Midfoot

When the mid-foot has stabilized, the patient can now progress from a total-contact cast to a bivalved cast or Aircast (see Chapter 4) fitted with a cradled moulded insole. When the patient comes out of the cast there will be wasting of the calf muscles and joint stiffness. The physiotherapist must be aware of the dangers of reactivating the bony destruction phase by excessively rapid

Fig. 3.23 (a) Anterior view of the CROW (with front piece), (b) Anterior view of the CROW with removal of the front piece to show interior. Extra internal padding (blue) has been added to cushion the vulnerable medial malleolar area.

Fig. 3.23 (a) Anterior view of the CROW (with front piece), (b) Anterior view of the CROW with removal of the front piece to show interior. Extra internal padding (blue) has been added to cushion the vulnerable medial malleolar area.

mobilization or protracted weightbearing in the early stages of rehabilitation.

Too rapid mobilization can be disastrous, resulting in further bone and joint damage. Extremely careful rehabilitation should be the rule, beginning with just a few short steps in the new footwear. The patient rests for the remainder of the day and monitors the foot. If there is no increase in warmth, swelling and redness then he can walk a few more steps the next day, and very carefully build up to a reasonable amount of walking.

Finally, the patient may progress to bespoke footwear with moulded insoles. The rockerbottom foot with plantar bony prominence is a site of very high pressure. Regular reduction of callus can prevent ulceration. If ulceration does occur, an ostectomy (see Chapter 8) may be needed. If stabilization cannot be achieved by conservative means then it is possible to carry out operative procedures in the mid-foot.

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