The "rigid rocker" posterior shell orthosis: A convenient, effective alternative for neuropathic ulcers?

Current treatment of neuropathic foot ulcers focuses on pressure offloading. The total contact cast (TCC) is the criterion standard offloading treatment because it provides pressure relief, limits activity, and enforces adherence. However, TCCs are time consuming and resource intensive and prevent wound inspection and care. An alternative is a custom bivalved ankle-foot orthosis (Charcot restraint orthotic walker [CROW]). However, CROWs are bulky and hot and may cause a leg-length discrepancy. These factors can affect treatment concordance that ultimately impairs neuropathic ulcer healing. We devised an alternative posterior shell orthosis called the "Rigid Rocker" with a custom footbed for pressure relief, multipoint stabilization to reduce shear forces, a rigid ankle for offloading and support, an ankle-foot orthosis (AFO) for neuropathic weakness, and a rocker-bottom sole for reduced ambulatory pressures and joint motion. Improvements compared with other devices include a one-piece shell for weight and temperature management and easy manufacture and modification. We conducted a retrospective, observational study of patients who received Rigid Rockers between January 1, 2009, and September 30, 2011. Nine eligible patients were identified. All had neuropathic foot ulcers and received the device after treatment failure in CROWs or other orthoses. The most common reasons for the use of an alternative device were impaired mobility and patient dissatisfaction. All patients experienced improvement of ulcer size and depth, and six patients had complete resolution of their ulcers. Two patients underwent biomechanical testing, revealing good relative pressure reduction as compared with their typical footwear or orthoses. Our findings validate prior reports that offloading is important in the management of neuropathic wounds and suggest that the Rigid Rocker is a reasonable alternative for offloading and may be preferable in selected patients.