My second week
On Monday I visited a local leprosy clinic for outpatients. Patients visit twice a month for ulcer treatment, this includes ulcer debridement and 30 minutes soaking their feet in water to soften their skin and provide personal hygiene (picture 1). This ladies profession is begging, it was explained that her ulcer (picture 2) will not heal as she walks over 20km a day, and she will not give this up as it is her only income basis. Customised sandals are manufactured and provided at this clinic (picture3), although recently they have had to change their sandal design due to members of the community identifying a leprosy patient by the sandal they were wearing. This has lead to patients refusing to wear their customised sandal and so a different design has had to be developed. Below are pictures of the previous design (picture 4), and the new design (picture 5).
On Tuesday the physio, orthotist and I assesses this leprosy patient (picture 6). There were two ulcers on the plantar aspect of the left foot, one on the heel and one on the 5th metatarsal head. This patient previously suffered from osteomyelitis after toe amputations on the right foot causing bone loss leaving him with this everted stance, a large ulcer was present on the lateral aspect. We prescribed a customised sandal with a hatti pad (shown later) for the left foot, and a moulded rocker shoe for the right. I then followed the manufacturing process for both the scandal and the moulded shoes. Firstly, we cast the right foot marking the location of the ulcer with a crayon (picture 7). We constructed the positive cast posting the area where the ulcer is present by 1 cm in order to deflect pressure from the affected area. A flannel like material was attached with nails to the positive cast ensuring there were no creases on the plantar aspect of the positive cast (this process took approximately 40 minutes and required a lot of skill, needless to say, I left this part to the experts) (picture 8). Small pieces or cork were then attached with glue to the flannel material and filed until creating a flat base and sides (this was very time consuming taking approximately 1.5 hours). The patient was brought back to check the fit and when the orthotist was happy (picture 9), a cushioning material was applied inside the shoe, leather was stuck to the side, straps were manufactured and a sole was applied giving the final product (picture 10). This entire process took one and a half days.
The scandal for the right foot was manufactured by cutting holes in the base material which the straps could fit through. These are cut individually according to the patient’s foot. Once the orthotist was happy with the fit and location of the straps, he stuck the sole onto the base holding the strapping in place. The hatti pad is then applied to the top of the scandal; the purpose of this pad is to deflect pressure away from the ulcer on the heel and the 5th metatarsal head (picture 11). The patient was then fitted with his scandal and moulded shoe (picture 12).
It is clear that each process takes a lot of skill and are very time consuming. I have found it incredible what can be made from such cheap material and skillful manpower. It is hard to think of easier ways to manufacture these customised scandals or moulded shoes, as the resources and money are simply not available.