The trimlines for the Malaga brace are the following:
- Anterior superior shape: the brace reaches to the superior sternum border and subclavicular laterally, so that it can prevent antepulsion of the shoulder.
- Posterior superior shape: extends up until it totally covers the scapulas.
- Anterior inferior shape: extends to the symphysis pubis and curves upward at the thighs to permit sitting without discomfort.
- Posterior inferior shape: follows a horizontal line from the symphysis pubis and is above the greater trochanter.
The anterior portion of the brace consists of a large open space that leaves room for the breasts so they are free from impinging by the brace, therefore growth is permitted without causing discomfort. The anterior inferior portion of the brace has abdominal pressure build into the brace, of which extends up to the xiphoid process. The abdominal pressure helps maintain the correction of lumbar hyperlordosis.
The brace could have holes pierced in the plastic therefore provides a reduction of sweating and facilitates ventilation. The posterior fasteners must be protected to avoid damage to the clothes. A chin piece superstructure could be utilised in curves with the apex higher than T5-T6.
The pressure pads are thoracic, lumbar or both, the number and location of these depending on the type of curve presented. The pressure pads normal ranges are from a 5mm to 10mm thickness and are fabricated in Pelite. A copper wire is placed on the inside of the pad in the form of cross at the apex of the curve or around the entire external edge of the pad, this allows correct pad placement to be identified on the X-ray.
The thoracic pad has an oblique arrangement following the direction of the ribs, with a greater thickness at the spinous processes. The vertical length extends along the entire distance of the curve and horizontally expands to 2-3cm medial to the midline of the axilla. The thickness of the pad depends on the amount of rotation presented. The lumbar pad is also fabricated in pelite and is pisiform shaped. It has a derotating action that is applied over the lumbar transversal processes of the convex side of the curve, also, the lumbar pad acts to reduce the lumbar curve in the coronal plane (Hidalgo, 1993).
c)
Figure 3.8 Anterior view of the Malaga brace with a large anterior opening that provides space for the breasts of the patient. b) Posterior view of the Malaga brace with a posterior opening for donning and doffing of the brace. Three metal fasteners secure the brace on the patient. This Malaga brace was designed, hand modified and delivered to the patient by Grant Wood in Malaga, Spain, 2001, Grupo IDEO (ITECO).
The biomechanical forces of the brace are applied by the 3-point force system, where the pressure is more effective when applied at the level of the apex of the curve with the counterpressures at the iliac crests, lateral side of the pelvis and the midline of the contralateral axilla. In the case of double scoliotic curves, double systems of the 3-point pressure systems are applied simultaneously.
The lumbar pad has a double action that adds to the lordosis correction originated by the brace by maintaining lumbar flexion and providing permanent retroversion of the pelvis. This action is also based on the biomechanical principles of the three-point force system, the forces being applied through the intrabdominal pressure, the sacrogluteal support and posterior thoracic pressure.
From the biomechanical point of view the brace should obtain the following objectives (Hidalgo, 1993):
1. Mixed correction (active and passive) of the lumbar hyperlordosis by the voluntary action of the musculature of the pelvis (pelvic retroversion). Also by intrabdominal pressure applied by the abdominal support.
2. Passive correction of the hump of the scoliotic curve and derotation by means of pressures applied by the corrective pads.
3. Active axial elongation is provided by voluntary and conscious contraction of the spinal musculature.
Indications for the Malaga brace are the following (Hidalgo, 1993):
- Curves up to 20 degrees are treated with corrective physiotherapy.
- Progressive curves between 20 to 30 degrees Cobb angle are treated with the Malaga brace.
- Curves between 30 to 40 degrees Cobb angle are first treated with Cotrel traction. (night traction) in the patients’ home or in hospital during 15 days. Subsequently if the correction is good, therefore, the Malaga brace is prescribed. However, if the correction is not satisfactory or presents a hump greater than 10mm, it is reduced with Cotrel frame and plaster cast brace, subsequently the Malaga brace is adapted.
Curves greater than 40 degrees Cobb angle are treated with night traction during 15-20 days, orthopaedic reduction with a Cotrel frame and plaster cast during three to four months; subsequently the Malaga brace is adapted with a follow up every six months.