Evaluation of ischial weight-bearing

orthoses, based on in-vr’vo hip joint force

measurements

G Bergmann Dr.-lng, M Correa da Siiva Dr. med, G Neff Prof,

A Rohlmann Dr.-lng, F Graichen Dr.-lng
Oskar-Helene-Heim, Biomechanics Laboratory, Orthopaedic Hospital of the Free University,
Berlin, Germany

Summary
The reduction of hip joint forces by ischial weight-bearing orthoses, used for the treatment
of Legg-Perthes and other joint diseases, was measured in vivo in a patient with two
instrumented endoprostheses. Three different types of orthoses reduced hip joint loading
by about 30%, independent of their cuff design and the position in which the femur was
held. The direction of the joint forces was changed in such a way that the size of the
load-carrying joint areas decreased by up to 3.4% with two conventional orthoses. With the
third model with improved containment of the femoral head this area increased by up to
8.2%. All the orthoses studied support the pelvis too close to the affected joint, leading to
insufficient load reduction. A design concept is proposed which prevents tilting of the
pelvis in the frontal plane and may improve the force reduction at the hip joint.

Relevance
lschial weight-bearing orthoses are still widely used, although their clinical benefit is
controversial. The observed reduction of the joint load is not better than achievable with
two forearm crutches. New data about very large joint forces during fast walking and
stumbling indicate that a potential benefit of orthoses for the course of Legg-Perthes
disease may mainly be caused by the restrictions put on the patients’ activities. With regard
to the encumbrance of the patients, other methods of treatment should therefore be
preferred.

Keywords: Orthoses, hip joint, Legg-Perthes, joint load, measurement, in viva, telemetry, biomechanics

Clin. Biomech. 1994; 9: 225-234, July

Introduction (IWBO) not only reduce the joint loading but also
increase the containment of the femoral head by
Legg-Perthes disease causes necrosis of the capital
changing the position of the femur. They are sometimes
femoral epiphysis which can lead to a deformity and the
also used in the treatment of idiopathic or cortisone-
loss of mechanical strength’. This idiopathic process is
induced necrosis of the femoral head.
followed by a revascularization and a reossification.
IWBO consist of a cuff around the proximal thigh
The treatment* attempts to maintain the shape of the
connected to uprights on which the patient steps
head by reducing the joint loads, and by maintaining
during walking (Figure 1). Their rationale assumes that
femoral-head containment, the area which is covered
the ground reaction force is transferred through the
by the acetabulum3. Ischial weight-bearing orthoses
uprights and the cuff directly to the pelvis at the ischial
tuberosity (force T at point I), and that the hip joint is
Received: 22 December 1992 hence unloaded. But an unknown portion of the force
Accepted: 10 June 1993
is also transferred via the cuff to the femur, causing hip
Correspondence and reprint requests to: Dr.-Ing G Bergmann.
Oskar-Helene-Heim. Biomechanics Laboratory, Orthopaedic
joint forces R of unknown magnitude. Several designs
Hospital of the Free University, Clayallee 229, D-14195 Berlin, of IWBO are common and vary with respect to the
Germany shape of the femoral cuff and the position of the
@ 1994 Butterworth-Heinemann Ltd
femur4-s. Clinical results with the IWB09,‘c have
0268-00331941040225 - 10 to be compared to the treatment by adduction
226 Clin. Biomech. 1994; 9: No 4

calculated, which influences the pressure in the joint

and thus the stresses in the femoral head. A design
concept is proposed which possibly improves the load
reduction with IWBO.

Methods

Instrumented hip joint endoprosthesis

A cemented titanium hip implant with a ceramic
head was modified to measure the three-dimensional
hip joint force in viva”,“. An inductively powered
telemetry sytem was built into the neck of the
prosthesis and its deformation was measured at 250 Hz
using three strain gauges. From the transmitted signals
the three components of the resultant joint force were
calculated with an accuracy of about 1%21, using
a femur-based coordinate system x-y-z (Figure 2).
From these data the resultant force R and its directions
F in the frontal plane and T in the transverse plane
were computed20,21. The patient’s activities were
videotaped, together with the telemetry signals from
the two implants22. The forces at both hip joints

Figure 1. Function of the ischial weightbearing or-theses.

The ideal function of the orthosis would be if the force Plane x-z
transferred through the uprights to the cuff were
transferred (force T) directly into the pelvis at the point of Plane x-y
the ischial seat (bundle of arrows). A more realistic
concept assumes that the abductor force Fa (lever
arm la2) counterbalances the moment caused by the
weight G5 of the upper body (lever arm 192). Fa pulls the
femur into the acetabulum and causes a force Rat the hip
joint. The real situation is statically indeterminate and no
ventral
points of rotation or force transfer exist.

osteotomies”.“, plaster splints13, crutch walking14.i5 or

bed rest16. A survey of this literature and other clinical dorsal
reports indicates that the use of IWBO does not offer
reliable and consistent advantages over the other
methods of management.
It was determined indirectly that the Thomas splint
insufficiently reduces the joint loads”. The most
effective was found to be a quadrilateral cuff (neutral
leg position), which transferred 30-50% of the ground
reaction force to the ischial seat. Calculations showed
that a Thomas splint transferred 50- 100% of the loads
through the uprights to the ischial seat and reduced the
joint force by 31-57%6. With pronounced limping the
reduction was improved to 60-86%. However, the Figure 2. Coordinate system and measured loads.
load transfer at the ischial seat was only 30% of the Left femur and frontal plane x-z are seen from behind in
an a/p view. The direction y points into the paper.
ground reaction force. A hip joint force of 200% of the
The axis z is parallel to the idealized (straight)
body weight was calculated statically for the position of longitudinal axis of the whole femur. Together with the
maximum hip flexion during walking with orthoses”. knee axis it defines the frontal plane. The axis x lies in the
These investigations suggest that the load reducing frontal plane and points medially, the axis y points
effect of IWBO may be insufficient. ventrally. Reported are the resultant joint force R and its
directions F in the frontal plane x-z (measured from z)
In this study instrumented hip endoprostheses were
and T in the transverse plane x-y (measured from x).
used for the first time to measure in viva the reduction A positive angle F indicates that the force acts from
of joint forces with various types of IWBO. Additionally medial, a positive value of T represents a force from
the size of the load-transferring cartilage areas was ventral.
 Bergmann et al.: lschial weight-bearing orthoses 227

and pelvis, aimed at preventing the cuff becoming

loose during the swing phase.
3. NGHE orthosis (‘Null Grad Hueft Entlastungs
Orthese’ = ‘Zero degree hip load reducing orthosis’).
This (unpublished) design from R. Volkert is similar
to the MHE orthosis, but has a straight upright
and holds the leg in a neutral position. Again
measurements were taken with and without a belt to
the pelvis.

All devices were used with an additional elastic strap

from the tip of the shoe to the upright (Figure 4)
because earlier measurements had shown that any
contact between shoe and floor increased the forces at
the hip joint.
Figure 3. Investigated models of ischial weightbearing
orthoses. Left, NGHE orthosis. The PTF socket with
a large contact area at the OS ischii leaves the area of the Measurements
greater trochanter free. The leg is held in a neutral
Training of several hours by a physiotherapist preceded
position. This design was tested with and without an
additional belt between socket and pelvis. Middle, MHE the measurements, taken 24 months postoperatively for
orthosis. Similar to the NGHE design, but the leg is held the Thomas splint and 33 months for the other
in 15” abduction, 5”flexion, and neutral rotation. orthoses. The patient repetitively walked a distance of
The bottom plate has an outrigger to prevent extension 10 m in a gymnasium, and the middle 6-8 steps were
and adduction of the leg during walking. Tested with and
used for the evaluation. Between 29 and 95 steps at a
without belt. Right, Thomas splint. The socket covers the
thigh tightly at four sides, the contact area at the OS ischii
is only small. The two uprights are fitted with a small bar
at the bottom. This design holds the leg in a neutral
position.

could be computed and displayed immediately during

the exercises or evaluated repeatedly after the
measurements.

Patient

In May and August 1988 an 82-year-old male patient

with degenerative hip disease (weight 650 N, height
168 cm) received instrumented implants in both hip
joints. This patient (EB) is medically very fit and a
variety of activities have been investigated throughout
5 years, including jogging at 8 km/h21,23.

Investigated orthoses

Three different orthotic designs were investigated on

the left leg of EB (Figures 3, 4):
1. Thomas splint. The cuff with ischial contact
area tightly encloses the proximal femur; the two
uprights have a small bar at the bottom.
2. MHE orthosis (‘Mainzer Hueft Entlastungs
Orthese’ = ‘Mainz hip load reducing orthosis’). This
orthosis uses a PTF socket (‘Pelvis-Trochanter-
Femur’) which has a wide contact area at the ischii,
encloses the femur on three sides, and contacts the
lateral side only above the greater trochanter2”. The
single upright was adjusted to hold the leg in 15”
abduction, 5” flexion, and in neutral rotation. Its
Figure 4. Patient EB with MHE orthosis. Patient with
bottom plate has an outrigger to prevent adduction two instrumented hip prostheses to measure the
of the leg during walking. This orthosis* was tested three-dimensional joint forces. An induction coil around
with and without an additional belt between socket the hip powers the electronics.
228 Clin. Biomech. 1994; 9: No 4

Force [ KBW ] Bbmn OH” %“h Angle [ Deg. ]

400 EBLlHlO 60
1.Ma.x Rmax 2.Max
350-1
-45
300.

250.

200.

150.

100.

50.
‘Max. Flexion
“1
0
0 0:5 i 1:5 i 2:5 j 3:5 4 -- -0 OS5 1 1.5 2 2,5 3 3,5 4 495

nme[s] nmetsj
Walking without Ofihosb, 3 kdh, Measured LetI, Patbnt EB, 33 Months Pdop. Wdklng with MHE-Orthab Left, 3 km/h. Mwsumd l&t, Patbnt EB, 33 Month Postop.

Bbn*ch.OHH n.“h Angie [ Deg. ] Force [ %BW ] B!Qnnch.

OH” 8.M Angle [ Deg. ]
Force %BW ]
400 EBRIIII 60

_. __ OJ
Y
L-30
0 0:5 i 1;5 i 2;5 3 3,5 4 0 1 115 2 2.5 3 3.5 4 4.5
0.5
nme[s] Time[s]
Wdklng wlthout Orthoab, 3 k&h. Measumd Right, Patbnt EB, 33 Months Postop. Walking without Orthosb, 3 kmR8, Measured Left. Patient EB, 33 Months Postop.

Figure 5. Walking without orthosis, resultant joint force R

Figure 7. Walking with MHE orthosis after gait training.
and its directions F and T. a, Left joint; b, right joint.
a, Left joint with orthosis; b, right joint without orthosis.
Resultant joint force R during three steps; left scale in
Compared to free walking the peak force Rmax at the left
percent of the body weight (%BW). Force directions F
joint has decreased by about 30%. but a better force
in the frontal plane and T in the transverse plane;
reduction is obtained during the second half of the
right scale in degrees. HS, heel strike; TO, toe off.
stance phase. The duration of the swing phase is
Evaluated were the first force maximum Rmax during
prolonged on the orthotic side. The patterns of the force
each walking cycle and its directions F and T. F and T
directions F and T have changed on both sides.
are not charted if R is lower than 40% BW, because
(See Figure 5 for key.)
their accuracy decreases at low force magnitudes*‘.
(-1 Resultant force R; (-1 angle F (frontal plane);
(-----) angle T (transverse plane). Evaluation of data

The time patterns of the resultant joint force R and its

speed between 3 and 3.5 km/h were included in the
directions F and T in the frontal and the transverse
statistical data. The force on the right hip joint was also
plane were used to investigate the influence of the
measured, either immediately after the measurements
orthoses on the hip joint force throughout the whole
were taken on the left side (Thomas splint) or con-
walking cycle (Figures 6,7), and were compared to free
currently with the left side (MHE and NGHE). For
walking (Figure 5). Peak forces were assumed to be the
comparing the data with ‘normal’ joint loads, readings
most sensitive reflection of the effect of the orthoses,
without orthoses were taken on the same days and at
therefore the values of R, F, and T were evaluated
the same speeds as with orthoses. Additional hip force
when the joint force reached its absolute maximum
data for comparison were obtained at other times while
Rmax during each walking cycle (Figure 5). Rmax
the patient walked with one and two forearm
always corresponded to the first maximum during the
crutches23S28 or stumbled on one occasion2’.
stance phase, and occurred just before the vertical leg
Force [ %BW ] mm”.ch OH” e.“h AngleDeg.
]
]
position. All data were not normally distributed,
250, therefore median, minimum and maximum values were
chosen for the evaluation (Table 1). The force R is
200.
given as a percentage of the patient’s body weight
150. (%BW). If not mentioned otherwise, the reported data
toc-
refer to the left hip joint, where the patient wore
the orthoses. The significance of the statistical data
50. could not be evaluated because only one patient was
OJ , . , I I I I ‘-30
investigated. From slow-motion video pictures of the
0 0,5 1 1,5 2 2,s 3 3,5 4 4.5 5 5.5
shoes during walking the instants of heel strike (HS),
FwS”L Force R AnpIe F ,Fvxa. Plans) Angle
------- T (T,_“. Plans, nme[s]

Walking w”h Tham. Splint Left, WHhout T”lnlng, Y~.suml Lett, P.tb”t EB, 24 Months Pootop
toe off (TO) and maximum flexion were determined.
Changes of the joint force directions influence the
Figure 6. Walking with Thomas spint without gait
training. Left joint with orthosis. Additional force peaks joint area which transfers the load (Figure 8). A
act during the swing phase. (See Figure 5 for key.) decrease of F or an increase of T are both detrimental
 Bergmann et al.: lschial weight-bearing orthoses 229

Table 1. Hip joint force, force directions, and load-carrying cartilage areas for free walking and different orthoses

Value Rmax F (Rmax) T (Rmax)

(%BWI (“I (“I BLEW, ,kG,
Hip joint Lefl Right Left Right Left Right Left Lefl

Free walking without Min 265 284 23 20 7 10 95.0 95.2

orthosis Med 300 320 25 22 13 18 100 100
(AA = 0”. IR = 0”) Max 365 371 27 23 21 23 102.2 103.8
Thomas splint Min 201 294 16 18 11 1 92,3 94.9
(AA = O”, IR = 0”) Med 216 325 18 21 13 13 96.6 97.0
Max 249 362 21 23 17 27 102.1 97.8
MHE orthosis Min 167 272 9 16 14 16 102.0 103.6
(AA=15”,IR=5”) Med 206 315 14 18 24 30 106.1 108.2
Max 247 406 17 20 37 39 109.7 111.4
MHE orthosis and belt Min 182 301 11 18 21 12
(AA= 15”,IR=5”) Med 217 341 15 21 27 22
Max 243 390 18 25 38 27
NGHE orthosis Min 197 323 15 20 -16 18 92.2 91.4
(AA = 0”, IR = 0”) Med 212 349 16 21 -6 26 98.5 98.9
Max 236 410 18 22 0 31 102.9 104.7
NGHE orthosis and belt Min 160 303 12 20 -17 19
(AA=o”) Med 204 363 17 22 -4 24
Max 235 399 20 23 0 30

Rmax, maximum resultant hip joint force in percent of body weight BW; F(Rmax), direction of Rmax in the frontal plane; T(Rmax),
direction of Rmax in the transverse plane; A L,,, total force-transmitting cartilage area in percent of its value during free walking (%FW);
ALd5, area with less than 45” surface inclination against direction of Rmax; AA, abduction angle of leg; IR, inner rotation of the leg;
Min, absolute minima; Med, median values; Max, absolute maxima; belt, between orthosis and pelvis.

since the joint force is then shifted towards the rim AR pressure in the joint. The force cannot be transferred
of the acetabulum (or the prosthetic cup) and the by the whole surface Ac of the femoral (or prosthetic)
loaded area becomes smaller. This will increase the head which is in direct contact with the acetabulum.
Only those parts of Ao carry load which are visible
in a projection parallel to the force direction
(area ALO), but such parts of ALo which are inclined
too much against the load direction will not
contribute much to the load transfer. ALo and ALd5
were therefore used to describe the size of the force-
carrying area. ALb5 is that part of ALo where the surface
is inclined by less than 45” relative to the force
direction. The projections of ALO and ALd5 in the
direction of the maximum joint force Rmax were
computed from drawings as in Figure 8 (middle). For
++y free walking their values were calculated in percent of
the circle areas Co and C&, which determine the
(hypothetical) 100% maximum. For walking with
I Load Carrying Area = 71.7% / 87.0%
I orthoses the projected areas of ALO and ALa were
-Z +X = Medial +Y = Ventral +Z = Proximal _Z
determined as a percentage of their values during free
Figure 8. Resultant joint force acting at prosthetic head.
walking (Table 1). Angles of 35” and 30” were used for
Free walking at 3 km/h. Left, view in frontal plane from
ventral, left hip joint. Middle, view from above in
the inclination (against the vertical) and the ante-
direction of the maximum force Rmax. Right, view in version of the acetabulum, the centre of the femoral
sagittal plane from medial. AR, rim of acetabulum or head was located 5 mm outside of the acetabular plane.
prosthetic cup; CO, contour of femoral or prosthetic The leg was assumed to be adducted by 8” and flexed by
head, seen in direction of Rmax; C45, circle
Y, which corresponds to the moment of maximum hip
perpendicular to Rmax where inclination of head surface
is 45” relative to Rmax; Rmax, median of peak resultant force. For the MHE orthosis the abduction of 15” and
force (300%BW); F, angle of Rmax in the frontal plane, inner rotation of 5” were additionally taken into
(25”); T, (approximate) angle of Rmax in the transverse account.
plane (13”). The ‘anatomical containment’ area Ac of the
joint is enclosed by AR. The force can only be transmitted
by that part AL0 of the ball surface above CO which is
Results
covered by the acetabulum AR (dark and light grey
areas). The surface area ALd5carries most of the load, it is
defined by C45 and AR (light grey). The projections of ALO Temporal data
and ALa in the direction of Rmax (middle), are calculated
in percent of the circle areas of CO and C45 and are used During free walking. R showed large forces during the
as criteria for the areas of load transfer. stance phase and small forces during the swing phase
230 Clin. Biomech. 1994; 9: No 4

(Figure 5). Rmax had median magnitudes of 300% BW lateral hip joint.
at the left hip joint and 320% BW at the right During the one-legged stance on the orthoses with
joint (Table 1). The second maxima varied more in slight support at the patient’s fingertips the joint force
magnitude. The load direction F in the frontal plane was in the range of 200% BW. This is the same as the
stayed at about 25” throughout the first half of the peak load during walking with orthoses.
stance phase, whereas the direction T in the transverse
plane varied more. Detailed data from normal walking
can be found elsewhere’i . Load directions and areas of load transfer
Without prior training the patterns of R, F, and T
The median direction F of the peak force in the frontal
were irregular during the swing phase (Figure 6). The
plane (Figures 2, 5, 8) was 25” from medial during
patient needed an ‘extra’ force for swinging the orthosis
normal walking in the left joint and decreased with all
forward without touching the ground. After some
orthoses (Figures 5,7, Table 1). The largest decrease of
hours of training these extra maxima vanished with
11” was observed with the MHE design. F was only
improved walking patterns (Figure 7). A comparison
slightly changed by the additional belts. On the contra-
with the force curves for free walking showed that all
lateral side the median direction F deviated less than 4
the orthoses studied reduced the hip joint force better
from its 22” average.
during the second half of the stance phase than during
During normal walking, the median load angle T of
the first (Figure 7). The second force maximum was
the peak force in the transverse plane (Figures 2,5) for
lacking with all orthoses and the duration of the stance
the left joint was 13” (Figure 5, Table 1). The Thomas
phase was shorter on the orthotic side.
splint had no effect on T, the MHE orthosis increased it
The patterns of the load angles F and T on the
by ll”, while the NGHE design caused a decrease of
othotic side differed from those during free walking.
19”. Only a small influence of the additional belt on the
The Thomas splint shifted the F curve downwards and
magnitudes of T was observed. At the contralateral
increased the angle of T during the second half of the
joint the direction T of the peak force was 18” for free
stance phase. Large deviations were observed for the
walking, but a difference between both joints was
MHE and the NGHE orthoses. The MHE orthosis
typical for EB. The Thomas splint affected T very
(Figure 7) shifted the F curve to lower values
slightly, while the other othoses caused an increase
throughout the stance phase and increased T during
of S-12”.
most of its duration. This indicates that R acts closer to
During free walking the average force transmitting
the femoral shaft axis and further from the ventral side
areas ALo and ALd5 were 78.6% and 96.7% respectively
compared to free walking. With the NGHE orthosis the
of their (hypothetical) maximum sizes. If the absolute
curves for both force directions were shifted towards
areas from free walking were used as a 100% reference
smaller angles, indicating that R had a direction closer
(Table l), the Thomas splint decreased the median
to the femoral shaft axis and further from the dorsal
areas by up to 3.4%) the NGHE device caused less than
side than normally.
1.5% smaller areas and with the MHE orthosis they
On the orthotic side, the largest hip flexion occurred
increased by up to 8.2%. Only small differences were
when the joint force was close to its absolute minimum,
found whether the areas ALO or AL4s served as a
about 0.15 s before it began to rise sharply (Figure 7).
criterium for the median size of the load carrying area.
When the force was at its maximum Rmax, the leg was
Additional calculations were performed to determine
approximately 5” before the vertical position.
whether the load carrying joint area was more sensitive
against changes of F or T. The data from free walking
Peak forces
were taken and the angle F was changed by *lo”,
Initial measurements showed that the joint force Rmax holding T constant at 13”. AiAo then changed by
increased to free walking magnitudes as soon as the +9.5%1-6.2%. If T was varied by &lo” and F was kept
patient walked with contact between the toe and the at 25”. differences of -3.7%1+3.4% were found for
floor, therefore an ankle extension was fixed between A Lo. Slightly smaller changes were determined when
the tip of the shoe and the uprights on all orthoses the same calculations were performed for AL4s.
(Figure 4).
During free walking the median peak force on the
Discussion
left hip joint was 300% BW (Figure 5, Table 1). With
the orthoses it reached 206% to 217% BW, a reduction Can the results, obtained from an old patient with total
of about 30%. The influence of the additional belt to hip replacements, be extrapolated for children with
the pelvis was negligible; with the MHE type it even Legg-Perthes disease? The hip joint mechanics are not
increased the joint force slightly. altered in principle by the implantation of a prosthesis,
During walking Rmax was 320% BW on the contra- although the gait patterns of healthy persons can be
lateral side. Higher values than on the left side were different from those of patients with hip implants26x27.
typical for patient EB”. The Thomas splint and the The joint loads of different patients are similar”. The
MHE orthosis did not affect the force values. but the recorded joint forces were nearly the same for orthoses
load increased with the NGHE orthosis. Belts were of different designs with large variations in walking
always a disadvantage for the loading of the contra- patterns. Obviously the walking behaviour has no

major impact on the load reduction. This suggests that
the obtained data can be applied to children with
Legg-Perthes disease and even better describes the hip
mechanics of elderly patients treated with IWBO.
All the types of orthoses investigated decreased
the peak force by only 30% but showed better load
reductions during the second half of the stance phase.
This is probably due to the higher muscular effort
required at the beginning of the stance phase to prevent
tilting of the pelvis and to stabilize the gait pattern.
EMG measurements of other authors confirmed that
most of the muscles acting across the hip joint even had
an increased activity during walking with orthoses,
compared to free walking28.
It was assumed that only the fraction of the forces in
the uprights which is not transferred to the ischial seat
acts at the hip joint”. The PTF socket, which does not
cover the area of the greater trochanter, was suggested
to be advantageous because no pressure could be
transferred directly from the socket via the greater
trochanter to the hip joint24.
Both opinions describe the real mechanical situation
inadequately. When walking or standing without
IWBO the weight G5 of the upper body and swinging
leg acts around the hip joint H at the lever arm lgl
(Figure 1). The abductor muscles force Fa has the lever
arm la1 and prevents the pelvis from tilting down.
Because lgl is 2-3 times longer than lal, Fa has to be
much larger than G529. The joint force R is the sum of
G.5 and Fa and is therefore in the range of 300% BW.
Even for the idealized situation that the patient used
the IWBO with a supporting force transferred only at
the ischial tuberosity I, the abductor force Fa (then
acting at the lever arm la2) still has to balance the
weight G5 (lg2) as long as the supporting point I is
lateral to G5. The balancing force Fa pulls the femur
into the acetabulum and causes a hip joint force even
if no load from the ground is transmitted through the
femur. To prevent such loads the upper body has either
to be supported directly below G5 or any tilting of the
pelvis must be prevented by a mechanism as described
further down.
Even the mechanical explanation just given is
too simplified to describe the mechanical situation
accurately. In reality the IWBO has no distinguished
point of rotation at the ischial tuberosity, but the
contact to the pelvis takes place over a wide area6. This
mechanical system is statically indeterminate and could
be analysed precisely only if the material properties and
the geometry of all involved structures were known.
One possibility for further reducing the maximum
joint forces would be to shift the upper body more
laterally towards the affected joint. But even
exaggerated limping did not show an improved force
reduction in our patient.
Using a static mechanical model, a joint force of
about 200% BW was calculated for the moment of
maximum hip flexion (35”) shortly before heel strike”.
Instead it was found that the force is close to its
absolute minimum at this moment. This discrepancy
Bergmann et al.: lschial weight-bearing orthoses 231
can only be partly explained by the much smaller
flexion angle of our patient (18’). Obviously this part of
the forward swing of the leg is mainly passive and
cannot be described by static models.
Peak forces
Although the leg position and the kind of ischial
support were very different for the investigated
orthoses, this had an only marginal influence on the
force reduction at the hip joint. Load decreases were
always about 30% of normal. These findings are in
accordance with other investigations” and confirm the
worst case assumptions for the mode of load transfer6.
An influence of the shape of the cuff on the reduction
of loads” could not be validated by our study. Any foot
contact with the floor increased the hip joint forces
to about normal values. Perhaps the variable loads
obtained by these authors for different bottom parts
of the uprights depended on the possibility of foot
contact.
The additional belt between orthosis and pelvis is
thought to prevent loosening of the cuff during the
swing phase. This could, in theory, minimize the
stabilizing muscular effort required immediately after
heel contact, but such a mechanism was not found in
our investigation.
On the contralateral side some orthoses led to a force
increase, which is probably caused by the changed
walking patterns with orthoses and by their additional
weight. These observations confirm EMG measure-
ments in which increased muscle activities at the
opposite hip joint were found2’ and should be taken
into account when treating patients with bilateral
necrosis of the femoral head.
When judging the amount of load reduction achieved
by orthoses, it must be kept in mind that forces of
300% BW during free walking at 3 km/h are less than
the maxima expected in children with unrestricted
activity. In patient EB the average joint force increased
to 500% BW and more for fast walking and running
and a peak force of 720% BW was observed when he
once stumbled slightly21. If children with orthoses
really limited their activities to normal walking, joint
forces of 200% BW had to be compared to possible
peak loads of 500% BW and more for unrestricted
movements. Reported positive influences of orthoses
on the course of the Legg-Perthes disease could
therefore rather be due to the restrictions put on the
children’s activities than to the 30% of load reduction
during normal walking. This would then be a side-effect
of the orthoses and could possibly be also achieved by
other less restricting means.
The load reduction with orthoses also has to be
compared with the effect of two forearm crutches25. An
analysis of walking with forearm crutches showed that
the effect of crutches varies greatly23. The patients with
instrumented hip prostheses only used their crutches
with sufficient forces during the first postoperative
weeks. After that time only 20% to 30% of load
reduction at the hip was demonstrated. The effect of
232 Clin. Biomech. 1994; 9: No 4

one or two crutches was not very different. However, if calculated area decreases of about 4-6% for simulated
children with Legg-Perthes disease are really motivated angle deviations of F = - 10” and T = + 10” in the two
and disciplined, walking with two crutches could planes are very small, however. Obviously the joint
unload the hip joint to the same extent as orthoses. If pressure is much less sensitive to changes of the force
these preconditions are lacking, however, crutches are direction than assumed.
no alternative to orthoses. A change of the load direction F also causes the
idealized point of load transfer to change its position on
the femoral head. For a head diameter of 50 mm, this
Load directions and areas of load transfer point is shifted up to 5 mm with the investigated
devices, but with regard to the often large deformation
All investigated orthoses decreased the angle F of the
zones of the femoral head in the case of Legg-Perthes
peak force R (Table 1) in the frontal plane. The value
disease this shift will not help very much to unload
of F during free walking differed considerably from
destructed bone areas.
published data and even the trend of the observed
variations with orthoses was contradictory6. This
Proposed orthosis with improved force reduction
suggests that mathematical models to date are not
sufficient to describe the real mechanical situation of An improved load reduction can probably be achieved
walking with orthoses. with a design incorporating cuffs around both thighs
The course of the Legg-Perthes disease depends connected by hinge joints to a pelvic band (Figure 9).
on the ‘containment’ of the femoral head3,9,‘“. This The cuff on the affected side has no ischial seat and
containment could be defined as the total area A, of the is supported above the knee joint against sliding
three-dimensional articular surface which is in direct
contact with the acetabulum (Figure 8). Because this
contact area depends only on the anatomy and the
relative position of the femoral head and acetabulum, Affected side - Contralat. side
it should more precisely be named ‘anatomical
containment’. It seems reasonable to assume, however, Hinge joint Hing\e joint
I
that the preservation of a load-carrying shape of the
femoral head depends on the pressure magnitudes and
pressure distribution in the contact zone, because high
pressure will cause destruction of the weakened bone
and cartilage. The joint pressure is not directly related
to A, but to the size of ALO of the cartilage area
(Figure 8) which really transfers the load29,30. A
calculation of the real pressure distribution in the joint
could not be performed for these investigations; instead
the projected sizes of the load-transmitting areas ALO
and AL4s were used as a criterion for the pressure in the
joint. If their values become larger, more cartilage area
is available to carry the joint force and the average joint
pressure will accordingly decrease. The definition of (Cuff without) Cuff with
AL4s is somewhat arbitrary, but the results show that
the changes of both areas are not very different.
An improved anatomical containment area A,
does not necessarily increase the size of the load-
transmitting area by the same amount, as ALU also
depends on the force direction. As demonstrated with
the MHE orthosis, the 15” abduction of the leg is to
some extent compensated by an unfavourable decrease
of F and increase of T, compared to free walking.
Nevertheless the load-carrying area became larger
by some percent. The small changes of the force-
transmitting joint surfaces with all orthoses areas led
Figure 9. Schematic design of orthosis with improved
to the conclusion that the observed 30% decrease of load reduction. The affected femur is fitted with a cuff
the hip joint forces corresponds to nearly the same without ischial seat; the contralateral femur has a cuff
reduction of the joint pressure. with ischial seat. Both cuffs are connected with joints to
Previous investigations in the frontal plane suggested a band around the pelvis. This stiff structure prevents
tilting of the pelvis in the frontal plane and this reduces
that even a small decrease of the force angle F should
the joint force. The load G5 of the upper body is
have a very pronounced and detrimental influence on distributed between the affected hip joint (R) and the
the load-carrying joint area2s.30,“. The same was contralateral seat area (T). The left cuff is supported
expected for the angle T in the transverse plane. The above the knee against sliding downwards.

downwards, while the cuff on the contralateral side has
a well-shaped ischial seat area. The patient can use
the affected leg with unrestricted knee function and
full weight support by the foot. The weight G5 is
distributed among the affected joint (force R) and the
contralateral ischial support area (force T). T is then
transferred via the contralateral cuff and the pelvic
band to the cuff on the affected side. With this design,
tilting of the pelvis is resisted by the long lever arm of
the supporting force T relative to the centre of the
affected hip joint. This design resembles the Atlanta
brace; however, it does not abduct the legs. The whole
construction must be extremely stiff in the frontal
plane. Alternative designs may be possible which do
not require the pelvic band and the contralateral shaft,
as long as the pelvis is supported as far away from the
affected joint as possible.
Considerable training would be required to walk with
such an orthosis, because some deformation of the
device itself and between cuffs and thighs in the frontal
plane under the load G5 are unavoidable. Any muscle
activities, normally used to stabilize the pelvis against
tilting have to be firmly prevented. During the stance
phase a slight adduction of the leg is always required to
hit the ground under the centre of gravity of the body.
If the hinge joint at the affected side is stiff enough in
the frontal plane, this adduction could possibly help to
support the contralateral side of the hip and avoid
stabilizing muscle activities. Instead of supporting the
cuff above the knee it could also be attached to uprights
as in conventional orthoses. This may prevent problems
possibly arising from the supporting force at the knee,
but would also prevent motion in the knee joint or it
would require an additional hinge joint. Furthermore,
it would presumably not contribute much to an
improved load reduction. The mechanical effect of such
an orthosis would have to be measured as in the current
investigation. It should also be checked whether
possible changes of the force angles F and T may
decrease the load-carrying area of the femoral head.
Conclusions
All investigated models of ischial weight-bearing
orthoses reduced the joint load by only one-third
compared to normal walking. The design of these
devices played a minor role for the achieved force
reduction, which was not better than achievable with
two crutches. With data now available on the much
higher forces during running and when stumbling, it
seems probable that such orthoses may improve the
course of Legg-Perthes disease in children simply by
preventing them from fast or dangerous activities. The
load-carrying area of the femoral head decreased by
some percent with the Thomas splint and the NGHE
orthosis and was only slightly enlarged by the MHE
model which holds the leg in abduction. It seems
therefore questionable that the sometimes reported
clinical benefit of an improved anatomical containment
of the femoral head can be attributed to a decreased
Bergmann et al.: Ischial weight-bearing orthoses 233
pressure in the loaded joint. Should ischial weight-
bearing orthoses be used further in the future,
the proposed change of their design may possibly
contribute to an improved load-reducing effect.
Acknowledgements
We gratefully acknowledge the enthusiastic cooperation
of Erwin Balcerek, the patient on whom the force
measurements were taken. H Jendrzynski, G Grosshans,
C Vogt, F HaulJler, LH Riley, H Mellerowicz, and
several physical therapists helped to perform and
complete this work. Financial support was provided by
the German Research Society.
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VIII BIENNIAL CONFERENCE OF THE

CANADIAN SOCIETY FOR BIOMECIXANICS

AUGUST l&20,1994
THE UNIVERSITY OF CALGARY, CALGARY, CANADA

Scientific Highlights

LocomotionSymposium:
T. Andriacchi, M. Epstein, G. Loeb, R. Stein, C. Vaughan, D. Winter

Muscle Mechanics and Control: J.A. Hoffer, R. Lieber, U. Windhorst

Simulation Symposium: R. Yeadon, A. van den Bogert

ISB Working Group on Functional Footwear: M. Lafortunre, B. Nigg, E. Hennig, P. Cavanagh, G.

Valiant, M. Shorten

Prosthetics Symposium: P. Allard, R Zemicke

Keynote Lecture:

Bryan Finlay, University of Western Ontario

The Challenges of Biomechanical Studies on Sop Tissue

For information please contact: Margaret-Anne Stroh, Conference and Special Event Services, The
University of Calgary, 1833 Crowchild Trail, NW Calgary, AB T2M 4S7 Canada.
Tel: +1403 220 7101 or Fax: +1403 284 4184.