Responses to patient with clubfoot

Responses to patient with clubfoot

Paula Martinek

7/15/2009

Thanks to everyone who has responded to my inquiry about my patient. As you can see the ideas were very varied. We are trying a Cro-boot/PTB brace with a wedge sole so that he can stand with proper support. I have already done a check fit to make sure he could tolerate the pressures and will keep you informed if you like, how everything works out. Here are the responses:

 

I'm Bob Diamond, owner of Diamond's Fab, LLC, a small orthotic Central Fab
in Milwaukee. We see and do a lot of weird stuff.
As I read you post I remembered a job we did in February- pictures attached.
A molded calf lacer, with or without a lateral ear and strap could be
incorporated onto a brace. (I am attaching one of the pictures he sent me-it's a metal AFO. I'm impressed with the contouring. Paula)
 
 
I have a patient now with a similar situation --except more
equinus, LLD and Medicare. He has had custom boots with internal lift
in the past and that has worked well for him, but Medicare won't pay
for that now. I am doing an AZ boot with a cut out of the plastic
around that lateral malleolous and a lateral post/flare. The hope is
that he will be able to use an extra depth boot like the one from APIS
-- that has a zipper.
I have taken pictures of the foot and cast because I will have to
appeal Medicare for the extra codes of full insole, and heel lift.


 

I have had a similar situation in which I had American shoe fabricate custom shoes for the patient, in which the sole would be on the weight bearing side of the ankle. With the supination, there is already a leg length discrepancy in which the shoe can be balanced/adjusted to accomodate the discrepancy and the slight plantar flexion. Talk to Vedin @ American shoe.

I'd use a double upright PTB AFO, lateral T-strap, custom insert. Can he wear a shoe? If you can unweight the ankle, and you should be able to, you will eliminate progression of deformity and pain for the most part. I would incorporate double action ankle joints, plastic shell upper and stirrup mounted to shoe lower. If any questions call. I've seen similar cases many times. Kevin

 would tend to shy away from the Arizona AFO style, as it limits future adjustability and is difficult to get just right. I had a patient with a severe equinovarus deformity secondary to polio, who presented similarly to your patient. A co-worker put him into an AZ AFO and we had to do multiple shoe modifications bilaterally to accommodate the single-sided deformity. It worked well to reduce his pain, increasing his walking endurance, and decrease the callous on the lateral border of his foot. However, he wears out the soles of his shoes every 3-4 months and wore through the inner leather within one year. This is not a good long term solution for him. I have considered making a PTB AFO (axial resist), but the physiatrist is sending him to orthopedics for a surgical consultation, as he is a teenager.

 

I've come across this many times. For years now I have been incorporating
left over scraps of Gel liners in my orthoses. This poses many problems,
but I have gotten past many of them and find that the Alpha liners work
best. Remember, in the ideal world, you want to be able to weight bear on
this area, and not have any discomfort nor breakdown. This IS possible. I
actually did a study with a local Children's Hospital on the effects of Gel
padding in Orthoses. Needless to say you know how long it takes for those
results to get published.
Anyway, I would definitely go with a laminated AFO. Fused or not, you need
to protect that ankle for forces that could cause it to snap the rest of the
way into 100% varus where that fusion will fail, not to mention the forces
translated up to the knee during gait. Any thermoplastic AFO will flex, I
don't care where you put reinforcements, and you DO NOT WANT flexibility in
this appliance which also knocks out and ARIZONA brace (as nice as they are
made). The shoe will need serious lateral posting to create a base of
support keeping the knee stable. Now, you might think donning and doffing
would be a problem. Nope.

 

I HAVE USED A SEBRING BOOT FROM BRANIER CUSTOM SHOES It's like a boot
with a plastic afo incorporated
In-between the leather of a custom boot. You can have the plastic
relieved/removed in high pressure


Have you thought of a PTB Orthosis? Take some of his weight through the patella tendon, just like a prosthetic.

 

Again thank you all who have responded. Paula Martinek, LPO