Can you improve his gait?

PM&R News   •   March 2018

A 63-year-old male comes from his rural home to your big city practice with a chief complaint of “I just want to walk normally again!”. You learn that he had a traumatic tractor accident 5 years ago which resulted in a left below the knee amputation. He was fitted with a transtibial prosthesis but has never really been happy since it was fitted. He received a polycentric hydraulic swing/stance control device but has loss of balance often with heel contact of the prosthetic limb. He often feels he is walking on a tight rope and reports skin breakdown at the proximal medial border of the prosthesis against his residual limb and the distal lateral side of residual limb. You watch him walk and it appears as if he scissors at times and he does have a loss of balance with a near fall. You remove his prosthesis and you see non-blanching erythema at the two areas he mentioned above. In addition, his distal limb has a warty like appearance and is moist.

What adjustments can you make to his prosthesis to correct his gait pattern? Will this improve his skin concerns or do you need to make other adjustments? What is the warty skin change?

The foot is likely set too far medially. This results in a lateral thrust as well as skin breakdown on the proximal medial residual limb as well as the distal lateral residual limb. This can be remembered by the thrust occurring opposite of the foot placement. In addition, with each stance phase, the foot is placed too far midline causing the center of gravity falling outside of the base of support leading to misbalances. Lastly, the warty like appearance is likely verrucose hyperplasia. It develops due to chronic “choking” of the residual limb. A tight proximal prosthesis can decrease blood flow in and decrease venous return out of the residual limb. The patient could have developed this from the pressure of his misaligned prosthesis as well as the distal end not having total contact in the joint. The best way to improve this is to be sure the distal limb is in total contact with the bottom of the prosthesis and that the proximal socket fits snuggly but is not too tight.

Review Question

You make an adjustment and laterally set the foot. If it is set too laterally, what would you see?

Answer

You would expect the opposite of the patient’s initial presentation. You would see a medial thrust at the proximal brim. The patient would develop skin concerns at the medial distal aspect of the socket and the lateral proximal aspect of the socket.