Advice for orthotics following partial foot amputation

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hi,
here with presenting this 50 year old man with 8 months since mid tarsal amputation for forefoot malignant melanoma for footwear advice .
suresh

 

Re: advice for orthotics

How likely is your client to wear a lace up ankle boot considering the environment?

 

Re: advice for orthotics

Hey there, I'm not sure how accessable are prefabricated ankle foot orthotics in india but something that could be lined with a 6mm poron around the plantar surface of the stump and heel and adding a full rocker sole to the outer sole. The rocker sole would help in propulsion.
This kind of device may to be more suiteable to indian weather and be more durable than an orthotic.

 

Suresh

The problem with this Lisfranc's/Chopart's amputations is that the hindfoot always goes into equinus (+ varus often). You can easily appreciate that on the lateral view of the foot.

Because there is an imbalance in dorsiflexion capability, you should consider a percutaneous tendo Achilles lengthening to allow the heel to get to the floor, otherwise the calf will contract and stump breakdown is possible.

Only then, I feel, will you get adequate results from a casted orthosis with a forefoot filler in a lace-up shoe.

LL

 

Hey suresh

I'd be thinking in terms of lost function.

Without the foot there is no way for the patient to control dorsiflexion of the foot / shoe after the COG passes over the foot. The Force is still there but the lever has gone .Perhaps a part of the TA Shortening LL mentioned is down to the TA trying to decellerate progression over the leg over the foot and failing because there is nothing to push with!

Personally i would go for a polyprop GRAFO with a full length foot plate and a stump cradle in something softer (lunarsoft for EG) to simulate the tensile function of the TA.

Bit like blade runner. Replacing propulsive force with elastic recoil of the orthotic material.

Regards
Robert.

 

Suresh,

What are his goals? What prevents him from doing what he wants to do? Does he care what his footwear looks like?

Is the problem his shoe falls off. Is the problem that his foot falls into varus weight bearing?

Does he have an intact attachment of the peroneus brevis or more precisely can he actively evert his stump? Can he dorsiflex his stump with his extensors?

You have to identify what is missing (in terms of ability to generate moments) before you can get a good prescription.

As mentioned earlier, from the picture it appears that his foot is going into inversion. If this is part of the problem then you would have to figure out how to generate an eversion moment from your device. A shoe with a lateral flare may help if (big if) the stump will move with the shoe. If not, you are looking at a hinged AFO that can prevent the heel from going into varus.

When you lose the forefoot you lose a source of dorsiflexion moment and eversion moment from the ground. The muscles, if attached, can still produce moments, but there will be less resistance from the ground. The achilles and posterior tibial will still create supination moments, if there was a laterally deviated STJ axis to begin with then there will be a lot of sources of supination moment.

Good luck with your patient,

Eric

 

Excuse my ignorance but what is a polyprop GRAFO???

I agree with the balde runner concept it could be practical.

 

Polypropelene Ground Reaction Foot Orthosis

 

No excuse needed. That how we learn.

Polyprop is polypropylene,

A grafo is a Ground Reaction Ankle Foot Orthotic. looks like this


Although this is a somewhat inelegant example of the species, (best i could find on google).

The Principle is pretty simple. The ground reaction force is redirected into the shin pushing the knee into extension (Fy+ -> Fx- for those who like that terminology)Usually used in Pead CP for this purpose. In this case the objctive is to replace the function of the Achillies tendon in propulsion and decelleration after the center of mass (COM) passes over the foot.

Heres fun. Stand on one leg. Right now. Really, do it. Now lean forwards (you'll probably need to hang onto something.) Notice how your achillies fires and your forefoot presses into the ground. Now imagine, if you will, what that would be like during gait if you had no forefoot to push into the ground. I suspect your Achillies would be firing like mad to try to decellerate you (putting your calc into equinus) whilst acheiveing little. Now imagine the effect of a grafo pushing back on your shin.

Does that help?

Regards
Robert

 

Hi Suresh,
I have had a really good result for a girl that had most of her forefoot amputated after a bus ran over her foot. She walks without a limp and with comfort in her MBT shoes compared to ordinary shoes. The only difference being, this girl had a little more of her foot laterally and distally preserved. Thereby she did not have a problem with the shoe staying on. It is worth a try as she swears by them.

Talking about keeping the shoe on, does anyone have a solution to heel slippage apart from 1) Correct shoe size, 2) Insole fillers 3) Lacing technique 4) adding new lacing holes proximally and 5) Heel fillers? Is there any other little trick?
Regards
Con

 

Suresh

Here's a paper I wrote on Transmetatarsal amputation. Not quite the same as your foot but might help. It is in terms of a critical review of research methods but may be helpful with references if nothing else.

Dave

 

David Smith,
i couldn't access your paper .
could you send this file again or to my mail id
bsg.ortho@gamil.com

suresh

 

Suresh

I have twice tried to send thid by the email link above but it is returned undelivered.

I'll try bsg.ortho@gmail.com see if that does it.

Keeps a look out.

Dave:hammer: