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Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
0868
/002
0
9/20
06
200
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoestmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Table of contents
Foreword 2Introduction 4Choosingbetweendifferentdesigns 4Castingandrectification 51.FlexibleAFO 6
1.1MouldingofEVA 61.2Orthosistrimline 61.3Vacuummouldingofthepolypropylene 61.4Preparationofthepolypropyleneshell 71.5Preparationofthestraps 81.6Initialfittingandfinishing 8
2.RigidAFO 82.1MouldingofEVA 82.2Orthosistrimline 92.3Plasticreinforcement 122.4Vacuummouldingofthepolypropylene 132.5Preparationofthepolypropyleneshell 142.6Proximalstrap 142.7Distalstrap 152.8Instepstrap 162.9Initialfittingandfinishing 18
3.AFOwithTamarackFlexureJointTM 183.1MouldingofEVA 183.2Orthosistrimline 183.3Plasticreinforcement 183.4InstallationofTamarackFlexureJointTM 193.5Vacuummouldingofthepolypropylene 193.6Preparationofthepolypropyleneshell 203.7Preparationofthestraps 223.8Initialfittingandfinishing 22
4.AFOanti-talus(anteriorshell) 224.1MouldingofEVA 224.2Orthosistrimline 234.3Plasticreinforcement 244.4Vacuummouldingofthepolypropylene 244.5Preparationofthepolypropyleneshell 254.6Preparationofthestraps 264.7Initialfitting 264.8Finishing 26
Listofmanufacturingmaterials 27
� ICRC Physical Rehabi l i tat ion Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuseoftechnologythatisappropriatetothespecificcontextsinwhichtheorganizationoperates,i.e.,countriesaffectedbywarandlow-incomeordevelopingcountries.
Thetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountriesconcerned.
Thetechnologyadoptedmustthereforebe:
• durable,comfortable,easyforpatientstouseandmaintain;• easyfortechnicianstolearn,useandrepair;• standardizedbutcompatiblewiththeclimateindifferentregionsoftheworld;• low-costbutmodernandconsistentwithinternationallyacceptedstandards;• easilyavailable.
Thechoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitationservices.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-madeorthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhichtheorganizationworks.ThecostofthematerialsusedinICRCprostheticandorthoticdevicesislowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-madecomponents.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailablematerialssuchaswood,leatherandmetalwereused,andorthopaediccomponentsweremanufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthetechniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweentheprojects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprostheticsockets.Thefirstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponentssuchasvariousalignmentsystemswerefirstdevelopedinColombiaandgraduallyimproved.Inparallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowofpolypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,aftercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductioninordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Objective of the manuals
TheICRC’s“ManufacturingGuidelines”aredesignedtoprovidetheinformationnecessaryforproductionofhigh-qualityassistivedevices.
Themainaimsoftheseinformativemanualsareasfollows:
• TopromoteandenhancestandardizationofICRCpolypropylenetechnology;• Toprovidesupportfortrainingintheuseofthistechnology;• Topromotegoodpractice.
Thisisanotherstepforwardintheefforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRCAssistanceDivision/HealthUnitPhysicalRehabilitationProgramme
� ICRC Physical Rehabi l i tat ion Programme
Choosing between different designs
Withoutgoingintodetails,somefeaturesofdifferenttypesofAFOaresetoutbelowtoassistinthechoiceofdesign.
Flexible AFO• Dorsiflexionassistance• Poormedio-lateralstabilizationofthesubtalarjoint
Rigid AFO• Blocksanklemovements• Mediolateralstabilizationofthesubtalarjoint• Possibilityofcontrollingforefootadduction/abduction
AFO with Tamarack Flexure Joint TM
• Mediolateralstabilizationofthesubtalarjoint• Freeankledorsiflexion• Freeorrestrictedankleplantarflexion
AFO anti-talus• Blocksanklemovements.Particularlyefficientforpreventingankledorsiflexion• Poormediolateralstabilizationofthesubtalarjoint
Introduction
Theaimofthisdocumentistodescribeseveralmethodsformanufacturingankle-foot orthoses (AFO),workingwiththepolypropylenetechnologyusedattheICRC’sphysicalrehabilitationcentres.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
Casting and rectification
Patientassessment,castingandrectificationofpositivecastimpressionsareperformedinaccordancewithprostheticandorthotic(P&O)standards.
ForflexibleAFO,thecastcanbetakenwith5degreesofdorsiflexionsoastoprovideapreloadandensuresomespringaction.
� ICRC Physical Rehabi l i tat ion Programme
1.1 Moulding of EVA
AflexibleAFOdoesnotusuallyrequireanyEVA.However,incaseswhereitisnecessarytheproceduredescribedinsection2.1(page8)shouldbefollowed.
1.2 Orthosis trim line
Toachievethegoalofallowingdorsiflexionoftheanklewhilepreventingpassiveplantarflexion,thereareanumberofdesignoptions.
FlExIblE AFO1
4Markthetrimlineasfollows:
A Thetopishorizontal,2cmbelowthefibulahead.
B Attheankle,pass2cmbehindthetipofthemalleolitoallowflexionofthepolypropylene.
C Attheforefoot,leavethesidesofthetoesandtheheadofthemetatarsuscompletelyclearandpassthetrimlinebelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
Pullastockingovertheplastermodel.
1.3 Vacuum moulding of the polypropylene
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
� Calfcircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.(Seenextpicture.)
Thickness3mm,4mmor5mm,dependingonthepatient’sweight.
�
2
1
3
Manufac tur ing Guidel ines Ankle -Foot O r thosis
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconebymeansofaropeorsomethingsimilar.
Openthevacuumvalve.
4CutofftheexcessPPwithapairofscissorswhileitisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
1.4 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection1.2(page6).
Followingtheoutline,cuttheorthosiswithanoscillatingsaw.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
� ICRC Physical Rehabi l i tat ion Programme
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
1.5 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Adistalstrapmightbeneeded,dependingonthecapacityofthepatient’sshoetoholdthefootinsidetheorthosis.Ifthisisneeded,followtheproceduredescribedinsection2.7(page15).
1.6 Initial fitting and finishing
IfEVAisused,glueitpartiallyinsidetheorthosis.
TheinitialfittingisperformedaccordingtoP&Ostandards.
Carryouttherequiredmodificationonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
RIgId AFO2
2.1 Moulding of EVA
EVA(6mm)maybemouldedpriortothedrapingofthepolypropylene,forthefollowingreasons:• toimprovecomfort;• topreventskinbreakageinpatientswithsensationloss;• fororthosesusedatnight.
Followtheproceduredescribedbelowor,ifthecasedoesnotrequireEVA,goontothenextsection.
�Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Positiontheplastermodelwiththeforefootpointingdownwards.
MeasurementoftheEVAsheet:• width,instepcircumference;• length,thatoftheplastermodel
(leg+foot);• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAmanuallyovertheplastermodelandholditinplaceuntilithascooledcompletely.
4Cutofftheexcesswithacutterorapairofscissors.
StapletheEVAontothefrontoftheplastermodel.
2.2 Orthosis trim line
2.2.1 “Standard” trim line
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Attheankle,passtheline1cmanteriortothetipofthemalleoli.
C Attheforefoot,leavethesidesofthetoesandtheheadofthemetatarsuscompletelyclearandpassthetrimlinebelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
�0 ICRC Physical Rehabi l i tat ion Programme
2.2.2 Trim line to correct forefoot adduction
Forefootadductioniscommonincasesofclubfoot.
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Increasecoverageofthelateralmid-foot,passinginfrontofthecuboid,to enlarge the area of pressure.
C Attheforefoot,thelinemustbeproximaltothe5thmetatarsalhead.
D Decreasecoverageofthemedialmid-footatthenavicular/malleoli,to facilitate donning.
E Attheforefoot,coverthemedialsideofthemetatarsalheadandtoe,to correct forefoot adduction.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
2.2.3 Trim line to correct forefoot abduction
Forefootabductionisoftenseenincasesofcerebralpalsy.
4Markthetrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthefibulahead.
B Decreasecoverageatthelevelofthelateralmalleoli,to ease donning.
C Attheforefoot,thelinemustbedistaltothe5thmetatarsalhead,to avoid metatarsus abductus.
D Increasecoverageofthemedialmid-footatthelevelofthenavicular,to increase mid-foot support.
E Attheforefoot,thelinemustbeproximaltothe1stmetatarsalhead.
�� ICRC Physical Rehabi l i tat ion Programme
2.3 Plastic reinforcement
TheAFOmayneedreinforcement,especiallyatanklelevel.Ifnecessary,useoneofthefollowingmethods;otherwisegoontothenextsection.
2.3.1 double layer of polypropylene
4Asecondlayerofpolypropylenecoveringtheankleandthefootismouldedatthesametimeasthemainlayer.
Cutapieceofpolypropylene:• thickness,3mm;• width,instepcircumference;• length,footlength+10cm
Grindthelast3cmattheproximalendtograduallyreducethethicknessofthepolypropylene.
4Thetwolayersareheatedatthesametime.
Thereinforcementisplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperfectsealbetweenthetwo.
A double layer of polypropylene has the disadvantage of reducing flexibility of the forefoot in relation to the metatarso-phalangeal joint.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
2.3.2 Channels in the polypropylene
Thepresenceofchannelsintheplasticsignificantlyimprovesitsstrength.Thereareseveralwaysofmakingthesechannels.
4CuttwostripsofEVA:• thickness,6mm;• width,7mm;• length,15cm.
GrindbothdistalandproximalendstograduallyreducethethicknessoftheEVA.
Pullastockingovertheplastermodel.
Gluethestriplightlyontothestocking.
The more anterior the position of the channel, the more the AFO will resist dorsiflexion of the ankle.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
2.4 Vacuum moulding of the polypropylene
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efficiency, the EVA used to make channels in the polypropylene must not be covered with a stocking.
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsenceofadoublelayerofpolypropylene(section2.3.1,page12).
�� ICRC Physical Rehabi l i tat ion Programme
2.6 Proximal strap
Useaready-madeVelcrostrap40mmwide,ormakeastrapwithPerlonwebbingorsomeotherstrongmaterial.
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,1.5cmbelowtheproximaltrimline.
Theloopshouldbeplacedonthepolypropyleneandnotbeincontactwiththepatient’sleg.
2.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection2.2(page9).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperfectlyhorizontalbeforefixingit.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
4Fixthestrapwithalargetubularrivetonthelateralside.Makesurethestrapisperfectlyhorizontalbeforefixingit.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
2.7 distal strap
Youmustchoosebetweenadistalstrapandaninstepstrap.Thelatterhastheadvantageofholdingthecalcaneumfirmlyinsidetheorthosis(equinuscorrection).
UseaVelcrostrap25mmwide.
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,4cmabovethemalleoli.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
�� ICRC Physical Rehabi l i tat ion Programme
2.8 Instep strap
UseaVelcrostrap25mmwide.
Twotechniquesarepresented,dependingonwhetherthebackofthefootisinaneutralpositionorneedsavalgus/varuscorrection.
2.8.1 Neutral position
4Withalargetubularrivet,fixthebeltholdingthelooponthemedialside,atanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
4Insertthebeltthroughthelooptomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetonthelateralside,atthesameangleof45°.
Coverthesurfaceofthestrapincontact
withthepatient’slegwith3mmEVA.
2.8.2 Varus/valgus correction
Thestrapwillpassthroughaslotcutinthepolypropylene.
4Theslotiscutonthelateralsideforvaruscorrectionandonthemedialsideforvalguscorrection.
Markthepositionoftheslot40mmfromthebackofthefootandperpendiculartoalinedrawnatanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theslotshouldbe30mmlong.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Makeholesalongtheslotaxiswithadrillfittedwitha4mmbit.
4Withacutter,connecttheholeswitheachother.
Finally,smooththetrimlinewithafile.
4Theloopisplacedonthemedialsideforvaruscorrectionandonthelateralsideforvalguscorrection.
Fixthebeltholdingtheloopwithalargetubularrivet,atanangleof45°passingthroughtheposteriordistaltipofthecalcaneum.
Theloopshouldbeplacedoverthepolypropyleneandnotbeincontactwiththepatient’sleg.
4Insertthebeltthroughtheslotononesideandthroughtheloopontheothersidetomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetjustoutsidetheslot.
Coverthesurfaceofthestrapincontactwiththepatient’slegwith3mmEVA.
�� ICRC Physical Rehabi l i tat ion Programme
AFO wITh TAMARACk FlExuRE JOINT TM3
2.9 Initial fitting and finishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
3.1 Moulding of EVA
Followtheproceduredescribedinsection2.1(page8),orgoontothenextsectionifEVAisnotrequired.
3.2 Orthosis trim line
Followtheproceduredescribedinsection2.2.1(page9).
3.3 Plastic reinforcement
Posteriorreinforcementforgreaterplantarflexioncontrolisrequiredwhentheorthosisisintendedtopreventplantarflexion(notfullydescribedbelow).
Followtheproceduredescribedbelow,orgoontothenextsectionifplantarflexionisleftfree.
AsecondlayerofpolypropyleneforpositioningattheleveloftheAchillestendonismouldedatthesametimeasthemainlayer.
4Cutapieceofpolypropylene:• thickness,5mm;• width,2cm;• length,7cm.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Firstthereinforcement(heatedatthesametimeasthepolypropylene)isplacedontheplastermodel,thenthesecondlayerisvacuum-mouldedimmediatelytoobtainaperfectsealbetweenthetwolayers.
4UsethemouldingdummiestoformasnuglyfittingcavityfortheTamarackFlexureJointTM.
Nailthemverticallyontotheplastermodelsothatthemidpointislocatedontheankleaxis.
3.4 Installation of Tamarack Flexure JointTM
Ontheplastermodel,markthepositionofthejointaxis:• laterally,attheapexofthemalleoli;• medially,slightlyposteriortothedistaltipofthemalleoli.
Makesurethatthejointsareatthesamelevelonbothsides.
3.5 Vacuum moulding of the polypropylene
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsenceofaposteriorreinforcement(section3.3,page18).
Pullastocking(cottonstockinetistoothick)overtheplastermodel.
�0 ICRC Physical Rehabi l i tat ion Programme
3.6 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.2(page18).
Cutonlythecontouroftheorthosiswithanoscillatingsaw.Donotcutalongtheseparationbetweenfootsectionandcalfsection.
Removetheplasticshellfromtheplastermodel.
ExtractthemouldingdummiesandthestockingfrominsidetheAFO.
4Drawtheseparationlinebetweenthefootsectionandthecalfsection:• Markthemiddleofthecavitiescreated
bythedummies.• Drawa“V”anteriortothemidlineof
eachcavity.Ensurethatthe“V”doesnotextendbackwardspastthecentreofthecavity.
4ForAFOwith plantar flexion control,drawahorizontallineposteriortothemarksjoiningthetwosides.
4ForAFOwith free plantar flexion,drawa“V”posteriortothemidlineofeachcavity.Ensurethatthe“V”doesnotextendforwardpastthecentreofthecavity.
Correct Incorrect
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Drillholesatthedimplesleftbytheholesinthemouldingdummies:• 5mmforlargesize;• 4.5mmforsmallsize.
4Useathin-bladedsaw(1/16’’bladekerforless)toseparatethefootsectionfromthecalfsection.
Do not use an oscillating saw because too much material is lost along a ragged, wide cut line.
Smooththetrimlineedgewithahanddeburringtoolorapieceofglass.Do not grind the trim line because this will reduce flexure coverage and reduce the ability of the cavity to anchor and control the flexure effectively.
4InserttheTamarackFlexureJointTMandsecurewithmetalfastenersandanchoringscrews.
Dependingonthethicknessofthepolypropylene,itmaybenecessarytoadjustthelengthofthescrewsiftheendsprotrudeinsidetheAFO.
�� ICRC Physical Rehabi l i tat ion Programme
3.7 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection2.7(page15).
3.8 Initial fitting and finishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofftheexcessandsmooththetrimline.
Gluetheflexureanchoringscrewswitharemovablethread-lockingcompound(Loctite).
AFO ANTI-TAluS (ANTERIOR ShEll)4
4.1 Moulding of EVA
EVA(6mm)maybemouldedpriortodrapingofthepolypropylene:• toimprovecomfort;• topreventskinbreakageforpatientswithsensationloss.
Do not cover the foot, to avoid an increase of volume which may prevent the patient from wearing normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthecasedoesnotrequireEVA.
Positiontheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:• width,calfcircumference;• length,leglength;• thickness,6mm.
HeattheEVAat120°for3to5minutes,dependingontheefficiencyoftheoven.
DrapetheEVAovertheplastermodelmanuallyandholditinplaceuntilithascooledcompletely.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
4Cutofftheexcesswithacutterorapairofscissors.
Grindthedistaltrimlinetograduallyreduceitsthickness.
StapletheEVAontothebackoftheplastermodel.
4Marktheorthosistrimlineasfollows:
A Thetopmustbehorizontal,2cmbelowthetibialtubercle.
B Ontheleg,1cmposteriortothemid-line.
C Ontheankle,atthetopofthemalleolitofacilitatedonning.
D Ontheforefoot,clearthesidesandtopofthetoesandtheheadofthemetatarsuscompletely,passingbelowthem.This will allow the polypropylene to follow the movement of the metatarso-phalangeal joints.
4.2 Orthosis trim line
��
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3
ICRC Physical Rehabi l i tat ion Programme
4.3 Plastic reinforcement
Thepresenceofchannelsintheplasticsignificantlyimprovesitsstrength.Thereareseveralwaysofmakingthesechannels.
4CuttwostripsofEVA:• thickness,6mm;• width,10mm;• length,20cm.
Grindbothdistalandproximalendstograduallyreducetheirthickness.
Gluethestripsontotheplastermodel,1cmanteriortothelateralandmediallongitudinalaxes.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it may no longer fit into the patient’s shoe.
4.4 Vacuum moulding of the polypropylene
The procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do not try to make a single seam on the anterior side, because the creases gathering at the ankle will make it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efficiency the EVA used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
� Calfcircumference+10cm.� Instepcircumference+10cm.� Legandfootlength+10cm.
PPthickness:4mmor5mm,dependingonthepatient’sweight.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthepolypropyleneandtheefficiencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideandunderthefoot.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutofftheexcesswithapairofscissorswhilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
4.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection4.2(page23).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutofftheexcesswithapairofscissors.
�� ICRC Physical Rehabi l i tat ion Programme
4.7 Initial fitting
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TheinitialfittingisperformedinaccordancewithP&Ostandards.
4Itisoftennecessarytoflarethepolypropyleneattheposteriorpartoftheheelinordertofacilitatedonningandtoavoidpainfulcontactwiththeedgeoftheplastic.
4.6 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection2.7(page15).
4.8 Finishing
Carryouttherequiredmodificationsonthepolypropyleneandsmooththetrimline.
GluetheEVAinsidethepolypropylene,cutoffthesurplusandsmooththetrimline.
��Manufac tur ing Guidel ines Ankle -Foot O r thosis
ICRC Code Description Unit of measure Quantity
For negative and positive cast :ODROSTOCOT60 Tubular stockinet, 60 cm cm 70According to size:• MDREBANDP10• MDREBANDP12• MDREBANDP15
Plaster of Paris bandages10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As requiredFor EVA and plastic moulding :If required, according to colour:• OPLAEVAFERA06• OPLAEVAFLIV06• OPLAEVAFKIN06
EVA 6 mmTerra, olive or beige colour
Each As required
None Nylon stockinet Piece 1According to colour and thickness:• OPLAPOLYCHOC03• OPLAPOLYCHOC04• OPLAPOLYCHOC05• OPLAPOLYLIV03• OPLAPOLYLIV04• OPLAPOLYLIV05• OPLAPOLYSKIN03• OPLAPOLYSKIN04• OPLAPOLYSKIN05
HomopolymerTerra, olive or beige colour3, 4 or 5 mm thickness
Each As required
For the TAMARACK Flexure JointTM:According to size:• OCPOSOOTTAL• OCPOSOOTTAS
Large size (740L)Small size (740S)
Piece 1
EHDWGLUEL243 Glue, Loctite 243, blue, threadlock, 50-ml bottle As required 4For the proximal strap:OSBOSTRVP440 Strap, Velcro, PVC, with loop, brown, 400 x 40 mm Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
orOSBOVSBO30 Strap, polyester, black, 40 mm cm 25None Strap, Velcro, 40 mm cm 20None Loop, 40 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2For distal/instep strap:OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
orOSBOVSBO24 Strap, Perlon webbing, 25 mm cm 20None Strap, Velcro, 25 mm cm 15OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian principles. Established in 1863, the ICRC is at the origin of the International Red Cross and Red Crescent Movement.
Acknowledgements:
Jean François GallayLeo GasserPierre GauthierFrank JoumierJacques LepetitBernard MatagneJoel NiningerGuy NuryPeter PoetsmaHmayak Tarakhchyan
and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross19 Avenue de la Paix1202 Geneva, SwitzerlandT + 41 22 734 60 01 F + 41 22 733 20 57E-mail: [email protected]© ICRC, September 2006All photographs: ICRC/PRP
Physical Rehabilitation Programmeankle-Foot orthosis
Manufacturing guidelines
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