Can Bracing Have An Impact For The Charcot Foot?

Author(s): 
Alan Banks, DPM, FACFAS

   Double upright brace. The double upright brace functions similarly to an AFO but one affixes the brace to the heel of the shoe. Accordingly, one may employ sufficient protective measures within the shoe for a deformed foot to accommodate prominences.

   In addition, when one combines a double upright brace with a 1-inch heel raise and a rocker sole, it may help to reduce bending forces within the foot during gait. Typically, the articulation of the brace is either locked at neutral or it only allows plantarflexory motion, stopping dorsiflexion at neutral. In this manner, the brace and shoe disperse much of the mechanical stress that may otherwise disrupt the foot with weightbearing. This has been the most common form of bracing that I have employed for many years.

   Patellar tendon brace. The patellar tendon brace represents a more restrictive type of device and is also more difficult to fit and fashion for the patient. The brace fits around the knee and directs vertical weightbearing forces through the knee as opposed to the foot.

   One study has shown that a well fitted patellar tendon brace can reduce vertical load to the rearfoot by approximately 30 percent but the offloading effect is diminished as one proceeds from proximal to distal.3 Specifically, Saltzman and colleagues found that patellar tendon braces reduced load transmission to the hindfoot but not to the midfoot or forefoot.

   Patient acceptance of the patellar tendon brace is not as great as it is with the AFO or double upright brace due to the difficulty in application of the device and the overall bulk of the brace. In addition, patients with chronic knee arthritis or other problems at this level may not tolerate this type of device. However, this type of brace is helpful in reducing risk in patients with ankle or rearfoot deformity in which the direct effects of vertical load may be more pronounced. One may also combine patellar tendon braces with depth oxford or molded shoes with the necessary lining materials, or orthotics to protect the foot more effectively.

   Charcot restraint orthotic walker (CROW). The CROW devices appear to be in use with increased frequency in patients with Charcot deformity. Casts appear to provide the greatest limitation of motion in the ankle and foot in comparison to other devices. Additionally, it would appear that, in theory, a CROW device would more closely reproduce the fit and function of a cast.4 Therefore, the CROW may be a very effective type of bracing modality. One can incorporate a rocker sole to facilitate weightbearing. However, there is great deal of bulk with this device and at times, I have experienced problems in finding prosthetists who can fashion a device that provides a good fit.

Case Studies In Using Braces For Charcot

Figure 1 shows the foot of a neuropathic patient with Charcot deformity involving both the transverse and sagittal planes, and following excision of the fifth metatarsal for osteomyelitis. Postoperatively, I placed the patient into a double upright brace with a locked ankle, a 1-inch heel raise and a rocker sole. She functioned with this device with no recurrent ulceration and no additional Charcot episodes for several years prior to her death.

   Figure 3 shows the foot of another neuropathic patient who presented with acute Charcot involvement of the rearfoot. She wore a cast until the acute phase resolved and in spite of a significant loss of bone, there was sufficient fibrosis that developed to provide some stability. Due to the rearfoot involvement, she wore a patellar tendon brace to reduce loading to the rearfoot with success.

Comments

Great article by Dr. Banks. I've been practicing orthotics and prosthetics over 30 years. I work with many Charcot patients. I currently work at wound care center clinics in my existing practice in Tennessee.

The CROW has its disadvantages. I have been using a device known as TORCH, which is a true problem solver and patients and docs appreciate the results. TORCH is made by American Orthopedics (Mount Vernon, NY) with a cast and a completed detailed instruction form. It is a type of boot made out of any leather color with an AFO built into it. Different types of closures may be used so you don't have constant repadding issues for adjustments. You can have all your buildups and partial foot and/or custom orthotics built right into the TORCH. Patients can have a matching shoe for the opposite side. Patient compliance is better.

I've also been using American's new patented dynamic suspension AFO known as the Revolution for some Charcot and other foot and ankle conditions. I have gotten excellent results and can share patient videos for both Revolution and TORCH. The controlled motion in the Revolution brace allows improved functional outcomes and addresses gait in all three planes unlike traditional AFOs. Leather gauntlets lock the calcaneus.

I recommend that podiatry, orthopedics and therapy offices try some of the new innovations in bracing to include in their care and treatment plan. I do a lot of teaching and courses across the country. I spoke in Orlando to a podiatry group just a couple of weeks ago. The doctors in attendance were very impressed with the bracing and techniques I use in my clinical practice. I would be more than happy to offer advice to any one to help improve lives and cost of healthcare. fbcaru1@comcast.net

Add new comment