiotics ,  debridement  of infectious and  necrotic  tissue and local antibiotics applied to the joint space. The bacteria that usually cause prosthetic joint infections commonly form a  biofilm , or a thick slime that is adherent to the artificial joint surface, thus making treatment challenging.


The most common symptom of periprosthetic joint infections is  joint pain . [ 2 ]  Other local symptoms are also present, including  erythema  (redness of the joint),  joint swelling , warmth of the joint, and loosening of the prosthetic joint. [ 2 ]  A  sinus tract , or a tract connecting the joint space to the external environment, is more common in chronic PJI, and is definitively diagnostic of PJI. [ 3 ]  Fever may be present in PJI, but is uncommon. [ 2 ]


Prosthetic joint infections can occur any time after a joint replacement. Early infections (occurring within 4 weeks of a joint replacement) are usually due to Staph aureus,  streptococci  or  enterococci . [ 4 ]  Whereas late infections (occurring 3 months or later after the joint replacement) are usually due to coagulase negative staphylococcus or  cutibacterium . [ 4 ]  The highest risk of PJI is in the immediate post-operative period, when direct inoculation of bacteria into the joint space may occur during surgery. [ 4 ]  The risk of PJI is highest in this early period; within 2 years of the joint replacement. [ 1 ]   Hematogenous spread , or infection of a prosthetic joint via direct seeding from a bloodstream infection, may occur at any time after a joint replacement, with the risk being as high as 34% in staph aureus  bacteremia . [ 4 ]  An additional possible cause of PJI is from direct spread to the joint from a nearby skin or soft tissue infection, a bone infection ( osteomyelitis ), or from more distal spread to the joint from a respiratory tract infection,  gastroenteritis ,or  urinary tract infection . [ 4 ]  Dental procedures may cause a transient bacteremia which can lead to inoculation of the artificial joint and PJI, with  strep viridans  being the most common causative organism. [ 4 ]


The most common causes of PJIs are aerobic, gram positive bacteria, including staph aureus and coagulase negative staphylococcus (such as  staph epidermidis ), which make up greater than 50% of all causes of hip and knee PJIs. [ 3 ]  With regards to acute PJIs, the most common causative organism is staph aureus (comprising 38% of acute infections) followed by aerobic gram negative bacilli (making up 24% of acute infections). [ 3 ]  70% of PJIs are monomicrobial (with a single causative organism identified), whereas 25% of cases are polymicrobial (with multiple causative organisms identified). [ 2 ]  3% of PJIs are due to fungal organisms. [ 2 ]   Propionibacterium acnes  is the most common cause of shoulder PJIs. [ 3 ]


Risk factors for PJI include  diabetes ,  immunosuppression ,  smoking ,  obesity ,  chronic kidney disease , the presence of a soft tissue infection, or an infection in another part of the body or increased fat tissue around the replaced joint. [ 1 ]  Surgical factors that may lead to an increased risk of PJIs include  wound dehiscence  (unplanned opening of the surgical wound after the surgery) and  hematoma  (collection of blood) formation. [ 1 ]


The presence of multiple artificial joints,  MRSA  PJIs,  rheumatoid arthritis  or bacteremia place people at risk for multiple PJIs (either concurrent or subsequent infections). [ 2 ]


Prolonged operative times, in which the joint is left open to the external environment, determined as greater than 90 minutes in a single study, also increases the risk for PJIs. [ 2 ]


Prosthetic joint infections are generally difficult to treat as most causative organisms form a biofilm, or a thickly adherent membrane, against the artificial joint surface. The bacteria secrete  adhesion proteins  which help them attach to each other and to the joint surface. [ 1 ]  The bacteria then secrete  autoinducer  proteins that act as bacterial signals which facilitate the secretion of an intricate extracellular matrix, the biofilm. [ 1 ]  Biofilms greatly decrease antibiotic penetrance thereby shielding bacteria from the  bacteriocidal  effects of antibiotics. [ 2 ] [ 1 ]  Biofilms usually take 4 weeks to fully mature. [ 4 ]   Granulocytes  have decreased  phagocytic  activity encountering the biofilm, also allowing the bacteria to persist. [ 2 ]


The presence of a PJI is confirmed when one of the proposed major diagnostic criteria are met: [ 4 ]


Polymerase chain reaction  testing of the joint fluid or sonification fluid may aid in the diagnosis. [ 4 ]


Skin swabs, sinus tract swabs, swabbing of the artificial joint surface during surgery is not recommended due to the high risk of contaminants and low diagnostic yield (including the risk of contaminants rather than the pathologic organism being cultured). [ 4 ] [ 2 ]


Blood cultures are positive in approximately 25% of cases of PJIs, especially in acute PJI, however, the organism isolated from blood culture does not always correlate to the organisms isolated from the joint fluid, and therefore blood cultures are not diagnostic of PJIs. [ 2 ]


Routine blood work attempting to identify infection including elevated white blood cells on a  complete blood count , elevated inflammatory markers ( erythrocyte sedimentation rate  and  C-reactive protein ) or  procalcitonin  are not sensitive nor specific in diagnosis PJIs. [ 4 ]


Plain radiography  (X-ray) has a low sensitivity and specificity for diagnosing PJI but it may show radiolucent lines around the prosthetic joint, bone breakdown, loosening or migration of the prosthetic joint. [ 2 ] [ 4 ]   Functional imaging  tests such as white blood cell  Scintigraphy  or  PET scan  may help to identify hypermetabolic areas consistent with infection and aid with the diagnosis. [ 4 ]


Magnetic resonance imaging  is specific to soft tissue infections, with metal artifact reduction sequence (MARS) MRIs having great utility to aid in the diagnosis of PJIs. [ 4 ]


Antibiotic treatment alone, without surgical debridement, usually results in treatment failure. [ 2 ]  Acute infections (in which the biofilm is thought to be immature) are usually treated using the DAIR technique;  debridement , systemic and local antibiotics, and implant retention (the implant is not removed). [ 4 ] [ 2 ]  However, the mobile, easily interchangeable components of the implant are often replaced in the DAIR approach. [ 4 ]  DAIR is contraindicated if there is a sinus tract, loosening of the prosthesis, or the surgical wound cannot be closed. [ 2 ]  The microbial cure rate of DAIR is 74%, 49% and 44% in early, sub-acute and late infections respectively. [ 2 ]


Antibiotic loaded  polymethylmethacrylate  (PMMA) which are placed in the joint are helpful, however these non-resorbable beads may themselves be colonized by bacteria with an associated  biofilm , therefore bio-absorbable local antibiotic carriers (calcium sulfate beads, resorbable  gentamicin  sponges) are preferred. [ 4 ]


Chronic PJIs may be treated using 1 stage revisions, where the artificial joint is replaced with a new one during the same surgical procedure, or with a 2-stage revision; in which the infected joint is removed and an antibiotic spacer is placed, this is followed by a second surgery in which a new artificial joint is placed. [ 4 ]  Two step revisions are associated with increased morbidity, longer hospital stays, longer immobilization time, worse functional outcomes and higher costs. [ 4 ]  Therefore, for intact, or mostly intact bone and soft tissue, and without a history of joint replacement revisions; a 1 step exchange is the treatment of choice. [ 4 ]  In the case of hip PJIs both kinds of surgery are equally effective but one-stage surgery results in faster recovery. [ 5 ] [ 6 ] [ 7 ]


Negative pressure wound therapy  is not recommended as the sponges used are often themselves colonized by the biofilm or by new organisms from the environment (including  multi-drug resistant organisms ). [ 4 ]


An extended course of antibiotics is required in PJIs, usually 6–12 weeks of antibiotic therapy. [ 2 ] [ 4 ]  Intravenous antibiotics are initially used and then transitioned to oral antibiotics. A strategy of surgical debridement to decrease the bacterial load prior to starting systemic antibiotics is sometimes employed. [ 4 ]  Common practice involves switching to oral antibiotics after 14 days. [ 4 ]  Intravenous  ampicillin-sulbactam  or  amoxicillin with clavulanic acid  with  vancomycin  added in cases of MRSA is a commonly employed empiric antibiotic treatment strategy. [ 4 ]


If surgery fails or the PJI persists despite optimal antibiotic therapy, resection arthroplasty of the hip with a pseudarthrosis ( Femoral head ostectomy ) is sometimes done. [ 2 ]  Or in cases of knee PJIs failing treatment; an  arthrodesis  (artificial induction of ossification of the knee joint) is done. [ 2 ]  These are considered last line therapies due to significant disability. [ 2 ]


Antibiotic prophylaxis , or giving small doses of antibiotics as a preventative measure, during the perioperative period (usually less than 60 minutes prior to the start of joint replacements)(usually using second generation  cephalosporins ) is believed to reduce the risk of acute PJIs. [ 2 ] [ 1 ]


Screening for and eradication of MRSA carriage and  chlorhexidine  wipes or soap and water skin cleansing prior to surgery may possibly decrease the risk of PJIs. [ 2 ]


According to the  American Dental Association : in patients with prosthetic joint implants, prophylactic antibiotics prior to routine dental procedures are generally not recommended in the prevention of PJI. However specific circumstances placing patients at higher risk, as determined by the dentist or other physicians, may warrant antibiotic prophylaxis. [ 8 ]


The 5-year mortality after hip PJIs is 21%, which is 4 times that of age adjusted controls. [ 2 ]  And the 10 year mortality after hip PJIs was 45%, as compared to 29% in people with non-infected hip replacements. [ 2 ]  25% of people with PJIs have an unplanned re-operation within 1 year of PJI treatment. [ 2 ]  Hospital stays are longer in those with knee and hip PJIs as compared to un-infected knee and hip replacement controls; at 5.3 vs 3 days (knee) and 7.6 vs 3.3 days (hip). [ 2 ]


PJIs are the most common cause of knee replacement failures, and the third most common cause of hip replacement failures. [ 1 ]  As of 2017, 2.1% of hip and 2.3% of knee replacements will at some time develop a PJI. [ 2 ]  The incidence of PJIs have more than tripled in the last 20 years, with the incidence expected to further increase in the future. This increase is believed to be due to the much greater number of hip and knee arthroplasties being performed presently. [ 2 ]


Shoulder reduction  is the process of returning the shoulder to its normal position following a  shoulder dislocation . Normally, closed reduction, in which the relationship of bone and  joint  is manipulated externally without surgical intervention, is used. A variety of techniques exist, but some are preferred due to fewer  complications  or easier execution. [ 1 ]  In cases where closed reduction is not  successful , open (surgical) reduction may be needed. [ 2 ]   X-rays  are often used to confirm success and absence of associated  fractures . The arm should be kept in a sling or immobilizer for several days, prior to supervised recovery of motion and strength.


Various non-operative reduction techniques are employed. They have certain principles in common, including gentle in-line traction, reduction or abolition of muscle spasm, and gentle external rotation. They all strive to avoid inadvertent injury. Two of them, the Milch and Stimson techniques, have been compared in a randomized trial. [ 3 ]  Pain can be managed during the procedures either by  procedural sedation and analgesia  or by injecting  lidocaine  into the shoulder joint. [ 4 ]


The person's arm is brought against their side. [ 2 ]  The elbow is then bent to 90 degrees and the forearm is slowly and gently externally rotated. [ 2 ]  Any discomfort or spasm interrupts the process until the person is able to relax. Reduction usually takes place by the time full external rotation has been achieved. [ 5 ]


This is an extension of the external rotation technique. The externally rotated arm is gently abducted (brought away from the body into an overhead position) while external rotation is maintained. Gentle in-line traction is applied to the arm while some pressure is applied to the humeral head via the operator's thumb in the armpit to keep the head from moving inferiorly. [ 2 ] [ 6 ]


In the Stimson technique, also known as prone technique, the person lies on their stomach on a bed or bench and the arm hangs off the side, being allowed to drop toward the ground. A 5–10 kg weight is suspended from the wrist to overcome spasm and to permit reduction by the force of gravity; [ 3 ]


The person is on their back and gentle upward traction is applied to the extremity coupled with external rotation. [ 2 ]


The  Cunningham technique  was originally published in 2003 and is an anatomically based method of shoulder reduction that utilizes positioning (analgesic position), voluntary scapular retraction, and bicipital massage. [ 7 ]  If performed correctly most patients do not require analgesia for the performance of this technique. Inappropriate use of traction will result in pain for the patient with subsequent spasm and failure to reduce. If the patient is unable to adduct the humerus or unable to cooperate with positioning the technique should not be attempted. The patient may require analgesia or sedation if they are in pain or unable to relax spasming muscles.


FARES stands for fast, reliable, and safe. With the person lying on their back, the operator holds the person's hand on the affected side while the arm is at the side and the elbow is fully extended. The forearm is in neutral position. Next, the operator gently applies longitudinal traction and slowly the arm is abducted. At the same time, continuous vertical oscillating movement at a rate of 2–3 "cycles" per second is applied throughout the whole reduction process. [ 8 ] [ 9 ]


Traction countertraction involves pulling the dislocated arm down and outwards while an assistant pulls the body upwards. [ 2 ]


Kocher's method was described in 1870 and has been incorrectly associated with neuromuscular complications and humeral fractures due to the inappropriate addition of traction by later users. It was designed for subcoracoid dislocations.
"This method: Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward." [ 10 ]


A  sling , also known as  arm sling , is a device to limit movement of the shoulder or elbow while it heals. [ 1 ]  A sling can be created from a  triangular bandage . [ 1 ]


This  health -related article is a  stub . You can help Wikipedia by  expanding it .


The  Spurling test  is a medical maneuver used to assess nerve root pain (also known as  radicular pain ).


The patient rotates their head to the affected side and extends their neck, while the examiners applies downward pressure to the top of the patient's head.


A positive  Spurling's sign  is when the pain arising in the neck radiates in the direction of the corresponding  dermatome  ipsilaterally. [ 1 ]  It is a type of cervical compression test.


Patients with a positive Spurling's sign can present with a variety of symptoms, including pain, numbness and weakness. In addition to the clinical history, the neurological examination may show signs suggesting a cervical  radiculopathy .


The Spurling test is used during a spinal or neck examination to aid in the diagnosis and assessment of cervical radiculopathy. It should be used to assess patients with radicular symptoms. The results of this test can guide a clinician when considering further imaging and necessary steps needed to make a proper diagnosis.


However, caution should be used when assessing patients with acute cervical injuries, critically ill patients, and those with other neoplastic or infectious processes. Cervical instability is also a reason to avoid performing this medical maneuver.


Spurling's test is somewhat specific when used for individuals with an abnormal  electromyogram study  and is a relatively sensitive physical examination maneuver in diagnosing  cervical spondylosis  or acute cervical radiculopathy. It is not a very sensitive test when used for individuals without classic radicular signs suggestive of cervical radiculopathy. [ citation needed ]   In 2011, one study evaluated 257 patients with clinical cervical radiculopathy and correlated  CT scan  findings with clinical exam findings using the Spurling's test. The Spurling's test was 95% sensitive and 94% specific for diagnosing nerve root pathology. [ 2 ]


In another study done in the late 1900s, 255 patients were examined using a Spurling test and afterwards received an electrodiagnostic examination. The study results showed the Spurling test was 30% sensitive, and 93% specific for finding cervical radiculopathy diagnosed by electrodiagnostic examination. The conclusions drawn from this study demonstrate clinical utility of the Spurling test to confirm cervical radiculopathy rather than for screening purposes. Overall, there continues to be limited data on the specificity and sensitivity of the Spurling test. [ 3 ]


The  sulcus sign  is an  orthopedic  evaluation test for  glenohumeral  instability of the shoulder.  With the arm straight and relaxed to the side of the patient, the elbow is grasped and traction is applied in an  inferior  direction.  With excessive inferior translation, a depression occurs just below the  acromion .  The appearance of this sulcus is a positive sign. [ 1 ]


This  medical sign  article is a  stub . You can help Wikipedia by  expanding it .


Tenodesis grasp and release  is an  orthopedic  observation of a passive  hand grasp  and release mechanism, affected by  wrist extension  or  flexion , respectively.   It is caused by the manner of attachment of the finger tendons to the bones and the passive tension created by two-joint muscles used to produce a functional movement or task (tenodesis). [ 1 ]   Moving the wrist in extension or flexion will cause the fingers to curl or grip when the wrist is extended, and to straighten or release when the wrist is flexed. [ 2 ] [ 3 ]


The tenodesis grip and release mechanism is used in occupational therapy, [ 4 ]  physical therapy [ 5 ] [ 4 ]  and rehabilitation of fine motor impairment, typically various levels of spinal paralysis, [ 6 ] [ 7 ]  and in kinesiology and sports mechanics that are concerned with efficient grasp and release mechanics.  Wrist extension is noted for bat grip in baseball. [ 8 ]    Wrist extension is also noted in the form of grip used in most schools of Japanese swordsmanship or  kenjutsu .


This particular function serves to enhance gripping capabilities for individuals with tetraplegia exhibiting wrist extension against gravity but lacking active finger functionality (C6 Motor Level). The active wrist extension, when initiated, draws the fingers and thumb into a flexed position passively. Acquiring tenodesis function is crucial for enabling task execution, as it allows for the passive holding of objects between the thumb and index finger or within the palm. [ 9 ]  People with tetraplegia devise adaptive approaches to optimize the utility of their hands. Many individuals create alternative techniques to carry out their daily activities. One such strategy involves leveraging the impact of gravity to enhance grasping capabilities. This adjustment is inherent in the tenodesis grasp, where the hand is often opened through wrist flexion assisted by gravity, reflecting a reliance on this natural force. [ 10 ]


The tenodesis grasp entails extending the wrist (specifically the extensor carpi radialis longus and brevis), leading to two distinct types of grips: a passive whole hand grasp attributed to the shortening of finger flexors and a passive lateral grip resulting from the shortening of the flexor pollicis longus. [ 11 ]


There are a number of ways that a patient in a rehabilitation or healthcare setting can optimize their tenodesis Grasp to boost their independence after a spinal cord injury. A physical therapy or occupational therapy professional may guide the patient in the following ways:


The use of an effective tenodesis grasp after a spinal cord injury can have a substantial impact on the activities of daily living for a patient after suffering a spinal cord injury. The majority of individuals with tetraplegia opt against undergoing surgical reconstruction for hand function, relying instead on the inherent passive properties of their musculoskeletal system to carry out functional tasks. [ 10 ]


The following  outline  is provided as an overview of and topical guide to trauma and orthopaedics:


Orthopedic surgery  – branch of  surgery  concerned with conditions involving the  musculoskeletal system .  Orthopedic surgeons  use both surgical and nonsurgical means to treat  musculoskeletal injuries ,  sports injuries , degenerative diseases, infections,  bone tumours , and  congenital limb deformities .   Trauma surgery  and  traumatology  is a sub-specialty dealing with the operative management of  fractures ,  major trauma  and the multiply-injured patient.


History of trauma and orthopaedics


Pet orthotics  refers to the use of  orthotics  for  pets .  Orthotics  is an allied health care field concerned with the design, development, fitting, and manufacture of orthoses. Orthoses, sometimes called braces or splints, are devices that support or correct musculoskeletal deformities and/or abnormalities of the body.


Animals that might benefit from the use of an orthosis commonly have an injury to a lower limb or paw, such as a fracture, torn  meniscus , ruptured  Achilles tendon , or injured  cruciate ligament  (ACL or CCL). They may also have an orthopedic condition due to arthritis, spinal cord injury, or a  congenital abnormality . Animals that have used orthoses and  prostheses  (artificial limbs) include dogs, cats, horses, llamas, and an orangutan. Each animal's situation is unique and should be evaluated by a  veterinarian . [ 1 ]


Orthoses can decrease pain and increase stability in an  unstable joint , as well as prevent potential progression or development of a deformity or contracture. An orthosis will prevent, control or even assist the motion of a joint, depending upon how it is made. An orthosis can be made for short-term use during a post-operative healing period, for example, or for long-term chronic use. [ 2 ]  They can provide a good quality of life for an animal that might otherwise have to be euthanized. [ 3 ]


With a few exceptions, orthoses for animals are custom-made from a  cast . They are typically formed from lightweight plastic or carbon fiber material with a comfort liner inside and velcro to hold them in place. They may have solid joints or hinged joints. [ 4 ]


An orthotic differs from a prosthetic in that a prosthetic completely replaces a missing limb or body part, whereas an orthotic is an external device that is meant to help support or protect a limb or body part.


The most common orthotic, especially for dogs, are  booties . They have a wide range of uses for the dog, including traction while getting up or walking on slippery surfaces such as hardwood or tile flooring. They can especially help dogs with hip issues and dogs with neurological conditions who are less aware of their self-movement ( proprioception ). [ 5 ]


Another form of orthotic is a leg brace that can improve stabilization for issues caused by age, worn-out bones in the foot, or  ectrodactyly . This is the deficiency of one or more central digits of the foot, causing the animal's foot to become deformed. Proper support is necessary or more serious health issues can arise in the future. [ 6 ]


Malpositions should be corrected as early as possible. The sooner the problem is resolved, and the younger the animal, the easier and faster a correction using dog  braces  or other methods is possible since the bones are still remodeled due to the growth. The misaligned teeth are often congenital, i.e., the causes are genetic. They are already visible in the young dog, e.g., excess teeth,  deciduous teeth  that have not failed, or jaw malformations. As with humans, there are also braces or other appliances for orthodontic treatment in dogs. With the help of these methods, teeth in the jaw, for example, can be realigned and thus integrated into the healthy row of teeth. There are different systems of dog braces. [ 7 ]


When looking at purchasing or constructing an orthotic for a pet, several factors must be taken into consideration to ensure the animal's health and wellness. These include how the orthotic sits on the body, the material being used, and the functionality of the product. The fit is also important for prosthetics for the area of attachment so it is comfortable and does not cause irritation to the skin. Material is also a consideration: if the skin is irritated or damaged, it can have a greater impact on the animal than if it were not wearing the orthotic at all, in some cases. The functionality of the orthotic affects both owner and pet. An orthotic or a prosthetic needs to be monitored regularly. Orthotics need to be removed several times daily to check the condition of the skin. For this reason, it is better if they are easier to take on and off, both in terms of ease and in avoiding irritation to the skin by removing or putting on the orthotic in a cumbersome way. It also helps the pet to stay calm if it is not such a laborious task. For functionality, the product itself and how it will serve the pet are important considerations. An orthotic that interferes with the pet's daily life and  range of motion  is problematic. Even if the pet wears it while standing, it might not function well enough when trying to get up from lying down. The orthotic must also be kept clean, both from dirt from everyday activities and sweat build-up, and if the pet gets dirty. [ 8 ] [ 9 ]