New SAFO article

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The SAFO - a review by Paolo Vinci. M.D. (From December 2004 AICMT

Newsletter - (translated from the Italian by Gretchen Glick)

From England, a new orthotic for footdrop.

It is called SAFO, from the initials of " Silicone Ankle Foot rthoses "

(ortesi ankle-foot to the silicone), the new dynamic orthotic to

correct the deficit of ankle dorsiflexion that happens in numerous

neurological illnesses, among which is CMT. It has been available

for two years from the Dorset Orthopaedic, close to Salisbury, in the

south of the England.

In creating the SAFO, Dorset claims to have kept in mind the

patients' need of aesthetics and comfort, that are not present in the

orthotics available on the market.

The SAFO is an anklet, entirely in silicone, extended from the

metatarsal heads (basis of the toes) to the lower part of the leg, 25

cm above the heel. The part that surrounds the foot is put on like a

sock, the one covering the leg is closed back by three Velcro

strips. It is worn directly on the skin, so it is necessary to apply

some talc powder in the inside part of the SAFO to reduce friction

between skin and silicone.

The SAFO works due to a reinforcement which runs down the anterior

aspect of the leg and onto the dorsum of the foot. This supports the

foot during swing phase to prevent the toes from dropping or catching

and allows the patient to achieve a good heel strike. It then acts as

a dampener from heel strike to foot flat to prevent the foot from

slapping down uncontrollably.

Each SAFO is individually made from a plaster cast mould of the

patient's foot to insure an excellent fit. The SAFO can be

manufactured in a color that matches the leg. However, since the

ankle looks bigger because of the SAFO and the strap fastening is

visible, cosmesis is improved only partially.

The SAFO is manufactured only in England, where plaster casts taken

in other countries by Dorset's trust orthotists are sent. The cost

is very high (1600 Euros for one pair - $2,086.00 US), as compared to

traditional AFOs (OttoBock or Roten AFOs cost 166 Euros [$216.42 US]

for one pair in Italy). SAFOs are guaranteed against faulty

workmanship (but not against cuts or piercing that may be produced by

contact with sharp objects) only for the first six months.

In the beginning of 2004 I was contacted for a free test of the SAFO

by an orthotist from Dorset, since this company was interested in

selling its product also in Italy. In June he came to Italy and took

a plaster cast of my feet, then, after 2 weeks I received the SAFOs

by express mail. I wore them immediately: they fit perfectly.

Unfortunately, in the warm Italian summer, I could wear the SAFOs

only every 3-4 days, because the SAFO is an inextensible shell of

plastic and does not allow perspiration and the foot swelling that is

caused by heat. In this latter case an intense pain compelled me to

take it off, wherever I was, even in the street.

In addition several red spots appeared on the feet: according to my

dermatologist, they are due to obstruction of the sweat glands by the

talc powder that, as I said before, is necessary to avoid the

silicone be tacky. I tried to wear a thin sock between the SAFO and

the skin, but, being SAFO very adhering, a wound appeared immediately

in a fold of the sock.

At the end of October I put the SAFOs on for longer time, but they

cut the skin on my Achilles tendon and the dorsum of the foot, which

caused me severe pain, like electric shocks.

Finally, from the second half of November, I have succeeded in

wearing the SAFO for the whole day, because my feet are cold from the

morning to the evening and therefore do not swell. In these latter 2

months of full-time use, I have never tripped and can walk better

than with any other device for footdrop.

Someone asked why I continue to use the SAFO even with the above-

described drawbacks. The reply is simple: because no better orthotic

exists in case of dangling foot associated with quadriceps

weakening. In fact the SAFO, being very elastic, does not push onto

the back of the leg and therefore the knee is not forced to bend, as

generally happens with the other types of orthotics for footdrop: so

the risk of a sudden fall due to knee flexion is reduced. Besides,

since the silicone is soft and elastic, the part under to the foot

represents an excellent insole, no calluses under the foot develop

and the gait is better. Finally the SAFO, surrounding the ankle,

prevents the foot rotation in supination.

However, it is necessary to say that some of these functional

advantages are not due only to the SAFO but also to the shoes that I

chose with patience among the hundreds in the shops and to the

modifications of the soles made by my pedorthist (lateral wedges,

heel and tip smoothing, elastic oversole). In fact, if we put the

SAFO into slippers, part of the functionality is lost.

I think the SAFOs should be improved to allow the Italian patients to

use them also when it is not cold. However they should be available

now to the Italian patients who have a weakening of the quadriceps

muscle in addition to footdrop, if they can replace the more

uncomfortable and expensive KAFOs.

(NOTE: This article will be archived in the FILES under SAFOs

with other articles and photographs)