Saturday, May 18, 2024

RESPONSES: Complicated Chopart

Kelsey Holden

1. BKA, don’t even waste your time and his time. Email if you want a detailed reason why.

2. Consider an Arizona AFO partial foot AFO or walker shoe

3. I have struggled with many of these and they often break down repeatedly. I would highly recommend that you urge him to consider a heel cord lengthening unless he is a high-risk healer that no one wants to operate on. If his contracture now involves a boney block this may not be an option. Whenever I get the chance, speaking to surgeons and podiatrists, I urge them to avoid this level unless they are willing to lengthen the achilles tendon and get them into a device quickly that maintains a better alignment. My best results usually involve a bivalved design with a sole attached directly, -sort of an abbreviated CROW walker. Not pretty but functional with minimal leg length discrepancy.

4. Allardusa.com has a very good online course “Managing the partial foot”. It describes how to align a chopart that is plantarflexed.

5. From the description I would say at the minimum he needs the heel built up on the chopart side, so that his heel is taking some weight instead of all the weight being on the end of amputation. Because that foot is plantar flexed, it makes that side longer; necessitating a build up on the opposing side also. I’ve done mixed and matched combinations of this in the past.I’ve even made a custom floor reaction AFOs (part prosthetic) to try to extend the footplate on the chopart side. My laminated footplates worked the best, but they tend to delaminate in a year or less. Plastic lasted longer but the footplate extensions would have a bend in them relatively quick. This is one those cases where the product ends up being part prosthesis and part orthotic. I was thinking on my next case like this I may try Coyotes new carbon that is supposed to flex a little. Maybe the flex would keep it from delaminating as fast. Please post responses.

1. If this gentleman is a surgical candidate, the very best option for him would be to have an Achilles lengthening. This would allow him to obtain a plantar-grade foot. If not, he will not be able to be truly functional in his ADLs; and will always be prone to chronic skin breakdown and ulceration on his affected foot. Afterwards, based on his skin integrity, he could be accommodated either with a Floor Reaction AFO / Custom Molded Total Contact Partial Foot Orthotic / Depth Inlay Shoe with Rocker Sole; or a Double Upright AFO (Modified to a Static 90 Degrees) / Custom Molded Total Contact Partial Foot Orthotic / Depth Inlay Shoe with Rocker Sole. This is the approach that myself and most Orthopedic Foot and Ankle Fellows in this medical community would take.

2. Assuming he’s neuropathic: Arizona style AFO with toe filler, made into a walking boot. I’d be surprised if he gets any ROM back without surgery. Then get a matching shoe for the other side with lift. Still a great option even if he isn’t neuropathic. I’ve found people like the “one and done” for donning… meaning, they don’t have to put on a device, and then put on the shoe too .

3. Heel cord release. Toe off afo with custom insole

4. I would suggest that you call Orthomerica and speak with either Claude Reynolds, or Norm Yankus. These guys have seen it all and worked miracles for many customers, as well as come up with creative ways to treat the most difficult conditions. Just a thought.

5. SACH heel and rocker bottom on shoe to simulate ankle motion. Soft custom made silicone foot bed

6. Clamshell posterior opening and shoe lift other side is good thinking.

* Good Orthotic/prosthetic management will have far greater impact on getting the foot plantargrade again. Aggressive progressive support under the ST (sustentaculum tali). Drop the first, de-rotate the foot and ankle. Put the patient in slight stretch and they will walk it out, usually need to adjust ever 2-5 weeks be sure to leave enough room for their correction as they go. Final socket change when they are plantargrade and you can reduce the height. This amputation is muscle imbalanced so common to see what you are seeing. Good Prosthetic care and most patients are happy with it. Look toward revision if you do not get the foot plantargrade with good care. Also if patient is frustrated by the limited prosthetic foot you can do sometimes raise them so you can get in a low profile full foot like the Pacifica. Rarely activity and options will drive a revision, make sure to get them real improvements if it is drifting that direction. Bone bridge AND muscle innervation. Without both their trans tib may not be a better outcome.

1. Ran this case by my CPO and his suggestions are as follows: Custom shoe with cushion interior and compensatory heel height, not a full-length shoe, perhaps a couple of inches shorter than his sound side so he can clear his toe easily when he swings through. The sole will need to be rolled at the heel and the toe but not a rocker bottom because a rocker would make him feel like he’s falling and unstable. The heel and toe can be sanded to round it out as needed until he’s comfortable but don’t finish it off until then based on how it feels to the patient. A clamshell AFO could work in conjunction with this as long as there is enough cushion at the forefoot. If he’s older than 70, he will more than likely not regain ankle motion. However, if he does start regaining ankle motion back, the heel height on the custom shoe could be lowered at that time but if you put it in a brace or prosthesis, he will never regain it because he will be locked in. All of this is dependent skin pressure tolerance, circulation and sensation.

1. I’d call Bio-Mechanical Composites and ask for Noel regarding their Partial Foot Phatt Prosthesis

2. Good news… we’re going to make you the expert here.

Firstly, you have bilateral gastrocnemius contractures, so let’s hope your gentleman has an affinity for cowboy boots with a heel! Start with that… because the sound side contracture is complicating everything else by always being on the verge of buckling the knee. Sitting ankle ROM only measures soleus. Grab the physical therapist’s notes and check ROM with knee extended. See if they match. And the gastrocnemius already has 15 degrees less dorsiflexion ROM and 18 degrees less plantarflexion ROM in healthy subjects, not to mention that diabetics have less 10 degrees less dorsiflexion ROM than non-diabetics… So, if the physical therapist or physician is going to stand there pretending to be the expert without getting into the details, it doesn’t mean that you have to.

While Wolff’s law explains why TF femurs lose 50% bone mineral from lack of skeletal support, it’s Davis’ Law that tells us that patients develop a functionally limiting contracture in just 2 weeks. And after a year they want to dump everything on you?

So you say this, “I want to know who allowed this plantarflexion contracture to develop and why is it okay to project blame on the person who’s here to clean up your mess?” And through it all, nobody will want to pay for anything other than what’s covered by Medicare… Consider a rocker sole to reduce pressure on the incision (externally) with total contact under the arch and anti-migration at the calcaneus to keep pressure off the incision as well (internally).In short, give him heel lifts or whatnot, then reassess, throwing out that other stuff to get people to get off your back and give you a little bit of the respect you deserve. I assume that you have other colleagues making suggestions on the standard stuff, so I’ll stick with a few “wild card” ideas.

1. That’s a tough one. If he’s open to surgery and is physically a good candidate, then he should speak with a good surgeon. Patients are often reluctant to visit the idea of more surgery but he will be functionally limited with anything you provide. If you’re forced to fabricate something then I would do a carbon chopart plate on whatever socket you can get away with. Maybe a medial window, pelite liner

2. Phone convo response: Arizona AFO, Can be build up and an indentation can be added to stay in the shoe. For a more active patient: anterior pretibial shell, urethane bonded to distal end of the socket, posterior open with 1 strap

3. Phone convo response: Carbon fiber brace with the Becker trip action ankle joint. The joint can be adjusted if the contacture works itself out. PTB clamshell is a good idea as well.

Kelsey Holden, CP
ABC Certified Prosthetist
Befitting You Medical Supply

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