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Amputated 2nd, 3rd & 4th digits

Discussion in 'General Issues and Discussion Forum' started by markleigh, Jun 2, 2009.

  1. markleigh

    markleigh Active Member


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    I have just seen a 73 year old lady 9 months post left 2/3/4 digital amputation for non-healing infections of digits associated with arterial occlusion. The wounds have largely healed but she was sent to me by her GP who is concerned with the space left between her 1st & 5th digits. His concern is that the remaining digits may abduct (hallux & the 5th adduct) & therefore wanted a block of "something" placed in between the toes. She is on a waiting list at the local public hospital but feels she may be on it for a long time before anything occurs.

    She currently is wearing a post-op sandal & is comfortable. She is moderately pronated/flat-footed in the midfoot. The dorsal wound has almost healed & the surgeon is happy with that.

    My advice was:
    1. wait for the wound to fully heal before doing anything further
    2. then purchase footwear that is square toed with a rocker sole
    3. then see me for review of the footwear & possibility of fitting with an orthosis of some form to reduce GRF to the 1st MPJ as this may increase the likelihood of the 1st MPJ abducting
    4. from my limited experience in this area, I didn't think a block or wedge placed in between the 1st/5th digits would be comfortable but if needed, would send to an orthopaedic footwear manufacturer

    What is others experience with this type of amputation & long term effects on the 1st/5th digits & what would you have suggested? Would a block/wedge/spacer be comfortable/needed?
     
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    The toes will indeed try and ad/abduct to "fill the void".

    The question is - how significant is this in an ischaemic lower limb?

    The only reasonable approach to take would be to have a toefiller prosthesis made to insert into the toe box of the shoe, made of suitable material.

    Otherwise - let the toes do what the want to...the foot would be probably more functional if they were amputated too in due course, so you have a reasonable stump to work with.

    I personally wouldnt bother trying to stop them deforming out of the sagittal plane in an ischaemic 73yo - they clearly have bigger things to worry about.

    LL
     
  3. markleigh

    markleigh Active Member

    Do you see any benefit in using an orthosis to reduce GRF sub 1st MPJ? She has a moderate amount of MTJ collapse & still ambulates reasonably well. I'm not sure what effect a loss of 3 digits has on the hallux & in combination with the MTJ collapse whether this will lead to greater problems in this area. Due to her medical history there is obviously an increased risk of further amputation of other digits or more proximal. Surgeon is supposedly now happy with local & more proximal circulation.
     
  4. Adrian Misseri

    Adrian Misseri Active Member

    G'Day,

    I'd agree, use a stiff soled rocker bottom but I wouldn't bother too much with the orthosis as you're already reduced foot function with the shoe. What's to stop you using some 9mm HAPLA felt folded over as a temporary toe filler? Use some lastonet to make loops either end to hook over the 1st and 5th digits, essentially giving a 18mm sausage of felt which will help to stop migration, but wont rub or affect the dressings of metatarsal heads 2-4?

    Cheers!
     
  5. Leah Claydon

    Leah Claydon Active Member

    Don't know what the reason for amputation was but surely putting toe loops may further occlude an at-risk digit? I don't think I'd bother filling the gap - I agree with an earlier poster, 'let the toes to their own thing'. A good rocker shoe is a good idea - have you looked at RSScan's D3D shoes - they are excellent for offloading the forefoot and don't look too orthopaedic (mind you there's not really a ladie's shoe).
     
  6. Camo

    Camo Member

    Would'nt recommend toe loops around distal ischaemic digits. We normally just get them into a solid rocker bottom shoe with a moulded total contact insole - simple EVA/poron/plazatzote full length device. Usually only use toe fillers for missing 1/2/3 in combination with mortons extensions.
     
  7. Boots n all

    Boots n all Well-Known Member

    It would be good to stop the 1st and 5th rotating/adducting together, as this action in the past has proven in my experience to expose the PIP to pressure, were it can least afford it.
    A filler built as part of an Orthosis and a ridged rocker sole is the way l would go
     
  8. efuller

    efuller MVP

    I certainly see benefit if there is evidence (Callus, blister) sub 1st met. PVD with history of ulceration and amputation secondary to non healing is by itself a good reason for extra depth shoes with an insert. The insert can be designed to decrease pressure sub 1st met if you feel that it is likely to break down. If you decrease the force under the first that force has to go somewhere else.

    My working theory on toes is that they take some of the load off of the met heads. If she has been walking for 6 months post amputation, you should be able to get a good idea of where the forces are high by looking at the shoe, or the foot. If there is an area that looks like it is getting too much force then you should use a custom insert designed to reduce force in the problem area. If she is increasing her activity level, I would get her out of the post op shoe. It's hard to imagine a 6 month old post op shoe staying in one place on the foot. If she is becoming more active I would worry about blisters/tripping in the post op shoe.

    Regarding the spacer to prevent deformity. It would be really sad if the spacer caused an ulcer. You could make a spacer thinner than needed if you wanted to treat the referring doctor.;)

    Cheers,

    Eric
     
  9. drsarbes

    drsarbes Well-Known Member

    In retrospect the surgeon most likely should have taken the 5th digit as well.

    Steve
     
  10. markleigh

    markleigh Active Member

    I like your comment Eric about "treating the referring Doctor". Very true.
     
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