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ADJUSTABLE HIP ORTHOSIS

Presented by Guided by
SHANTHINI. A Mr. Arul Thomas
DPO Second year, Course coordinator
CMC, Vellore. P&O CMC,Vellore.




ABSTRACT



This orthosis designed for congenital dysplasia of hip and it is a ball and socket hip
joint. I hope the design will help the patient for the normal gait.


It allows every normal movement similar to anatomical hip joint and its having
a adjustable mechanism. This is not available in the existing model.

















1. INTRODUCTION


Orthotic Hip Joint for congenital hip dysplasia:

This Orthotic hip joint is mainly prescribed for the congenital hip dislocation.
Function of this orthosis is support and encourage the hip joint movement and
allowing the normal gait. The hip joint can be repositioned (head of the femur is
placed to seat in the acetabulum cavity) while abduct the hip joint.

Indication:
Congenital hip dysplasia ..
Hip sublaxation
Progressive contractures of all spastic muscles.


Adjustable hip orthosis:

Adjustable hip orthosis for congenital hip dislocation it will allow flexion,
extension, abduction, internal and external rotation like our normal anatomical hip
joint.

Existing orthosis have flexion extension and abduction movements only; in this
orthosis we can achieve all the movements so its works to support normal gait and
movement & its having adjustable components mechanism in pelvic band and
both thigh shell region so its helps to use long time.


ANATOMY OF HIP JOINT

HIP JOINT
Hip joint is unique in having a high degree of stability and mobility.

TYPES Synovial joint, ball and socket variety.








BONES
Articulating ends
Proximally Acetabulum of hip bone. The labrum acetabulare, a
fibrocartilaginous rim is attached to the margin of the acetabulum.
Distally- head of femur











LIGAMENTS
1. Capsule
2. Transverse ligament.
3. Round ligament of the head of femur
4. Iliofemoral ligament. (it is the strongest ligament in the boby).
5. Pubofemoral ligament
6. Ischiofemoral ligament






Intracapsular ligament. Left hip joint from within pelvis with acetabular floor
removed (left); right hip joint with capsule removed, anterior aspect (right).

The hip joint is reinforced by five ligaments, of which four are extracapsular
and one intracapsular.The extracapsular ligaments are the iliofemoral,
The hip joint is reinforced by five ligaments, of which four are extracapsular
and one intracapsular.The extracapsular ligaments are the iliofemoral,
ischiofemoral, and pubofemoral ligaments attached to the bones of the pelvis (the
ilium, ischium, and pubis respectively). All three strengthen the capsule and
prevent an excessive range of movement in the joint. Of these, the Y-shaped and
twisted iliofemoral ligament is the strongest ligament in the human body.

In the
upright position, it prevents the trunk from falling backward without the need for
muscular activity. In the sitting position, it becomes relaxed, thus permitting the
pelvis to tilt backward into its sitting position.
The ischiofemoral ligament prevents medial rotation while the pubofemoral
ligament restricts abduction in the hip joint. The zona orbicularis, which lies like a
collar around the narrowest part of the femoral neck, is covered by the other
ligaments which partly radiates into it. The zona orbicularis acts like a buttonhole
on the femoral head and assists in maintaining the contact in the joint.
The intracapsular ligament, the ligamentum teres, is attached to a depression
in the acetabulum (the acetabular notch) and a depression on the femoral head (the
fovea of the head). It is only stretched when the hip is dislocated, and may then
prevent further displacement. It is not that important as a ligament but can often be
vitally important as a conduit of a small artery to the head of the femur. This
arterial branch is not present in everyone but can become the only blood supply to
the bone in the head of the femur when the neck of the femur is fractured or
disrupted by injury in childhood.





MOVEMENTS


Movements Muscles responsible for the movements
1. Extension - Gluteus maximus, hamstrings.
2. Flexion - ijiacus, psoas major.
3. Abduction - Gluteus medius, gluteus minimus.
4. Lateral rotation - Piriformis, gamely, obdurate externs and
interns, quadrates femoras.
5. Medial rotation - Gluteus medius and minimus.


The hip muscles act on three mutually perpendicular main axes, all of which pass
through the center of the femoral head, resulting in three degrees of freedom and
three pair of principal directions: Flexion and extension around a transverse axis
(left-right); lateral rotation and medial rotation around a longitudinal axis (along
the thigh); and abduction and adduction around a sagittal axis (forward-backward);
and a combination of these movements (i.e. circumduction, a compound movement
in which the leg describes the surface of an irregular cone). It should be noted that
some of the hip muscles also act on either the vertebral joints or the knee joint, that
with their extensive areas of origin and/or insertion, different part of individual
muscles participate in very different movements, and that the range of movement
varies with the position of the hip joint. Additionally, the inferior and superior
gemelli may be termed triceps coxae together with the obturator internus, and their
function simply is to assist the latter muscle.
The movements of the hip joint is thus performed by a series of muscles which
are here presented in order of importance

with the range of motion from the
neutral zero-degree position indicated:

Lateral or external rotation (30 with the hip extended, 50 with the hip
flexed): gluteus maximus; quadratus femoris; obturator internus; dorsal
fibers of gluteus medius and minimus; iliopsoas (including psoas major from
the vertebra

column); obturator externus; adductor magnus, longus, brevis, and minimus;
piriformis; and sartorius.

Medial or internal rotation (40): anterior fibers of gluteus medius and
minimus; tensor fascia latae; the part of adductor magnus inserted into the
adductor tubercle; and, with the leg abducted also the pectineus.

Extension or retroversion (20): gluteus maximus (if put out of action,
active standing from a sitting position is not possible, but standing and
walking on a flat surface is); dorsal fibers of gluteus medius and minimus;
adductor magnus; and piriformis. Additionally, the following thigh muscles
extend the hip: semimembranosus, semitendinosus, and long head of biceps
femoris.

Flexion or anteversion (140): iliopsoas (with psoas major from vertebral
column); tensor fascia latae, pectineus, adductor longus, adductor brevis, and
gracilis. Thigh muscles acting as hip flexors: rectus femoris and sartorius.

Abduction (50 with hip extended, 80 with hip flexed): gluteus medius;
tensor fascia latae; gluteus maximus with its attachment at the fascia lata;
gluteus minimus; piriformis; and obturator internus.

Adduction (30 with hip extended, 20 with hip flexed): adductor magnus
with adductor minimus; adductor longus, adductor brevis, gluteus maximus
with its attachment at the gluteal tuberosity; gracilis (extends to the tibia);
pectineus, quadratus femoris; and obturator externus. Of the thigh muscles,
semitendinosus is especially involved in hip adduction.

ARTICULATION



Radiograph of a normal human hip joint
The hip joint is a synovial joint formed by the articulation of the rounded
head of the femur and the cup-like acetabulum of the pelvis. It forms the primary
connection between the bones of the lower limb and the axial skeleton of the trunk
and pelvis. Both joint surfaces are covered with a strong but lubricated layer called
articular hyaline cartilage. The cuplike acetabulum forms at the union of three
pelvic bones the Ilium, pubis, and Ischium.


The Y-shaped growth plate that separates them, the triradiate cartilage, is
fused definitively at ages 14-16.

It is a special type of spheroidal or ball and socket
joint where the roughly spherical femoral head is largely contained within the
acetabulum and has an average radius of curvature of 2.5 cm. The acetabulum
grasps almost half the femoral ball, a grip augmented by a ring-shaped fibro
cartilaginous lip, the acetabular labrum, which extends the joint beyond the
equator.

The head of the femur is attached to the shaft by a thin neck region that is
often prone to fracture in the elderly, which is mainly due to the degenerative
effects of osteoporosis.


The acetabulum is oriented inferiorly, laterally and anteriorly, while the femoral
neck is directed superiorly, medially, and anteriorly.
The transverse angle of the acetabular inlet can be determined by measuring
the angle between a line passing from the superior to the inferior acetabular rim
and the horizontal plane; an angle which normally measures 51 at birth and 40 in
adults, and which affects the acetabular lateral coverage of the femoral head and
several other parameters.
The sagittal angle of the acetabular inlet measures 7 at birth
and increases to 17 in adults.




Transverse and sagittal angles of acetabular
inlet plane.



Femoral neck angle:
The angle between the longitudinal axes of the femoral neck and shaft, called
the caput-collum-diaphyseal angle or CCD angle, normally measures
approximately 150 in newborn and 126 in adults (coxa norma).

An
abnormally small angle is known as coxa vara and an abnormally large angle as
coxa valga.

Because a change in shape of the femur naturally affects the knee, coxa
valga is often combined with genu varum (bow-leggedness), while coxa vara
leads to genu valgum (knock-knees).
Changes in trabecular patterns due to altered CCD angle. Coxa valga leads to
more compression trabeculae, coxa vara to more tension trabeculae.
[9]

A change in CCD angle is the result of changes in the stress patterns applied to
the hip joint. Such changes, caused for example by a dislocation, changes the
trabecular patterns inside the bones. Two continuous trabecular systems emerging
on auricular surface of the sacroiliac joint meander and criss-cross each other down
through the hip bone, the femoral head, neck, and shaft.
In the hip bone, one system arises on the upper part of auricular surface to
converge onto the posterior surface of the greater sciatic notch, from where
its trabeculae are reflected to the inferior part of the acetabulum. The other
system emerges on the lower part of the auricular surface, converges at the
level of the superior gluteal line, and is reflected laterally onto the upper part
of the acetabulum.
In the femur, the first system lines up with a system arising from the lateral
part of the femoral shaft to stretch to the inferior portion of the femoral neck
and head. The other system lines up with a system in the femur stretching
from the medial part of the femoral shaft to the superior part of the femoral
head.

On the lateral side of the hip joint the fascia lata is strengthened to form the
iliotibial tract which functions as a tension band and reduces the bending
loads on the proximal part of the femur.









BIOMECHANICS OF THE HIP

The importance of the normal hip in any athletic activity IS emphasized by
the role this joint plays in movement and weight-bearing. An understanding of the
biomechanics of the hip is vital to advancing the diagnosis and treatment of many
pathologic conditions. Some areas that have benefited from advances in hip
biomechanics include the evaluation of joint function. The development of
therapeutic programs for treatment of joint problems, procedures for planning
reconstructive surgeries and the design and development of total hip prostheses
[19]. Biomechanical principles also provide a valuable perspective to our
understanding of the mechanism of injury.

TWO-DIMENSIONAL ANALYSIS OF JOINT FORCES AT THE HIP
JOINT
Basic analytical approaches to the balance of forces and moments about the
hip joint can be useful in estimating the effects of alterations in joint anatomy or
different treatment modalities on the hip joint reaction force. The static loading of
the hip joint has been frequently approximated with a simplified, two dimensional
analysis performed in thefrontal plane. When the weight of the body is being borne
on both legs, the centre of gravity is centred between the two hips and its force is
exerted equally on both hips. Under these loading conditions, the weight of the
body minus the weight of both lgs is supported equally on the femoral heads, and
the resultant vectors are vertical




In a single leg stance, the effective centre of gravity moves distally and
away from the supporting leg since the nonsupporting leg is now calculated as part
of the body mass acting upon the weight-bearing hip. This downward force exerts
a turning motion around the centre of the femoral head the moment is created by
the body weight, K, and its moment arm, a (distance from femur to the centre of
gravity). The muscles that resist this movement are offset by the combined
abductor muscles, M. This group of muscles includes the upper fibres of the
gluteus maximus

he tensor fascia lata, the gluteus medius and minimus, and the piriformis and
obturator internus. The force of the abductor muscles also creates a moment around
the centre of the femoral head; however this moment arm is considerably shorter
than the effective lever arm of body weight. Therefore the combined force of the
abductors must be a multiple of body weight.

The magnitude of the forces depends critically on the lever arm ratio, which is that
ratio between the body weight moment arm and the abductor muscle moment arm
(a:b) Typical levels for single leg stance are three times Body weight,
corresponding to a level ratio of 2.5. Thus, anything that increases the lever arm
ratio also increases the abductor muscle force required for gait and consequently
the
Force on the head of the femur as well (see Fig. 4). People with short femoral
necks have higher hip forces, other things being equal. More significantly people
with a wide pelvis also have larger hip forces. This tendency means that women
have larger hip forces than men because their pelvis must accommodate a birth
canal [21]. This fact may be one reason that women have relatively more hip
fractures and hip replacements because of arthritis than men do. It is also
Conceivable that this places women at a biomechanical disadvantage with respect
to some athletic activities, although studies do not always show gender differences
in
The biomechanics of running, particularly endurance running




Normally the tissues and bones of the hip joint function without causing
pain, but various diseases and injuries can damage the tissues so that the
deformations associated with loading are painful [20]. Management of painful hip
disorders aim to reduce the joint reaction force. Bearing in mind the basic
principles outlined above, this can be achieved by reducing the body weight or its
moment arm, or helping the abductor force or its moment arm. Increases in
Body weight will have a particularly harmful effect on the total compressive forces
applied to the joint. The effective loading of the joint can be significantly reduced
by bringing the center of gravity closer to the centre of the femoral head
(Decrease the moment arm b). This can be accomplished by limping, however the
lateral movements required take considerable amount of energy and is a much less
efficient means of ambulation. Another strategy to reduce joint reaction force
involves using a cane or walking stick in the opposite hand. The moment produced
from both the cane and abductor muscles together produce a moment equal and
Opposite to that produced by the effective body weight. The two-dimensional
static analysis indicates that the joint reaction force can be reduced by 50% (from 3
times. Use of cane on the unaffected side. While this lengthens the level arm of the
load (the partial body weight), it also provides a force (the cane) which counteracts
the body load at the end of that level arm. body weight to 1.5 times body weight)
when approximately15% body weight is applied to the cane [19]. The substantial
reduction in the joint reaction force, predicted when a cane is used for support
arises because the cane-ground reaction force acts at a much larger distance from
the centre of the hip than the abductor muscles. Thus, even when a relatively small
load is applied to the cane, the contribution it makes to the moment opposing body
weight is large enough to significantly decrease the demand placed on the abductor
muscles.

MEASUREMENTS OF JOINT FORCES AT THE HIP
Walking transmits significant body weight to the hip joint, while jogging,
running and contact sports generate forces significantly greater. To verify the
estimates of hip joint forces made using free-body calculations, many in vivo
measurements have been carried out using prostheses and endoprostheses
instrumented with transducers (staingauges). Rydell was the first to attempt
measuring direct hip joint forces using an instrumented hip prosthesis [24]; which
yielded force magnitudes of 2.3 to 2.9 times body weight for single leg stance and
1.6 to 3.3 times body weight for level walking [25]. More extensive studies have
recently been carried out, which are summarised. These studies have shown that
although patients in the early postoperative period can execute planned activities of
daily living with relatively low joint contact forces, unexpected events such as
stumbling or periods of instability during single leg stance can generate resultant
forces in excess of eight times body weight [25]. It is important to remember that
although the data from hip prostheses have established the magnitude of the loads
acting on the hip joint, the patients in these studies have undergone total hip
replacement and therefore the results cannot be directly correlated to the
physiology of the normal hip.


PATHOANATOMY OF DEVELOPMENTALHIP
DYSPLASIA AND DISLOCATION

In the normal hip at birth, there is a tight fit between the femoral head and
the acetabulum .The femoral head is held in the acetabulum by the surface tension
created by the synovial fluid. In postmortem specimens, even after the capsule
is sectioned, it is very difficult to dislocate a normal infants hip. In developmental
hip dysplasia or dislocation, however, this tight fit is lost and the femoral head can
be made to glide in and out of the acetabulum with a palpable sensation, which
feels almost as if the head is gliding in and out over a ridge; this is known as the
Ortolani sign7,11,12. The majority of the abnormalities in developmental hip
dysplasia or dislocation are on the acetabular side. Changes on the femoral side are
secondary to anteversion and pressure changes on the head from the acetabulum or
ilium associated with the subluxation or dislocation. With growth and
development, however, acetabular growth is affected by the primary disease
(abnormal acetabular cartilage either primary or secondary to pressure changes
from the femoral head and neck) and any growth alterations incurred from
secondary acetabular procedures. Proximal femoral anatomic abnormalities are
generally secondary to growth disturbances incurred from treatment. At birth, the
pathological findings in developmental hip dysplasia or dislocation range from
mild capsular laxity to severe dysplastic changes13. The typical dysplastic hip has
a ridge in the superior-posterior and inferior aspects of the acetabulum. This ridge,
or neolimbus, as described by Ortolani is composed of very cellular hyaline
cartilage13. It is over this ridge that the femoral head glides in and out of the
acetabulum, producing the palpable sensation known as the Ortolani sign. In most
newborns with developmental hip dysplasia or dislocation, the labrum is everted.
There is empiric evidence (such as the 95% success rate of devices like a Pavlik
harness) that these pathological changes are reversible.
























STATEMENT OF PROBLEM


DEFINITION :
The patient having hip dislocation or sub laxation of hip. This is due to
the congenital problem at the time of birth.


CAUSES:
Risk Factors
1/1,000 born with dislocated hip
10/10,000 born with subluxation or dysplasia
80% Female
First born children
Family history (6% one affected child, 12% one affected parent, 36% one
child + one parent)
Oligohydramnios

CAUSES OF GENERAL SYMPTOM TYPES

Embryonic
7th week - acetabulum and hip formed from same mesenchymal cells
11th week - complete separation between the two
Prox fem ossific nucleus - 4-7 months




:

DIAGNOSIS
Ortolanis and Barlows maneuvers with a thorough history and physical
Warm, quiet environment with removal of diaper
Head to toe exam to detect any associated conditons (Torticollis,
Ligamentous Laxity etc.)
Baseline Neuro and Spine Exam
Key physical findings of hip dislocation
Asymmetry
Limb length- Galeazzi
Abduction ROM
Skin folds
Limp
Waddilng gait / hyperlordosis - bilateral involvement


TREATMENT:

Regular follow up by the doctors.
Regular muscle strengthening.
Surgery
using orthosis.




DESIGN OF THE ORTHOSIS


It is ball and socket hip joint.
It maintains hip in abduction and external rotation so therefore it corrects the
hip dislocation therefore its a anatomical hip joint.
It is having adjustable mechanism in pelvic band and in both thigh shells.
So we can use this orthosis for long period.



















FABRICATION PROCEDURE OF ADJUSTABLE
HIP ORTHOSIS

MATERIALS REQUIRED

S. no. Nomenclature Specification Quantity
1 Pop bandage 4 3
2 Pp Sheet 3mm 20 *20
3 Ethaflux 5mm 15*15
4 Pop 1 kg
5 Velcro (hook and loop) 1 40
6 Leather ( lining) 20 *20
7 Pelvic band 1 1 no
8 O ring 1 5 no
9 Copper rivet 1/8 8 no
10 Aluminum rivet 1/8 10 no
11 Washer 1/8 15 no
12 Aluminum flat 1*1/8 20





Marking Area
Anterior superior iliac spine (ASIS)
Greater trochanter (GT)
Any bony land marks
Casting procedure
Wrap the pop bandage in the thigh and thigh should maintain in a extension
position.
Modification
Add the pop in any bony prominent
Smoothened the mold.
Sheet draping
3mm pp sheet
Drape the sheet by using vacuum forming method
The seeming should be I anterior side.
Trim line
Just cover the of thigh
Cut the anterior wall.
Joint fixing
After finished the pelvic band and thigh shell fabrication fix the hip joint.
The upper and lower upright is help to support the pelvic band and thigh
shell and connection of hip joint.

Trial
Hip us maintained in abduction & external rotation
Thigh is maintained in extension

Final Finishing
After the trial we start to finish the orthosis proper padding orthosis should
be cosmetically and functionally good, Straps are attached for easy donning
& doffing
Working Principle
It maintains the hip in abduction so that the head of femur goes inside and
works a normal hip joint.


















ADVANTAGES AND DISADVANTAGES


ADVANTAGES
It is a supportive and functional device
Low cost
Easy maintenances
Easy donning and doffing
DISADVANTES
Need more maintenance
Workman ship is more
















INDICATION
For congenital dysplasia of hip
Hip sub laxation



CONTRAINDICATION
Scissoring gait
Hip bone and femur fracture
Hip contracture















CONCLUSION

Already there are many orthosis available but each having some short
coming but my orthosis adjustable hip orthosis will satisfy the patient
expectation and better functions.
This model is having adjustable mechanism in pelvic band and in both thigh
shells. So it helps to adjust in height and circumferential manner.
So it helps to use for long period.


















FUTURE PLAN

I hope this orthosis it is help for patient whos having congenital dysplasia of
hip and tried over the patient soon and I will get a successful out come from
this orthosis.























REFRENCES

Prosthetics and orthotics in rehabilitation second edition
Journal of Prosthetics and orthotics
Journal of rehabilitation and development

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