Below is the list of replies to my ? regarding a calf WB AFO with the
names of the individuals who replied:
Re: Calf WB AFO
Date:
Wed, 21 Oct 1998 07:55:43 +0930
From:
“A Wicks”
To:
“Molly Pitcher”
Hello Molly,
My facility has fitted quite a number of calf corset AFO’s and it is our
device of choice for unweighting the hindfoot and ankle complex. Our
method of fabrication is not too dissimilar to the original design – we
use
copolymer for the foot and calf shells moulded over USMC LM aluminium
uprights & modified stirrups. The internally articulated leather corset
laces up to provide suspension and the actual design of the articulation
is
quite important. We have tried calf corsets with velcro closures but
this
does not give the same positive grip as lacing. The leather calf
section
usually requires trimming once or twice during the first twelve months
due
to atrophy.
There is probably no reason why you couldn’t utilise a composite
reinforced
polypro design but we have had really great results with the original
configuration. It is vastly superior to the PTB orthosis.
Don’t forget to add material to the plantar surface of the hindfoot
before
moulding and to provide a small internal heel lift to the contralateral
side. If you need more info please email.
From:
To:
Dear Molly,
As far as the knee pain is concerned , it is not unusual for residual
knee
pain to persist when the pressure of the patient’s weight is being born
unnaturally for an extended period of time. When comparing the
usefullness of
a PTB plastic orthosis to a leather lacer the most important factor is
going
to be whether your going to have trouble with your stirrups again and
whether
the cause of the paient ‘s knee pain can be adjusted or accounted for.
Second
is whether the continued reduction in size can be adequately
accommadated for
in the plastic orthosis.
The third problem will be whether the patient will accept a 70 to 100
percent
increase in weight betwee the two orthoses.
In my experience with the leather lacers they work well but do require
maintanence.
in particular leather breakdown and rivet replcaement. Also the need to
explain proper hygiene and sock wear with the orthosis. Most patients
who need
the continous support like the adjustability and their ability to
control
pressure which is definitely less with a plastic ptb orthosis.
As far as the knee pain I have had some patients say that the pain was
less
while wearing the leather lacer but when removed for rest or sleep it
came
back. Others have had enough of a reduction that the pain went away
altogether.
Subject:
RE: Calf WB AFO
Date:
Wed, 21 Oct 1998 08:12:39 -0300
From:
“Ferris, Peter (WHSCC)”
To:
“‘Molly Pitcher'”
-My experience was not successful. The patient found to make it work
the calf corset cut off his circulation.
-Be aware of the time it will make to fabricate it.
Subject:
RE: Calf WB AFO
Date:
Wed, 21 Oct 1998 08:36:35 -0500
From:
“Anderson Harold R.” To: “‘Molly Pitcher'” Molly, I’ve used that design successfully along with variations of it. Just an idea: Make a calf lacer for your patient using the PTB principles. Then form your solid ankle (poly) AFO around the lacer and attach the two suspending the lacer from the inside of the AFO. If you need more rigidity, use carbon fibre or other composite material as inserts to give strength. You would want to have plenty of strength from the poly AFO to bear the weight of the leg semi suspended in the lacer(you may not need full suspension). Subject: Re: Calf WB AFO Date: Wed, 21 Oct 98 07:43:21 -0600 From: To: Hi Molly, Why does he need an AFO again? What was the orginal diagnosis? IE foot drop? Is the knee pain from wearing the PTB? Have you ever considered KAFO with an Ischial Gluteal seat? Subject: Re: Calf WB AFO Date: Wed, 21 Oct 1998 11:07:09 -0500 From: To: “Molly Pitcher” I read your message about the calf-bearing AFO. In the practice I worked in SC we did quite a few “calf-corsets” and they seemed to work very well. In fact, I think patient compliance was better in the leather corset than in the standard plastic and foam lined PTB orthosis. I skimmed the mention JPO article. We did not achieve 100% wt bearing at the calf belly as the authors describe. We split the load bearing between the gastrox and the medial tibial flare. We usually attached the uprights of the orthosis to the shoe in a conventional manner. We did not use a plastic insert independent of the shoe as shown in the article. However, I think the foot and ankle design (conventional or plastic) are variable depending on your patient’s needs. I hope this input helps you. Subject: Re: Calf WB AFO Date: Wed, 21 Oct 1998 21:27:47 EDT From: To: Molly, Contact Roger Marzano, CPO at Yankee Bionics in Akron, OH (330) 668-4070. He’s very knowledgable and has had much experience in the use of this orthosis in the treatment of Charcot Arthropathy. He even wrote an article on it; I have a copy of it but there is no indication of where, or if it has ever been published. Subject: Gastroc Bearing AFO Date: 22 Oct 1998 07:14 CST From: To: [email protected], [email protected] Ref: Calf corset A.F.O. Molly, we have used this design of an A.F.O. for almost 10 years. I first saw this design when I was doing an internship at Gillette Childrens Hospital in 1990. We call it a G.B.O. ( Gastroc Beraing Orthoses ) I work at the V.A. Medical Center in Minneapolis, so my patient population is essentially geriatric. We see numerous charcot ankles and trauma related foot-ankle malady. The G.B.O. design has increased patient compliance tremendously. Patients that were non-compliant with a PTB design, appreciate not having the knee involved in the unloading process. The majority of the patients I see for G.B.O.’s have limited ankle ROM, though we have fabricated G.B.O’s with an articulated ankle. I suspend the calf corset with nylon webbing to the superstructure. This accomadates volume change in the extremity when necessary. Our fabrication technique is difficult to explain, but if you want more info perhaps we can mail some pictures or send you a sample. Subject: Re: Calf WB AFO Date: Thu, 22 Oct 1998 08:58:20 -0700 From: “ecat” To: “Molly Pitcher” Yes Molly, I have done this (rigid poly AFO with PTB trimlines). I found that I had most success when I reinforced across the ankle axis with a corrugation moulded into the material by the impression of a piece of 3/16″ cord tacked to the cast on both sides. This gave it the strength without appreciably increasing bulk or weight. I have done this with both Polyester laminations and Polypropylene. However, something tells me that the knee pain will not go away in your patient’s case. I don’t completely follow why a PTB is necessary; it is almost surely one of the reasons why he is getting calf atrophy apart from the fixation of the ankle. Is this person subject to compensatory pension from the service? I guess that I’m just a bit suspicious. hope these few thoughts help. Subject: RE: Calf WB AFO Date: Thu, 22 Oct 1998 20:09:10 -0600 From: “Tom Padilla” To: “Molly Pitcher” The calf lacer has worked well on a few patients. You may still get some flex at the ankle with poly pro depending on the size and weight of the patient. A laminated AFO will give you the strength at the ankle without the bulk. You may also consider a rocker sole on the patients shoe to aid rollover. A prominent tibial crest may also warrant padding or counter-relieving. Good Luck Subject: Re: Calf WB AFO Date: Fri, 23 Oct 1998 13:17:28 -0500 From: “Lux orthotics” To: “Molly Pitcher” Hello Molly. I have had similar problems with a patient using a PTB design that was made for me by OOS. When she required a new orthosis, she developed non-specific knee pain that could not be dignosised. the pain was only present using the new orthosis. It turned out that the new orthosis put a slight varus stress on the knee aggravating some osteoarthritis in the knee. A slight heel wedge in the shoe alleviated the problem. I realize that I am not specifically answering your question, but it should be important to find out why your patient has knee pain before making such a drastic change in his orthosis Subject: Re: Calf WB AFO Date: Fri, 23 Oct 1998 21:35:08 EDT From: To: Hi Molly- I have treated 6 or 8 patients with the design described by Marty Carlson with some modification from time to time. All in all, very good results. Some issues that we have encountered are: vascular status is critical whether it has been an issue for the patient before or not…potential for volume fluctuations due to variable edema is directly correlated to vascular status (potential vascular insufficiencies, no matter how insignificant previously are magnafied)…patient requires reliable upper ext. function to tighten the system adequately (tightly!)…requires appropriate footwear to attatch to…requires contralateral lift to equal leg lengths often…and it tends to be technically demanding to fabricate. On the topic of ankle control, it seeems the ankle joint is invaluable once you have the patient ambulating, you can dynamically align and have the ability to “fine tune” by adjusting the joints to optimum df/pf angle. I have a question as to your patient’s knee pain…is it pathologic or orthotic in origin?? I imagine it is orthotic due to the PTB trims but if it’s pathological…this design offers little without significant modifications. Editorial: In use, I really felt like this was a far superior design to the PTB but it has some limitations. On the other hand, I have one patient who currently tolerates 100% WB through the orthosis. Subject: Re: Calf WB AFO Date: Mon, 26 Oct 1998 16:16:43 EST From: To: Dear Molly, I have used that particularly design once. I had a Central Fab do the work. They did a fair job. It was fit about two years ago. It continues to be worn. The individual wearing it does not clean it well, nor does the person have good hygiene. But, he does manage to come in once a year to complain about “cheap” velcro and gets one strap repaired. I cannot really say if the design works. This person never seemed to understand that it must be worn snug. When I snug it up it does function as the article described. I would be sure the plastic is very rigid. Leave plenty of space within also for the edema. From: “shane jansen” To: I have used it once.The patient has OA ankle with of pain++ on WB and with mov’t. He had been fit with a number of AFOs previously to immobilise the ankle. These had all helped to some degree. Tried the calf corset WB/AFO with metal ankle hinges. This was worn for a period of time with some success(some unweighting of the ankle and reduction in pain). Eventually discontinued due to swelling in that limb, distally I think. Patient lives a long way from clinic and has firm ideas about what is going to do the job. Wont hesitate to modify an orthosis himself. Not ideal test case. In summary it can work but patient selection and regular follow-up are crucial. Calf corset must be a very good fit and it’s proximal posterior trimline needs to be quite high and even flared so as not to dig in. No experience with fixed ankle sorry. Subject: Re: Calf WB AFO Date: Mon, 26 Oct 1998 16:34:34 EST From: To: Molly, Is your patient having a back bending moment of the knee? Where is the knee pain? Since you are restricting dorsi flexion, did you put a rocker on the shoe? When you go PTB you are really positioning the “knee in space”. Does he walk to this leg or past it? Subject: Reply to: Re: Gastroc Bearing AFO Date: 2 Nov 1998 07:20 CST From: To: Molly, your observation is correct. The majority of the weight borne through the corset is posterior, the medial flare is also modified to provide an unloading effect. Each case is unique, as with all O&P. I have even used a bladder in some cases, placed where the undercut is located. The patient could “fine tune” the corset by changing the volume of air in the bladder. It worked well, but most patients just want to slap it on and run. The work of the bladder was more than they cared to deal with.
