Thursday, May 26, 2022

Digest of Response to Shoe/Stirrup Problem

Harry Phillips

Original Query:

Patient has severe peroneal tendon dysfunction, beginning with rupture,
followed by repair and several rounds of infection, debridement,
revision of the surgery resulting in resection of all remaining peroneal
tendons. Essentially has little resistance into varus and uses metal and
leather AFO with lateral wedge inside shoe for protection. Requires the
use of steel toe boot for work. Failed polypropylene AFO over the long
term, although this provided great control, recurring cellulitis made
us leery to come in contact with his skin anywhere along the lateral
side. Has been using standard AFO for 7 months, during which time the
stirrup has pulled through the sole and out of the shoe several times,
as well as issues with the rivets pulling through the shoe and the added
reinforcements. This is primarily due to the fact that he climbs a
ladder on a truck with limited space for his foot, and therefore puts
all of his weight on his forefoot while climbing and this is beyond the
reach of the long tongue stirrup. The problem is compounded by the fact
that he uses a hose to wash cement off the boots multiple times a day so
the leather is damp most of the time.

Past inadequate solutions were to add an internal carbon plate the
entire length of the shoe and rivet the stirrup through this, change to
a heavy duty sole, increase the number of rivets to decrease the stress
on each, etc. At this time, I have him with the longest tongue stirrup
that Becker makes, I have reinforced both the inner and out sole with
carbon plates and have the stirrup sandwiched between, attached with
broad head rivets. This lasted only 4 months. I am hopeful that adding a
full length steel plate contoured along the inside of the footbed, so
that the stirrup could be attached through this, sandwiching most of the
sole, would prove more durable.

Question to the list:

Can anyone recommend a central fabricator that might undertake this
project? Can anyone recommend an alternative that might prove more
durable?

Try fillauer with a Craig-Scott stirrup with alum inner plate

ALAN HAMMER, CPO

Contact Tony Wickman at Freedom Fabrication (800-304-3733) regarding the
Havana boot design brace. He can tell you about the brace and they are
an outstanding central fabrication facility.

Alexander L. Lyons, C.P.O.

Steel toe is the curse in this equation. Would the company allow a break
in this. Often they do, if you are lucky.

The #1 idea that I have is the Asolo Makalu GV this is a great boot.
Solid as a rock and built to withstand use. Now this may be over kill,
but if it fits well you will find that it does have the work for you .
Meaning the brace does not have to do all the work. I keep the Asolo gps
520 line in stock and use them for this purpose.

#2 If that is not a choice you can have a local welder add to the
stirrup to make it longer and stronger. We do this in house. Remember if
attaching to a weak shoe, the failure level is still great.

Good luck.

#3 I think becker still does custom plates?

Warren Hagen

First I would place patient in a compression garment to control the
cellulitis and fluid changes.

I would either fit the patient with a mid calf DRAFO or an ankle brace
(Arizona style).

These 2 styles of bracing will support the posterior tibial tendon
issues very well. If volume control is a major issue, you can go full
height in either brace to normal AFO height. I don’t think it would be
necessary with the compression socks.

Couple of key things to think about in the brace.

1) I would go at least to sulcus with the outter shell of a DRAFO and
would maybe go full to toe with the ladder issues, depends on where he
hits on the ladder with his shoe.

2) If he is constantly hosing off his shoes, the plastic DRAFO design
will handle water much better.

3) Cut the heel in the plastic of the Arizona if you go that way. It
will allow the patient a normal 1st rocker in gait and make the rigid
ankle not such a big deal.

Both designs allow the patient to get his own work boots as needed and
he just has to make sure he gets one with a removable inner sole.

Kevin L Hines CPO

Hi Harry,

We had a similar problem a few years ago and tried the mild steel toe
plate, however we later discovered that we our material choice was too
rigid and instead opted to replace the mild steel toe plate with a
polyprop version. Even the mild steel fracture at the toe break.

With the polyprop version we had to reinforce the areas around the
attachment points for the chopart side steels by using ribs (electrical
flex cable nailed to cast and draped over). This increased the longevity
from a few months to 3 years.

Unfortunately I do not have a picture of the custom made polyprop
reinforcement, but have attached a picture of the previous version with
the mild steel toe plate. The chopart side bars are available from Otto
Bock. We made this in-house.

Best wishes

Peter

Peter McLachlan

Why not keep it simple & try an Allard Blue Rocker. It offeres great ML
control, its lightweight, dynamic. We’ve been having great success with
these, especially with previous custom AFO users. And at least then
you’re not making something custom that ends up not working.
~Subie Marvin, CP

It sounds like you could not do much more than you have!

Here is just a thought. I think the full length stirrup is part of the
issue. They are so rigid they do not flex at all. This means any
motion at even at the MTJ joint will apply stress to the caliper plate.
I would try a stirrup met length with a full length spring steel shank.
The spring steel shank can be contoured to the rocker shape of the sole.
This will function like the long tounge stirrup but have more give and
flex yet protect the met length stirrup from tearing through the shoes.
I would use a carbon insert in the shoe like you have previously done.
Before adding the steel shank I would add the firmest EFM rubber they
sell as the first layer. Then the spring steel and then the stirrup and
more EFM and then finish the sole. May need to add a little to the
contralateral side to make the height the same.

Also I would tell the patient to go to a snow ski store and buy some
shoe waterproof paste. It works incredible on leather. The water just
beads and falls of. He will need to make some adjustments to his life
as well. He may not be able to completely soak his shoes with a hose
like before. There has to be some give and take.

A lot or work! Especially for what you will get paid. It would seem a
happy patient counts for something though, they will think great of you
forever. Good luck.

Jim Del Bianco, CPO

Fillauer has done some good custom work for me. Communication and
adjustment of plan will be a requisite. Of course this costs time and
money.

My experience is that these cases resolve best with understanding and
input from the patient prior to and during fabrication and trial use.

If the patient is not concerned with cosmesis and can adapt for “Gadget
Tolerance” an externally buttressed custom stainless foot plate might
support his needs.

From the usage so well described, the boots will be the expendable part.
The metal orthotic structure will be transferred as the leather boots
wear out.

Jerry Stark CPO at Fillauer would be the first contact I would make. He
has good clinical/analytical credentials and may come up with other
resolutions for you.

W.Doyle C.P.O.

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