“Which pediatric orthoses stand up best to heavy use?”

Most of the pediatric braces that we do here are AFOs. We’re always tied between using either an RJ Industries off-the-shelf—you just take a few measurements and they have all different kinds of sizes—or a Cascade. They each have their pros and cons.

A nice part of the RJ is [that] if you have just a simple control issue with the foot, [and] if the patient has been traumatized a lot through just the doctor visits and stuff, it [allows us to] get as close to a custom [brace] as we can without ever having to cast the patient. That’s an excellent benefit that I’ve used numerous times in that [situation], just because the patient is already freaked out and nervous just from walking in the door.

For a custom [brace], I think Cascade is the best, hands down, just because of the options they provide. You can make it as durable as you need to with their options. You can make it [so the patient] can wear it without the shoe, with the shoe, [and] you can pad it to no end. That’s the advantage of the custom lines. Aaron P. James, CO
Four Corners Artificial Limb & Brace
Durango, Colo.

We do a fair amount of DAFOs, and there’s kind of a weight limit; you get up to a certain size and they’re going to crush those things down, or wrinkle the forefoot or crumple them a little bit. So we do a lot of bracing with Oklahoma joints and Arizona stops, and we do a ton of articulating DAFOs as well.

[When using] a 3/16 polypro with the Oklahoma [joints] and the Arizona stops, we generally don’t have much problem with those breaking down. Kids are really tough on things, and if we have someone that we know is just going to be brutal, we’ll do a double overlap mold to create the articulation. You can do that also with an Arizona stop.

With kids, you’re looking at a year or 18 months to replace [the orthoses], because they’re growing. Also, there are built-in features that allow the orthosis to grow a little bit with the child. For instance, if we have a toe crest, we make that removable, [so] it can be slid forward and repositioned.

There are a lot of therapists who want to do a wraparound design with a dynamic AFO. Those are a little more fragile because the plastic’s pulled so thin over the dorsum of the foot—if you have someone who’s crouching or just really rough on these, they can crumble a little bit easier.

So, all things being equal, a brace that has no joints at all, like a solid ankle, is going to hold up very well. But if it’s possible or desirable to give a child ankle motion, then we use Arizona stops and Oklahoma joints.
Jeff Fetherston, CPO
Akron Orthotic Solutions
Akron, Ohio

We make most of it in-house. We use other companies too, like DAFO for AFOs. We’ve used Orthomerica, their TC2 system, but when we go out-of-house, DAFO is usually who we go with. Becker also has a really good lab that we’ve had some success with.

[In-house] we just try to use polypropylene-designed AFOs. They seem to hold up just fine to heavy wear and tear.

 [With] some kids that are heavy, or kids with spina bifida, a lot of times we’ve seen better success with rigid laminated AFOs.
Christopher Dang, CPO
Human Designs Prosthetic & Orthotic Laboratory
Long Beach, Calif.

I would say the common solid AFO. We do everything in-house. That’s the way I like it because we have total control over the modification, the fabrication and the quality control.

With our system, we can manufacture a brace to the exact specifications that the orthotist needs. Say I’m modifying my own AFO and my technician pulls it—then I can actually be there during the time that he pulls it, ask him for certain stretches around wherever I need it, or to keep it thick in a certain area. Typically, I’m not there because I trust my techs so much, but if it’s an intricate case and I want something [specific], I will be there when the technician’s ready to pull it, just to make sure that it’s getting done exactly the way I want.

We’ve never really had a problem [with the plastic]. [We do a] visual inspection after we pull the brace, or during the process if we’re not getting enough vacuum on it. We have a set system of doing things. Our techs just pull plastic all day, and we have a head tech that oversees everything from the oven man’s work to the finishing man’s work. If there’s any problem, typically he will come to me and check if it’s okay.
Zsolt Zentai, CO
NOPCO of New Jersey
East Brunswick, N.J.