1. Handle
2. Screw Mechanism
3. Parallel guide tunnels
4. Guide sleeves to take various diameter guide wires
5. Femoral neck footplate with long horizontal rod
6. Femoral footplate with spikes
7. Screwdriver
8. Repositioning jig

Two wire guides are inserted through the guide sleeves and the distance between the pointed ends of the guide wire is adjusted using the screw mechanism. One revolution of the screw mechanism in a clockwise direction moves the guide wires closer to each other by one millimetre. Similarly, one revolution anti-clockwise direction diverges the guide wires by one millimetre.

The distance between the guide wire tips is set to the anteroposterior radius. The long horizontal bar of the footplate (5) is engaged through the hole in the device and is locked into position using the butterfly nut (Fig 2).

It is noted that the top guide wire is parallel to the horizontal long arm of the footplate. The top guide wire, when advanced through the guide sleeve, lies parallel and just below the small footplate with its two spikes (6). The superior and inferior head-neck junction is marked on the dislocated head (Fig 3). Midpoint of the femoral head is marked on the femoral head. Another superoinferior midpoint is marked posteriorly on the middle of the femoral neck, using a marker pen or diathermy. Another such midpoint is marked at the base of the neck posteriorly.

All three midpoints are joined to give the midline on the anterposterior projection of the femoral neck. The femoral neck is positioned in the horizontal plane by rotating the femur. The spiked femoral footplate is placed on the posterior cortex of the femoral neck, in line with the marked mid-line on the posterior aspect of the femoral neck.

With the handle of the device held vertically, the guide wire through the inferior guide sleeve is power driven into the femoral head and neck. This will give accurate position of the guide wire in the mid anteroposterior and superinferior planes of the femoral neck (Fig 4). The device is removed and the guide wire is left in situ. The femoral notch guide is slipped over the guide wire and rotated circumferentially onto the neck at the head-neck junction to make certain that no notching will occur. If however, notching is deemed to occur, the repositioning guide jig is secured on the targeting device.

The screw mechanism must be rotated clockwise fully until it stops rotating any further. The guide sleeve than can be secured onto the targeting device using the screwdriver. The top guide wire repositioning sleeve is inserted over the guide wire in the femoral head neck. The guide wire repositioning sleeve can be rotated circumferentially round the guide wire to find the most appropriate point. A second wire is placed into the inferior guide repositioning sleeve. The initial guide wire is removed and a further check is made to make certain that notching does not occur.

In case of a large posterior femoral head osteophyte, the femoral footplate 5 will catch the osteophyte preventing footplate 6 from lying on the femoral neck posteriorly. In this case a shallow trough is made into the posterior femoral osteophyte in line with the posterior mid line to allow 6 to rest on the femoral neck. The trough is shallow and will be removed when the peripheral cut of the femoral head is made.

7th EFORT CONGRESS

Situated as it is in Southern Europe, it offers unrivalled opportunities for pre- and post- congress vacations and has easy access from all major cities. The waterfront congress centre is a state of the art building with exceptional facilities for delegates, speakers and exhibitors, with a wide range of hotels close to the centre offering modern or traditional accommodation.

Boasting springtime temperatures during the winter and cool summers freshened by a breeze blowing in from the Atlantic, Costa de Lisboa, on the southwestern coast, offers a rich and impressively integrated diversity.

The capital of Portugal since its conquest from the Moors in 1147, Lisbon is a legendary city with over 20 centuries of History. The Alfama is one of the oldest quarters in Lisboa. Since it largely survived the earthquake of 1755, the area still retains much of its original layout.

Adjacent to the Alfama are the likewise old quarters of Castelo and Mouraria, on the western and northern slopes of the hill that is crowned by St. George’s Castle. Every year in June, the streets of all three quarters come alive with the feasts in honour of the popular saints.

The Graça quarter and the churches of São Vicente de Fora and Santa Engrácia are within walking distance of this area. Radiant skies brighten the monumental city, with its typical tile covered building façades and narrow medieval streets, where one can hear the fado being played and sung at night.

But Lisbon is also the stage for popular festivities, the place for exquisite shopping, exciting nightlife, and interesting museums, a place from where motorways branch off in different directions.

To the west lie Bairro Alto and Madragoa, with their typical streets, and on the western extreme is Belém, with its Belém Tower, (the sentinel over the Tagus river that protects the entrance into Lisbon), the Jerónimos Monastery (masterpieces of Manueline architecture and classified in UNESCO’s International Heritage list) and the Cultural Centre of Belém.

The main shopping areas are: Downtown; Avenida de Roma, Praça de Londres, Avenida Guerra Junqueiro, and Amoreiras.

The Ajuda and Fronteira Palaces are both open to the public, while the range of museums on offer include: Ancient Art, Chiado (Contemporary Art), Archaeology, Ethnology, Maritime, Military, Modern Art Centre, and the Ricardo Espirito Santo Silva Foundation. Estoril Renowned worldwide as an important tourism spot, it boasts casinos, golf courses, and an F1 racing track. The Verdades-Farias Museum - which hosts an important collection of musical instruments related to popular music assembled by Michael Giacometti - and the beautiful Santo António Church stand out in this cosmopolitan resort, which also boasts an exciting nightlife for tourists to enjoy.

Cascais Amongst the numerous restaurants, bars and discotheques of this stylish summer resort are the historic places such as Castro Guimarães Museum and Sea Museum; the 18th century churches of Nossa Senhora da Assunção and Nossa Senhora dos Navegantes. Just a few minutes away also lies the beautiful Guincho beach.

Ericeira A fishing village 50 km northeast of Lisbon, 25 km from Sintra and 10 km from Mafra, it has the Atlantic Ocean as an eternal companion. The hospitality of its people, the harmony of the ‘old village’ with its narrow cobblestone streets, characteristic housing, the cuisine and the multiplicity of cultural programming interlace here in a grand way to welcome its visitors.

Loures The county chief-town since 1886, it borders with Lisbon, Mafra, Sintra, Arruda dos Vinhos and Vila Franca de Xira. Thirty minutes from the capital, its major attraction is, without doubt, the Quinta do Conventinho (Little Convent Farm), with the Municipal Museum, its beautiful gardens, and the convent that inspires its name. Only three minutes from the city centre, it is a culture centre, with events for every age set.

Mafra A Palace-Convent built in the 18th century, it is the largest Portuguese religious monument. It consists of lavish royal apartments as well as 330 cells for its monks, a magnificent library (which houses about 36,000 collectors books that include a first edition of “Os Lusíadas” by the Portuguese poet Luís de Camõe), carillon, basilica and museums.

Queluz Originally a summer palace of the kings of Portugal in the 18th century, it encloses a series of rambling and beautiful gardens with lakes and sculptures, and housing an important collection of furniture, paintings, tiles, and decorative arts.

Sesimbra Picturesque small fishing town, with a medieval castle. Like a sentry, the ruins of this 13th Century castle built by Sancho II protectively overlooks the village. The Sanctuary of Nossa Senhora in Cabo Espichel (which was constructed at the turn of the 17th Century as a sanctuary and has often been used as a location for filming due to its singular architectural design) is certainly worth visiting as is Lagoa de Albufeira, a favourite spot for windsurfers.

Setúbal Opposite to the Tróia Peninsula (18 km of beaches and golf courses) is the city of the Sado river (an important natural reserve). It’s museum, churches of Jesus and São João (Manuelina) are all perfect for visitors, while the castle includes a Pousada, overlooking Setúbal.

Sintra In the centre stands the National Palace, with its beautiful painted rooms and huge pair of conical chimneys, the Village’s ex-libris. Other palaces include Pena, Seteais (18th century and currently a luxurious hotel) and Monserrate, renowned for its gardens and water courses.

The Toy Museum, has over 20,000 pieces from the 16th to the 20th century and in the suburbs is Cabo da Roca, the westernmost point in continental Europe.

Other specialities typical of this area include the goat and sheep cheeses from Sobral de Monte Agraço and from Azeitão, the pastries from Malveira and the ‘pão de ló’ from Loures, the nuts and egg dainties from Cascais, the ‘zimbros’ (gin cakes) from Sesimbra, the ‘queijadas’ (cheese cakes) from Síntra; the wines from Colares, Bucelas, Setúbal, Carcavelos and the famous ‘moscatel’ wine from Setúbal.

In Lisbon itself, you can try all the specialities of Portuguese cuisine. In this city, you will mainly find typical country dishes like grilled sardines, clams ‘à Bulhão Pato’ style, fish soups ‘à fragateira’ style and varied and tasty dishes cooked with codfish. Apart from all the desserts available to you, do not forget to try the local Belém custard pies.

Then in the late 80’s plastic was seen as the way forward for orthoses. Most of the traditional orthoses were then manufactured in plastic or a mixture of metal and plastic, they were certainly were lighter but the philosophy was the same, rigid splinting with very little consideration to the biomechanics of walking. What we have developed at DO is a new type of orthotic treatment which we describe as “ Minimal Dynamic Orthotics”.

Bob who had been experimenting with a supple silicone material for his prosthetic cover work began to develop a new ankle foot support which would combine both functional support and comfort for the wearer with the added benefit of being discrete. The SAFO was born. Lisa was the first SAFO “guinea pig” and she was instantly impressed at her improved comfort and walking.

Over time she also regained some lost confidence and was able to walk for longer periods and faster. Dorset Orthopaedic has now manufactured in excess of 2500 SAFO’s to date. On the 22nd April 2004 the SAFO received The Queen’s Award for Enterprise (Innovation).

The SAFO is pulled onto the foot and fastened using velcro tabs or external straps on the inside of the lower limb and because of its total contact around the ankle it gives support without interfering with normal biomechanics. The prioprioception feedback is that things feel normal and the patient has control over their feet.

Each SAFO is individually made to a cast of the patients limb. A negative cast is taken ideally with the foot in approximately 0-5 degrees dorsiflexion. The positive mould is then reduced to set measures. Individual specifications are chosen by the orthotist e.g. No of straps, colour & reinforcements.

Establishment: Salisbury District Hospital, Salisbury Wiltshire
Investigator: Professor Ian Swain, Department of Medical Physics & Biomedical Engineering
Study title: The use of a silicone boot orthosis on the speed and effort in walking in patients with lower motor neuron lesions.
Presented: The 10th World Congress of the International Society for Prosthetics & Orthotics, 1st July 2001
Method: 12 subjects with lower motor neuron lesions were fitted with the orthosis. Walking speed and Physiological Cost Index (PCI, effort of walking) were then individually measured and analysed using Wilcoxon signed ranks test. This was carried out initially and after six months use. All patients completed a questionnaire.
Findings: Comparison of walking speed and PCI at 6 month assessment with the orthosis compared to the initial assessment without showed an increase in speed of 20% and a reduction of PCI of 32%.

Establishment: Strathclyde University Hospital
Investigator: Peter McLachlan B.Sc (Hons)
Study title: Comparision of Silicone Ankle Foot Orthoses versus Plastic Ankle Foot Orthoses in subject with lower motor neuron lesions using the CODA mpx30 gait analysis system.
Presented: The 11th World Congress of the International Society for Prosthetics & Orthotics, August 1-6 2004 Hong Kong
Method: Six subjects were selected who had been previously supplied with AFO’s. They were then assessed, cast and fitted for a custom made SAFO. They wore the SAFO for a minimum of four weeks. They then returned for gait analysis unbraced, with AFO and with SAFO.
Findings: Results showed that the AFO had a greater dorsiflexion on swing through, however there was less knee and hip flexion, with the SAFO on during swing phase. The SAFO also produced a smoother transition from heel strike – foot flat.

More research is due from Temple University School of Podiatric Medicine in Philadelphia, USA and the Yeovil CP Childrens trial.

At 14 years of age, Emily had an operation for hip dysplasia. It was during this surgery that a nerve was accidentally cut, which resulted in drop foot condition. Despite trying a number of supports and braces to rectify the solution, it wasn’t until Emily’s Mum discovered the Silicone Ankle Foot Orthosis (SAFO) that things changed.

Emily said, “I had a rigid ankle support but I couldn’t walk without crutches, which meant I wasn’t confident enough to go out on my own or with friends. I tried a flexible brace but this still didn’t solve the problem for me and could only be worn with supportive trainers. With the SAFO I don’t have to lift my foot clear of the ground, which means I don’t limp anymore.” Emily, who is an active teenager and currently taking GCSE dance is hoping that the SAFO will allow her to fully resume her classes.

Stuart (30) was an accomplished sports man enjoying mountain walking, kayaking, football, tennis and snowboarding. He left school to play football for Fulham FC and then moved into Outdoor Education as an instructor once the football career finished. But in 2000 he suffered an arterial thrombosis.

Stuart underwent a number of major operations to remove the dead muscle, which resulted in his drop foot condition. He was prescribed rigid AFO’s by his local hospital but he found it uncomfortable to wear, an eyesore, problematic for shoe fitting and confidence sapping, not to mention too restrictive and uncomfortable to walk or play sports in. Stuart was introduced to the SAFO via his GP. At first he took some convincing that it would work as it “looked so flimsy and small” but he is on his 3rd SAFO now and he finds it allows him to fit it under his socks and in a normal sized shoe.

• Charcot Marie Tooth CMT (HMSN).
• Peripheral neuropathies.
• Trauma (peroneal and sciatic nerve).
• Polio (below knee).
• Incomplete Spinal Injuries.
• Hemiplegia (CP children).
• Multiple Sclerosis.
• Diplegia (CP children).
• Stroke (CVA).

• Flaccid drop foot.
• Active plantar flexion without dorsi flexion.
• Weak dorsi flexion and plantar flexion.
• Media lateral support to ankle (shock absorption).
• Mild clonus/spasticity accompanying drop foot

Traditionally the limb has been placed in a plaster of Paris cast and the patient taught to use crutches. Plaster of Paris has the advantage of low material costs and ease of moulding to the required contour. Unfortunately, it and, to a lesser extent, its synthetic successors, are labour-intensive to apply and, if in use for long periods, may require several changes of cast. They may prove heavy and cumbersome and are difficult to remove for wound and skin care or rehabilitation exercises.

One alternative to plaster of Paris casting is the removable ankle foot orthosis. At their simplest these may be low-profile splints such as the ankle stirrup (made, with subtle variations, by many manufacturers) that can be worn inside a shoe (Fig 1). Such stirrups, when fitted with air cells, have been shown to allow patients with ankle sprains to return to work earlier than would otherwise have been possible1,2. Others are more complex composite devices taking the form of a rigid or semi-rigid shell and an inner liner. The outer shell provides protection and structural support.

In most devices it also immobilises the enclosed joints, but in some, such as the Pincam Walker (Breg Inc, Vista, CA), carefully controlled motion may be permitted. This is particularly useful for patients who have undergone repair of a ruptured Achilles’ tendon. The inner liner is designed to conform to the contour of the limb, thus facilitating controlled distribution of weight transfer. Many devices, such as the Pincam Walker, the Body Armor Walker II (Darco, Huntington, WV) and the Ventura Walker (Breg), aim to achieve an even distribution of load by using generous padding and a conforming insole to obtain maximum contact with the limb. Others, such as the DH Walker and DH Boot (Technology in Motion, Wimbledon, UK), rely on a sole liner made from many small suspension cells, each of which can be independently removed, to accommodate unusual foot shapes and offload problematic areas.

The most comprehensive liner moulding, however, is provided by the pneumatic systems used in the Aircast Walker and the Air-Equalizer Walker (Technology in Motion). The Pneumatic Walker (Aircast, Summit, New Jersey, Fig 2) consists of a rigid outer shell, similar to a ski boot, with a pneumatic liner that allows it to fit snugly the changing contours of the limb. There is also a diminutive version, the SP Walker that extends just above the ankle.

They may be used full, partial or non-weight bearing. They are easy to remove for the inspection and dressings of wounds, rehabilitation exercises and to allow the patient to bathe. Initial material costs of a pneumatic walker are higher than plaster of Paris, but these may be offset by the savings made in material and labour costs by avoiding serial cast changes. The pneumatic walker has been used for:

1. treatment of acute ligamentous injuries of the ankle;
2. splinting of ankle fractures after internal fixation;
3. splinting of arthrodeses of the ankle and hindfoot.

The most logical way to allow a patient to mobilize with the minimum of work while remaining non weight-bearing on a particular foot or leg is to use a device that allows them to bear weight through a more proximal limb segment. This is more easily achieved for a distal site of injury than for a proximal. After forefoot surgery, for example, the Barouk type I or Orthowedge shoe (Darco, Huntingdon, West Virginia, Fig 3), a removable overshoe based upon a semi-rigid platform with a built -up heel, is sufficient to allow weight-bearing to occur mainly behind the metatarsal necks. This is designed to alter load distribution sufficiently to be effective in the treatment of plantar forefoot ulcers, and the rehabilitation of metatarsal osteotomies, metatarso-phalangeal fusions and surgery of the digits.

More proximal problems, however, require more sophisticated solutions. A little known alternative to the use of crutches following hindfoot or ankle surgery is the K9 orthopaedic scooter, (John Reid and Sons, Christchurch, Dorset, Fig. 4), which transfers weight to the knee thereby allowing the patient to remain non-weight bearing with less effort. Designed by an engineer who found that he had to spend a prolonged period of time non-weight bearing following an injury to his foot, it incorporates a handle for balance and has a cradle which can be adapted for use either with or without a below knee cast or other form of splint. The ankle can be kept elevated with respect to the knee thereby reducing the amount of swelling that is induced by a prolonged non-weight bearing. Use of the orthopaedic scooter also avoids the sore hands associated with crutches and allows one limb to be free for normal day-to-day activities.

As a wheeled device its use is limited to smooth flat surfaces, but as mean energy expenditure when walking “non-weight bearing” with the scooter is 4.8 Kcal/Kg/Hr (more than the 2.8 for normal gait, but considerably less than the 6.6 required for crutches)3 it has been used by many office workers and professionals, including surgeons, as a means of continuing their employment whilst non-weight bearing on the lower leg. A ‘K9’ orthopaedic scooter has been useful for patients with:

1. non-weight bearing for patients with a tendo-Achilles injury whether treated surgically or conservatively;
2. patients with foot and ankle injuries such as Pilon, ankle, talar, calcaneal and midfoot fractures;
3. patients with neuropathic feet e.g. diadetic ulcers and Charcot joints;
4. patients having hindfoot or ankle fusions who have difficulty in coping with crutches.

1. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med 1994; 22(1): 83-88.
2. Leanderson J, Wredmark T. Treatment of Acute Ankle Sprain: Comparison of a Semi-Rigid Ankle Brace and Compression Bandage in 73 Patients. Acta Orthopaedica Scandinavica 1995; 66(6): 529-531.
3. Roberts P, Carnes S. The Orthopaedic Scooter. An Energy Saving Aid for Assisted Ambulation. J Bone Joint Surg Br, 1990, Jul, 72(4): 620-1.