Custom Dynamic Orthoses to Reduce Articular Contact Stress

Study Overview
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Brief Summary
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The proposed study evaluates the effect of carbon fiber brace design on forces across the ankle. Research suggests that ankle arthritis develops following ankle fracture due, in part, to elevated forces on the cartilage. It is expected that carbon fiber braces can reduce forces in the ankle joint thereby reducing the risk of developing arthritis following injury. In this study, carbon fiber braces will be tested to determine how they influence the forces acting on the ankle cartilage. The proposed study will provide evidence that can be used by clinicians and researchers to design carbon fiber braces to effectively reduce forces on ankle cartilage.

Detailed Description
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The primary purpose of this line of research is to investigate the effects of carbon fiber custom dynamic orthosis (CDO) use on forces and contact stress at the ankle, with the goal of reducing the development of post traumatic osteoarthritis (PTOA). Research suggests that PTO develops, in part, due to increased ankle contact stress following fracture. It is expected that reducing articular contact stress has the potential to delay or prevent PTOA development. CDOs have been shown to significantly improve function after extremity injury, and show promise for offloading the injured ankle joint after severe lower extremity injuries. Therefore, the proposed effort is designed to evaluate CDOs effects on forces and articular contact stress at the ankle. Adult participants who have sustained a traumatic ankle fracture of the tibial pilon will be evaluated while wearing two CDOs, with a primary dependent measure of ankle joint contact stress. Following consent and enrollment weight bearing computerized tomography (CT) images will be collected and used to determine the geometry of the joint, and the articular contact stress using discrete element analysis. Participants will be cast and fit for two CDOs. Participants will be blinded to the design variation of each device and will only know them as CDO-A or CDO-B. Testing will be completed under 3 conditions: No-CDO, CDO-A, CDO-B, with each bracing condition (A/B) representing a different CDO. Physical performance measures will incorporate tests of agility, speed, and lower limb power to ensure that the CDOs do not negatively affect physical function. Questionnaires will be used to evaluate participants' current and desired activity level, pain with and without using a CDO, satisfaction with the study CDOs, perception of comfort and smoothness between CDOs, and preference between CDOs. Semi-structured interviews will be completed to fully capture the participant's perspective with each study CDO. Lower limb forces and motion will be assessed using a computerized motion capture system and force plates embedded in the floor. Forces between the foot and CDO footplate will be measured using force sensing insoles, and muscle activity data will be collected using wireless surface electromyography sensors. Each CDO will be mechanically tested, and participant demographic and anthropometric data will be recorded.

Official Title
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Custom Dynamic Orthoses to Reduce Articular Contact Stress

Conditions
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Ankle Fractures, Post-traumatic Osteoarthritis, Osteoarthritis Ankle

Intervention / Treatment
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* Device: Carbon Fiber Custom Dynamic Orthosis (CDO)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Between the ages of 18 and 65 Sustained unilateral fracture of the tibial pilon The fracture has completely healed Ability to walk 50 feet without use of an assistive device (cane, crutch, etc.) Ability to walk at a slow to moderate pace Shoe size between women's 8 and 13.5 or men's 6.5 and 12 Ability to read and write in English and provide written informed consent Individuals with elevated contact stress according to model generated using standing CT images (will be answered after completing visit one) Exclusion Criteria: Pain > 6/10 while walking Increase in pain during testing of 3/10 or greater Neurologic, musculoskeletal (including bilateral fractures) or other condition limiting function of the contralateral extremity Medical or psychological condition that would preclude functional testing (ex. moderate or severe brain injury, stroke, heart disease) Wounds to the calf that would prevent CDO fitting Fractures secondary to neuropathy or severe osteopenia Classification as non-ambulatory Previous fractures near the tibial pilon on the involved limb Surgery on involved limb anticipated in the next 6 months Requirement of a knee stabilizing device (i.e. KAFO, KO…) to perform daily activities Visual or hearing impairments that limit walking ability or limit the ability to comply with instructions given during testing BMI greater than 40 Pregnancy- Per participant self-report. Due to the expected small number of pregnant individuals and resulting inability to account for its effect on resulting outcomes, participants will be withdrawn from the study.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: All participants will be cast and fit with two CDOs. Each CDO will be labeled as CDO-A or CDO-B. Participants will be randomly assigned to one of two CDO testing sequences (AB, BA) to prevent testing order from influencing study results.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: NoCDO<br>Participants will be evaluated without a CDO | |
| Experimental: CDO-A<br>The first study CDO will be designated CDO-A | Device: Carbon Fiber Custom Dynamic Orthosis (CDO)<br>* The carbon fiber custom dynamic orthosis will consist of a semi-rigid foot plate, a posterior carbon fiber strut, and a proximal cuff below the knee.<br>* Other names: Ankle Foot Orthosis (AFO);|
| Experimental: CDO-B<br>The second study CDO will be designated CDO-B | Device: Carbon Fiber Custom Dynamic Orthosis (CDO)<br>* The carbon fiber custom dynamic orthosis will consist of a semi-rigid foot plate, a posterior carbon fiber strut, and a proximal cuff below the knee.<br>* Other names: Ankle Foot Orthosis (AFO);|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Joint Contact Stress Exposure (Model estimated) | Joint contact stress exposure (MPA-s/gait cycle) will be estimated using a participant specific musculoskeletal model. | Baseline | 
| Peak Plantar Force (total foot) | Plantar forces (N) will be measured across the forefoot (100% of sensor) as participants walk without a CDO and with each CDO. | Baseline | 
| Plantar Force Impulse (total foot) | Plantar force impulse (Ns) across the forefoot (100% of sensor) will be calculated using the integral of the force over the stance phase as participants walk without a CDO and with each CDO. | Baseline | 
| Peak Plantar Force (forefoot) | Plantar forces (N) will be measured across the forefoot (distal 40% of sensor) as participants walk without a CDO and with each CDO. | Baseline | 
| Plantar Force Impulse (forefoot) | Plantar force impulse (Ns) across the forefoot (distal 40% of sensor) will be calculated using the integral of the force over the stance phase as participants walk without a CDO and with each CDO. | Baseline | 
| Peak Plantar Force (midfoot) | Plantar forces (N) will be measured across the forefoot (middle 30% of sensor) as participants walk without a CDO and with each CDO. | Baseline | 
| Plantar Force Impulse (midfoot) | Plantar force impulse (Ns) across the forefoot (middle 30% of sensor) will be calculated using the integral of the force over the stance phase as participants walk without a CDO and with each CDO. | Baseline | 
| Peak Plantar Force (hindfoot) | Plantar forces (N) will be measured across the forefoot (proximal 30% of sensor) as participants walk without a CDO and with each CDO. | Baseline | 
| Plantar Force Impulse (hindfoot) | Plantar force impulse (Ns) across the forefoot (proximal 30% of sensor) will be calculated using the integral of the force over the stance phase as participants walk without a CDO and with each CDO. | Baseline | 
| Numerical Pain Rating Scale | Pain will be assessed using a standard 11-point numerical pain rating scale, in which 0 = no pain and 10 = worst pain imaginable. | Baseline | 
| Participant Device Preference | The participant will rank order their preference for their standard of care device (if applicable), NoCDO, CDO-A, CDO-B on a questionnaire. | Baseline | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Four Square Step Test (4SST) | The 4SST (s) is a standardized timed test of balance and agility. | Baseline | 
| Sit to Stand 5 Times (STS5) | STS5 (s) is a well-established timed measure of lower limb muscle strength and power. Participants are instructed to stand up and sit down 5 times as fast as possible. | Baseline | 
| Ankle Range of Motion | Ankle range of motion (degrees) during gait. | Baseline | 
| Peak Ankle Moment | Peak ankle moment (Nm/kg) during gait. | Baseline | 
| Peak Ankle Power | Peak ankle power (W/kg) during gait. | Baseline | 
| The Orthotics Prosthetics Users' Survey (OPUS) | Satisfaction with device will be assessed using the Orthotics Prosthetics Users' Survey Satisfaction With Device Score (11-55). Lower scores indicate a better outcome. | Baseline | 
| Modified Socket Comfort Score (Comfort) | Comfort scores range from 0 = most uncomfortable to 10 = most comfortable. | Baseline | 
| Modified Socket Comfort Score (Smoothness) | Smoothness scores range from 0 = least smooth to 10 = most smooth. | Baseline | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Carbon Fiber, Gait Analysis, Ankle Foot Orthosis, Arthritis, Biomechanics, Ankle, Adult