Original Post
This has recently come up in discussions with other prosthetists. It’s
my practice and the practice at the VA in Houston to initially use the
foot we think the patient will benefit from in the long term, whether
it’s a Talux, Renegade, Sureflex, or whatever.
We do not put a pt on a sach or other stiff foot initially. It has been
explained to me that this is done for getting initial balance.
My opinion is that the pt’s mind and body adjusts to the foot’s dynamics
and there is no point in having him/her learn another set of
proprioceptive clues. Of course if it turns out to not be appropriate at
the time, we change out the foot.
My assumption was that our approach has become a standard of practice.
Is it?
Mark Benveniste RN BS CP
I post the following responses without names because I didn’t ask for
prior permission with the post.
Mark, I agree with you 100%. I follow that standard of practice myself.=09
It has everywhere I’ve worked in Maryland. Exception, IPOPs & Medicare
as they will allow only a SACH.
Definitely not standard practice in my region. This sounds better from
gait dynamics perspective. Assuming you take existing foot off prep and
apply to definitive, just wondering thoughts on potential disadvantages
(i.e. Pt only has 1 prosthesis, cannot return to prep at any point if
they experience complications with definitive, may require change in
some/all endoskeletal componentry as you switch foot, etc.). Please
post responses.
I agree Mark. A very similar situation occurs with the practice of
having an upper extremity prosthetic patient first “prove” his
competency with a cable-driven system prior to being considered for an
externally powered one.
Nothing could be more illogical for a variety of reasons and yet this
methodology is still in practice today.
It is in my practice.
Mark, we do the same thing here at the University of Michigan O&P
Center.=20
It has always (or should I say was) a standard for my practice. I think
you state it best. Why learn a new set of proprioceptive clues?
I do the same, for the same reasons you have mentioned
This has been my philosophy since Medicare established a L code for
socket replacements. For the same reasons you described I stopped
getting prescriptions for temporary prostheses and started fitting new
amputees with the components that I felt would be the definitive
components that they would use long term.=20
My philosophy has been to provide the new amputee with a durable,
predictable foot that will give them the chance to re-develop their
sense ofbalance: the Otto-Bock 1D10 Dynamic foot, for example, can be
aligned initially for stability, then realigned to take advantage of
the energy storing capabilities of the foot. A weight and activity level
appropriate foot of a true energy storing nature (flex-foot, Renegade,
etc.), if truly designed for the patients’ current activity level, would
be much too flexible to provide the kind of balance and stability a new
amputee is looking for. Remember, their first week or two on the
prosthesis is usually spent “standing only” to get them used to the fit
of the socket. We don’t want the foot giving out from under them as they
shift their weight. Let me pose a question for you: How do you know what
an amputee’s ultimate activity level is going to be before they have
begun to use their first prosthesis? They have no track record
whatsoever.It used to be that an insurance company would question the
provision of a Flex-foot until the patient had proven themselves to have
a higher activity level. My sense is that Ossur then started making feet
to specifically target the lower activity patient (Sureflex, etc.) to
get into the preparatory patient market. As far as I am concerned, the
preparatory feet offered by Flex-foot are much softer and forgiving than
other Ossur products, and, therefore, more dynamic (less stable in
balance).You wouldn’t give your teenager the keys to the Ferrari to go
out and learn how to drive. You’d give him the keys to the good old
reliable and predictable pick-up truck.Sudden acceleration or
deceleration does not inspire confidence in your patients’ gait or
standing.Just my opinion…
I agree. I also used to do the sach foot first, but now simply get the
foot I plan to use. I also do a pin lock for a prep and only charge for
the silicone liner without pin because it suspends better. I can reuse
the lock mech for the definitive.
The benefit I see to using a low-cost foot – e.g. Seattle Light,
Campbell Childs CK SACH or eq. is that you have a foot/pylon system to
use as a back up while you are making the definitive prosthesis. It is
always nice for people to have a second leg to use for whatever purpose,
whether to spare their “permanent” from excess wear or water/dirt, or
just to have something to fall back on when having maintenance done.
Sometimes I will attach one of the test sockets to the “old” foot for
this purpose (I usually have a “test”=20
socket made of co-poly at some point in the process) It seems that the
foot is the least of the concerns when getting used to a new prosthesis,
the different socket seems to cause more alarm… but I can’t say for
sure. I do look forward to the responses…
I’ve never fit a SACH in 8 years except for when I need to get someone
standing asap, so I raid the used parts bin. I’ll usually start with a
Sureflex, 1C40, Tribute or Cadence depending on the patients predicted
outcome. I find it difficult to predict someone’s future walking ability
by watching them wear a SACH foot.
That is my practice standard. I prefer to give the pt. an option and let
them participate in the component selection. From other prostheses I
have seen and pt. experiences related to me not all prosthetists share
that pt. management perspective.
Just a note to let you know that I to feel it is appropriate to start
out on the final foot of choice. I often use a College Park foot so that
I can change the bumpers if it feels to soft or hard. I have only had to
switch to something different several times over the past 15 years or
more. I do use other feet if they are more suited for an individual
case.
Yes you are absolutely right
I agree with your protocol. I no longer do “preparatory” prostheses. The
first prosthesis is a definitive prosthesis. When the socket no longer
fits due to resolution of post op edema and atrophy, the socket is
replaced.
