Responses: Charcot joint unloading

Responses: Charcot joint unloading

Timothy Darling

2/3/2003

I am seeking suggestions for a patient with bilateral
Charcot joint. He has been in bilateral conventional
AFO's and custom shoes the past three years. His left
talus has deteriorated and now needs to be unloaded.
He physician believes the right will soon follow.
What I need suggestions with is the type of device to
use. This man is at or near 400 pounds, has edema in
his lower leg. He is unable to donn compression hose
so he uses neoprene knee sleeves to help control the
edema. Any suggestions would be appreciated and past
experiences would also be beneficial.

Thanks to all who responded, the following are just
some the responses I recieved. I hope this will
benefit others.

Tim Darling CPO

I have a patient very similar to yours. My pt is 38
yo, 6'8, 400+ lbs. (Max out the 400 lb. scale). He is
diabetic and has severe edema. He constantly gets
stasis ulcers on the feet and legs and has Charcot
foot and ankle. He is limited in flexibility being
able to reach only to mid-calf. The physical
therapists have increased the flexibility over 10
months to allow him to reach to the medial malleolus.
I used a 1/4 polypro SA-AFO with high trim lines and
slightly padded (much like the lower section of a crow
walker) with a heavy leather anterior panel and Velcro
straps to tighten. I used a long dorsal pad and straps
to hold the foot in place. Donning would be to
distract +/- 1 and tighten, then let the leg swell
into the AFO and this would support (let him hang) in
the AFO. This has worked quite well over the last 15
months of treatment. The wound clinic also did a lot
of work stabilizing the volume with Co-ban. I then had
Medi fabricate a custom compression stocking with!
medial side zipper which has worked well. He has been
ulcer free for 3 months and the compression hose is
controlling volume. We are pleased with the progress.

I have successfully used PTB bracing for this type of
condition with great success. If the patient has a
rocker bottom foot, then specific shoe modifications
are required, or a custom shoe made. I treated a
patient of similar build successfully with this system
and he has been ulcer free for two years.

Langer makes a custom molded, leather device w/ a 3/16
plastic AFO lined w/ Plastizote, soft leather inner
boot and a semirigid leather outer liner, w/ Lace
Velcro combination all seamed together. Great total
contact device w/ adjustability for edema


You can use a bivalved PTB, and use Fx socks like
stump socks to take up volume in the device as the
edema fluctuates or you can do a leather calf lacer
attached to a double up afo with multiple bands to
provide m/l stability. As the patient shrinks in the
lacer, cut a v-notch in the posterior going from the
distal edge to the apex of the calf. Put a tongue in
and secure eyelets on each side of the v-notch. As the
patient shrinks due to edema changes or atrophies, you
can snug up the posterior notch to get greater
purchase on the gastrocsoleus group to ensure
unloading can occur over the life of the device.

The only thing I can think of which may help your pt.
would be a pair of Arizona Braces. They are a wrap
around design which makes them extremely strong and
effective in controlling anatomy. The swelling can be
accommodated to some degree by loosening the anterior
straps (I usually use Velcro for ease of donning). We
have been extremely successful with the Arizona braces
here (UVA)but total contact does have its problems if
it is not put on the right patient. Hope this helps.

You have a very difficult case on your hands, with
potential liability issues. If I were you, I'd contact
Yankee Bionics in Ohio. As far as I'm concerned, he is
an expert in dealing with cases like these. (He's done
lectures on the subject) I've consulted with him
myself and he is willing to help.

Check the web sight www.arizonabrace.com There I think
you might find another choice in orthotic management
that has worked for me in the past. Now then, his
weight will always be a challenge, however I think
that the Arizona is another viable option. If you want
to call me and talk further about the Arizona.


Try a conventional double upright metal brace with
custom molded calf lacer. I also fabricate growth
extensions on the uprights to increase unloading of
the ankle joint. I find this style of bracing to be
more effective and increases patient compliance.

I had a gentleman with a Charcot ankle, weighing
approximately 350 pounds. He had severe edema,
complete deteriorating of the talus, ankle
circumference 35 inches, and a diabetic ulcer on the
lateral aspect of the ankle (lat./malleolus).
What I ended up making for this gentleman is a full
contact foam lined boot. The boot was bivalved with
the liner overlapping(1/2) the lateral malleolus and
(1/4) on the medial side.
The boot was made out of a posterior part (polyprop)
and anterior part (poly-eth), these two parts
inter-locked and were attached with straps.
The lateral side of the liner is flared and only then
is plastic molded over the liner, rocker sole is added
last.
Had very good results, size of ulcer reduced, patient
was able to bear weight - walk small
distances/transfer.
The only problem with this brace is that when edema
goes down the liner has to be adjusted. Also check
overlapping seem of liner for pinching of skin.


Custom molded leather calf lacer attached to double
upright AFO- protocol for local orthopedic clinic with
unparalleled success for patients similar to your
description.

I have had similar problems in the past and have used
PTB plastic clamshell with rocker bottom to contain
the joint. If you make the brace hinged at the brim
or at the toe, the patient should be able to donn the
device with only one Velcro strap .I have also used
hydrostatic custom leather molded gauntlets that mold
an AFO within the brace and also the brace can be
turned into a shoe. This method, with various
alterations per patient, has worked in stabilizing the
unstable Charcot areas.

I have a similar patient that is 350Lbs, L rear foot
Charcot for 8
yrs, that just went Charcot over Xmas. There is no way
you will be able
to unloaded with a PTB style orthosis with a guy
this big
bilaterally. The best thing to do is to immobilize,
contain, and
rocker. My guy's feet are so huge (deformity, fat,
edema) that I sole
the brace. I've attached some jpeg’s of the latest
brace and an X-ray
taken on the day of the casting. On the L side I used
the same design
but laminated with epoxy the outer shell(saves about
1/2 a lbs. in
weight compared to copolymer)


How about a CROW orthosis? Heard of it? It is an AFO
type with a anterior shell that Velcro to the
posterior shell. usually use Propylene for heavier
patients. Do a search on the www.oandp.com web site
and see if you come up with something. search under
CROW, (Charcot Restraint Orthotic Walker) or CMT
(Charcot Marie Tooth Disorder) and see what you get.


Bilateral crow walkers, comcore reinforced ankles, and
planter surfaces. Add 1/2 extra layer of plastizote
and wrap up medial side over malleolus and just distal
lateral malleolus. Roll up toes slightly use heavy
crepe for the rocker sole keep sole surface wide for
stability. Use 1/4 poly pro. and 3/16 liner.
I have several big guys that are in this type of
brace. One who weights in at 450! Make straps heavy
duty use rivets and burs. Straps on the lateral side
buckles on medial, this makes it easier for patient to
reach to reach. Remember to keep them on the shorter
side with a fat thigh the tissue will rub the proximal
edge of the brace, Make sure you give the proximal
edge a flair, it will help with this rubbing.
The only draw back is you may still get some popping
noise, from the posterior shell underlap of the
anterior shell. To help with this adjust the rocker
sole, make it roll faster. Above all make sure you
don't have a big gap at the distal ends of the toes!!
This will make it much harder for the patient to walk,
and cause many problems!!!!!

We use a Taylor Un-weighting Orthosis.
You will need to take a cast impression just like an
AFO but wrap to the tibial plateau. The cast will be
used to form a custom calf lacer. I also take a AFO
tracing to build the super structure (double upright
AFO).
We modify the cast to create an under cut below the
gastrochs. If he has a large calf and pretty funnel
shaped from mid calf down the undercut is your call.
Form you leather and trim like a PTB/Fx orthosis.
Posterior now real need to go to far above the apex of
the calf, again your call. We also sandwich 2 dacron
in the lacer medial and lateral to retard stretching
of the leather.
The double upright AFO is fabricated in the usual
manner except the uprights extend to the tibial
plateau.
Use the largest stainless steel you can find. The calf
band is contoured to the outside of the uprights.
Attach calf band with top holes only. Double action
ankle joints with pins not springs and long tongue
stirrup.
The shoe is modified with an extended rigid shank and
rocker bottom.
At the fitting I like to have the calf lace unattached
with no holes punched.
Have patient don the AFO without the lacer. Check fit
be sure there is room for lacer and swelling.
I remove the AFO, don the lacer, not tight, more
concern for placement and fit. I put a ½ thick piece
of plastazote in the heel of the shoe, don AFO. Before
I mark where the lacer for placement I hold the lacer
and shift it and the tissue up then mark the lacer. I
don't want to slide the lacer up the leg.
Attach the lacer to the AFO at four points two at the
top of the uprights. The bottom attachments are the
bottom holes of the calf band via a 1-1 ½ strip of
spring steel. this allows for fluctuation in calf size
while maintaining good circumferential containment of
the calf.

We have been Central Fabricating a orthosis called the
Skywalker Suspension Orthosis. We provide several
different models, all have a custom molded full tibia
length calf lacer. This allows for complete
compression of the soft tissue, giving total contact
support and can achieve 100% un-weighting of the foot.
The lacer allows for the fluctuating edema problems we
all fight with these patients. We can attach it to her
custom made shoes, and make a custom insert for them.
We have made one for a gentleman that is 375 and
active. We were able to totally un-weight him, he has
been wearing it everyday for almost a year with no
problems. Please call me and we can talk further about
design possibilities. I can also fax you pictures,
brochures, pricing, and possible L-codes for the
orthosis.

He needs a CROW Charcot Restraint Orthotic Walker. My
technique for build one of these is available online
at: <URL Redacted>


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