Friday, December 2, 2022

transmet recurring issue

Gary Berke

Thank you all for your rapid replies and great advice.

Original question:

* After reading once again the work of Dillon and the Academy SSC on
> foot amputation, it is clear that the optimum treatment for a
> transmetatarsal amputation must include an anterior shell up the tibia if
> are to offset poor late stance phase moments. For the past few years, we
> have been using a custom insert (toe filler) with slight relief of the
> plantar distal metatarsals in conjunction with a blue-rocker AFO. This
> seems to be stiff enough (visually) to support the patient at late stance
> and provide improved gait.
> Unfortunately, many of the transmet patients we see (and slightly higher
> levels too) tend to get impingement on the lateral upright of the blue
> rocker, usually distal to the base of the 5th with the widening of the
> metatarsals. We have tried other manufacturer’s prefabricated carbon AFO
> with medial upright but the toe plate seems too soft to provide adequate
> kinetic improvement.
> My question is: Is there an alternative to the lateral upright that is
> stiff enough and if not, how are you all managing these patients to
> improved gait parameters and maintain some level of acceptable cosmesis?


You can now order a custom Blue Rocker from Allard that would take care of
the pressure/impingement your patients may be getting from the standard Blue

I have been going to a Dura Flex socket attached to an anterior AFO with
Ultraflex USS ankle joints. I uses a carbon foot plate and attaché the
socket to it with a toe filler on the distal end. If you rocker the toes
there is a nice roll-over. The joints allow stops to be set over a 40 degree
ROM so you can even accommodate contractures and work them out.

I like the options from custom composites (

If lateral contact will be an issue, you can try the Ossur Dynamic AFO which
is a medial strut. This AFO is softer for the patient as it has some tibial
reliefs. Also, I find the more rigid an AFO the more the residual end acts
as a fulcrum due to the patient powering through their gait cycle. The only
issue I have is with the Ossur Dynamic is fitting it in the shoe. Some last
shapes of shoes will not allow the medial strut to seat in properly.

If the patient does not have excessive heel rise or quad weakness you could
consider the Spinal Solutions EZ Stride AFO. These can be ordered medial
strut or lateral strut. This AFO is posterior versus anterior, good for
recurvatum patients.

The blue rocker is not always aligned with tibia and foot placement.
Sometimes it needs to be changed manually. Having a cast to realign the blue
rocker is a guaranty that it will work as you want.

Have you considered using the PHAT Brace with toe filler.

These are made by anatomical concepts.

Very good quality product with great clinical support.

In my clinic, we have used inner SMO to control varus of the hindfoot which
presents a problem with lateral pressure with the blue rocker braces. Also
you may want to try some of the custom carbon products that Custom Composite
out of Rhode Island ( I believe they are in RI) I agree with your message
about the importance of the anterior shell for late stance, but I have seen
so many partial foot amputee move into equino varus and inner SMO bracing
helps control this. In some sever cases, I have fabricate a rear entry
floor reaction AFO too.

I use the Matrix Max.

Have you tried the Trulife Raw?

The most successful means of keeping the side of the foot from hitting the
lateral upright is to padd above the “hitting” point. Although this doesn’t
always work. I have also used as an alternative a posterior opening
prosthesis with a symes foot.

springplate into a t c close fitting ankle gautlet;

Silly question but have you tried grinding the posterior heel area so the
AFO can be shifted posteriorly? I have to do that occasionally dur to
pressure from the upright.

Thanks again for all your help! What a great resource. gary

Gary M. Berke MS, CP

Adjunct Clinical Instructor,

Department of Orthopaedic Surgery

Stanford University

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