Abstract:
An attachment system for an orthopedic brace incorporates at least one cinching system assembly haying a knob rotatable in a first direction and a second direction. At least one cinching plate is engaged by the knob for rotation in the first direction in a first orientation and transitions to a second orientation upon rotation in the second direction. A ratchet wheel is engaged by the cinching plate in the first orientation for rotation in the first direction. At least one ratchet arm engages the ratchet wheel for ratcheting operation and is engaged by the cinching plate in the second orientation for disengagement from the ratchet arm. A shaft is rotated in response to rotation of the ratchet wheel and a strap is extendible from and retractable on the shaft upon rotation of the shaft.

Description:
REFERENCES TO RELATED APPLICATIONS 
       [0001]    This application claims the priority of U.S. provisional application Ser. No. 61/860,215 filed on Jul. 30, 2013 entitled ORTHOPEDIC BRACE SECURING AND TENSIONING SYSTEM having a common assignee with the present application, the disclosure of which is incorporated herein. 
     
    
     BACKGROUND INFORMATION 
       [0002]    1. Field 
         [0003]    Embodiments of the disclosure relate generally to the field of anatomical support braces and more particularly to a system for securing and tensioning including ratcheting tensioning with optional selectable spring loaded strap retraction, strap quick release and orientation relief for orthopedic braces including knee braces. 
         [0004]    2. Background 
         [0005]    While orthopedic braces come in various overall sizes, each brace typically require adjustable straps to fit various anatomically sized users. For knee braces as an example, thigh and calf circumference may vary widely for users of a brace having a common size based on leg length. For most applications users prefer to easily don the brace and quickly adjust the various straps for appropriate size and tension. Having appropriate tension in the straps may be critical for proper operation of the brace. Equally as important is the ability to quickly and easily remove the brace when an activity requiring the brace is complete. 
         [0006]    It is therefore desirable to provide a securing system for orthopedic braces which can incorporate rapidly and easily adjustable tensioning and release for securing straps encircling the anatomical element. 
       SUMMARY 
       [0007]    Embodiments disclosed herein provide as a first feature an attachment system for an orthopedic brace which incorporates at least one cinching system assembly having a knob rotatable in a first direction and a second direction. At least one cinching plate is engaged by the knob for rotation in the first direction in a first orientation and transitions to a second orientation upon rotation in the second direction. A ratchet wheel is engaged by the cinching plate in the first orientation for rotation in the first direction. At least one ratchet arm engages the ratchet wheel for ratcheting operation and is engaged by the cinching plate in the second orientation for disengagement from the ratchet arm. A shaft is rotated in response to rotation of the ratchet wheel and a strap is extendible from and retractable on the shaft upon rotation of the shaft. 
         [0008]    Embodiments herein also provide as a feature a tensioning assembly for orthopedic braces which incorporates a knob having a spindle with an attached ratchet. A spool is engaged for rotation by the spindle. A floating arm has a first position and a second position. The floating arm includes a locking tooth extendible into a connection channel in the second position, a ratchet release loop positioning a ratchet lock for engagement of the ratchet in the second position and a release button for moving the floating arm from the second position to the first position. A strap has a bullnose removably receivable in the connection channel. The bullnose has a slot to receive the locking tooth and releases the floating arm from the first position to said second position upon insertion into the connection channel. The strap is extendible from and retractable on the spool. 
         [0009]    The features, functions, and advantages that have been discussed can be achieved independently in various embodiments of the present disclosure or may be combined in yet other embodiments further details of which can be seen with reference to the following description and drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0010]      FIG. 1  is a lateral isometric views of an embodiment of an example orthopedic knee brace on which the present embodiments may be employed; 
           [0011]      FIGS. 2A and 2B  are lateral and medial isometric view of the upper attachment assembly; 
           [0012]      FIGS. 3A and 3B  are downward exploded and upward exploded isometric views of a first embodiment of the cinching system assembly; 
           [0013]      FIG. 3C  is aside section view of the first embodiment; 
           [0014]      FIG. 4A  is a top view of the cinching plates in the cinching system assembly in the disengaged position; 
           [0015]      FIG. 4B  is a top view of the cinching plates in the cinching system assembly in the engaged position; 
           [0016]      FIG. 5A  is a top view of the ratchet arms in the cinching system assembly in the disengaged position; 
           [0017]      FIG. 5B  is a top view of the ratchet arms in the cinching system assembly in the engaged position; 
           [0018]      FIG. 6  is a top isometric detail of the body bottom of the cinching system assembly with the gear assembly, shaft and coil spring; 
           [0019]      FIG. 7  is a bottom isometric detail of the cinching system assembly; 
           [0020]      FIG. 8  is an exploded isometric view of a second embodiment of the cinching system assembly; 
           [0021]      FIG. 9A  is a side section view of the embodiment of  FIG. 8  with the rotation teeth engaged; 
           [0022]      FIG. 9B  is aside section view of the embodiment of  FIG. 8  with the rotation teeth disengaged; 
           [0023]      FIG. 10  is an exploded, isometric view of a third embodiment of the cinching system assembly; 
           [0024]      FIG. 11  is a side section view of the embodiment of  FIG. 10  with the rotation teeth engaged; 
           [0025]      FIG. 12  is an exploded isometric of the quick disconnect assembly; 
           [0026]      FIG. 13  is an isometric of the quick disconnect assembly with the strap tip disconnected; 
           [0027]      FIG. 14  is an isometric partial section view showing detail of the release button and resiliently depressible tongue on the strap tip; 
           [0028]      FIG. 15  is an isometric view of a second embodiment of the strap tip employing a D-ring extending from the neck; 
           [0029]      FIG. 16  is an isometric view of the single point tensioning system; 
           [0030]      FIG. 17  is a top view of the single point tensioning system; 
           [0031]      FIG. 18  is a side view of the single point tensioning system; 
           [0032]      FIG. 19  is an isometric view of the floating arm; 
           [0033]      FIG. 20A  is an isometric view of the ratchet and ratchet stop in the disengaged position without the floating arm ratchet release loop for clarity; 
           [0034]      FIG. 20B  is an isometric view of the ratchet and ratchet stop in the engaged position without the floating arm ratchet release loop for clarity; 
           [0035]      FIG. 20C  is an isometric view with the ratchet release loop shown; 
           [0036]      FIG. 21A  is an isometric detail view prior to insertion of the bullnose of the center pivot lever arm engaged to restrain the floating arm in the first position; 
           [0037]      FIG. 21B  is an isometric detail view of the center pivot lever arm after insertion of the bullnose with the floating arm released to the second position; 
           [0038]      FIG. 22  is an isometric detail view of an embodiment of a living hinge embodiment for the lateral relief hinge of  FIGS. 1A and 2B ; and, 
           [0039]      FIGS. 23A and 23B  are simplified front and side views of the knee brace demonstrating orientation and operation of the lateral relief hinge. 
       
    
    
     DETAILED DESCRIPTION 
       [0040]    Embodiments disclosed herein provide a strap adjustment system for orthopedic braces which incorporates ratcheting tensioning elements and quick release attachments. Spring loaded retraction of straps is selectively accomplished for convenient storage to prevent entanglement warping of straps when not in use. Strap engagement features of the quick release attachments provide angular orientation relief for the straps when secured. As shown in  FIG. 1 , an example orthopedic knee brace  10  is composed of an upper attachment assembly  12  to be received on the thigh of the patient and a lower attachment assembly  14  to be received on the lower leg of the patient. Each attachment assembly (which is shown in detail in  FIGS. 2A and 2B  for the upper attachment assembly) incorporates a lateral support  16 ,  18  and a medial support  20 ,  22 . Hinges  24  and  26  interconnect the lateral and medial supports, respectively, of the upper and lower attachment assemblies. Each attachment assembly includes an anterior arch support  28 ,  30 . 
         [0041]    As shown in  FIG. 1  (for a right leg brace) and additionally in  FIGS. 2A and 2B  (for a left leg brace to demonstrate use of the embodiment for either leg), the upper attachment assembly  12  for the example embodiment employs a upper posterior strap  32  extending from an upper cinching system assembly  34  adjacent the anterior arch support  28  on the lateral side of the upper attachment assembly around the posterior of the thigh to a quick release attachment assembly  36  on the medial side of the upper attachment assembly adjacent the anterior support. Similarly, a lower posterior strap  38  extends from a lower cinching system assembly  40  adjacent the lateral hinge  24  on the lateral support element  16  around the posterior the thigh to a lower quick release attachment assembly  42  on the medial support element  20  adjacent the medial hinge  26 . 
         [0042]    As shown in  FIG. 1  the lower attachment assembly  14  has a bottom posterior strap  44  extending from a bottom cinching system assembly  46  adjacent the anterior arch support  30  on the lateral side of the lower attachment assembly around the posterior of the calf to a quick release attachment assembly  48  on the medial side of the lower attachment assembly adjacent the anterior support. 
         [0043]    The cinching system assemblies  34 ,  40  and  46  are identical for the example embodiment and are shown in detail in  FIGS. 3A-8 . As best seen in  FIGS. 3A and 3B , each cinching system assembly incorporates a knob  50  which is rotated by the user to tension or retract the associated strap, as will be described in greater detail subsequently. Paired cinching plates  52   a  and  52   b  are operatively engaged and disengaged from a ratchet wheel  54 . Paired ratchet arms  56   a  and  56   b  also releasably engage the ratchet wheel  54 . The cinching plates, ratchet arms and ratchet wheel are constrained in a body top  58  over which the knob  50  is received. A slotted shaft  60  is employed for rolled storage and dispensing of the associated strap, as will be described in greater detail subsequently. A beveled gear set  62  is driven by the ratchet wheel  54  and attached to the shaft  60  having a first gear  64   a  engaged with the ratchet wheel  54  through the bolt  55  for rotation and a second gear  64   b  engaged to the shaft  60  for rotation of the shaft. A coil spring  66  is employed for rotational tensioning of the shaft  60  during dispensing to retract the strap upon release, as will be described in greater detail subsequently. Beveled gear set  62  allows an orthogonal orientation between the shaft  60  and an axis of rotation  61  of the knob  50  extending through the connecting bolt  55 . A body bottom  68  provides a storage cavity  70  for the shaft  60  and associated strap. 
         [0044]    When the brace is first applied, the ratchet arms  56   a,    56   b  and the cinching plates  52   a,    52   b  have been moved away from the ratchet wheel  54  allowing the strap to be withdrawn from the shaft  60  of the associated cinching system assembly  34 ,  40 ,  46 . The details of how the components achieve this position will be explained subsequently. The user will extend the strap from each cinching system assembly  34 ,  40  and  46  against the resistance of the coil spring  66  in each assembly. They will then insert the strap end into the associated quick release assembly  36 ,  42  or  48  (described in greater detail with respect to  FIGS. 8-11  subsequently) on the opposite side of the brace. The spring  66  will then take up any slack in the strap. At this point the user will turn the knob  50  clockwise to tighten the strap to the desired tension. The knob  50  has two pins  72   a,    72   b  (best seen in  FIG. 3B ) that extend down into slots  74   a,    74   b  in the cinching plates  52   a  and  52   b,  respectively. The initial position of the cinching plates is shown in  FIG. 4A . The cinching plates each have a pin  76   a,    76   b  that extends down into the interior volume  78  of the body top  58  occupied by the ratchet arms  56   a,    56   b.  At this point the cinching plate pins are holding the ratchet arms away from the ratchet wheel. When the knob is turned to the right the knob pins  72   a,    72   b  slide along the slots  74   a,    74   b  in the cinching plates  52   a,    52   b  and cause the plates to move inward and engage the ratchet wheel  54  with contact faces  80   a,    80   b  as shown in  FIG. 4B . As the knob  50  continues to be turned clockwise the ratchet wheel  54  turns the gear set  62  cousin the straps to be tightened around the slotted shaft  60 . Meanwhile the pins  76   a,    76   b  that extend down from the cinching plates  52   a  and  52   b,  respectively, slide off contact surfaces  82   a  and  82  on the spring arms  84   a,    84   b  allowing the ratchet arms  56   a,    56   b  to also engage the ratchet wheel  54 . For the embodiment shown, spring arms  84   a  and  84   b  are integral with ratchet arms  56   a,    56   b  which include pivot pins  86   a,    86   b  received in retainers  88   a  and  88   b  extending from the surface  90  of body top  58 . As the knob  50  continues to be turned the cinching plates  52   a,    52   b  rotate urged by pins  76   a  and  76   b  in the slots  74   a,    74   b  and cause the ratchet wheel  54  to turn which in turn causes the gear set  62  and slotted shaft  60  to turn and tighten the strap. Rotation in this direction will cause the cinching plate pins to slide past the spring arms  84   a,    84   b  causing them to flex as passed, snapping back into a more relaxed position when passed. The spring arms  84   a,    84   b  urge the ratchet arms  56   a,    56   b  to maintain contact with the ratchet wheel  54 . When the knob  50  is released the ratchet arms  56   a,    56   b  prevent the ratchet wheel  54 , gears  62  and slotted shaft  60  from rotating in the opposite direction therefor maintaining tension on the straps. 
         [0045]    When it is time to remove the brace, the quick release buttons are pushed, as will be described in greater detail subsequently, releasing the straps and allowing the brace to be removed. To retract the straps and ready the brace and system to be re-applied, the knob  50  is turned to the counterclockwise about a half turn until it stops. This rotation caused the knob pins  72   a,    72   b  to slide in slots  74   a,    74   b  in the cinching plates  52   a,    52   b  the opposite direction which causes the plates to move away from the ratchet wheel. Once the pins  72   a,    72   b  hit the end of the slots  74   a,    74   b  the plates will start to rotate. Within a half revolution the cinching plate pins  76   a,    76   b  will encounter the contact surfaces  82   a,    82   b  of the spring arms  84   a,    84   b  of each ratchet arm  56   a,    56   b.  As the knob  50  is continues to be turned counterclockwise the pins  76   a,    76   b  will ride up the contact surfaces  82   a,    82   b  of the spring arms  84   a,    84   b  pulling the ratchet arms  56   a,    56   b  away from the ratchet wheel allowing the coil spring  66  which was tightened during withdrawal of the strap to wind in the strap. The brace is now in the same state as initially described. 
         [0046]      FIGS. 6 and 7  provide additional detail on the body bottom  68  which houses the slotted shaft  60  in the storage cavity  70 . The storage cavity provides sufficient volume for the strap in the retracted condition when wrapped around the slotted shaft  60 . To provide clearance and operation of the centrally located gears  62  and coil spring  66 , the strap incorporates two parallel bands as shown in  FIGS. 1A ,  1 B,  2 A and  2 B which are engaged on opposite ends of the slotted shaft. As seen in  FIG. 7 , two exit slots  71   a  and  71   b  are provided for the strap bands. The            
         [0047]    While described as a clockwise tightening system for typical right handed operation, the elements of the cinching system assemblies  34 ,  40  and  46  may be fabricated in mirror image to operate in a counterclockwise tightening system for left handed operation. 
         [0048]    A second embodiment for the cinching system assembly with a push button release is shown in  FIGS. 8 and 9A ,  9 B. As with the first described embodiment, the shaft  60  is rotated by a gear set  62  with bevel gears  64   a  and  64   b  driven by a bolt  55 . However, the engagement element for transferring rotation of the knob  50  to the gear set  62  is an assembly including a ratchet ring  202  engaged within the knob  50  which is constrained by pawls  204   a  and  204   b  mounted in retainers  206   a  and  206   b.  The directional orientation of the pawls allows rotation of the knob  50  and associated ratchet ring  202  in only one direction. An engagement ring  208  having an external spline  210  is received by an internal spline  212  in the knob  50 . Engagement ring  202  is vertically depressable from a first position as shown in  FIG. 9A  to a second position shown in  FIG. 9B  using a button  213 . In the first position internal teeth  214  on the engagement ring  208  engage a tooth set  216  on gear drive ring  218  connected to the gear set  62  by bolt  55 . In the first position, rotation of knob  50  therefore imparts rotation of the gear set  62  rotating shaft  60  to tighten the strap element ( 32 ,  38  of  FIGS. 2A ,  2 B) on the shaft. Pawls  204   a  and  204   b  engaging ratchet ring  202  prevent loosening of the strap element. Depressing engagement ring  202  to the second position as shown in  FIG. 9B  disengages internal teeth  214  on the engagement ring  208  from tooth set  216  on the drive ring  218  allowing drive ring to freely rotate. In the second position with engagement ring  208  depressed, the strap element may be extracted from shaft  60 . 
         [0049]    As shown in  FIGS. 9A and 9B , a snap shelf  220  encircling a lower periphery of engagement ring  208  is engaged in the second position by resilient retainers  222  extending from surface  90  of body top  58  to maintain the engagement ring in the depressed second position, Rotation of the knob  50  rotates engagement ring  208  for operable contact with ramps  224  extending from surface  90  urging the engagement ring upwards disconnecting snap shelf  220  front the resilient retainers  222  and returning engagement ring  208  to the first position, for operable reengagement of tooth set  216  on drive ring  218  with the internal teeth  214  on engagement ring  208 . 
         [0050]    A third embodiment for the cinching system employing the push button release with an alternative engagement element retainer is shown in  FIGS. 10 and 11 . Elements and operation of the third embodiment are substantially identical to the second embodiment described above however, snap shelf  218  has been eliminated and one or more snap features  226 , seen in  FIG. 11  extending across selected teeth of spline  212  support associated teeth on the external spline  210  of engagement ring  208 . Depressing engagement ring  208  with button  213  resiliently displaces snap feature  226  for passage of the associated tooth of spline  210  into the depressed second position. Frictional engagement of the snap features  226  on the external spline  210  retains the engagement ring in the depressed second position until rotation of the knob  50  engages ramps  224  to urge the engagement ring  208  back to the first position as previously described. 
         [0051]    In each of the cinching system embodiments, rotation of the knob  50  in the tightening direction automatically reengages the ratcheting elements of the cinching system for tightening the strap. 
         [0052]    The quick disconnect assemblies  36 ,  42  and  48  described with respect to  FIGS. 1A and 1B  are shown in detail in  FIGS. 12-15 . As shown in  FIG. 12 , quick disconnect assembly (assembly  42  shown as an example) is mounted to the medial longitudinal supports (upper attachment assembly  12  medial longitudinal support  20  shown as an example). A capture shoe  90  with a guidance flap  91  is attached to the medial support  20  to receive a strap tip  92 . The inserted end  94  of the tip  92  is substantially semi-circular and the receiving end  96  of the shoe also has a semi-circular profile. For the embodiment shown, receiving end  96  incorporates a resilient leaf spring  97  engaging inserted end  94  to assist in ejection of the tip  92  upon release as described subsequently A resiliently depressible tongue  98  extends from a surface of the tip to be engaged in a capture bracket  100 . A release button  102  resiliently mounted to the capture bracket may be depressed to resiliently deform and flatten the tongue  98  into the tip releasing it from the capture bracket. Leaf spring  97 , resiliently engaged by the tip  92  upon insertion, urges the tip  92  out of the capture shoe  90  upon flattening of the tongue  98 . For the embodiment shown, the button  102  extends through a mating hole  104  in the medial support  20  as shown in  FIG. 13  allowing the quick release to be mounted on the interior surface of the medial support.  FIG. 14  shows a partial cutaway view of the quick disconnect assembly showing engagement of the button and tongue to release the tongue from the capture bracket  100 . 
         [0053]    The semi-circular profiles of the inserted end  94  of the tip  92  and the receiving end  96  of the capture shoe  90  provide the ability for the tip  92  to swivel in the capture shoe through an angle  106  about a nominal insertion axis  108  before contact between a neck  110  extending from the tip  92  and walls  112  of the insertion slot in the capture shoe thereby allowing the associated strap ( 38  for the example shown in  FIG. 14 ) to assume a natural angle about the posterior portion of the leg without bending or cutting into soft flesh. 
         [0054]    The neck  110  terminates in a flanged attachment  114 , as shown in  FIG. 14 , into which the strap  38  is secured by sewing or similar means. Alternatively, the neck  110  may terminate in a D-ring  116  as shown in  FIG. 15  through which a strap may be inserted, folded back and connected to itself with hook and loop fasteners or similar means. 
         [0055]    Returning to  FIG. 1 , an alternative strap tensioning system is provided for the upper strap  120  on the lower attachment assembly  14 . This strap  120  differs from the other straps on the brace in that it encircles the calf as opposed to originating on a lateral support and terminating on a medial support after passing posterior to the leg. A single point tensioning assembly  122  is provided with ratcheting tensioning and a single point attachment and release system as shown in  FIGS. 16-21B . Strap  120  extends from the single point tensioning assembly  122  traversing the posterior of the calf and extending through a guide  124  on the medial support  22  in the lower attachment assembly  14  (as best seen in  FIG. 1 ). The strap  120  then passes anterior to the calf just below the knee and attaches to the single point tensioning system  122 . As shown in  FIGS. 16 ,  17  and  18 , strap  120  (shown in phantom) terminates in a bullnose  126  which is received in a connection channel  128  (the front of the connection channel is not shown for clarity of the remaining elements) on the single point tensioning assembly  122 . A knob  130  is turned for tensioning the strap as will be described in greater detail subsequently. A gear assembly  132  employs a drive gear  134   a  on a spindle  136  extending from the knob  130  to drive a bevel gear  134   b  attached to a spring loaded spool  138  to retract and extend the strap  120 . A single point release having a floating arm  140  is integrated in the single point tensioning system  122 . The floating arm  140 , shown in detail in  FIG. 15 , includes a lock tooth  142  which is received in an engagement slot  144  in the bullnose  126  to constrain the bullnose in the connection channel  128  (best seen in  FIGS. 16 and 18 ). A release button  146  extends from the floating arm for single point release actuation and strap retraction as will be described subsequently. A ratchet release hoop  148  is rigidly attached to the floating arm to release the tensioning ratchet as will be described in greater detail subsequently. 
         [0056]    Operation of the single point tensioning assembly  122  is best understood with regard to  FIGS. 20A-20C  and  21 A,  21 B. As shown in  FIG. 20A , in an initial state the floating arm  140  is held, as will be described in greater detail subsequently, in a first position which causes the ratchet release hoop  148  (shown in  FIG. 20C  but not shown in  FIG. 20A  for clarity) to disengage a ratchet stop  150 , which is spring biased along the axis of the spindle  136 , from a ratchet wheel  152  attached to the spindle behind drive gear  134   a.  In this condition, the spring loaded spool  138  is tensioned to retract the strap  120  or allow extension of the strap winding the spool against its spring. The user extends the strap from the spool  138  around the posterior of the calf, through the guide  124  on the medial support  22  and inserts the bullnose  126  into the connection channel  128 . Prior to insertion of the bullnose into the connection channel, a center pivot lever  154  rests in a lock position, urged by a spring  156  as shown in  FIG. 21A , restraining the floating arm  140  in the first position. Upon insertion of the bullnose  126  into the connection channel  128  as shown in  FIG. 21B , the bullnose engages and causes the center pivot lever  154  to pivot to a second position compressing spring  156  and releasing the floating arm  140  which is urged by spring  158  into a second position engaging the tooth  142  into the slot  144  in the bullnose to constrain the bullnose in the connection channel and repositioning the ratchet release hoop  148  to release the ratchet stop  150  allowing it to engage the ratchet wheel  152  as shown in  FIG. 20B . In this configuration, the knob  130  may be rotated clockwise to rotate the spool  138  through gear assembly  132  to tension the strap  120  as desired. Ratchet stop  150  urged axially along the spindle by springs  151  engages the ratchet wheel  152  to maintain tension. 
         [0057]    To remove the brace, strap  120  is released by depressing the release button  146 , which by depressing the floating arm against spring  158  back to the first position simultaneously disconnects the bullnose  126  from the connection channel  128  by retracting the connected lock tooth  142  from slot  144  and releases the ratchet stop  150  with the release loop  148 . Center pivot lever  154 , released by removal of the bullnose, is urged by spring  156  into the lock position constraining the floating arm  140  in the first position for free rotation of the ratchet wheel  152 , gear assembly  132  and spool  138  to retract the strap  120 . 
         [0058]    While described as a clockwise tightening system for typical right handed operation, the elements of the single point tensioning assembly  122  may be fabricated in mirror image to operate in a counterclockwise tightening system for left handed operation. 
         [0059]    While described herein as a unitary assembly on a knee brace embodiment, the cinching system assemblies and single point tensioning assembly with their associated strapping may be employed separately on various orthopedic braces or other devices for strap tensioning. 
         [0060]    The knee brace additionally incorporates a lateral flex feature to allow non-parallel alignment of the side hinges  24  and  26  on the knee brace  10  without binding during flexing of the knee. A hinge element  160  is integral to the anterior arch support  28  seen in  FIGS. 2A and 2B  and shown in detail in  FIGS. 22 ,  23 A and  23 B. The hinge element  160  is located in the anterior arch support  28  substantially at the intersection of the anterior arch support and the medial support  20 . An axis  162  of the hinge element  160  is substantially perpendicular to an axis of rotation of the medial hinge  26  and substantially parallel to a neutral axis  164  of the leg, medial support  20 , and lower medial support  22  with the knee in the normal unflexed position. The hinge element  160  is sufficiently flexible to allow a medially inward angular offset of the medial support  20  of up to 6° from a neutral position with the leg and brace unflexed to a flexed position. This feature allows the medial hinge  26  to operate without binding without requiring that the axes of rotation of the medial and lateral hinge be aligned. The hinge element  160  may be a living hinge as shown in  FIG. 22  with a reduced thickness portion  166  of material more flexible than the attachment portions  168  engaging the anterior arch support  28 . A conventional hinge, such as a piano hinge, may alternatively be employed or a molded thinning of the material of the anterior arch support  28  at the desired hinge element location. 
         [0061]    Having now described various embodiments of the disclosure in detail as required by the patent statutes, those skilled in the art will recognize modifications and substitutions to the specific embodiments disclosed herein. Such modifications are within the scope and intent of the present disclosure as defined in the following claims.