Crouched Gait - HKAFO's Ineffective- PT Upset

The patient is in the office today for a follow-up on her HKAFO's. At today's visit, the comment from the mother was that the physical therapist is upset that the patient continues to walk with a crouched gait with her knees and hips flexed, and could we do anything with the orthoses to alleviate this. Upon evaluation as previously noted, the patient has tight hip flexors and hamstrings. This is the primary cause of her crouched-type gait. At today's visit I have plantarflexed the ankle angle in hopes of achieving more knee extension. This was ineffective. I have called patients therapist and left a message for her to call me back to discuss the patient's case. The patient will follow-up after she sees her therapist.

Bypass Surgery -Conventional AFO's with Double Action Joints

The patient was seen today for fitting of his bilateral conventional AFOs with double-action ankle joints attached to extra-depth shoes with custom inserts and Velcro closures on the shoes. Fit was appropriate today. On the right brace the medial upright was just touching the patient's ankle. We shifted this 1A inch medially. Fit was appropriate. On the left side, the calf band was touching the fibular head. We lowered this to the correct height. The patient is still recovering from bypass surgery and is still very weak. He was able to stand in the orthosis today. He has not begun therapy. His wife indicated that she will call to receive the therapy schedule once he receives the braces. She reported that he will receive therapy 3 times per week. I instructed the patient and his wife in donning, doffing, wear, and care procedures as well as weaning schedule and proper shoe wear. I emphasized the importance that she monitors the patient's skin for any areas of irritation lasting longer than 30 minutes each time she removes the braces from his feet. I also gave them written instructions to follow today. They should begin weaning into the braces 2 hours today and increase by 2 hours each day. The patient is not ambulating very much at home at this time. I instructed them to call us should they have any problems or questions, and to return for a recheck on the braces 1 week after he begins therapy. They will contact us to set up this appointment once they know when therapy will begin. Otherwise, we will see them back for adjustments as needed.

P W Minor Orthopedic Shoes for Irregular Heel

The patient is in the office today for new shoes. I will order style #1079 from PW Minor for him. I will

increase the size from 1¹A D to 8 D. I will also modify the posterior aspect of the left shoe to

accommodate his irregular heel. This will be done after the prefitting of the shoes. I will order the

shoes 3-day and see the patient in 1 week for prefitting of the shoes.

Tibial Torsion and Genu Varus

Tibial torsion and genu varus.

This 15-month-old female has no known allergies. She is not taking any medication on a daily basis. She is an active independent community ambulator, and she has not had any surgery. She has previously had a Denis-Browne bar and straight last shoes with an 1/8 inch lateral wedge.

The shoes that she is currently wearing measure a 6 D. I measured her at an 8 D or E. She began walking at 9 months old. She did not have abnormalities at birth in regards to being born early. Tracings and measurements were taken of her feet today.

Below Knee Prosthesis

The patient has returned to the office today complaining of pressure on the posterior aspect of her
socket. At today's visit we find that the modification for the popliteal area is causing pressure and
discomfort to her. As I cannot change this in the socket itself, I will remake the socket. At today's visit 1 have replaced her original socket back on to her prosthesis and will remake the socket with appropriate modifications. We will follow up with her in 1 week.

Preparatory Prosthesis

The patient is in the office today for final fit and delivery of his preparatory prosthesis. The device fit very well. We achieved a 3-ply fit. He was able to hold suction quite well. He understands sock ply management. He understands that if there are any irritations to the limb, he should contact us immediately for adjustment. The patient walked quite extensively in the office utilizing his prosthesis. At today's visit, as expected, he is slightly hesitant on weightbearing on his prosthesis. I expect that this will resolve over time. Additionally, he noted after ambulating quite significantly here in the office he was sore in the hamstring area. I felt that this was due to stretching them out. I feel as though in 2 weeks he should be ambulating without crutches. He ambulated in the parallel bars and out utilizing forearm crutches. He also went up and down steps here in the office. I feel very comfortable with the fit and function of the patient's prosthesis. He noted no discomfort. All bolts and nuts were Lok-Tited and torqued to manufacturer's specifications. I provided him with 6 single ply and 6 multi-ply socks with two 3-mm suspension liners and 2 silicone gel liners. We will follow up in 2 weeks for further adjustment.

Clubfoot

The patient has returned to the office today. He was here earlier today for fitting of his clubfoot orthosis. It was too small because he had grown. Because it had never been delivered, I remade it adding material in the appropriate areas. He returned this afternoon for the fitting. It fit very well. Appropriate trimlines and proper clearances were established. Donning, doffing, weaning, and wearing was discussed with his mother. Of note today was that the patient has the presents of chaffing and mild irritation of the skin on the calcaneal area and on the 1^st metatarsal area. I think this is because he sweats a lot within the orthosis. I recommended that his mother change his socks at least 2 times per day. I also drilled a vent hole in the heel of the orthosis to provide him with air circulation in this area. Followup as needed. They will be returning to the physician for a checkup.