A Guide To Shoe Gear Selection Following A Transmetatarsal Amputation
Studies have found both of these modifications aid in increasing the shoe’s stability, limiting distortion of the shoe and aiding in generating ankle plantarflexory power due to recreation of the rigid lever arm lost with amputation of the forefoot.13,14 Researchers have shown that use of a total contact insert in a custom molded high type shoe with a rocker bottom sole decreases pressure to both the forefoot and the heel.12
One must ensure proper placement of the apex of the rocker bottom sole in order to decrease plantar forefoot pressures. If the apex is under or just proximal to the distal metatarsal, the clinician can increase plantar pressures under the fifth metatarsal.14 Proper placement of the apex of the rocker bottom sole proximal to the residual metatarsals and consideration of previously described tendon balancing techniques to reduce varus deformity of the residual foot are imperative to aid in reducing plantar pressures under the entire forefoot.15,16
The goal of long-term management of the patient who has undergone a TMA is to return or improve upon the patient’s ambulatory status postoperatively and minimize the potential for further breakdown of the residual foot.5,7,13 Orthotics, shoe gear and bracing are essential to this goal. The proper combination of these will augment stability, aid in ambulation and protect the residual forefoot from increased pressure and shear strain.
In addition, the selection of shoe gear and/or bracing should be cosmetically appealing to the patient to promote and maintain their use. From the studies to date, the use of a custom or customized full length shoe with a rocker bottom sole and total contact insert meets all of these goals. One should consider an AFO in patients with an associated dropfoot deformity or proximal TMA.
Physicians must work with certified orthotists and pedorthists, and educate patients on the importance of lifelong use of these items to minimize future complications.
Dr. Schade is the Chief of the Limb Preservation Service and the Director of the Complex Lower Extremity Surgery and Research Fellowship at Madigan Healthcare System in Tacoma, Wash.