• Knee-Ankle-Foot Orthosis:


Individuals with more extensive paralysis or limb deformity may benefit

from KAFOs, which consist of a shoe, foundaAon, ankle control, knee
control, and superstructure. KAFOs oCen include foot control. The shoe,
foundaAon, ankle control, and foot control of the KAFO may be selected
from the components already described. PaAents with poliomyeliAs who
wore carbon-composite KAFOs walked beFer than with leather/metal or
plasAc/ metal KAFOs.84-86 Donning a plasAc and metal KAFO 

is appreciably faster than puMng on a metal and leather orthosis because
the shoe can be separated from the rest of the orthosis. Knee Control The
simplest knee joint is a hinge. Because most KAFOs include a pair of
uprights, the orthosis has a pair of knee hinges that provide medial–
lateral and hyperextension restricAon while permiMng knee flexion. The
offset joint (Fig. 30.25 [leC and middle]) is a hinge placed posterior to the
midline of the leg. When the wearer stands and walks on a level surface,
the individual’s weight line falls anterior to the offset joint, stabilizing the
knee in extension during the early stance phase of gait. The offset joint
does not hamper knee flexion during swing or siMng. The joint may,
however, flex inadvertently when the wearer walks on ramps. The most
common knee control is the drop ring lock (Fig. 30.25 [right]). When the
client stands with the knee fully extended, the ring drops, prevenAng the
uprights from bending. Although both medial and lateral joints should be
locked for maximum stability, manipulaAng a pair of drop ring locks is
inconvenient, unless each upright is equipped with a spring-loaded
retenAon buFon. The buFon permits the wearer to unlock one upright,
then aFend to the other one without having the first lock drop. The
buFons also enable the physical therapist to give the paAent a trial period
of walking with the knee joints unlocked. The pawl lock with bail release
(Fig. 30.26) provides simultaneous locking of both uprights. The pawl is a
spring-loaded projecAon that fits into a notched disk. The paAent unlocks
the brace by pulling upward on the

posterior bail. Some people are agile enough to be able to nudge the bail
by pressing it against a chair. The bail is bulky and may release the locks
unexpectedly if the wearer is jostled against a rigid object. The offset joint
and knee joints with basic drop ring or pawl locks are contraindicated in
the presence of knee flexion contracture. If one cannot achieve full
passive knee extension, an adjustable knee joint such as the fan lock,
serrated lock (Fig. 30.27), or ratchet lock is required. Such joints usually
have a drop ring lock for stability in the parAally flexed aMtude.



or an anterior band or strap that completes the threepoint pressure
system necessary for stability. The cap or band applies a posteriorly
directed force to complement the anteriorly directed forces from the back
of the shoe and the thigh band. The leather knee cap has four straps
buckled to both uprights above and below the knee. The knee cap
requires the paAent to buckle two straps when donning the orthosis.
When the straps are Aght enough to stabilize the knee, the cap is likely to
restrict flexion when the wearer sits. A more pracAcal alternaAve is a rigid
anterior band, either a preAbial band or a suprapatellar band, both of
which apply posteriorly directed force, but do not interfere with siMng
and are easier to don. The bands generally are molded of plasAc and thus
not readily adjustable. The prepatellar band rests over the bony proximal
porAon of the leg and requires careful contouring to be comfortable. The
suprapatellar band fits over the fleshy anterodistal thigh. Examples of
combined metal and plasAc KAFOs are presented in Fig. 30.28 (B and C).
Another means of obtaining sagiFal stability involves a KAFO with an
electronic stance control mechanism that prevents knee flexion during
stance phase and permits knee flexion during swing phase. By moving a
lever on the side of the joint, the paAent can select the mode of acAon:
(1) stance control that is disengaged during swing phase, (2) no stance
control, and (3) lock in full extension. Preliminary invesAgaAon indicates
that adults with LE paralysis walked faster and more efficiently, with
increased cadence and step length, and fewer compensatory trunk
movements, as compared with use of a locked KAFO.87-95 KAFOs with
computer-controlled knee joints are also available96 (Fig. 30.29). A KAFO
with electronic knee control enables some paAents with stroke and other
neuropathies to walk97 (Fig. 30.30).

Frontal plane control may be achieved with plasAc calf shells shaped to
apply correcAve force for genu valgum or genu varum. To reduce genu
 valgum, the medial porAon of the shell extends proximally in order to
apply laterally directed force at the knee. The semirigid shell is more
effecAve than a valgum correcAon strap, which is a knee cap with a fiCh
strap designed to be buckled around the lateral upright. The opposite
force applicaAon is indicated for the paAent who has genu varum. The
shell does not require Ame in donning and applies force over a broad area
without impinging on the popliteal fossa. Superstructure Thigh bands
provide structural stability to the orthosis. If the distal porAon of the limb
cannot tolerate full weight-bearing, then the proximal thigh band may be
shaped to form a weight-bearing brim. To eliminate all weight-bearing
through the lower extremity, the orthosis must include a weight-bearing
brim, a locked knee joint, and a paFen boFom. The paFen is a distal
extension that keeps the foot on the braced side off the floor (Fig. 30.31).
To maintain a level pelvis, the paAent must also wear a liC on the opposite
shoe; the height of the liC should equal the height of the paFen.

Reference: Physical Rehabilita.on. Susan B. O'Sullivan PT EdD ; TherapeuAc

Exercise: FoundaAons and Techniques. Carolyn Kisner PT MS.