The Genucentric Knee OrthosisA New Concept

ROBERT FOSTER, B.S.

JOHN MILANI, B.S., CPO

The
Genucentric
Knee
Orthosis
( F i g . 1) offers a u n i q u e polycentric
( G e n u c e n t r i c ) joint a s a n alternative to

single axis or conventional polycentric

joints for patients with m e d i o l a t e r a l
instability or g e n u r e c u r v a t u m . C o n -

F i g . 1. A n t e r i o r a n d m e d i c a l view o f t h e G e n u c e n t r i c K n e e O r t h o s i s .

ceived by the a u t h o r s a n d d e v e l o p e d at
the V e t e r a n s A d m i n i s t r a t i o n Prosthetics
Center ( V A P C ) , this orthosis features
lightweight
construction,
improved
cosmesis,
supracondylar-suprapatellar
suspension, a n d a knee-tracking c a p a
bility that eliminates p i s t o n i n g a n d m i
g r a t i o n . T h e m o s t distinct feature is the
G e n u c e n t r i c joint (Figs. 2 a n d 3), with
its ability to a p p r o x i m a t e its instan
t a n e o u s center of rotation with the struc
turally
sound
and/or
pathologically
d e r a n g e d knee. Clinical results thus far
i n d i c a t e that the intended g o a l of de
s i g n i n g a polycentric joint to a c c o m m o
d a t e the a n a t o m i c a l knee, such as to
e l i m i n a t e completely the joint as a source
of p i s t o n i n g at the orthosis-limb inter
face, h a s b e e n achieved.

T h e Genucentric Joint
A d e t a i l e d description of the m e c h a n i
cal aspects of the Genucentric j o i n t m u s t

F i g . 2 . C l o s e - u p view o f G e n u c e n t r i c J o i n t .

b e g i n with a discussion of the m o v e m e n t s

of the a n a t o m i c a l knee, since m i m i c k i n g
the a n a t o m i c a l knee is the desired result.
A l t h o u g h c o n s i d e r a b l e research h a s been
devoted to the b i o m e c h a n i c s of the knee
j o i n t , it is b e y o n d the s c o p e of this arti
cle to restate this r e s e a r c h in full. W e
will, however, discuss briefly points
f o u n d pertinent to the d e v e l o p m e n t of
the G e n u c e n t r i c j o i n t .
K a p a n d j i (2) states that m o v e m e n t of
the f e m o r a l condyles u p o n the tibial
p l a t e a u is a c c o m p l i s h e d by a c o m b i n a
tion of rolling a n d sliding. A purely rol
ling m o t i o n requires a tibial p l a t e a u of
a p p r o x i m a t e l y twice the width that
actually exists to prevent d i s l o c a t i n g the
knee. A purely sliding m o t i o n would
cause the femur to strike the posterior
aspect of the tibial p l a t e a u , b r i n g i n g
flexion to a p r e m a t u r e h a l t . T h e ratio
of rolling to sliding varies t h r o u g h o u t
the flexion r a n g e . B e g i n n i n g with rol
ling for the first 10 to 15 d e g . for the

F i g . 3. C l o s e - u p view o f G e n u c e n t r i c J o i n t fully
flexed.

m e d i a l condyle, a n d 20 d e g . for the

l a t e r a l condyle, sliding b e c o m e s p r o
gressively m o r e i m p o r t a n t until it b e
c o m e s the only m o t i o n t o w a r d the e n d of
the flexion r a n g e . T h e difference b e
tween the rolling-to-sliding r a t i o o f the
m e d i a l a n d lateral condyles e x p l a i n s
why the lateral condyle covers a g r e a t e r
d i s t a n c e t h a n the m e d i a l condyle, a n d
a c c o u n t s for the transverse rotation f o u n d
at the k n e e j o i n t .
T h e c h a n g i n g r a d i u s of c u r v a t u r e of
the s u r f a c e of the f e m o r a l condyles c a u s e s
the i n s t a n t a n e o u s center of rotation of
the knee to d i s p l a c e d u r i n g flexion a n d
extension. It is never d i s p l a c e d b e y o n d a
2.3 c m circle a b o u t the l a t e r a l f e m o r a l
condyle, unless severe structural de
r a n g e m e n t is present.
F r a n k e l a n d Burstein (1) state that
"It h a s b e e n w e l l - d o c u m e n t e d that nor
m a l m o t i o n (of the knee) involves a
m o v i n g instant center o f rotation. T h e r e
fore, it is u n r e a s o n a b l e to e x p e c t that
n o r m a l m o t i o n m a y b e forced or c r e a t e d
by the use o f a well-fitted, single-hinged
knee b r a c e . If there is sufficient c l e a r a n c e
or p l a y between the elements of the
b r a c e a n d the l e g , n o r m a l m o t i o n m a y b e
p e r m i t t e d p r o v i d i n g the joint itself is
c a p a b l e of p r o d u c i n g it b y b e i n g dis
p l a c e d . However, if it is d e s i r a b l e to force
n o r m a l m o t i o n with well-fitted b r a c e s
or h i n g e d casts, a knee which p r o d u c e s
a m o v i n g instant center of rotation is
necessary."
T h e inherent p r o b l e m in u s i n g a sin
g l e - a x i s j o i n t to b r a c e the m u l t i - a x i s knee
is that the single-axis j o i n t tends to b e
c o m e d i s p l a c e d in its effort to follow the
m o v i n g center-of-rotation of the a n a
t o m i c a l k n e e . T h i s m o v e m e n t is trans
m i t t e d to the cuff sections a n d p r o d u c e s
a n a n g u l a r c h a n g e in the cuff sections
that c a u s e s them to shift u p a n d down
a l o n g the l i m b (pistoning). Discomfort
a n d s l i p p a g e a r e the result.
Polycentric joints c o m m o n l y used

t o d a y utilize a m o v i n g center-or-rotation
to r e d u c e pistoning. However, they
p r o v i d e only one ideal p a t h of instant
centers a n d lack the flexibility n e e d e d to
c o n f o r m to individual v a r i a t i o n s f o u n d
in healthy a s well as p a t h o l o g i c a l l y de
r a n g e d knees. By contrast, the slotted
disk s a n d w i c h e d between the thigh a n d
c a l f sections p e r m i t s the instant center
of the G e n u c e n t r i c j o i n t to m o v e t h r o u g h
a variety of p a t h s , thereby allowing the
j o i n t to follow the p a t h of the individual
a n a t o m i c a l knee while p r o v i d i n g the
necessary s u p p o r t ( F i g s . 4 a n d 5 ) . Plots
of the instant center, using the m e t h o d s
outlined by F r a n k e l a n d B u r s t e i n , show
a c o n c e n t r a t e d locus o f centers that lie
within a 2 . 5 c m circle, i n d i c a t i n g that the
m o t i o n s of the G e n u c e n t r i c j o i n t c a n
m i m i c the m o t i o n s of the a n a t o m i c a l
j o i n t . L i k e the a n a t o m i c a l knee, the
G e n u c e n t r i c joint h a s a sliding a s well a s
a rolling c o m p o n e n t in its m o t i o n . T r a n s
verse r o t a t i o n o f the a n a t o m i c a l knee
was not considered significant in the
d e s i g n of the Genucentric joint since this
m o t i o n is a d e q u a t e l y a b s o r b e d by the
soft tissues between the skeletal m e m b e r s
a n d the cuff sections.
Polypropylene is u s e d in the construc
tion o f the G e n u c e n t r i c j o i n t b e c a u s e it
afforded the opportunity to m a k e the
joints continuous with a n intimately
fitting polypropylene calf a n d thigh
cuffs ( F i g . 5 ) . T h i s was a c c o m p l i s h e d
d u r i n g m o l d i n g by e x t e n d i n g the thigh
piece below the k n e e center on the cast,
t e r m i n a t i n g in a semicircle. T h e calf
piece w a s e x t e n d e d a s e q u a l d i s t a n c e
a b o v e the knee center a n d thigh p i e c e ,
t e r m i n a t i n g in a similar m a n n e r . T h i s
p r o v i d e d a circle of o v e r l a p p i n g plastic
a b o u t the knee center within which to
construct the j o i n t . S a n d w i c h e d between
the plastic cuff extensions a r e a l u m i n u m
disks with two holes drilled in a hori
zontal p l a n e . (See f a b r i c a t i o n s e q u e n c e
below.) T h e holes p r o v i d e the r e q u i r e d

joint pivot points that a r e m a t c h e d by

a single hole in e a c h of the plastic cuff
extensions. T w o stops ( c a p screws) a r e
then a d d e d to e a c h j o i n t , o n e to the distal
e n d of the thigh extension, the other to
the p r o x i m a l b o r d e r of the a l u m i n u m
disk, that a r e m a t c h e d by slots in the a d
j a c e n t structures. T h e stops k e e p the
joints in p r o p e r a l i g n m e n t while d o n n i n g
a n d doffing the orthosis, a n d p r o v i d e a
halt to extension at full extension or at
the desired d e g r e e of flexion.
T h i s m a n n e r of construction offers
significant a d v a n t a g e s over conventional
orthoses. T h e t i m e c o n s u m i n g processes
of b e n d i n g , polishing, a l i g n i n g , a n d
riveting s i d e b a r s to cuffs a r e e l i m i n a t e d .
A n d , by r e m o v i n g the bulky s i d e b a r s ,
a lighter-in-weight, m o r e s t r e a m l i n e d ,
a n d m o s t cosmetically a p p e a l i n g a p p l i
a n c e is p r o d u c e d .
S u s p e n s i o n is a c c o m p l i s h e d b y a c o m
bined
supracondylar-suprapatellar
system in which tissue is c o m p r e s s e d
a b o v e the p a t e l l a a n d the condyles. A
built-in flare for the d i s p l a c e d tissue in

the distal posterior section of the thigh

cuff at the level of the suspension im
proves the effectiveness of the suspension
and enhances comfort.
T h e G e n u c e n t r i c K n e e Orthosis in
c o r p o r a t e s m a n y i m p r o v e m e n t s over the
conventional knee orthosis while m a i n
t a i n i n g the b a s i c b i o m e c h a n i c a l princi
ples o f the conventional orthosis. T h i s
orthosis, like the conventional orthosis,
relies o n a three-point pressure system to
stabilize desired m o t i o n s of the extremity
while preventing u n d e s i r e d m o t i o n s .
Clinical results i n d i c a t e that the G e n u
centric K n e e Orthosis c a n b e worn with
significant i m p r o v e m e n t s in
comfort
when c o m p a r e d to m o r e c o m m o n knee
orthoses, with p i s t o n i n g r e d u c e d to the
point of b e c o m i n g u n d e t e c t a b l e , a n d
with m i g r a t i o n e l i m i n a t e d .

Casting a n d Modification Procedures

1. T a k e s t a n d a r d m e a s u r e m e n t s of
l i m b . T o utilize s u p r a c o n d y l a r suspen-

F i g . 4 . A s k n e e is flexed, it's i n s t a n t a n e o u s c e n t e r o f r o t a t i o n is d u p l i c a t e d by t h e G e n u c e n t r i c J o i n t .

mally above mid-thigh. Compress areas

i m m e d i a t e l y a b o v e condyles with p a l m s
of h a n d s a s plaster b e g i n s to set to accen
t u a t e suspension a r e a s .
6. O n c e cast is set, d r a w a vertical
reference line on anterior s u r f a c e of
c a s t . T h i s line s h o u l d b e p a r a l l e l to the
m i d - s a g i t t a l line.
7. R e m o v e cast a n d p r e p a r e for pour
ing.
8. After plaster sets, use a n awl to
p e n e t r a t e w r a p o n vertical reference
line to transfer it to positive m o l d .
9. R e m o v e w r a p a n d s m o o t h positive
m o l d o f all irregularities. T a k e c a r e not
to r e m o v e indelible m a r k s , especially
those i n d i c a t i n g knee center.
10. T a k e M - L d i m e n s i o n a b o v e con
dyles down to within 3 m m o f the m e a
s u r e m e n t . E n s u r e that all circumferences
a r e b r o u g h t down to m e a s u r e m e n t s a n d
b l e n d e d into the c o n t o u r s o f the l i m b .
F i g . 5 . E x p l o d e d view o f t h e G e n u c e n t r i c J o i n t .
Pressure sensitive a r e a s a r e relieved with
s t a n d a r d plaster b u i l d u p s .
1 1 . B e c a u s e tissue is s q u e e z e d a b o v e
the condyles a n d p a t e l l a for suspension,
it tends to b u l g e p o s t e r o m e d i a l l y a n d
posterolaterally. T o a v o i d flesh from
sion, t a k e a tight medicolateral m e a s u r e
b e i n g p i n c h e d by the e d g e s of the ortho
m e n t a b o v e condyles.
sis, e x t e n d the m o d i f i e d cast in these
2 . P l a c e T u b e g a u z o n l i m b a n d secure
areas (Fig. 6). T h e amount extended
from m o v i n g . U s e l a t e x t u b i n g to h e l p
d
e p e n d s o n the a m o u n t of s u b c u t a n e o u s
facilitate cast r e m o v a l in the usual
tissue present. C a s t s h o u l d b e e x t e n d e d
manner.
12 m m on slender patients, a n d 25 m m
3. M a r k the following a n a t o m i c a l
o n heavyset p a t i e n t s .
l a n d m a r k s with indelible p e n c i l : patel
12. T h e joints of the G e n u c e n t r i c
la, p r o x i m a l b o r d e r s o f f e m o r a l condyles,
K n e e Orthosis a r e built as continuations
knee center ( d e t e r m i n e d by a d d i n g 18
of the cuff m o l d i n g s ( F i g . 6 ) . E a c h cuff
m m (3/4 in.) to the m e d i a l tibial p l a t e a u
overlaps the other at knee-center level.
height), iliotibial b a n d , h e a d of fibula,
F l a t , circular b u i l d - u p s o n the cast a r e
tibial crest, a n d any pressure sensitive
n e e d e d to create flat surfaces for j o i n t s .
areas.
T h e b u i l d - u p s s h o u l d b e 4 2 m m in d i a
4 . C a s t l i m b with all defomities cor
meter, p a r a l l e l to b o t h the m i d - s a g i t
rected as m u c h as p o s s i b l e . T o a c c e n t u a t e
tal line a n d the line o f p r o g r e s s i o n , a n d
bony p r o m i n e n c e s , cast the knee in five
b u i l d - u p s s h o u l d not increase the epicondyle
d e g . of flexion a n d with only p a r t i a l
b u i l d - u p s distally by 18 m m b e y o n d cir
w e i g h t - b e a r i n g while s t a n d i n g .
c u l a r portions of the joints, to allow
5. U s e elastic plaster b a n d a g e to o b
toi d b- cea lcf r eaantde d e xin
cuff a n d
tain a s m o o t h c a s t . S t a r t the w r a p distally offsets
below m
t e ncalf
d proxi

F i g . 6. A . A n t e r i o r view o f p o s i t i v e m o d e l s h o w i n g b u i l d u p s p a r a l l e l to t h e a n t e r i o r r e f e r e n c e l i n e . B . M e d i a l
view o f p o s i t i v e m o d e l s h o w i n g j o i n t b u i l d u p s , f l a r e e x t e n s i o n s , a n d t r i m lines.

thereby allow the thigh cuff to flex to 135

deg.
13. P l a c e trim lines a n d flares on cast.
M a r k e a c h joint b u i l d u p with vertical
a n d horizontal reference lines that will b e
used to align disks later.
Fabrication Procedures
Cast is p r e p a r e d for b o t h v a c u u m
drape molding and standard hand mold
i n g without v a c u u m .
1. Use 5 m m - t h i c k polypropylene to
v a c u u m m o l d thigh cuff. Set v a c u u m to
15 psi.
2 . After cooling, r e m o v e plastic from
cast, trim it to trim lines, a n d p l a c e b a c k
on cast.

3. T a p e a 3 m m - t h i c k b l a n k alu
m i n u m disk that is l a r g e r in d i a m e t e r
t h a n p r o p o s e d joint d i a m e t e r , to kneej o i n t position on thigh cuff ( F i g . 7 A ) .
M o l d calf cuff over both thigh cuff ex
tension a n d disk (Fig. 7 B ) .
4 . R e m o v e calf cuff after cooling a n d
trim to trim lines.
5. H a n d - m o l d tongues on cast using 2
mm-thick
low
density
polyethylene.
Skive tongues where they fit u n d e r cuffs.
6. A t t a c h reinforced Velcro straps,
tongues, a n d 25 m m stainless steel loops
reinforced with l a m i n a t e d D a c r o n t a p e ,
to cuffs.
7. P l a c e c o m p l e t e d cuffs on c a s t : 3
m m s p a c e s p a r a l l e l to b o t h the m i d -

F i g . 7. A . T h i g h c u f f with b l a n k a l u m i n u m d i s k o n c a s t . B . C a l f c u f f m o l d e d over t h i g h c u f f a n d b l a n k d i s k .
C . B o t h cuffs in p o s i t i o n a f t e r t r i m m i n g a n d p o l i s h i n g . J o i n t s p a c e s for a l u m i n u m disks s h o u l d b e p a r a l l e l in
all p l a n e s .

F i g . 8. D i m e n s i o n s o f t h e disk.

F i g . 9. A . R e f e r e n c e l i n e s t r a n s f e r r e d f r o m p o s i t i v e m o d e l to t h i g h cuff. B . D i s k s a r e p o s i t i o n e d o v e r refer
e n c e l i n e s . A n t e r i o r p i v o t s a n d d i s t a l # 3 0 h o l e s in disks a r e m a r k e d a n d d r i l l e d t h r o u g h p l a s t i c .

sagittal line a n d the line of progression

at j o i n t surfaces should b e observed
(Fig. 7 C ) .
8. T h e s p a c e s c r e a t e d a r e for two 3
m m - t h i c k a l u m i n u m disks. E a c h disk
will h a v e two pivots a n d two stops ( F i g .
5 ) . F a b r i c a t e disks as shown in F i g . 8.
9. R e m o v e c a l f cuff while m a i n t a i n i n g
thigh cuff in p l a c e on cast. T h e s o m e w h a t
translucent plastic will permit reference
lines previously d r a w n on cast to show at
knee-joint a r e a ( F i g . 9 A ) . Position disks
so that holes line u p with reference lines
(Fig. 9 B ) . T h e anterior pivot point of
e a c h disk should b e m a r k e d a n d drilled
t h r o u g h plastic with a 9 m m ( 3 / 8 in.)
drill. A t t a c h disks to thigh cuff using
s t a n d a r d ankle joint b u s h i n g s a n d screws.

F i g . 1 0 . C l o s e - u p o f disk b e i n g r o t a t e d a b o u t a n t e
rior p i v o t . A p e n c i l is u s e d to s c r i b e p a t h t h a t s t o p
travels t h r o u g h .

R e a l i g n disks, m a r k , then drill lower # 3 0

holes in p l a s t i c . Insert a pencil t h r o u g h
plastic j o i n t ( F i g . 10) a n d scribe a n a r c
on disks a s they a r e r o t a t e d a r o u n d a n
terior pivots. R e m o v e disks a n d e x p a n d
lower # 3 0 holes by drilling in disks to 7
m m o r 9 / 3 2 in. U s i n g the s c r i b e d a r c s
as g u i d e s ( F i g . 11A a n d B ) , cut slots into
disks ( F i g . 5 ) to p e r m i t 6 m m c a p screw
h e a d s to r u n smoothly within slots. E n
l a r g e # 3 0 holes by drilling in p l a s t i c to
# 4 size holes so that post screws c a n b e
inserted into p l a s t i c . P l a c e c a p screws
a n d post screws into plastic t h i g h cuff,
then a t t a c h disks a n d r o t a t e t h e m . T h e r e
s h o u l d b e n o b i n d i n g . P l a c e t h i g h cuff
b a c k on c a s t .
1 0 . S e c u r e disks a g a i n s t c a p screws
with m a s k i n g t a p e ( F i g . 1 2 A ) . A t t a c h
c a l f cuff to c a s t . U s e holes in disks for
reference m a r k s since disks now o b s c u r e
reference m a r k s o n cast ( F i g . 1 2 B ) . M a r k
posterior pivot points a n d u p p e r # 3 0
holes onto plastic calf cuff. R e m o v e calf
cuff a n d drill posterior pivots in s a m e
m a n n e r as anterior pivots. Drill u p p e r
# 3 0 holes into p l a s t i c . R e m o v e disks from
thigh cuff a n d a t t a c h to calf cuff at
posterior pivot points. Insert
pencil
t h r o u g h # 3 0 holes in disks, rotate disks
a b o u t posterior pivots, a n d scribe a r c s
onto plastic as previously d o n e for thigh
cuff in step 9 a b o v e . E n l a r g e # 3 0 holes
by drilling in plastic cuff to 10 m m or
5 / 1 6 in. U s e arcs o n plastic as g u i d e s to
cut slots in plastic ( F i g . 5 ) a n d thereby
p e r m i t cap-screw h e a d s to run freely
within slots. E n l a r g e u p p e r # 3 0 holes
by drilling in disks to # 2 1 size holes a n d
t a p holes for 10-32 t h r e a d e d c a p screws.
1 1 . R e a s s e m b l e orthosis. N o b i n d i n g
s h o u l d b e present a n d joints s h o u l d b e
s q u a r e in all p l a n e s .
1 2 . T h e orthosis is now r e a d y for fit
ting. N o localized p a i n or skin p i n c h i n g
s h o u l d o c c u r . However, s o m e initial dis
comfort over condyles m a y b e experi
enced owing to s n u g fit for suspension.
A p i e c e of t u b u l a r stockinet m a y p r o v i d e

relief until patient b e c o m e s a c c u s t o m e d

to orthosis ( F i g . 4 ) .
13. Since
only
minor
alignment
c h a n g e s c a n b e c a r r i e d o u t o n the or
thosis, all steps s h o u l d b e followed c a r e
fully.

Clinical Experience
T h e G e n u c e n t r i c K n e e Orthosis w a s
delivered to patients with m e d i o l a t e r a l
instability a n d / o r g e n u r e c u r v a t u m of
the knee. Following a r e reviews o f four
case studies o f patients who have worn the
device for sufficient p e r i o d s of time to
o b t a i n m e a n i n g f u l results.
1. Patient B . C . , a 24-year-old active
m a l e , an automobile body-and-fender
m a n , s u s t a i n e d g u n s h o t w o u n d s of the
left femur in 1 9 7 0 . R e s u l t i n g deformi
ties i n c l u d e : limited range-of-knee m o
tion (15 to 100 d e g . ) , g e n u v a r u m of 22
degrees, a n d a one-inch shortening. T h e
patient's m a j o r c o m p l a i n t was p a i n at
the lateral aspect o f the knee on s t a n d i n g ,
walking a n d s q u a t t i n g , which resulted in
loss of t i m e f r o m work. B . C . w a s ori
ginally p r o v i d e d with a d o u b l e b a r K A F O
with corrective p a d s . However, d u e to
weight,
bulk
and
overall extensive
b r a c i n g , he refused to wear the device.
A n elastic h i n g e d knee orthosis was then
p r e s c r i b e d , b u t while the p a t i e n t liked
the weight a n d f r e e d o m o f the orthosis,
his condition worsened.
T h e clinic t e a m , in April 1 9 7 8 , de
c i d e d to provide B . C . with a G e n u c e n
tric K n e e Orthosis. After w e a r i n g this
orthosis for five weeks, the patient was
seen in the clinic for follow-up e x a m i n a
tion. H e w a s a b l e to walk a n d s t a n d with
less p a i n a n d his deformities were con
trolled. In a d d i t i o n , h e f o u n d the ortho
sis to b e lightweight, cosmetic a n d c o m
fortable, a n d it p r o v i d e d sufficient free
d o m for his n e e d s . D u r i n g seven m o n t h s
o f w e a r i n g this orthosis, the p a t i e n t h a s
experienced no problems
concerning
function or wear of c o m p o n e n t s .

F i g . 1 1 . A . D i s k h a v i n g s c r i b e d p a t h o f s t o p o n it. B . S l o t s in disks p e r m i t c a p screw h e a d s to r u n freely

within t h e m .

F i g . 1 2 . A . D i s k a s s e m b l y on t h i g h cuff. B . C a l f c u f f p o s i t i o n e d over disk. P o s t e r i o r p i v o t s a n d p r o x i m a l # 3 0

holes are m a r k e d a n d drilled t h r o u g h plastic.

2 . Patient J . A . ( F i g . 13), a m i d d l e a g e d m a l e , injured his right k n e e after

falling f r o m a truck in 1 9 5 3 . T h e result
i n g t r a u m a c r e a t e d m i l d laxity in b o t h
the A - P a n d M - L p l a n e s . In a d d i t i o n ,
the patient h a s p a i n , atrophy a n d a m o d
e r a t e l i m p . Active range-of-knee m o t i o n
is limited from 0 to 100 d e g . d u e to
severe p a i n a n d joint d a m a g e . S i n c e
the onset of this condition, the p a t i e n t
h a s worn various knee s u p p o r t s ; the
latest b e i n g a n elastic knee orthosis with
m e d i a l a n d lateral p a d s . D i s a b l i n g p a i n ,
however, persisted.
T h e p a t i e n t was p r o v i d e d with a G e n u
centric K n e e Orthosis in M a y 1 9 7 8 , a n d
was seen for a follow-up e x a m i n a t i o n five
weeks after the orthosis was delivered.

A l t h o u g h J . A . still h a d p a i n , he n o
l o n g e r e x p e r i e n c e d the s h a r p p a i n h e h a d
with previous devices. L a x i t y in both A - P
a n d M - L p l a n e s were well c o n t r o l l e d ;
the patient f o u n d the orthosis to b e light
weight a n d c o s m e t i c , a n d it d i d not
piston a s previous devices h a d ( F i g . 1 4 ) .
3. Patient M . L . ( F i g . 1 5 ) , a 55-yearo l d m a l e , suffered a h e a d injury in 1 9 4 5 ,
s e c o n d a r y to shell f r a g m e n t w o u n d s ,
with resulting h e m i p l e g i a o n his right
s i d e . H e walks with a spasticequinova
q u a d r i c e p s a r e g o o d a n d h e is s t a b l e
while s t a n d i n g a n d walking. M . L . was
provided with a single b a r A F O with 90d e g r e e p l a n t a r stop a n d v a r u s corrective
s t r a p . With the p a s s a g e of time, stresses

F i g . 1 3 . P a t i e n t J . A . N o r m a l k n e e m o t i o n s a r e u n r e s t r i c t e d e v e n w h i l e h e is s e a t e d , e n h a n c i n g b o t h c o m f o r t
a n d cosmesis.

a c t i n g o n the right knee c a u s e d posterior

l i g a m e n t stress, anterior knee c o m p r e s
sion, a n d excessive hyperextension, all
resulting in p a i n a n d f a t i g u e .
T h e clinic t e a m , in A p r i l 1 9 7 8 , de
c i d e d to p r o v i d e M . L . with a K A F O
utilizing a polypropylene shoe insert a n d
a G e n u c e n t r i c K n e e J o i n t . T h e orthosis
was fitted, but d u e to u p p e r extremity
involvement a n d spastic e q u i n o v a r u s , the
p a t i e n t c o u l d not d o n the device inde
pendently. However, when assisted in
d o n n i n g the device, the patient func
tioned well with it o n . T h e orthosis w a s
m o d i f i e d by m a i n t a i n i n g the knee section
a n d r e p l a c i n g the shoe section with a n
aluminum
medial
upright,
caliper
stirrup with 9 0 - d e g r e e p l a n t a r s t o p , a n d
v a r u s corrective s t r a p . W i t h these m o d i
fications, M . L . was a b l e to d o n a n d doff
the orthosis independently. Five weeks
after delivery, a follow-up e x a m i n a t i o n
revealed that the patient was d o i n g well;
g e n u r e c u r v a t u m was controlled, p a i n
a n d f a t i g u e were e l i m i n a t e d .
4 . P a t i e n t G . H . , a 4 4 - y e a r - o l d active
m a l e truck driver, injured his left knee
when he fell from a l a d d e r in 1 9 5 6 . C a r
t i l a g e w a s r e m o v e d from the m e d i a l as
pect o f the knee. G . H . h a s m a r k e d
a t r o p h y o f the thigh, limited range-ofknee m o t i o n (15 to 90 d e g . ) , p a i n , a n d
s o m e A - P instability. H e was given a
J o n e s knee c a g e , with d r o p locks for o c c a
sional u s e . T h e V A P C K n e e Orthosis,
p r e s c r i b e d in O c t o b e r 1 9 7 4 , w a s lighter
in weight, p r o v i d e d g o o d function, a n d
h a d n o locks. T h e p a t i e n t w a s seen in
M a y 1978 for a new orthosis b e c a u s e the
V A P C K n e e Orthosis w a s n o l o n g e r
serviceable.
T h e clinic t e a m d e c i d e d to use the
G e n u c e n t r i c K n e e Orthosis to e l i m i n a t e
p i s t o n i n g . T h e patient f o u n d the new
d e s i g n to b e lighter in weight, m o r e cos
m e t i c , a n d better in function t h a n p r e
vious devices.

F i g . 14. I n t i m a t e fit c a n b e o b t a i n e d with G e n u

centric K n e e Orthosis.

F i g . 1 5 . P a t i e n t M . L . w e a r i n g p l a s t i c K A F O with G e n u c e n t r i c K n e e u n i t . C o s m e s i s o f this d e v i c e is excel

lent.

Summary
T h e G e n u c e n t r i c K n e e Orthosis e m
ploys a u n i q u e new j o i n t to e l i m i n a t e
p i s t o n i n g . T h i s is d u e to the c a p a b i l i t y
of the j o i n t to d u p l i c a t e the m o t i o n of
the individual a n a t o m i c a l knee it con
trols. W i t h pistoning e l i m i n a t e d , a n d
with a firm f o u n d a t i o n p r o v i d e d by its
supracondylar-suprapatellar
suspension
system, m i g r a t i o n of the orthosis b e c o m e s
clinically
undetectable,
even
after
lengthy p e r i o d s o f active u s e . In a d d i t i o n ,
to further e n h a n c e patient comfort a n d
a c c e p t a n c e o f this u n i q u e rehabilitation
a p p r o a c h , the orthosis is f a b r i c a t e d of
lightweight plastic utilizing v a c u u m f o r m i n g a n d d r a p e - m o l d i n g techniques.
T h e G e n u c e n t r i c K n e e Orthosis is
presently b e i n g clinically tested on p a
tients with various knee p r o b l e m s ; four
patients h a v e thus far worn the device
for sufficient p e r i o d s of time to c o m p i l e
definitive results. In e a c h c a s e , the p a
tient f o u n d the orthosis to b e c o m f o r t a b l e
a n d non-restrictive to the desired m o
tions of the l i m b . Neither wear nor m e
c h a n i c a l failure h a v e b e e n observed, even
t h o u g h s o m e of these patients a r e y o u n g
a n d quite active.

Acknowledgments
T h e authors would like to express
their a p p r e c i a t i o n to K e n n e t h L a B l a n c ,
Senior T e c h n i c a l Specialist, a n d M a x
Nacht,
T e c h n i c a l Writer, for their
c o o p e r a t i o n a n d assistance in p r e p a r i n g

this a r t i c l e ; to Michael L a m b e r t i , Photo

g r a p h e r , for his o u t s t a n d i n g
photo
g r a p h i c work;
a n d to G a r y Fields,
T e c h n i c a l Assistant to the Director of
the V A P C , a n d D r . G u s t a v R u b i n ,
Clinic Chief, for their e n c o u r a g e m e n t
a n d interest.

Footnotes
1Orthotist, V e t e r a n s Administration Prosthetics
Center, 252 Seventh Avenue, New York, New York
10001
2Orthotist-Prosthetist, Veterans Administration
Prosthetics Center, 2 5 2 Seventh Avenue, N e w
York, New York 10001
3 T h e t e r m " G e n u c e n t r i c " h a s b e e n c o i n e d to dis
tinguish o u r unique polycentric joint from the
polycentric joint now in c o m m o n use.

References
(1) Frankel, Victor H . , a n d Burstein, Albert H . ,
Orthopaedic
Biomechanics,
(Philadelphia:
L e a a n d Febiger, 1970), p p . 118-144
( 2 ) K a p a n d j i , I . A . , The Physiology
of the Joints,
Vol. T w o , (Edinburgh-London-New York:
Churchill Livingstone, 1970), p p . 86-91
(3) S m i d t , Gary L . , "Biomechanical Analysis of
K n e e F l e x i o n a n d E x t e n s i o n , "Journal
of Bio
mechanics,
V o l . 6, ( G r e a t B r i t a i n - N e w Y o r k :
P e r g a m o n Press, J a n u a r y 1973), p p . 79-91