Lisfranc amputation replies

Lisfranc amputation replies

As is the procedure and set-up for the OANDP List I am posting the replies
that I received relative to the clinical case I presented for input from those
subscribed.

Given what I presented I am surprised at the number of practitioners that do
use some type of AFO for this level of amputation. It would appear that those
subscribed to this List are the more progressive practitioners which is no
surprise.

Thank you,

Al Pike, C.P.

 >Was asked to see a young man in his late twenty's, slight of build, around
130
>lbs, with a Lisfranc amputation with minimal scarring. He is presently
>starting on his second slipper type prosthesis with in slightly more then one
>year.

>The slipper type prosthesis is molded leather with soft insert, anterior
>lacer, rigid non flexible steel shank, and toe filler. He continues to have
>the same problem as with the previous device of forward rotation in the
>appliance and breakdown of anterior distal part of the remaining foot.

>I am giving consideration to fitting him with a Ortho-Prosthesis (my
>colleagues in Europe are more familiar with this term) of an AFO combined
with
>a toe piece and filler. This concept in fitting was also presented by Gunter
>Gehl, C.P. of Northwestern a few years back.

>I would like to know of other experiences with this type of amputation and
>problem.

>Respectively,

>Al Pike, C.P.
> <URL Redacted>


REPLIES:

Subj: Re: Lisfranc amputation
Date: 98-07-21 18:35:13 EDT
From: <Email Address Redacted> (Terry Supan)
To: <Email Address Redacted>

Al, that is the approach that I use for similar cases, polypro or TPE for the
AFO.

The other approach is to use a totally flexible silicone prosthesis with extra
cushioning distally. Our technique is an take off of Wayne Koniuk's; we use
seattle foot as model for distal shape instead of the custom shaping that
Wayne does. One of the first cases studies on OANDP.Com was devoted
to our technque, authored by Tom Current when he was resident here.

Terry

Terry Supan, CPO
Associate Professor
Director, Orthotic Prosthetic Services
SIU School of Medicine
PO Box 19230
Springfield, IL., USA, 62794-1420
phone: (217) 782-5682
fax: (217) 782-7323
E-mail: < <Email Address Redacted> >

Subj: Re: Lisfranc amputation
Date: 98-07-21 18:58:51 EDT
From: <Email Address Redacted> (Ted A. Trower)
To: <Email Address Redacted>

Hi Al- I'm no expert on the Lisfranc amputation and I haven't seen one in ages
but I was under the impression that the reasons for it's unpopularity were
just the type of problems you describe. Strong muscle imbalances and poor
skin on the distal surfaces.

Ted A. Trower C.P.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
<Email Address Redacted>


Subj: Re: Lisfranc amputation
Date: 98-07-21 20:46:41 EDT
From: Harry3
To: AlPikeCP

I have done several laminated anterior panel partial foot prostheses with
foamed (then laminated) keel and a CC3 or Flexfoot foot cosmesis for
finishing--The crucial element is to cup the posterior calcaneus so that it
cannot plantarflex from under the talus. If there is already a equinus
deformity, then there is room for a SACH heel--but you will have to provided a
lift on the contralateral side--Otherwise casting the limb in a non
weightbearing position should cup the heel enough to create something of a
rocker heel (in flexible shoes). Hope this helps
Harry Phillips, CPO

Subj: Re: Lisfranc amputation
Date: 98-07-21 21:37:12 EDT
From: JTAndrew
To: AlPikeCP, <Email Address Redacted>

Al-

There is a better way than an AFO style that provides excellent results wrt
this anterior pressure on a partial foot amputation.

Call me so I can describe it properly.....

JTA
801-328-9728

Subj: Re: Lisfranc amputation
Date: 98-07-21 23:01:19 EDT
From: <Email Address Redacted> (Charles Martin)
To: <Email Address Redacted>


-----Original Message-----
From: <Email Address Redacted> < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Date: Tuesday, July 21, 1998 4:24 PM
Subject: Lisfranc amputation

Al,

In my experience, though limited, the concept has worked very well. It's a
simple way to provide enough leverage to control the toe lever. By molding in
the proper features, it also provides an opportunity to control any lateral
deviation tendencies at the ankle. The primary patient objection has been
cosmesis. Human nature, I guess. Most PF amputees seem to think that because
they still have some foot, nothing should show above their socks. Personally,
I think an AFO-type device is a lot neater than a funky leather lace-up
device.

C. Martin, CPO

Subj: Re: Lisfranc slippers
Date: 98-07-21 23:40:15 EDT
From: <Email Address Redacted> (Tony van der Waarde)
To: <Email Address Redacted>

Hi Al,

I just did 2 of these in the past 7 months. One for a diabetic old lady,
first prosthesis, walked great with it.

The other was for a 45 year old woman with a congenital Chopart ( almost
looked like a Symes) who was also 2 short. Hers I made with a 100% flexible
acrylic inner socket. She liked it better than the old (30 years!) leather
slipper made by a local shoemaker. Can give you more details if you wish!

Tony van der Waarde CP(c)
AWARD Prosthetics
<Email Address Redacted>
www.amputee-online.com/award

Subj: Re: Lisfranc amputation
Date: 98-07-22 03:42:39 EDT
From: <Email Address Redacted> (Carlos Quelhas)
To: <Email Address Redacted>

Dear Al:

I read your message concerning a young woman's Lisfranc amputation. In our
facility, we deal a lot with diabetic patients, and so, we've got lots of
cases like the one you describe.

Gennerally speaking we have had good results with the so called ortho-
prosthesis, combining an AFO made of PP and a toe filler, usually made with
plastazote. It seems to me that the results are better than with other kinds
of prosthesis, more appealing cosmetically, but lacking to secute the
ankle joint in place. We have tried silicone,Ureflex, leather, but at the end,
only a few of our patients do not go back to the old AFO style: it is easier
to don, its cleaner, it's lightweight and, as we have lots of heat here, it's
cooler:

Functionally, the push off is better, I think.

The only negative aspect I've found until now is that, in some cases where the
skin condition is not good at the distal end of the stump, we've had some
cases of skin breakdown and had to be very carefull with the interface
material we choose( mainly a piece of TEC).

Also, and as I mentioned before, ladies are not pleased with the cosmetics,
they cannot wear dresses but, even though, they prefer the more functional
type.

I just hope I could help you in deciding something.

Best regards.

Carlos Quelhas/ Padrão Ortopédico
<Email Address Redacted>

Subj: Re: Lisfranc amputation
Date: 98-07-22 11:21:55 EDT
From: <Email Address Redacted> (Northwest Orthotics)
To: <Email Address Redacted>

Al,

I have fit at least 6-8 AFO type partial foot prostheses with very good
results. I have used polypropylene with the foot area built up in shape like
a foot around the stump, but not contacting in other than the plantar surface.
Its a little tricky getting alignment and size just right, but a check socket
helps. I have also made them with a Springlite toe filler plate, wrapping the
vac form around the edges and a Bocklite insert. They work well and provide
much better control of plantar flexion problems like you describe.

Lane Ferrin CP

Subj: Re: Lisfranc amputation; One possible solution
Date: 98-07-22 12:42:21 EDT
From: NetRite
To: AlPikeCP

Hi Al,

I had a similar case a while back, and after more than one iteration ended up
with a design that provided a very satisfactory result.

This partial foot patient regularly walks on irregular terrain in his
occupation, and desires ML forefoot stability, however we didn't want to
unduly restrict his remaining ankle motion. The notion of device with a
proximal trim as high as a conventional AFO was not acceptable to the patient.
A previous attempt with an AFO style foot plate with metatarsal area rocker
and pastazote end pad resulted in both a hitch in his get along in mid to late
stance, and no resolution for the distal discomfort we had been challenged
with resolving.

The device that seemed to work the best has been an articulated pros-thosis
with a custom visco elastic gel distal end pad and rocker forefoot.

The fabrication technique for this device involves adding a removable build-up
to the anatomical model to create the gel end pad and the rocker plantar
section.

After taking a plaster impression to mid calf, I cut a small hole in the
anterior distal aspect of the impression, and attached a piece of aluminum bar
stock running the desired toe out axis of the foot to the pipe in the cast,
and after pouring and stripping the impression, had a model with a bar
protruding to support the model addition. When I poured the model, I placed
the cast in the vertical jig in the appropriate alignment relative to the
table. After stripping the anatomical model, and making appropriate
modifications, I replaced it in the vertical jig over a scrap piece of
plastic, and constructed a dam, around the area approximating the forefoot
shape, using 1/8 aliplast and duck tape. It is important to consider desired
toe in-out of the forefoot when doing this. Also make sure that the
reinforcing bar is contoured in such a way as to allow for subsequent
modification. Before pouring the forefoot I also applied a light coating of
petroleum jelly to the anatomical model to facilitate later removal of the
buildup.

After the forefoot section cured, I modified the outside perimeter to the
appropriate trimline to match the sound side and toe out. I then modified the
plantar surface to create a mild rocker shape, with the apex closer to mid
foot than the metatarsal break. The transition between the plantar section and
the sides of the forefoot buildup should be an appropriate radius to allow
leaving plastic material on the sides, which tapered into the plantar trim
line at about the metatarsal region. This trimline on the side contributes to
structural rigidity in late stance. The rocker obviously contributes to
relieving an abrupt floor reaction in mid to late stance, which would transfer
directly to the anterior distal residuum.

Because of the patient's preferance, and the fact that the proximal section
functions mainly to contribute to ML stability and suspension of the device,
the proximal section is only a few inches in height above the ankle, and
terminates at about the same level as a lace up workboot. I applied a roll to
the model at this point to create an out-flair on the proximal trim.

The device was fabricated using 3/16 co-poly. I used Tamarac joints (and
after the device was trimmed also applied a dorsi stop at about 15 +/- degrees
past neutral. I just riveted on a dacron tape strap posteriorly for simplicity
and to minimize bulk).

After removing the device from the model, it was trimmed out as defined by the
modifications, but the ankle articulation is left un-cut at this point.

The forefoot model addition is now broken off the reinforcing bar, and then
the reinforcing bar is cut off where it exits the anatomical model with a
hacksaw. The anatomical model is cleaned up, and a thin piece of cream cowhide
is soaked and stretched over the anterior distal end and tacked in place
proximal to the desired trim of the distal gel pad.

A toe filler is shaped, using desired material, to fit the distal trim and
roughly parallel to the contour of the distal anatomical model. However a gap
of about an inch is left between the distal model and the proximal toe filler.

After the leather has dried, it is removed trimed and skived is indicated, and
replaced in position on the model with double stick tape. The device is
replaced upon the anatomical model and secured firmly to the model proximal to
the distal residuum with tape, and place in a vice or sandbox in a relative
toe up position. Another dam is created with tape or aliplast over the distal
end to contain the gel resin. PQ Visco-elastic liquid polymer, which is a gel
similar to the Tec liner material, is then mixed in a soft durometer ratio and
poured into the cavity, and allowed to bond to the leather cover, and distal
end pad. The orientation of the dam and position of the model obviously
determine how appropriately the gel fills in the space.

The gel is allowed to cure twenty four hours, the device is removed from the
model, any excess gel cleaned up etc. In my case the gel bled through the
leather to the smooth side and talcum powder was used to remove tackiness.

The ankle articulation was cut in, and a velcro strap applied to the proximal
cuff, and 1/2 dacron tape used to create a dorsi stop. You can cover the
entire forefoot section with leather for a neat appearance.

This worked out so well for a patient I had had a difficult time with in
relieving distal pressure, I thought it worth taking the time sharing the
technique. It's been a couple years, and I may have left something out, but
this should be clear enough if you decide to try this.

Best regards,

Mark Smith, CP
Knit-Rite, Inc.
120 Osage Ave
Kansas City, KS 66103
913-279-6377
<Email Address Redacted>

Subj: Re: Lisfranc amputation
Date: 98-07-22 13:27:37 EDT
From: <Email Address Redacted> (Karl Montan)
Reply-to: <Email Address Redacted>
To: <Email Address Redacted>

Dear Al.

As a partial foot amputee myself (Lisfranc) I will inform you that a small
listserv has started for professionals interested in problems of this amputee
group and for amputees themselves. The address is < <Email Address Redacted> >.
Maybe you can have some ideas there. By the way, what is meant by AFO ?

My own prosthesis - a rigid carbonfibre built socket with a stiff shank on
the anterior part of the leg - is the type as shown to the right on my home
page <URL Redacted>

My solution is at the price of my ankle is stiff, but I have never sores. I
can see that you have got some answers on the net, and I would appreciate to
be informed about the result. Needless to say - it is a complicated service
for this group. A quotation: Partial foot as a category presents more anxiety
and angst amongst physicians, prosthetists and prosthetic rehabilitation set
ups than is generaly realised.

J.Kulkarni et al,Total contact silicone partial foot prostheses for partial
foot amputations,The Foot (1995) 5, 32-35

Best regards
Karl Montan


Hello friend,

ever concidered a silicone foot?
You can even incorporate a carbon fibre keel for that 'spring' and 'return'

contact me for more details if you so desire.
--
Thomas Wickerson M.B.A.P.O. BSc. (Hons)
Roehampton Rehabilitation
London

Subj: Re: Lisfranc amputation
Date: 98-07-22 17:13:49 EDT
From: SDLB CPO
To: AlPikeCP

Al - I use this type of prosthosis often. I use a Springlite flat carbon
graphite foot plate piece in my brace for a stiffer lever arm. As far as the
anterior section of the prosthosis, a friend of mine uses a posterior entry
design often....even laminated if needed, or she'll use a full padded anterior
foot shell that clams into the back. I have found that just a good anterior
tongue provides adaquate support, is easy for the patient and is easy to
adjust if need be. I line the plantar surface with plastizote. PPT ..and make
a toe filler from scrap 6R8 OttoBock foam cover material. best of luck
....Stephanie

Subj: Lisfranc Amputation
Date: 98-07-27 22:33:06 EDT
From: <Email Address Redacted> (David John Adams)
To: <Email Address Redacted>

Al,
I have primarily used a laminated ground reaction AFO with extended toe plate.
Extend toe plate with plaster as you would with plaztizote, but rocker it from
methead area to distal end. When trimming out, leave all material intact from
methead area distally. this will allow slight toe
break and smooth transition at toe off, while maintaining structural
integrity. I have been using Becker Ultra G carbon kevlar with minor
modifications to their recommended layup at toe plate.

Good Luck!

Dave Adams CPO