Podiatry Arena members do not see these ads

The chiropractor who works nearby wants to refer a lady to me with a missing first toe phalanx. He is treating her for hip problems same side which will not stabilize.
I haven't seen her yet but I wondered if anyone has ideas on effective ways to deal with it. I've thought Rocker bottom style footwear (not a great option for a woman I would think)met dome, mortons pad!!

Thanks for your thoughts
Paula

I would probaby go for some sort of first ray cut out to get more weightbearing into first met head - then rocker if that fails. Keep in mind that the windlass will not be working in feet like that, so thats the mechanism of problems.

Most of the expereince in treating gait problems with an amputated hallux is from the diabetes population and they usually have other gait problems associated with that (eg LJM; apropulsive; etc), so a lack of windlass is not an issue, but preventing tissue breakdown at others sites is the issue.

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

What about trying some kind of prosthetic add on lever to imitate the length of the missing lever, if there is enough toe left to connect it to?
Phill

I have wondered about that and I assume there is enough of the toe left to do that but how would you keep it on and stable enough.Velcro maybe!
Fillers don't appear to have much effect in attenuating the increased ground reaction forces at the MPJ.
PJ

Depending on the severity of the problem (I assume it is the proximal phalanx that is missing), you could graft in some cortical bone (eg fibula) to make a strut, and do ? an interpositional capsular graft to facilite ROM.

That will achieve length and function in the long term. ( I see you are in WA, so Mario Horta might be worth calling to discuss this).

Have you got any x-rays we can see?


LL

No, I don't have any information other than that which the chiropractor gave me (very quickly)
PJ

Howdy all,

It's funny Paula should have added this thread as I have been thinking for the last couple of weeks that I should post my post-amputation orthotic dilemma on the board - so here it is!

Am about to see a patient this afternoon who has had an amputation of both the proximal and distal phalanx of his left first.

Acute diabetic foot infection caused the amputation, but he is a reasonably young guy so am trying to get a functional device to try and maximise foot function.

I was wanting some thoughts on what I could do - I was thinking, as you suggested Craig first ray cut out. But do you start automatically with a rockersole, or do you add that to the shoe later?

Also, he is a pretty tall and heavy set guy, so there's a sizeable amount of ground reaction forces going through the foot.

Is there anyway of avoiding the clawing of the second digit, as I see far too many apical ulcers on the second, when there is no first.

Does anybody know of some good literature regarding 2nd toe mechanics when the first has been amputated?

Any thoughts?

Katrina Richards
Melbourne

My response to this would depend on the individual...I have seen people with "lumpy" met heads or poor tissue covereage of whats left or scar tissue in difficult spots....and have had a couple of healthy young bods who have lost the full hallux in an industrial accident.
With any of them I am hesitant to increase the ground reaction forces under the 1 st met head...which in theory is what a 1st ray cut out would do: plantarflex the 1st met more and get it loading up more, but with out the windlass functioning.
I have used prosthetic socket lining material ( over an orthoses) , like fat silipos jelly with a soft fabric cover to help protect from shear and replace plantar fatty padding.
I tend to think that you are going to get small ongoing changes for some time after these amputations and the final equilibrium of motion and forces won't be evident for some time.

I have seen gradually increasing 1st Ray plantarflexion....peroneus longus tension? and tried to stop/slow that using soft tissue therapy, but it seemed like putting your finger in the dike....I was going to lose in the long run. In that case I went for palliative lateral forfoot support over met rockers, with orthoses to even out ground reaction forces in general.
I think the first decision you have to make is are you dealing palliatively or are you trying to recover gait parameters...and what level of activity are you dealing with, this will be determined by all the health and risk factors in a specific case. I've got a 30yo working 12 hr shifts on concrete floors and coaching the local cricket team and a single legged 75yo using one prosthetic limb and one barely coping foot to get to the bathroom and back and a 97 yo still living in her own home independantly and doing fine....responses and trials by me vary in each case of course.

Good luck with it.
Regards Phill

Questions and Comments
A question first along this thread. What is the purpose of a toe filler added to an accomodative device for the trreatment of hallux amputation? I can see a forefoot filler for post trans metatarsal amputation, but I was wondering what are the pros and cons of adding a hallux filler.

The master knot of Henry is a slip or slips of tendon that go from FHL to the more medial slips of tendon of FDL. This effect can be seen by selectively flexing your first interphalangeal joint. Those people with the master knot of Henry will also flex their second and even third toes when they attempt to flex their first toe.

With hallux amputation you lose the distal attachement of FHL and the pull is transferred to the slip of FDL that goes to the second toe. A flexion moment at the mpj causes the tip of the toe to be forced into the ground. This ground reaction force causes a dorsiflexion moment on the toe at the MPJ. At the same time the pull of the tendon causes a plantar flexion moment at the pipj and dipj. The dorsiflexion moment from the ground at the MPJ is greater than the plantar flexion moment from the tendon and you get the classic hammertoe or claw toe appearence. Then with the hammertoe, the tendon creates a moment that forces the tip of the toe into the floor of the shoe.

Conservative treatment: You could try one of those custom molded silcon crest pads so that the pressure on the toe is dispresed over the entire length of the toe. You could try cutting a hole deep enough in the insert so that the tip of the toe does not contact. I don't particullarly like the latter idea as the hole would have to be pretty deep and you may get a plantar flexion contracture at the MPJ. It would be interesting to see if the contracture could be prevented by "physical therapy" by constantly stretching the toe to prevent the plantarflexion contracture.

Surgical treatment: Here is an interesting study. If you did a flexor transfer of the FDL tendon to the proximal phalnax you would decrease the plantarflexion moment at the PIPJ and DIPJ while maintaining the plantar flexion moment at the MPJ. I've seen some of these post op with pain at the head of the prox phalanx. I'm not sure how often this happens. Maybe this sould be combined with a toe fusion. Maybe a flexor tenotomy would be enough. There is a good surgical study.

First ray cut out:
I think this should be done on a case by case basis. More load on the 2nd met could have a positive outcome in that the fascia to the second would add plantar flexion moment at the MPJ and help prevent the hammertoe. On the other hand it could lead to stress fracture 2nd met.
A hallux amputation that eliminated the attachement to the base of the proximal phalanx would destroy the windlass mechanism. So, the plantar ligaments of the metatarsal would bear the entire load on the met. It will be able to bear less total load than it could before the amputation, but it still can bear some load. In my opinion, the force on the forefoot should be distributed evenly over as large an area as possible. In order to do this I would look first at the relative length of the metatarsals and height of the metatarsal heads. I would put an extension under the first met head if there was a long second metatarsal and/or dorsiflexed first metatarsal and so on. Then adjust as the callusses develop. The goal in this patient is not proper gait function, but prevention of ulcerations in the presence of neuropathy and diabetes.

Regards,

Eric

Hi Eric,
Thanks for your insight here.
In my years of fiddling with boots etc, I would see different footwear flexing and folding in different ways depending on its material and construction and on the foot also; natural met break angle etc, so I would see some value sometimes in influencing how the shoe creased and folded in gait and therefor how it effects the distal dorsal aspect of whatever remains.
Regards Phill

I have had similar problems. I have a young guy who had both his proximal and distal phalanx amputated last week. The surgeon is looking for footwear while the wound is healing. I have the same prob with a 75 yr old man who had his amputation yesterday.
The surgeon want s a heel bearing shoe shuch as the DARCO range, although the 70yr old is not stable anyway let alone with a heel bearing shoe. I was wondering about bledsoe boots, or is there anything that would be appropriate??