Patent Publication Number: US-2023141450-A1

Title: Surgical traction boot having resilient heel pad and medial and lateral straps

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims priority under 35 U.S.C. § 119(e) to U.S. Provisional Application No. 63/277,256, filed Nov. 9, 2021, which is expressly incorporated by reference herein. 
    
    
     BACKGROUND 
     The present disclosure is related to a support apparatus for supporting a patient. More particularly, the present disclosure relates to a surgical boot apparatus for use in surgery involving hip distraction. 
     Often, when a patient is sedated for a surgery, the patient is supported by and secured to braces or supports coupled to a surgical table. Sometimes, unique supports are provided for a patient&#39;s extremities such as arm boards, leg supports, hand boards, stirrups, and boots. Supports known in the art sometimes secure patients to resist patient movement. Such supports can sometimes allow excessive patient movement relative to the supports. The position and orientation of supports is often adjusted during surgery to improve access to a surgical site or to move portions of the patient&#39;s body such as bones, muscles, tendons, and ligaments to evaluate the surgical results. 
     SUMMARY 
     The present disclosure includes one or more of the features recited in the appended claims and/or the following features which, alone or in any combination, may comprise patentable subject matter. 
     According to a first aspect of the disclosed embodiments, a surgical boot apparatus for use in surgery involving hip distraction includes a boot shell having a sole portion configured for placement adjacent a sole of a foot of a patient and a calf portion configured for placement adjacent a calf of the patient. The boot shell has a heel-receiving opening located between the sole portion and the calf portion and configured for receipt of a heel of the patient. The calf portion of the boot shell has a plug-receiving opening spaced from the heel-receiving opening. A resilient pad is provided having a main portion configured for engaging an Achilles area of the patient and a plug extending from the main portion. The plug is configured for press fitting into the plug-receiving opening of the boot shell to attach the resilient pad to the boot shell. The main portion includes an end region that extends into the heel-receiving opening. The end region has an end edge that includes a notch configured for receipt of a calcaneus of the patient. 
     In some embodiments of the first aspect, the plug of the resilient pad may be formed integrally with the main portion. The resilient pad may be made of silicone rubber. 
     Optionally, in the first aspect, the heel-receiving opening may be defined, in part, by a U-shaped edge of the calf portion of the boot shell. The resilient pad may include a U-shaped lip having a groove that receives the U-shaped edge of the calf portion. The U-shaped lip may be formed integrally with the main portion. The plug-receiving opening may be a triangular opening with rounded corners. A periphery of the plug may be triangular with rounded corners. The plug-receiving opening may be defined by an opening edge and the plug may have a peripheral wall formed with a groove that receives the opening edge. The heel-receiving opening and the plug receiving opening may be both centered on a longitudinal axis of the calf portion of the boot shell. 
     It may be desired, in the first aspect, that a first medial strap may be attached to the boot shell and a first lateral strap may be attached to the boot shell. An instep pad may have a first medial buckle configured for attachment to the first medial strap and a first lateral buckle configured for attachment to the first lateral strap. The first medial strap and the first lateral strap may each include a ladder strap. The ladder straps of the first medial strap and the first lateral strap may be of substantially equivalent lengths. The first medial buckle and the first lateral buckle may each include a ratchet buckle through which the respective ladder straps ratchet. 
     It may be contemplated, in the first aspect, that a second medial strap may be attached to the boot shell and a second lateral strap may be attached to the boot shell. The instep pad may further include a second medial buckle configured for attachment to the second medial strap and a second lateral buckle configured for attachment to the second lateral strap. The first medial strap, the first lateral strap, the second medial strap, and the second lateral strap may each include a ladder strap. The ladder straps of the second medial strap and the second lateral strap may be of substantially equivalent lengths. The ladder straps of the first medial strap, the second medial strap, the first lateral strap, and the second lateral strap may be of substantially equivalent lengths. The second medial buckle and the second lateral buckle may each be ratchet buckles through which the ladder straps of the second medial strap and the second lateral strap ratchet. Proximal ends of the first medial strap and the first lateral strap may be attached to the calf portion of the boot shell. Proximal ends of the second medial strap and the second lateral strap may be attached to a junction region of the boot shell where the sole portion and calf portion meet. 
     In some embodiments of the first aspect, the instep pad may have a first pocket situated between the first medial buckle and the first lateral buckle. The first pocket may have open sides. Distal ends of the first medial strap and the first lateral strap may be insertable into the first pocket through the open sides of the first pocket to retain the distal ends of the first medial strap and the first lateral strap against the instep pad during surgery. The instep pad may have a second pocket situated between the first medial buckle and the first lateral buckle. The second pocket may have open sides. Distal ends of the second medial strap and the second lateral strap may be insertable into the second pocket through the open sides of the second pocket to retain the distal ends of the second medial strap and the second lateral strap against the instep pad during surgery. The instep pad may include a leg-engaging portion that is generally hour glass shaped. A first patch may be coupled to the leg-engaging portion. A second patch may be coupled to the leg-engaging portion. The first pocket may be defined between the first patch and the leg-engaging portion. The second pocket may be defined between the second patch and the leg-engaging portion. 
     According to a second aspect of the disclosed embodiments, a surgical boot apparatus for use in surgery involving hip distraction includes a boot shell having a sole portion configured for placement adjacent a sole of a foot of a patient and a calf portion configured for placement adjacent a calf of the patient. Four ladder straps are coupled to the boot shell. The four ladder straps include a first medial strap, a first lateral strap, a second medial strap, and a second lateral strap. An instep pad has four ratchet buckles to interface with the respective ladder straps. The ratchet buckles are operable to tighten the instep pad against the patient&#39;s leg when the patient&#39;s leg is situated within the boot shell. The ratchet buckles are movable to a released state to permit the instep pad to be completely detached from the four ladder straps. 
     In some embodiments of the second aspect, the ladder straps of the first medial strap and the first lateral strap may be of substantially equivalent lengths. The ladder straps of the second medial strap and the second lateral strap may be of substantially equivalent lengths. The ladder straps of the first medial strap, the second medial strap, the first lateral strap, and the second lateral strap may be of substantially equivalent lengths. Proximal ends of the first medial strap and the first lateral strap may be attached to the calf portion of the boot shell. Proximal ends of the second medial strap and the second lateral strap may be attached to a junction region of the boot shell where the sole portion and calf portion meet. 
     Optionally, in the second aspect, the instep pad may have a first pocket situated between the first medial buckle and the first lateral buckle. The first pocket may have open sides. Distal ends of the first medial strap and the first lateral strap may be insertable into the first pocket through the open sides of the first pocket to retain the distal ends of the first medial strap and the first lateral strap against the instep pad during surgery. The instep pad may have a second pocket situated between the first medial buckle and the first lateral buckle. The second pocket may have open sides. Distal ends of the second medial strap and the second lateral strap may be insertable into the second pocket through the open sides of the second pocket to retain the distal ends of the second medial strap and the second lateral strap against the instep pad during surgery. 
     It may be desired, in the second aspect, that the instep pad may include a leg-engaging portion that is generally hour glass shaped. A first patch may be coupled to the leg-engaging portion. A second patch may be coupled to the leg-engaging portion. The first pocket may be defined between the first patch and the leg-engaging portion. The second pocket may be defined between the second patch and the leg-engaging portion. Each ladder strap may have a proximal end that is pinned to boot shell to permit each ladder strap to rotate relative to the boot shell about a respective pivot axis. 
     It may be contemplated, in the second aspect, that the boot shell may include a heel-receiving opening located between the sole portion and the calf portion and configured for receipt of a heel of the patient. The calf portion of the boot shell may have a plug-receiving opening spaced from the heel-receiving opening. A resilient pad may have a main portion configured for engaging an Achilles area of the patient. A plug may extend from the main portion. The plug may be configured for press fitting into the plug-receiving opening of the boot shell to attach the resilient pad to the boot shell. The main portion may include an end region that extends into the heel-receiving opening. The end region may have an end edge including a notch configured for receipt of a calcaneus of the patient. 
     In some embodiments of the second aspect, the plug of the resilient pad may be formed integrally with the main portion. The resilient pad may be made of silicone rubber. The heel-receiving opening may be defined, in part, by a U-shaped edge of the calf portion of the boot shell. The resilient pad may include a U-shaped lip having a groove that receives the U-shaped edge of the calf portion. The U-shaped lip may be formed integrally with the main portion. The plug-receiving opening may be a triangular opening with rounded corners. A periphery of the plug may be triangular with rounded corners. The plug-receiving opening may be defined by an opening edge. The plug may have a peripheral wall formed with a groove that receives the opening edge. The heel-receiving opening and the plug receiving opening may be both centered on a longitudinal axis of the calf portion of the boot shell. A mount may be attached to an underside of the sole portion. The mount may be configured to lock the boot shell to a hip distractor. The mount may include a release input that is movable to unlock the boot shell from the hip distractor to permit the surgical boot apparatus to be detached from the hip distractor. 
     Additional features, which alone or in combination with any other feature(s), such as those listed above and those listed in the claims, may comprise patentable subject matter and will become apparent to those skilled in the art upon consideration of the following detailed description of various embodiments exemplifying the best mode of carrying out the embodiments as presently perceived. 
    
    
     
       BRIEF DESCRIPTION 
       The detailed description particularly refers to the accompanying figures in which: 
         FIG.  1    is a perspective view of a patient support apparatus including a limb-support unit according to the present disclosure; 
         FIG.  2    is a side view of a surgical boot apparatus for use with the patient support apparatus shown in  FIG.  1    during surgery involving hip distraction; 
         FIG.  3    is an exploded front perspective view of the boot shell and the leg-engaging portion of the instep pad of the surgical boot apparatus shown in  FIG.  2   ; 
         FIG.  4    is a side elevation view of the boot shell shown in  FIG.  3   ; 
         FIG.  5    is a front elevation view of the boot shell shown in  FIG.  3   ; 
         FIG.  6    is a front perspective view of the boot shell shown in  FIG.  3   ; 
         FIG.  7    is a rear perspective view of the boot shell shown in  FIG.  3    with a resilient heel pad inserted into the boot shell; 
         FIG.  8    is an exploded rear perspective view of the boot shell and the resilient heel pad shown in  FIG.  7   ; and 
         FIG.  9    is a cross-sectional view of the boot shell and the resilient pad taken along line  9 - 9  shown in  FIG.  7    and having a foot positioned in the boot shell without the leg wrap shown in  FIG.  2   . 
     
    
    
     DETAILED DESCRIPTION 
     While the concepts of the present disclosure are susceptible to various modifications and alternative forms, specific exemplary embodiments thereof have been shown by way of example in the drawings and will herein be described in detail. It should be understood, however, that there is no intent to limit the concepts of the present disclosure to the particular forms disclosed, but on the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention as defined by the appended claims. 
     Referring to  FIG.  1   , a support apparatus  10  includes, for example, a surgical table  12  and a limb-support unit  14  which is embodied as a hip distractor. The limb-support unit  14  is coupled to a foot end  16  of the surgical table  12 . In an example of use, the limb-support unit  14  supports a patient&#39;s legs and the surgical table  12  supports a patient&#39;s upper body. The limb-support unit  14  may be used to place tension on the patient&#39;s legs during surgery. This is also known as placing the patient&#39;s legs in traction. During a hip-replacement surgery, the patient&#39;s leg in which the hip is being replaced may need to be repositioned during the surgery to provide the surgeon with improved access while maintaining the patient&#39;s leg in traction. The limb-support unit  14  in accordance with the present disclosure provides the ability to reposition the patient&#39;s leg while maintaining that leg in traction. The limb support unit  14  is further configured to apply sufficient force on the patient&#39;s leg during hip distraction to pull the hip joint out of socket (i.e., pull the femoral head out of the acetabulum). 
     The limb-support unit  14  includes a countertraction unit  18 , such as a padded perineal post, and leg holders  22  that each support a boot shell  58  in the illustrative example. The countertraction unit  18  is coupled to the foot end  16  of the surgical table  12  in a fixed position. The leg holders  22  are coupled in spaced-apart relation to the countertraction unit  18 . A moveable leg holder  50  moves relative to the countertraction unit  18  as suggested in  FIG.  1   . The moveable leg holder  50  includes a joint mount  24 , a multi-axis joint  26 , and a spar  28 . The joint mount  24  is coupled to the countertraction unit  18  in a fixed position while the limb-support unit  14  supports portions of the patient. The multi-axis joint  26  is arranged to interconnect the spar  28  and the joint mount  24  to cause the spar  28  to move relative to the joint mount  24 . The spar  28  is coupled to the multi-axis joint  26  and arranged to extend away from the multi-axis joint  26  to support the patient&#39;s leg in traction during surgery involving hip distraction. A stationary leg holder  52  is stationary and is supported by an accessory rail at the side of the table  12  and the limb-support unit  14  to which the countertraction unit  18  and multi-axis joint  26  are also coupled. The stationary leg holder  52  is detachable from the limb-support unit  14  and surgical table accessory rail; however, in use during surgery, the stationary leg holder  52  is stationary. 
     Referring to  FIG.  2   , a surgical boot apparatus  100  for use in surgery involving hip distraction includes the boot shell  58  and an instep pad  102  positioned in the boot shell  58  and secured to the boot shell  58 . The boot shell  58  may be formed from plastic, composites, aluminum, or any other suitable material for supporting a patient&#39;s foot during surgery. The boot shell  58  includes a sole portion  104  configured for placement adjacent a sole of the foot of a patient and a calf portion  106  configured for placement adjacent a calf of the patient. The sole portion  104  extends along a longitudinal axis  108  from an end  110  to a junction region  112  of the boot shell  58  where the sole portion  104  and calf portion  106  meet. The calf portion  106  extends along a longitudinal axis  114  from an end  116  to the junction region  112 . The longitudinal axis  108  extends at an angle relative to the longitudinal axis  114 . In some embodiments, the longitudinal axis  108  extends at an orthogonal angle relative to the longitudinal axis  114 . In some embodiments, the longitudinal axis  108  extends at a non-orthogonal angle relative to the longitudinal axis  114 . In some embodiments, the longitudinal axis  108  extends at an acute angle relative to the longitudinal axis  114 . In some embodiments, the longitudinal axis  108  extends at an obtuse angle relative to the longitudinal axis  114 . 
     A mount  120  is attached to an underside  122  of the sole portion  104 . The mount  120  extends from the sole portion  104  is a direction opposite the calf portion  106 . The mount  120  is configured to lock the boot shell  58  to the hip distractor  10 . That is, the mount  120  is configured to lock the boot shell  58  to one of the leg holders  22  of the hip distractor. As seen in  FIG.  4   , the mount  120  includes a release input  124  that is movable to unlock the boot shell  58  from the hip distractor  10  to permit the surgical boot apparatus  100  to be detached from the hip distractor  10 . In the illustrative example, surgical boot apparatus  100 , and particularly mount  120  of surgical boot apparatus  100 , is configured for mounting to a model no. AR-6529S Arthrex Hip Distraction System (HDS) available from Arthrex Inc. of Naples, Fla. Additional details of mount  120  are shown and described in U.S. Pat. No. 9,381,130 which is hereby incorporated herein by reference to the extent not inconsistent with the present disclosure which shall control as to any inconsistencies (see particularly FIGS. 6-8 of the &#39;130 patent and the related discussion of quick disconnect receiver 15). In other embodiments, mount  120  is configured for connection to hip distraction systems of other manufacturers such as the Maquet subsidiary of Getinge AB, Steris Corporation, and Smith &amp; Nephew PLC, just to name a few. 
     A leg wrap  130  is configured wrap around the foot of the patient and at least partially around the calf of the patient. The leg wrap  130  is configured to be positioned within the boot shell  58 . The leg wrap  130  is formed from a disposable material that facilitates providing comfort to the patient, for example, foam, while the patient&#39;s foot is inserted into the boot shell  58 . Other materials may be contemplated. The material may also be selected to warm the patient&#39;s foot during surgery. The instep pad  102  includes a leg engaging portion  132  that positions over the leg wrap  130  and is configured to secure the patient&#39;s foot within the surgical boot apparatus  100 , as described below. 
     Referring now to  FIG.  3   , the boot shell  58  includes a medial side  136  and an opposite lateral side  138 . For reference, the medial side  136  is positioned adjacent a midline of the patient. That is, with respect to the hip distractor  10 , the medial side  136  is positioned adjacent a centerline of the hip distractor  10 . The lateral side  138  is positioned away from the midline of the patient. With respect to the hip distractor  10 , the lateral side  138  is positioned away from the centerline of the hip distractor  10 . In some embodiments, the surgical boot apparatus  100  is symmetrical about a centerline between the medial side  136  and the lateral side  138 . Four straps  140  are coupled to and extend from the boot shell  58 . The four straps  140  including a first medial strap  142 , a first lateral strap  144 , a second medial strap  146 , and a second lateral strap  148 . 
     A proximal end  150  of the first medial strap  142  is attached to the calf portion  106  of the boot shell  58  on the medial side  136 . A proximal end  152  of the first lateral strap  144  is also attached to the calf portion  106  of the boot shell  58  on the lateral side  138 . Referring to  FIGS.  6 - 8   , the boot shell  58  includes a plurality of pivot points  156 . The proximal end  150  of the first medial strap  142  and the proximal end  152  of the first lateral strap  144  are pinned to a respective pivot point  156  to permit the first medial strap  142  and the first lateral strap  144  to rotate relative to the boot shell  58  about a respective pivot axis. The first medial strap  142  and the first lateral strap  144  are each embodied as a ladder strap that includes a plurality of ridges  154  to enable the strap to be ratcheted through a buckle, as described below. In some embodiments, other types of straps are used in lieu of ladder straps  142 ,  144 ,  146 ,  148 . In the illustrative embodiment, the first medial strap  142  and the first lateral strap  144  are of substantially equivalent lengths. It will be appreciated that the first medial strap  142  and the first lateral strap  144  may have different lengths in other embodiments. 
     A proximal end  160  of the second medial strap  146  is attached to the junction region  112  of the boot shell  58  on the medial side  136 . A proximal end  162  of the second lateral strap  148  is also attached to the junction region  112  of the boot shell  58  on the lateral side  138 . Referring to  FIGS.  6 - 8   , the proximal end  160  of the second medial strap  146  and the proximal end  162  of the second lateral strap  148  are pinned to a respective pivot point  156  to permit the second medial strap  146  and the second lateral strap  148  to rotate relative to the boot shell  58  about a respective pivot axis. The second medial strap  146  and the second lateral strap  148  are each embodied as a ladder strap that includes a plurality of ridges  154  to enable the strap to be ratcheted through a buckle, as described below. In some embodiments, other straps may be contemplated. In the illustrative embodiment, the second medial strap  146  and the second lateral strap  148  are of substantially equivalent lengths. It will be appreciated that the second medial strap  146  and the second lateral strap  148  may have different lengths in other embodiments. In some embodiments, the first medial strap  142 , the second medial strap  146 , the first lateral strap  144 , and the second lateral strap  148  are of substantially equivalent lengths. 
     When it is stated herein that straps  142 ,  144 ,  146 ,  148  are of “substantially” equivalent lengths, it is intended to cover lengths that are within +/−10% of each other. For example, if a strap is 10 inches in length, then straps that are 9 inches to 11 inches in length are considered to be of substantially length to the 10-inch strap. That is, 10% of 10 inches is 1 inch. This is given as just one arbitrary example and is not intended to imply that any of straps  142 ,  144 ,  146 ,  148  are ten inches in length, but it is not intended to rule out such a possibility either. 
     The leg-engaging portion  132  of the instep pad  102  is generally hour glass shaped. Four buckles  170  are provided on the leg-engaging portion  132  of the instep pad  102  to interface with a respective strap  140 . The buckles  170  are operable to tighten the instep pad  102  against the patient&#39;s leg when the patient&#39;s leg is situated within the boot shell  58 . The buckles  170  are movable to a released state to permit the instep pad  102  to be completely detached from the four straps  140 . 
     A first medial buckle  172  is configured for attachment to the first medial strap  142 . A first lateral buckle  174  is configured for attachment to the first lateral strap  144 . The first medial buckle  172  and the first lateral buckle  174  are each embodied as a ratchet buckle through which the respective first medial ladder strap  142  and first lateral ladder strap  144  are ratcheted. A second medial buckle  176  is configured for attachment to the second medial strap  146 . A second lateral buckle  178  is configured for attachment to the second lateral strap  148 . The second medial buckle  176  and the second lateral buckle  178  are each embodied as a ratchet buckle through which the respective second medial ladder strap  146  and second lateral ladder strap  148  are ratcheted. 
     A first patch  180  is coupled to the leg-engaging portion  132  to define a first pocket  182  (shown in  FIG.  2   ) between the first patch  180  and the leg-engaging portion  132 . The first pocket  182  is situated between the first medial buckle  172  and the first lateral buckle  174 . The first pocket  182  includes open medial side  184  and an open lateral side  186 . A distal end  190  of the first medial strap  142  is insertable into the first pocket  182  through the open medial side  184  of the first pocket  182  to retain the distal end  190  of the first medial strap  142  against the instep pad  102  during surgery. A distal end  192  of the first lateral strap  144  is insertable into the first pocket  182  through the open lateral side  186  of the first pocket  182  to retain the distal end  192  of the first lateral strap  144  against the instep pad  102  during surgery. 
     A second patch  200  is coupled to the leg-engaging portion  132  to define a second pocket  202  (shown in  FIG.  2   ) between the second patch  200  and the leg-engaging portion  132 . The second pocket  202  is situated between the second medial buckle  176  and the second lateral buckle  178 . The second pocket  202  includes open medial side  204  and an open lateral side  206 . A distal end  210  (shown in  FIG.  4   ) of the second medial strap  146  is insertable into the second pocket  202  through the open medial side  204  of the second pocket  202  to retain the distal end  210  of the second medial strap  146  against the instep pad  102  during surgery. A distal end  212  of the second lateral strap  148  is insertable into the second pocket  202  through the open lateral side  206  of the second pocket  202  to retain the distal end  212  of the second lateral strap  148  against the instep pad  102  during surgery. 
     Referring to  FIGS.  5  and  6   , the boot shell  58  includes a heel-receiving opening  220 . The heel-receiving opening  220  extends entirely through the boot shell  58 . The heel-receiving opening  220  is located between the sole portion  104  and the calf portion  106  of the boot shell  58 . That is, the heel-receiving opening  220  extends partially through the sole portion  104  of the boot shell  58  and partially through the calf portion  106  of the boot shell  58 . The heel-receiving opening  220  is configured to receive a heel of the patient. Accordingly, when the patient&#39;s foot is positioned in the boot shell  58 , the heel of the patient positions within the heel-receiving opening  220 . 
     A resilient pad  230  is positioned in the calf portion  106  of the boot shell  58 . In some embodiments, the resilient pad  230  is made of silicone rubber. It will be appreciated that other suitable materials may be used to form the resilient pad  230 . In some embodiments, the resilient pad  230  is molded. For example, the resilient pad  230  may be molded to a specific patient&#39;s heel. The resilient pad  230  includes a main portion  232  that is configured for engaging an Achilles area of the patient&#39;s foot. The main portion  232  includes an end region  234  having a U-shaped end edge  236 . The U-shaped end edge  236  includes a notch  238  configured for receipt of a calcaneus of the patient&#39;s foot. The notch  238  is tapered from the main portion  232  to the U-shaped end edge  236 . 
     Referring now to  FIGS.  7  and  8   , the heel-receiving opening  220  is defined, in part, by a U-shaped edge  222  of the calf portion  106  of the boot shell  58 . The heel-receiving opening  220  is further defined, in part, by a linear edge  224  of the sole portion  104  of the boot shell  58 , as seen more clearly in  FIG.  6   . The heel-receiving opening  220  extends between the U-shaped edge  222  and the linear edge  224 . 
     The end region  234  of the resilient pad  230  extends into the heel-receiving opening  220 . The resilient pad  230  includes a U-shaped lip  250  extending along the U-shaped end edge  236  and having a groove  252 . In some embodiments, the U-shaped lip  250  is formed integrally with the main portion  232  of the resilient pad  230 . The groove  252  is configured to receive the U-shaped edge  222  of the calf portion  106  to attach the resilient pad  230  to the boot shell  58 , as illustrated in  FIG.  9   . It should be noted that, in  FIG.  9   , the patient&#39;s foot is shown without the leg wrap  130 , shown  FIG.  2   . The diagrammatic image of the foot and lower leg in  FIG.  9    is intended to include the leg wrap  130 , but optionally, the leg wrap  130  can be omitted. 
     The calf portion  106  of the boot shell  58  also includes a plug-receiving opening  240  spaced from the heel-receiving opening  220 . In some embodiments, the heel-receiving opening  220  and the plug receiving opening  240  are both centered on the longitudinal axis  114  of the calf portion  106  of the boot shell  58 , as illustrated in  FIG.  8   . The plug-receiving opening  240  includes a triangular opening defined by an opening edge  242  having rounded corners  244 . It will be appreciated that the plug-receiving opening  240  may have other shapes in other embodiments. 
     A plug  260  extends from the main portion  232  of resilient pad  230 . In some embodiments, the plug  260  of the resilient pad  230  is formed integrally with the main portion  232  of the resilient pad  230 . In other embodiments, the plug  260  may be formed separately from the main portion  232  of the resilient pad  230 . A peripheral wall  262  of the plug  260  is generally triangular with rounded corners  264 . It will be appreciated that the plug  260  may have other shapes in other embodiments. The plug  260  is generally sized and shaped to the plug-receiving opening  240 . The plug  260  is configured for press fitting into the plug-receiving opening  240  of the boot shell  58  to attach the resilient pad  230  to the boot shell  58 . The peripheral wall  262  includes a groove  266  that is configured to receive the opening edge  242  of the plug-receiving opening  240  of the calf portion  106  to attach the resilient pad  230  to the boot shell  58 , as illustrated in  FIG.  9   . 
     During use of the surgical boot apparatus  100 , traction pulls the calcaneus of the patient&#39;s foot into contact with the resilient pad  230  to prevent heel lift. It should be noted that with the leg wrap  130  present on the patient&#39;s foot, the calcaneus does not directly contact the resilient pad  230 . Rather, the leg wrap  130  is positioned between the calcaneus and the resilient pad  230 . In some embodiments, the resilient pad  230  comfortably captures the top of the patient&#39;s calcaneus to create a strong hold while reducing the risk of pressure injury. In some embodiments, the leg-engaging portion  132  of the instep pad  102  conforms to the top of the patient&#39;s ankle and lower shin. The leg-engaging portion  132  of the instep pad  102  has ratcheting buckles  170  at the top and bottom of the pad  102  on the lateral and medial side of the patient&#39;s leg to keep the pad  102  centered on the patient&#39;s leg/foot and to create symmetrical pressure to pull the heel back into the boot shell  58 . This pressure forces the heel to be captured by the resilient pad  230 . 
     Any theory, mechanism of operation, proof, or finding stated herein is meant to further enhance understanding of principles of the present disclosure and is not intended to make the present disclosure in any way dependent upon such theory, mechanism of operation, illustrative embodiment, proof, or finding. It should be understood that while the use of the word preferable, preferably or preferred in the description above indicates that the feature so described can be more desirable, it nonetheless cannot be necessary and embodiments lacking the same can be contemplated as within the scope of the disclosure, that scope being defined by the claims that follow. 
     In reading the claims it is intended that when words such as “a,” “an,” “at least one,” “at least a portion” are used there is no intention to limit the claim to only one item unless specifically stated to the contrary in the claim. When the language “at least a portion” and/or “a portion” is used, the item can include a portion and/or the entire item unless specifically stated to the contrary. 
     It should be understood that only selected embodiments have been shown and described and that all possible alternatives, modifications, aspects, combinations, principles, variations, and equivalents that come within the spirit of the disclosure as defined herein or by any of the following claims are desired to be protected. While embodiments of the disclosure have been illustrated and described in detail in the drawings and foregoing description, the same are to be considered as illustrative and not intended to be exhaustive or to limit the disclosure to the precise forms disclosed. Additional alternatives, modifications and variations can be apparent to those skilled in the art. Also, while multiple inventive aspects and principles have been presented, they need not be utilized in combination, and many combinations of aspects and principles are possible in light of the various embodiments provided above.