Re: Challenging orthotic patient
Description
Collection
Title:
Re: Challenging orthotic patient
Date:
1/29/2003
Text:
To the List,
I am soliciting ideas for managing a new patient that I evaluated today for a new orthosis for her left leg. She has had a good relationship with the orthotist who made her present orthosis, but she no longer wishes to travel to see him and has come to me for fitting because I am nearby. She is very active, exercising daily under the supervision of her husband, a retired physical therapist. She and her husband have been aggressive in pursuing her rehabilitation My patient is a 76 YO Female status post bilateral ORIF femoral crush Fxs following a 1979 MVA (caught between a car and a truck). No other orthopedic injuries. Left femoral Fx required free flap gastrocnemius graft to provide sufficient vascularity for bone healing. Subsequent osteomyelitis necessitated hardware removal from the left leg. Patient presents with absent quadriceps strength on the left and a peroneal nerve defect resulting in foot drop. Plantar flexion strength on the left is at least 3+. The ankle is architecturally sound with dorsiflexion limited to about 5 degrees due to heel cord tightness. There is active left knee flexion but knee range of motion is limited to from full extension to about 35 degrees of flexion. The knee is unstable and positioned in varus with the unsupported knee collapsing into about 12 degrees of genu varum. The lower leg can be corrected to approximately 4-5 degrees of varus. Since her injury, the patient has worn a variety of unilateral left KAFOs with locking knee joints to provide knee stability and prevent genu varum. She is 4’8” tall and 113 pounds. The right leg is fully functional but has some varus deformity as a result of the injuries. The problem with her present orthosis is abrasion and skin breakdown/infection at the lateral/proximal aspect of the calf section of the orthosis. I believe this the result of her leg posturing further into within the orthosis resulting in excessive pressure in that area. Unfortunately the lateral aspect of the femoral condyle is covered with fragile split thickness skin graft extending to about 12 cm proximal to the center of the knee joint. The lateral crest of tibia/fibular head area has a number of bony prominences that have been prone to abrasion in her various orthoses. She has attempted to use sections of gel liner and gel knee sleeves to cushion the orthosis with limited success. She suffers from episodes of osteomyelitis and is understandably anxious to avoid skin trauma. Traditional condyle pads or pull over straps cause intolerable pressure on the lateral side of the knee. My inclination is to mold the lateral side of the shin section to just below the knee joint axis and encompass the distal tibial supramalaeolar area with carefully padded extensions to try to achieve as much valgus directed corrective force on the lower leg as possible and then wedge the footplate to try and recruit as much floor reaction as possible in a valgus direction. I will try to negotiate as high a medial wall on the thigh section as possible and attempt to keep the medial/lateral dimension of the thigh section as narrow as possible to aid in compression of the medial thigh soft tissues. I considered a single upright design similar to those used for Blount’s disease but I doubt that it would provide sufficient rigidity to control the varus without a pullover strap, which is out of the question. I would appreciate any and all suggestions/alternatives/additions to the approach outlined above.
Yours in the Pursuit,
Harry Phillips, CPOTriangle Orthopaedic Associates, P.A.Department of Orthotics and Prosthetics 120 William Penn PlazaDurham, NC27704-2150(919) 281-1814Fax (919) <Email Address Redacted>
I am soliciting ideas for managing a new patient that I evaluated today for a new orthosis for her left leg. She has had a good relationship with the orthotist who made her present orthosis, but she no longer wishes to travel to see him and has come to me for fitting because I am nearby. She is very active, exercising daily under the supervision of her husband, a retired physical therapist. She and her husband have been aggressive in pursuing her rehabilitation My patient is a 76 YO Female status post bilateral ORIF femoral crush Fxs following a 1979 MVA (caught between a car and a truck). No other orthopedic injuries. Left femoral Fx required free flap gastrocnemius graft to provide sufficient vascularity for bone healing. Subsequent osteomyelitis necessitated hardware removal from the left leg. Patient presents with absent quadriceps strength on the left and a peroneal nerve defect resulting in foot drop. Plantar flexion strength on the left is at least 3+. The ankle is architecturally sound with dorsiflexion limited to about 5 degrees due to heel cord tightness. There is active left knee flexion but knee range of motion is limited to from full extension to about 35 degrees of flexion. The knee is unstable and positioned in varus with the unsupported knee collapsing into about 12 degrees of genu varum. The lower leg can be corrected to approximately 4-5 degrees of varus. Since her injury, the patient has worn a variety of unilateral left KAFOs with locking knee joints to provide knee stability and prevent genu varum. She is 4’8” tall and 113 pounds. The right leg is fully functional but has some varus deformity as a result of the injuries. The problem with her present orthosis is abrasion and skin breakdown/infection at the lateral/proximal aspect of the calf section of the orthosis. I believe this the result of her leg posturing further into within the orthosis resulting in excessive pressure in that area. Unfortunately the lateral aspect of the femoral condyle is covered with fragile split thickness skin graft extending to about 12 cm proximal to the center of the knee joint. The lateral crest of tibia/fibular head area has a number of bony prominences that have been prone to abrasion in her various orthoses. She has attempted to use sections of gel liner and gel knee sleeves to cushion the orthosis with limited success. She suffers from episodes of osteomyelitis and is understandably anxious to avoid skin trauma. Traditional condyle pads or pull over straps cause intolerable pressure on the lateral side of the knee. My inclination is to mold the lateral side of the shin section to just below the knee joint axis and encompass the distal tibial supramalaeolar area with carefully padded extensions to try to achieve as much valgus directed corrective force on the lower leg as possible and then wedge the footplate to try and recruit as much floor reaction as possible in a valgus direction. I will try to negotiate as high a medial wall on the thigh section as possible and attempt to keep the medial/lateral dimension of the thigh section as narrow as possible to aid in compression of the medial thigh soft tissues. I considered a single upright design similar to those used for Blount’s disease but I doubt that it would provide sufficient rigidity to control the varus without a pullover strap, which is out of the question. I would appreciate any and all suggestions/alternatives/additions to the approach outlined above.
Yours in the Pursuit,
Harry Phillips, CPOTriangle Orthopaedic Associates, P.A.Department of Orthotics and Prosthetics 120 William Penn PlazaDurham, NC27704-2150(919) 281-1814Fax (919) <Email Address Redacted>
Citation
“Re: Challenging orthotic patient,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/220302.
