DB Boots and Bars response

DB Boots and Bars response

Rod Lawlor

5/4/2005

Many thanks for the overwhelming flood of replies, especially to the two
Jims who went out of their way to chase up further information. The
replies are posted below the original question
Our referring orthopaedic surgeons have recently adopted the Ponsetti
method of treatment for CTEV, and are prescribing DB boots and bar set at
70 degrees ER for the affected side and 50 degrees ER on the unaffected side.

We are commonly asked to fit these on children aged about 8 weeks after
they have been in plaster for 6-8 weeks. We are using the Markell 1644
straight lasted boots.

Our problem is that these are quite wide, especially at the heel, and kids
are tending to pull their heels up. This leads to them either pulling
their foot right out, or else causes pressure on the posterior calcaneous.

We have attempted to counter this by gluing in an EVA crescent to hold the
calcaneous and punching a hole in the heel counter to allow parents to
ensure that the foot is correctly placed. This has had limited success.

Do other centres have any suggestions on how we might hold the foot more
effectively? Is there a better style of boot available, or a better way to
modify the Markells?

REPLIES

 From Jim:
When I received the above msg this morning, I contacted Markell Shoe and
here is their reply:
Subject: Re: [OANDP-L] DB boots and bar
Date: Thu, 21 Apr 2005 15:14:27 -0400
From: Markell Shoe Co. < <Email Address Redacted> >

Dear Jim,
I have 2 suggestions.

1. They should be sure to order the boot in a Narrow width if they have not
already done so.
2. Most Orthotists here use 1/4 plastazoes in an upside down horseshoe in
the shoe additionally.
3. We are just now coming out with an open-toe boot with a cut-out in the
heel which will be available in the Narrow, Medium, and a new Wide width.
The new model will allow doctor and parents to be sure that heel is well
seated. In addition the instep strap, which is crucial, can be tightened to
the max without fear of causing undue pressure on the calcaneus. The new
model
is our #1645. We will have them in stock by end of this month.

Thanks!
Jay Markell
M.J. Markell Shoe Company


-----------------------------------------------------------------------------------
We have an MD who trained with Ponsetti. Ponsetti visited our hospital
and we converted tot his technique and we had some of the same troubles
you're experiencing. When they backed off on the extreme external
rotation (from 70 degrees to around 45 degrees), most of it resolved. Our
MDs have backed off on the external rotation as standard protocol. I
believe that Ponsetti has somewhat too.
--------------------------
Take a look at the website www.mdorthopaedics.org . This gentleman has
worked with Dr. Ponseti to create a new style of sandal foot
abduction
orthosis. I have been told they work great.
------------------------------------
Yes, we are using lots of Ponseti
bars, and we have the same problems. We use the same shoes and
additional padding above the heel. IMHO, the problem is always that the
heel is not being placed well down in the shoe and/or not strapped and
laced in snuggly enough to stay. That said, the technique that I use
that seems to work is to cut a huge hole in the heel section of the
shoe. The hole extends from the strap attachment to the buckle
attachment and from the sole to the stitching that keeps the heel pad
in
place. I cut only through the white elk and heel counter reinforcement.
I then cut a couple of slits in the cream cow in order to reflect that
over the cut edge, gluing this to the outside of the shoe. I liken this
to an inspection port. I teach the families to look in this hole to
ensure that the heel is down in the shoe.

Once a blister forms on the heel, we are using hydrocolloid bandages,
especially Band-Aid Advanced Healing or Curad Hydroheal (these are
available OTC to families at major pharmacies, and are cheaper than
Duoderm).
---------------------------------------
Hi - here at shriners in Utah we do a ton of those. The markell shoes
with the leather strap helps. Tell the parents to pull the sock at the
toe to get the foot all the way in. then really crank the leather instep
strap down and buckle it tight. then lace them up. I ALWAYS glue a
horseshoe pad in above the heel. I use a rubbery foam called luna plast
from Germany. Still we have a few kids who escape - we call them
houdini's. In those cases we use the wheaton style brace - custom molded to
keep the knee bent at 90 degrees, the tibia externally rotated the
calcaneus everted and the forefoot abducted. With this brace, the thigh
section serves as the dennis brown bar to stabilize the correction.
-------------------------
We also have the docs who have gone nuts for this treatment, and
have been through trial and error for about 3 years now. We routinely
stretch the heel out with a ball and ring stretcher, and then add the
crescent pad on the heel counter. Sometimes it is necessary to add a
tongue
pad to the shoe also. We have also found that the kids with unilateral
involvement often have a smaller foot and it requires splitting shoe
sizes
to get a good fit. We also advise double socks and lacing tightly. If
the
physician has stopped serially casting prematurely the heel may be
still
plantarflexed and may not stay in the shoe, and then again we have some
little Houdini's who get out no matter what we do. We have found that
the
parent compliance and capability has a lot to do with it; the DB bar is
not
easy to apply and if they are befuddled or disinterested we have poor
outcomes. Sometimes the patient goes back for another round of serial
casting, or we try a Wheaton style abduction afo. I am curious to know
if
anyone has tried using the Langer torsion device that allows for
movement
while maintaining the external rotation?
--------------------------------------
We do alot here ourselves and seem to run into the same problems(maybe
1 out of 20). See if the Dr. agrees to a custom Wheaton KAFO. Much
easier to manage(don/dof) for caregivers.
-------------------------------------
We use a silicone horseshoe shape and cover it with a fabric type foot
orthotic top cover and stick in the shoes. If that doesn't work we make
the horseshoe out of plastazote.
--------------------------------------
A dorsal strap???
-----------------------------
Are you using Markells' redesigned shoe? I have also used custom
wheaton type afo's and attached the db bar to it.
------------------------------
We fit a number of these children with the same Markel shoes and add a
1/2
pink plastzote crescent to contain the heels along with a 1/4 pink
plastazote tongue pad. The shoes have to be slightly larger to
accommodate
this padding. I often add padding along the medial side of the first
metatarsal head to maximize the correction and set up frequent
followups for
the child.


Try lining the tongue of the boot with a soft 3-5mm EVA. This helps to
hold the foot in the boot.


We put the supracalcaneal pad in the heel and also a tongue pad of plastizote
  - that holds the heel back in the better.

Rod, Typically I use the same shoe but mostly always a narrow. P-cell 3/16
to heel area seems to work well. If pt. does not respond well try a custom
Wheaton kafo

Bebax booties made or distributed from WA...better fit around heel for kids
than Markell and perfect for DB's

For the kids that the extra pad does not work on, we have been adding a
posterior tee strut that is attached between the shoe and the D/B bar and
comes up the posterior of the leg. There is a simple, wrap around calf
strap. (I have attached photos.)
Last week I discussed this with Don Shurr, CPO, PT from Iowa City, who told
me that if the feet won't stay in the shoes then they go back into the
cast. That is also what Dr. Ponsetti told our local orthopedist earlier
this year.

Rod,
We 've had a substantial increase in eh number of BD bars and shoe setups
also. We've found that by adding a plastazote lining to the sole and
sometimes crescent lining the heel holds the foot in place better. In
addition we've added plastazote to the tongue. The plastazote thickness
will vary based on the childs shoe size and the selected shoe. In addition
for some of the Houdinis out there we've had to use coban to help create a
better gripping surface than just the sock. The coban wrap is applied over
the patient's sock.

We have the same problem. we use Spenco or neoprene glued or sewn to the
tongue with the sticky side against the dorsum of the foot. This tends to
stick to the socks and prevent the little squirmers from getting out! We
also use the EVA or any type of pad over the post calcaneus.
The problem that we ran into at our clinic with the Ponseti method was the
pt came out of the casts with tight Achilles. This was the main reason for
the pt coming out of the shoe. Our most successful adaptation was to use a
custom molded afo attached to the bar which was modified to act like a kafo
with the knee flexed to 45 deg. The foot is allowed to be in enough pl.
flexion to accommodate their position. The orthopod told me that the
external rotation was far more important to maintain than the amount of
dorsiflexion. If you like this idea I can send you a picture.

Fortunately we have not been getting as many patients recently that have
tight Achilles. Perhaps the Docs are getting better at holding the pt
position in the cast. I feel your pain because we had a very difficult time
managing these patients in the beginning.


I have had reasonable success fabricating a padded
figure 8 strap and wrapping the ankle with it attached
to the shoe. You can also add lace holes to a little
more towards the center of the ankle and capture the
foot more aggressively. ???? I'm watching this
response also....good luck

Rod, Are you removing the tongue? We also lace so that bow is at the
toe.And always add heel pad as you are doing. Good luck.
we have been using ponsetti braces manufactured by mitchell designs from iowa.
mdsgns @lisco.com
they have a silicone lined shoe turn- around about 2 weeks

My experience is that the physician is not getting the proper amount of ROM
in the heel before sending the patient to you. Dr. Ponsetti's orthotist
enlightened me to this about 7 years ago.

We have been doing the same modifications, but on the small babies have
succesfully used the Ponsetti afo with spreader bar from
www.mdorthopaedics.org 319-653-7435

We have had some success with adding a pad to the tongue of the shoe as
well as the heel counter. Are you using the wide model shoe, they come
in two widths. We have also added toe extensions to prevent the
mechanical advantage of leveraging off of the toes. There is a person in
Iowa who works with Ponsetti and makes sandals instead of the shoes. The
problem is that he charges $350.00 for them and our insurance companies
will not reimburse us enough to pay for them

Just double checking to make sure you are using the narrow width shoe
from Markell? I have had similar problems, even with narrow size shoes.
I have also added plastazote to the posterior heel in an effort to keep
the heel seated, with minimal results. Is the strap also on the lowest
slot? I am interested in hearing if you get any great responses.

I have sewn a t-shaped strap to the back of the heel counter. The vertical
is sewn to the heel counter and the horizontal wraps around the lower leg.
This has helped me in this situation in the past.

Thanks again, Rod
<Email Address Redacted>

Rod Lawlor
Senior Prosthetist/Orthotist
Royal Children's Hospital
Melbourne, Australia

Ph +61 3 93455870
Fax +61 3 93455106