to introduce Mr. Fay, Mr. Jeff Fay. So he's a certified orthotist and prosthetist graduating from Eastern Michigan University. So Mr. Fay, I love this, describes his passion for orthotics and prosthetics and the general biomechanics of things as a result of being fascinated by airplanes as a kid. So this has come full circle as he spent some time in the United States Air Force and his interest and affinity for fabrication enabled him to explore new solutions to prosthetic construction throughout his career now. So thank you very much for your time. I, you know, you spent some time in Michigan and then the University of Rochester. So my alma mater as well. And then at one of the SUNY schools also in upstate New York. So welcome, great to have you and thanks for your time. I'll turn it right over to you. All right, thank you very much. I'm just trying to get my slideshow going here. On the bottom right, you should be able to see the screen. Oh yeah. Went to the right of that. That's right. Okay. Am I on? All right. Okay. Well, yeah, my name is Jeff. I just want to say thank you again to, Dr. Hardy actually reached out to me and he was here at Walter Reed with me and our team here. So I appreciate that reach out and I'm happy to do this IDEO overview for everyone. I want to thank the Foot Ankle Society as well for putting this on and having this opportunity. So, but basically for this IDEO overview, I'm just going to give a brief history on the IDEO, go over basically some of the components to the IDEO, try to put the functions together, show basically who the best candidates are, maybe some of the more atypical candidates and then have a few videos along the way just to kind of emphasize some of the points that I'm making. So also we have no conflicts of interest, no financial interests or anything like that here. This is just basically my views on what I do here with the IDEO. So we'll move on. And also I just want to say good morning to everyone and good afternoon, good evening, whatever time zone that we're all in, maybe a happy hour out there and somewhere over the Atlantic or something, but hope everyone's having a good time and staying safe and healthy. So again, so the IDEO, it's just like many things in the military, there's another acronym to figure out what that is. So IDEO, it's Intrepid Dynamic Exoskeletal Orthosis. And it was originally created down at the CFI, the Brooke Army Medical Center and by a prosthetist named Ryan Blanc and began around 2009 and really kind of got hot and heavy, I'd say, around the 2010, 2011. And really I'm still doing them pretty frequently now. Obviously they've slowed up a little bit as far as true like blast injuries are concerned over in the, well, around the world. So, and generally speaking, I'll go on a little bit more about dealing with the type of patients, but trauma patients after limb salvage and I'll get a little bit more detail oriented there. So, and I've been here at the Walter Reed since 2013. I went down to the CFI and actually got trained by John Ferguson down there. So I'm kind of a third generation. Ryan originally trained John and then I was trained by John himself. And I came up here to do a, basically hired on 2013 for the priority study, which is another long acronym. And I have the resource in the reference in the back there at the end. So, but I've been happy to be here. You know, the study overall was just to see if the technology from Texas could be transferred up to other sites, Walter Reed obviously being one of them and San Diego was another one along with Texas. So I feel like it's been a success. I'm still here. So I'm happy to be here. So what is the IDEO? I think my title's up there. It might be a little covered, but basically IDEO is it's a highly customized, custom fabricated carbon fiber energy storage and return device. It's a mouthful, but I really kind of emphasize the highly customized portion of it because I mean, we do work with like custom fabricated devices, but the IDEO specifically takes a lot of work to optimize it and minute adjustments that need to be made. So certainly I do the normal, the procedure of casting and fabricating and getting the device, but once the device is fit, I still have to customize things and it takes a good amount of work and carbon fiber is not the easiest thing to work with. So it's really very labor intensive, but luckily I enjoy working with the carbon fibers and materials and all that. So, I mean, again, what it is, you could consider it a solid ankle AFO type device. So solid ankle, there's no joints, nothing to actually allow any type of ankle articulation. So generally speaking, you can kind of put it in that category. Could also be labeled, some people refer to it as a floor reaction type AFO and that's, all AFOs are floor reaction, but floor reaction type AFOs usually has an anterior, rigid anterior tibial shell many times to help also stabilize the knee, but also allows further stabilization of the foot and ankle. So, but it's also commonly referred to as a prosthesis because it's, again, it's kind of in its own little world in some ways and it's in between, what's an orthotic device? What's a prosthesis? I mean, I'd still consider it more an orthotic device, but there's some principles that are incorporated into the idea that might be a little prosthetic-like and some of it's because of the socket-like designs, the foot plate itself, but also the calf section. You see a couple behind me right here and I'll have some other pictures here too. And the focus of the energy storage and return solely on that posterior dynamic strut that's in the back. So a lot of AFOs will bend and warp and move in different directions that the IDEO really focuses all the bending and torques to take place purely in that posterior dynamic strut. So, and I also typically hold the foot in a plantar flex posture, which is unlike many standard neutral type AFOs. A lot of AFOs, when we cast, we usually are asked if you want it either left as casted or correct to neutral. A lot of off-shelf devices are usually in a neutral position. So in other words, the ankle is generally at close to like a 90 degree angle in that posture, but I typically hold it in a plantar flex posture and there's a couple of reasons for why I do that and I'll get to that here shortly too. Moving on. So why was the IDEO created? So just a picture there, that's kind of like more like the original IDEO and actually it's the one on the right side, far or far left, I guess you could say looking at me, but that one has the original clever bones, which are two posterior energy storage and return struts in the back and they're directly laminated in. But anyways, why was it created? So there's obviously significant lower extremity injuries. The amputations were obviously very well known through the Enduring Freedom, Iraqi Freedom operations over in the Middle East. So, but the problem was that there lacked the lower extremity orthotic devices to support the foot and ankle that's still intact. And also to, at the same time, while supporting and provide like the superior function and also the durability to withstand the conditions of high impact and semi-atypical loads that are required, especially of active duty soldiers. And that could be, you know, running with sacks on their backs, rucksacking, jumping out of airplanes, ass-roping, a number of things. So the foot ankle gets put through tremendous torques and stresses, just generally speaking, but then also trying to support a, in a sense, a limb that has suffered a injury, definitely needs something with great support, superior function and durability. And as prosthetic technologies continue to improve among manufacturers, there just wasn't much available orthotically. We all know that like prosthetics, it's fascinating. You know, it's like the missing, the limb is missing and engineers love it. And they're able to design and create all these things for these prosthetic patients. And sometimes, you know, I mean, I'm a prosthetist as well, but my heart's in the, some of these limb salvage patients, and there's not a whole lot of options out there. And there's always need for improvement. Moving on. So just getting into the components of it, this particular design. So this is what I, I commonly use this now, but this is called a BOA closure for the calf cuff. The patient's able to kind of control the actual tightening and loosening of the portion of the calf cuff, just anteriorly and posteriorly. There's padding in the front too. So it's not like they're hitting a carbon fiber shell. So it's comfortable, but the way it can be utilized is also, it can provide some axial unloading for the foot and ankle, but it's also used to transmit the forces that as the patient or soldier or client that actually rolls through that forefoot, they're able to transmit those forces to that posterior dynamic strut that you can see there. So on this, again, this is the BOA closure that I typically use. It's pretty nifty, and it's actually those strings right there. They're not your typical tight strings or anything like that. They're made out of a material called spectra, and they can withstand about 500 pounds tensile strength. And again, the way it's fabricated, as far as looping through those curves and all that, there's a lot of the forces are just kind of dispersed over that line, and it's actually quite strong. I still do the original IDEO for some of the patients, especially some of the special forces patients and all that, that might be a little bit more down in the dirt and just grinding very hard on these things. And anytime you have more moving parts and everything, the durability tends to go down. So the original design actually has a hinge closure, which I can show an example of too. But that's the calf component. The second component is the foot plate. And again, this is a rocker style foot plate. So this is where some of the, well, it all involves some artistic play in it, but the foot is, again, held in a plantar flex position, and the forefoot basically is modified, so it can roll as if it's kind of rocking on a wheel in many ways. So because you want to put all the flexibility, all the forces going through the dynamic strut, the foot plate is completely solid. But in order to make the foot plate smooth to roll through, there has to be a slope through that forefoot, which you can see there on the screen. And the most important thing is really maintaining a radius and making sure the radius doesn't drop off because one, it puts more stress on the foot plate, but also it allows it to roll through smoothly. Just unlike some other foot plates, the metatarsal heads basically kind of, they actually sit right within the foot plate. Most AFOs, the trim lines are brought down below, like where the metatarsal heads are, usually the foot plate is brought below, but for strength and durability purposes, and also to help control the foot, I fully encompass that metatarsal head. And then we have the medial and lateral tibial extensions, and those are kind of utilized for patients that still have some mobility within their foot. And I can use those as counter pressure areas to prevent from medial lateral play and further prevent a certain amount of pain that they might have in their foot. But this portion of the IDEO is, you know, it's within the shoe, but it's such a particular thing, and I'm very picky about how it fits. It's got to fit like a glove. It can wreak havoc on shoes if it's too big. So I spend a lot of time actually just modifying these foot plates. And they're actually, I mean, they're solid. There's not a ton of padding in them, but most of the patients at least tell me that they're pretty comfortable in it. So the posterior monostruts, these are the ones that I've been using more of, and these are detachable. So they come in seven different categories of stiffness and flexibilities. Basically, they're determined by weight and activity level. However, it's a little, not so scientific, I would say, because some patients, I want to eliminate more motion in their foot. So even though their weight and activity level might be put them in a category three, but if that category three provides too much flexion and creates more pain for the patient, then I have to utilize a slightly firmer strut. So I might put them in a category four or category five. So it's not a perfect science, so it's a little bit of a trial and error, and that's the beauty of having these removable type of struts. So they come in three different lengths, so I primarily use that middle side, the middle picture there of that length there. I feel like they can get the most torque and flexibility out of those, where they lose a little bit of torque and flexibility with the longer ones. All right, and this thing right here, so this is the heel cushion, and I put up there last but not least. And obviously there's also a contralateral insert and lift because since we have basically the foot plate in a plantar flex position, I have to utilize this heel cushion to basically bring the floor up to the heel. And this, I'm telling you, this little bugger right here, it's just made out of foam, is you see the IDEO, you see how, I don't know, it looks pretty fancy, it's shiny, it's got the posterior dynamic strut, the calf portion, but this little piece that's inside the shoe is absolutely critical for the function of the brace. So, and I'll explain a little bit more on a video that I have just coming up here, but it's custom cut to thicknesses, so some people are in different plantar flexion angles, and this right here allows for a smoother rollover and basically supports and prevents also a lot of knee moments that might not be good for the patient. So, but let me just go to the video here and I'm hoping the video doesn't go sideways on me, which is good, it didn't walk through, but it's a little blurry, but because it's in a plantar flex posture and it'll just keep on playing over and over again, you know, I need, again, that heel cushion that is underneath the brace within the shoe. And if I didn't have a heel, if I didn't have the heel cushion in there, they, one, they would feel like they're getting a hyperextension at the knee and they would have a really hard time getting over the toe. This person, for example, you can really see the compression of that heel cushion in the back. So, and that heel cushion right there is actually a softer version of the heel cushion. So you can see that pretty extreme heel compression, which actually also helps to control the advancement of the tibia as it goes over into the forefoot. And you can see as they get past that midfoot range and then they're starting to bend that strut a little bit more because they're getting pressure against that anterior shell. And then they're rolling through again, like where it has to be like a wheel rolling through the wheel of the forefoot there while they're putting energy into that strut and the strut returns the energy for them. So let's just go on to the next one. And this is just a quick example of just a running and you can really see the deflection of that strut there. So again, it's the footplate is completely stabilizing that foot and ankle, at least, especially in the coronal plane. Now, this person, as you can see the, as they make that contact, you can really see that strut in the back flexing a good amount. Now, some patients like this guy was perfectly good with that. Some patients, I may not be able to allow them to do that. They might just not have the comfort to actually be forced into that dorsiflexion range, which is what a lot of the patients tend to have difficulty with. So, but that's a good example of seeing really that deflection and energy return of that strut once it's applied. So the process for making it, again, casting essential for me to find the most optimal and comfortable position. Again, it's typically plantar flexed. Generally the ankle is in more of a relaxed position when it is plantar flexed. So a lot of patients have difficulty being able to, you know, be dorsiflexed passively. And I'll mention that here briefly, but the casting is, allows you to really find that optimal position that you want to hold them in that makes them feel most comfortable. So again, I mean, I try to keep them in a close to neutral, but I want to be able to utilize a heel cushion to be able to smooth that rollover shape of that AFO. Whereas when you sometimes just automatically put them in a neutral position, as you noticed in that previous slide of that person walking, that heel compression really kind of, again, kind of controls that tibial advancement over that forefoot or transition from heel strike into mid stance. So if it's, everything's put into a neutral position, then you're going to lose the ability to utilize a heel cushion, and it's going to drive that chin forward too abruptly, which you see often in solid ankle AFO sometimes. So modifying the plasters, where again, a lot of our art comes into play, and I could spend a long time talking about plaster modification, but just paying attention to the bony landmarks and all these curvy linear trim lines, I call them, because it's, again, utilizing the anatomy to actually create some of your trim lines and cupping the foot actually helps with the integrity of the device overall and the durability. So there's a lot that goes into it. So it's not just the materials, but it's also the geometry of the foot shape and all that, and how you modify around it. Tester fabrication, again, this being, as I mentioned, a highly customized device, it does require a tester brace. So most AFOs, usually you won't see that very often. You will in the prosthetics world. There's always like test fittings and all that, but this, I have to utilize a test brace because I don't want to spend forever trying to adjust that carbon fiber device. And sometimes you just can't adjust it without having to remake it. And it already takes a very long time to fabricate these. The fabrication of the finished carbon fiber idea, again, I could spend a long time talking about materials and direction of carbon fibers and all that, and it's really interesting. I love it, but I guess that's a totally other topic and everything, but it does, it takes a good six hours or more just to make one idea. So that's just the carbon fiber. So it's, again, very labor intensive. So who are the best candidates? I mean, trauma-related injuries to the foot or ankle, and I should emphasize kind of with the chronic range of motion and strength limitations, again, being chronic where they may not gain much more range of motion, they may not gain some strengths. So I feel like those are some of the better patients to be able to fit this to. Combat-related blast injuries on the outside, a lot of motor vehicle accidents have similar presentations with fractures, secondary deformities and nerve damage. Then there's other patients that just have pain upon specific ankle range of motion and weight acceptance over the foot. Commonly, I do see a lot of these people. So typically they have some form of maybe a specific location, osteochondral lesion, that's just where they just don't feel comfortable being able to passively dorsiflex their foot, especially in times when it's a high-impact activity. But avascular necrosis, I've had people with that condition as well. And then there's some people that have just done multiple sprains and tears over time that just wind up getting this severe arthritic conditions. And I've certainly fit patients like that. And partial foot amputation. So you lose a lot of your toe lever and your leverage to be able to support patients or support their body weight as they roll through. So this is where that rigid foot plate kind of helps them be able to support them and be able to utilize that energy storage and return. So activity specific, again, it seems like a lot of AFOs are kind of prescribed based upon a specific diagnosis, but this, I feel like it's kind of filled that role for like some prosthetic patients have running legs. Well, there's not a whole lot of running braces out there. I mean, I think it's becoming a little bit more common, but again, it's a little bit hard, especially on the outside due to reimbursement or just getting support from insurance companies for it. But again, the idea is kind of filled that role. So I see sometimes people coming in that can walk perfectly well. Even early on when I was first getting into the idea, I was like, why am I fitting in a day out of this person? But for whatever reason, they're unable to do that high impact activity or pass their PT tests. They want to stay in the military, a number of things, but they have a passion for running. So it's an option for them. And I've definitely fit quite a few of these. And I think Lisa, the physical therapist, has certainly seen some people that only need them for like a part-time basis. And again, as I mentioned, the return to duty work, jumping, what I mean is jumping out of airplanes, fast roping and rocking. So you think about a body weight of someone that's 200 pounds, but then you add their rucksack onto it, which could be another 50 pounds, sometimes even more, and then all their equipment. So next thing you know, you're getting up close to 300 pounds in their weight. So there's obviously a need to sometimes really hold these people on their foot and ankles in these positions to appropriately support them. So the atypical patients are usually like patients with a chronic regional pain syndrome, neurological conditions such as chronic inflammatory demyelinating polyneuropathy. And I've certainly, I've fit patients with this, with these before, and it's certainly worked for them, but I think there's other options available. The chronic regional pain syndrome is hard because they just generally just have pain. It's not always specified coming from a certain range of motion that they're forced through. It's just a general aching, just pain, just highly sensitive. And that's always very difficult to fit. So a couple of people have utilized the idea before and it's worked out for them, but it doesn't, it's not always the case. Flaccid equinus foot drop, this is a tricky one. I mean, it's not uncommon when it's, when foot drops the only presentation as I have there in STARS, I try to find some other options because they might have great calf strength, great range of motion and everything like that. And to put them into an IDEO, eliminating their own ability to utilize their calf. I don't always feel comfortable with it. Again, I mean, if it's someone that's able to, just utilize it just for part-time purposes, that's fine. I usually try to educate that to the patient as well, just to tell them, hey, don't wear this all the time. Because I mean, atrophy can kick in and take place there. So I just try to educate them as well as I can. Spasticity, haven't really, I've had a few patients that have certainly been fit to those with spasticity, but just not the best option I would say. And diabetes too, I haven't fit many diabetics and I don't think I would really, I really would rather not to. So just for the insensate neuropathic foot. So critical components to the success is a proper fit to the patient and the shoe. It seems kind of silly, but I get disappointed if it's like, if it's too bulky. Oftentimes, anyone at first started, these things were like enormous. They were thick, they were huge. They weighed like over three pounds sometimes, at least when I was here initially at Walter Reed. And patients sometimes had to go up a couple of sizes in shoes. So I've really worked on the layup and of the carbon fiber to, and the use of the geometry of the foot to try to keep things as thin as I can, but also as strong as possible. So they can continue on with their activities without requiring a monstrous shoe. So I really, that's where the detail really comes into play. Availability of the patient and the prosthetist for adjustments. Again, that highly customized portion. It's not the type of thing where you can just fit it to them and send them out the door. They really need to come in for follow-up appointments and be able to get minute adjustments to really optimize it. Some people completely rejected the idea at times thinking it was just the way it was, but a five minute adjustment sometimes makes it very comfortable. So physical therapy for the return to run. I know Lisa will get on with that very shortly, but that's a critical component, especially when it comes to running and knee stability and really making sure they don't hurt other portions of their body because it's a rigid device overall that doesn't allow that ankle to articulate and definitely sends forces up to the knee, which creates a sense of awkwardness and patients need to learn how do you utilize the device. This is just an alternative. It's a theroplastic device that a patient of mine had that they originally just had a regular floor reaction device but still had pain. So it's just kind of gives an example of how if it's not carbon fiber, there are options out there. And again, I kind of kept her in a plantar flex position by utilizing the same type of rollover shape and the foot plate, a little heel cushion in the back. You can see some reinforcements on the sides to prevent the buckling of the plastic. But I think this is important to kind of see that, you know, you can utilize, even though this doesn't have the energy storage and return capabilities with a dynamic strut, but it definitely provides great stability of the foot and ankle. And the patient was really happy with it. It was a dependent of an active duty soldier. So, and she was really happy with it and had less pain with what she was used to on the outside. So, but she wanted to keep it kind of still on the thermoplastic and keep it as lightweight as possible. And this wound up being a really good option for her. And so it's definitely, there are, it takes a good amount of, again, detail again. So, but it's definitely an option. So not everything has to be carbon fiber, but I've also done these in carbon fiber too without the posterior dynamic strut. And it just utilizes that heel cushion and the rollover shape of the foot acting like a rocker mechanism that really kind of helps smooth the gait and also prevent unwanted motions of the foot and ankle. So this is just my last two slides. I don't think I'm running over here, but just an example of a no idea. There are the guys walking there. This is very typical. They usually want to get off there. This is this right side that actually he, he had a scope surgery of some sort, but then he had osteomyelitis set in. But he's, I want to say he's actually kind of going through a fusion, surgical fusion of some sort, but it's very typical to see them very hesitant to roll through that forefoot on like this guy's right side. So, and just, I mean, even putting the sock on for him was kind of difficult. So, but you can see on the right side with the IDEO, as I kind of keep on streaming these things, you can see how he just kind of certainly picks up a better gait. I kind of, I certainly communicate with them and kind of talk to them about how I want them to actually roll through their forefoot, which they're not used to doing and be able to take equal step lengths and keep in good posture and all that. So, but certainly a self-selected walking speed definitely increases once he starts utilizing that brace. And just one last one here is just, there's just another guy, very similar, but this is an interesting case here where actually that you can see the bandage on there, but that was from a gunshot wound that he had a skin graft that was basically covering his wound. It was probably, you know, maybe, you know, two inches by two inches or so, but the skin graft was actually causing a lot of problems with just his ability to actually contract his calf muscle and he was getting like, calf felt like things were just like tearing and binding in there and a lot of pain. So actually I wound up having this guy see one of our plastic surgeons and to do the whole fascio cutaneous skin flap procedure. And really in the end, he probably won't need the IDEO. So, but he has a full skin flap and this is after a skin flap procedure, but he still feels a certain amount of instability in his foot and ankle. As you can see him walking there on the left, but IDEO, again, just kind of, they feel more confident cause they're very stable in it. And as long as that, again, that most important little piece, that heel cushion that's in there is providing the proper rollover speed and the use of the dynamic struts certainly smooth out his gait and certainly he can cruise around pretty good. So, but that is all I have for that. But I just want to thank you guys very much. Video's not playing. Of course it's supposed to be someone running there. Yeah, there we go. So, but yeah, I love the IDEO and everything. And it's also, there's a lot of old sidekicks that I do of IDEO like devices and can really be creative with these. And, but they can also, you know, just the act of plantar flexing the foot and ankle and utilizing a heel cushion, making sure that the level on the other side, there's options, you know, out there for people rather than just putting them in neutral, neutral AFOs. So thank you. Hey, Jeff, good to see you. Hey, Dr. Hardy, how's it going? Good, good. I didn't know you went to Eastern Michigan. I can look out my window in my office and see Eastern Michigan football stadium. Yeah, yeah, yeah. I think I noticed that. I think you're up in Ypsilanti there. That's right, in Arboripsy. But hey, thanks, Jeff. So quick question for you, if you wouldn't, and I'm not sure how much information you have on this, but one of the biggest difficulties I had going from the military to civilian is finding these braces on the civilian side. They're tremendously effective for the young patient with post-traumatic arthritis in the ankle. We don't have great surgical solutions for them. This brace gets them active and functional. It's great, but there's not a lot of options. Hanger has an option. It's a crazy expensive. Work Comp and Otto are the only two that really do it. But I don't know, Jeff, do you have any comments about, I know you worked with my orthotist here and I really appreciate that tremendously, but comments to us civilian guys about where do we have access to this? And then I have another question for you. Does Alex Smith for the Washington football team, is he playing with an IDEO right now? No, he's not. Actually on my next breakout there, I think he had an IDEO for part of the time when he was down at the CFI. That's where he went to his training and everything like that. That's basically the hub of the IDEO down there. But he has another device that actually allows a lot more flexibility and all that. And it primarily just focuses more on kind of keeping his foot up and pre-positioned and all that. But I guess he's gotta have some pretty decent calf strength of some sort to be able to go without the IDEO. So, but yeah, it's pretty impressive though what he's been able to do. So again, on my next breakout, I'll be able to show one that is similar to that brace. I think he did have it throughout part of his rehab process. And that's where sometimes the IDEO can be just kind of work with through like, you know, while the patients are doing some rehab and all that too. So some patients do wind up not having to utilize it as much anymore. But I think that's, you know, I think it's hard to track that though. But as far as on the civilian side, I know it's tricky. I've definitely seen the GoFundMe accounts out there for IDEO or with ones through hanger and everything. But there's the components that I use, like I showed the removable struts, those flat bar struts. Those are made by a company called Fabtech Technologies. And I've utilized a lot of their components but they have their own kind of version of it too. It's called the reactive brace. So there are some people on the civilian side that have certainly been utilizing those and it follows pretty similar principles of the IDEO. And I mean, I see some people that come in with their devices from like a company like that. And I either kind of help them out with those or, you know, usually they might have some anatomical changes or whatever, where I wind up just making them what I make them. Cause it's our own little art in some ways, but there's like different variations that are available on the outside. But yeah, insurance is very, it's hard. And no matter what, it's a labor intensive device. So, and it's gotta have that one-on-one kind of follow up attentive to detail and customization for the patient. So I still don't feel like it's anything that you can just kind of stick on someone and let them out the door. It really needs extra work. Just that little heel cushion. I know I've gone back to that a couple of times and it's hidden inside the shoe and it's often forgot. I've had people come, patients come in and say, oh, did I really need that? And I try to emphasize as well as I can because that creates, if it's not there, it creates quite a hyperextension moment at that knee and can certainly cause more problems. So it's really, there's little details that really need to be taken into account with this type of device, whether it's civilian or within the military. So, yeah, it really needs its time focused on optimizing and making sure you're making it functional for the patient. I've made a mistake before where I've had an older physical therapist that was here and they wanted to just to try one on. I was like, oh, okay, I guess we can try one on. And they put it on, of course, without the heel cushion or anything like that just to see what it's like. And it was like, oh my God, my knee, I don't see how people, and I was just like, oh, that was a mistake on my part because it's like, one, these are very custom fabricated and two, they really have to be optimized and you have to have that heel cushion and bring the floor up to the heel. But there are options on the outside, just a little bit harder to come by. And I know it's because of some, I really wish down the road there could be other L codes that can be attached to this kind of device to make it more feasible for companies to utilize them. But the Fabtech Technologies is one place for sure that I know has kind of worked on some with like these components that I utilize. What's the name of the hanger one? Somebody asked about that. The hanger one, they rebranded it, it's called the ExoSim. So if you're like, you could even look it up online, the ExoSim is the hanger version. And Ryan Blanc, he's the one that primarily does that out in Washington State. So, and I think they really kind of built a whole facility out there for them. So, but it's called the ExoSim and you'll literally see like, go find the accounts for people trying to get their ExoSim brace out there. All right, great. There's just one quick question if we can answer it quickly and then we'll go off into our breakout room. So there's a question about the planar flexion and why it's built in planar flexion if the struts stiffness can be adjusted. I've missed that last part of that question. It says, is the brace built in planar flexion because it was designed to assist running or why is it built in planar flexion if the strut stiffness can be adjusted? Well, the planar flexion it's built, I mean, generally speaking, because again, it's a, what I feel it's because again, it's a solid, it's more of a solid ankle device. And the planar flexion it's, I don't, that's where some of the art comes into play because I don't have a predetermined angle that I actually planar flex the mat. You know, if I can get them relatively close to neutral but still be able to use that heel cushion because that, again, that helps smooth over the rollover shape or the rollover up going from transition from initial contact, loading response and your gait cycle into the mid stance cycle of the mid stance of gait. So it allows you to smooth, smooth things out and allows the patient to be able to walk more effectively with that. And again, oftentimes I'm trying to prevent them from getting into a painful motion. So if they have that osteochondral lesion, you know, especially like talus related, then that passive range of motion, that passive dorsiflexion, they tend to get pain as they roll through their foot. So that's why you'll see a lot of them do get into that planar flex posture, but it does also allow you when you do have a planar flex, when you make that heel cushion, when you compress that heel cushion, you do hit the forefoot, which immediately allows you to start engaging that posterior dynamic strut in the back. So, and certainly I've tried to make some of the devices with a more flexible strut to kind of like that one video that I showed of a guy running. He was used to the old clever bones, which are generally more rigid, but he really liked the flexibility that he was able to achieve with that, the more flexible strut. And because it was planar flexed, I still kept him in a planar flex position as he really plows into that forefoot and is able to really load that entire strut, that energy storage on return was really giving him good timing as far as getting that return for him and that planar flexion assist. I think that will answer that question. A lot of the planar flexion angle, it honestly has to do with like where they're comfortable and I don't want to force them into a range, even if they flex a strut, I don't want to force them into a range that they're going to start getting that pain. And there's certainly, there's still a lot of patients that have the pain and some of these patients go on and they get elective amputations too. So, I mean, I could certainly touch up on that more too, because there's a lot of questions about, when's the right time to amputate, should have just amputated from the beginning. So it's hard to tell. But anyways, pain's a difficult thing to try to control at times, especially when you're trying to run too. Well, thank you for that. It's really remarkable what you guys are doing. Thank you. Thank you. So what we'll do is we'll go out into the breakout rooms now. So those of you in Jeff's room will be able to hear more about the prosthetics and orthotics, just kind of a basic overview and the others will go with Lisa to see about how to start utilizing the IDEO in your practice if you're a physical therapist. What will happen, you can see Elena just sent us a message that once we're done with these groups, you can just feel free to sign out. We don't need to come back together. But quickly, I just want to thank the AOFAS team for helping put this together. And while Chris and I are kind of on the front here, they're really the ones that did all the work in the background. So thank you to the AOFAS team for all your help. The other thing I want to put a quick plug that Chris and I could use everybody's help here. So if anyone is interested in being part of our workforce with the AOFAS, with the Allied Health Group, just working on ways that we can improve all of the symposium that we put together or any other ways that we can work together and collaborate with the physical therapists and PAs and PTs and APRNs, and we'd love to work with you. So please reach out to us if you're interested in helping out in any way.

IDEO

Jeff Fay

carbon fiber

lower extremity injuries

amputations

fitting

comfort

recovery