5 COMMON CONDITIONS IN THE FOOT & ANKLE

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1 5 COMMON CONDITIONS IN THE FOOT & ANKLE MICHAEL P. CLARE, MD FLORIDA ORTHOPAEDIC INSTITUTE TAMPA, FL USA IN A NUTSHELL ~ ALL ANATOMY & BIOMECHANICS >90% OF CONDITIONS IN FOOT & ANKLE DIAGNISED FROM GOOD EXAM / STANDING RADIOGRAPHS LIVING ANATOMY WHERE DOES IT HURT? WHAT LIVES THERE? 1

2 INSERTIONAL ACHILLES TENDINITIS POLL OPEN NON-SURGICAL TREATMENT OF INSERTIONAL ACHILLES TENDINITIS MAY INCLUDE ALL OF THE FOLLOWING EXCEPT: 1 BOOT/WEDGE IMMOBILIZATION 2 PTX / GASTROC STRETCHING 3 STEROID INJECTIONS 4 NSAID S 0% 0% 0% 0% CHRONIC TENSION PROBLEM DRIVEN BY GASTROC CONTRACTURE REPETITIVE TRAUMA / INFLAMMATORY PROCESS 2

3 CHRONIC ENTHESOPATHY CHRONIC INSERTIONAL THICKENING RETROCALCANEAL BURSITIS CALCIFICATION HAGLUND S DEFORMITY NON-SURGICAL TREATMENT DEPENDS ON SEVERITY GASTROC STRETCHING / HEEL LIFT BOOT / 2 HEEL WEDGE IMMOBILIZATION X 3 WEEKS THEN GASTROC STRETCHING 75M 3 MO HX HEEL PAIN SEEN BY LOCAL DPM DX: INSERTIONAL ACHILLES TENDINITIS STEROID INJECTIONS X 3 1 MO LATER WALKING: FELT POP 3

4 INSERTIONAL RUPTURE INSERTIONAL RUPTURE NO STEROID INJECTIONS! RISK OF INSERTIONAL RUPTURE REQUIRES SURGERY SOURCE OF LITIGATION 4

5 SURGICAL TREATMENT GASTROC RECESSION CENTRAL SPLITTING APPROACH INSERTIONAL DEBRIDEMENT CALCANEAL OSTECTOMY TENDON REATTACHMENT INSERTIONAL DEBRIDEMENT CALCANEAL OSTECTOMY SAW / CURVED OSTEOTOME 5

6 TREATMENT PROTOCOL SPLINT / CAST / NWB X 6 WKS NON-WEIGHTBEARING X 6 WEEKS BOOT / 2 HEEL WEDGE PTX / TRANSITION TO SHOE 6 MONTH RECOVERY ANKLE ARTHRITIS DISTINCT FROM HIP & KNEE OFTEN POST-TRAUMATIC YOUNGER / MORE ACTIVE SMALLER SURFACE AREA / MORE CONCENTRATED FORCES 6

7 PREMATURE BREAKDOWN 37F 8 MO S/P POORLY DONE ORIF JOINT SPARING CORRECTION 27F S/P ORIF / MODERATE PTOA CORRECTIVE OSTEOTOMIES 7

8 NOT NORMAL / BUYING TIME CLINICAL EVALUATION GOOD PHYSICAL EXAM STANDING X-RAYS NO ROLE FOR MRI NON-OPERATIVE TREATMENT LACE UP BRACE NSAID S CORTISONE INJECTIONS (CUSTOM) ARIZONA BRACE 8

9 OPERATIVE TREATMENT ANKLE ARTHRODESIS TOTAL ANKLE ARTHROPLASTY WHICH OF THE FOLLOWING IS TRUE ABOUT TOTAL ANKLE REPLACEMENT? 1 SO EASY A CAVEMAN COULD DO IT POLL OPEN 2 SIMILAR LONGEVITY TO TKA/THA 0% 3 IDEAL FOR YOUNG ACTIVE PATIENT 0% 4 PATIENT SELECTION IS CRITICAL 0% 0% ANKLE ARTHRODESIS STILL THE GOLD STANDARD MORE DURABLE: YOUNGER / ACTIVE RELIES ON ADJACENT JNT MOTION RISK OF COMPENSATORY ARTHRITIS 9

10 ANKLE ARTHRODESIS ANKLE ARTHRODESIS TOTAL ANKLE ARTHROPLASTY PATIENT SELECTION CRITICAL TECHNICALLY DEMANDING HOW LONG DO THEY LAST? MY HAPPIEST PATIENTS BY FAR 10

11 WHO TO OFFER TAR? REALISTIC PATIENT EXPECTATIONS NO HIGH IMPACT / HEAVY LIFTING INTACT PROTECTIVE SENSATION INTACT VASCULARITY OF BONE CORONAL DEFORMITY <30 TOTAL ANKLE ARTHROPLASTY 64F / HEALTHY / NON-SMOKER 18 VARUS TILT / (+) ANKLE LAXITY TOTAL ANKLE ARTHROPLASTY PARALLEL CUTS: TALUS & TIBIA 11

12 TOTAL ANKLE ARTHROPLASTY SOFT TISSUE BALANCING DELTOID PEEL IMPLANT PLACEMENT LATERAL BROSTRÖM TOTAL ANKLE ARTHROPLASTY FAILED TOTAL ANKLE VERY DIFFICULT SALVAGE 12

13 ADULT ACQUIRED FLATFOOT POLL OPEN WHICH OF THESE IS TRUE RE: TRIPLE ARTHRODESIS? 1 PRESERVES HINDFOOT MOTION 2 CONSIDERED A SALVAGE PROCEDURE 0% 3 TREATMENT OF CHOICE FOR ALL ADULT FLATFOOT PATIENTS 0% 4 HIGH NONUNION RATE 0% 0% NOT THE SAME AS FLAT FEET CHRONIC INFLAMMATORY PROCESS OF POSTERIOR TIBIAL TENDON DYNAMIC STABILIZER OF HINDFOOT 13

14 GAIT CYCLE PTT INVERTS HF AFTER FOOTFLAT AXES OF TN / CC NON-PARALLEL FLEXIBLE TO RIGID FOR PUSHOFF GAIT CYCLE ACHILLES INSERTION SHIFTS MEDIAL TO SUBTALAR JNT AXIS RIGID LEVER IN TERMINAL STANCE PATHOANATOMY OF AAF/PTTD NO HF INVERSION ACHILLES INSERTION REMAINS LATERAL TO SUBTALAR JNT AXIS WB AXIS OF LIMB SHIFTS MEDIALLY IN STANCE PHASE TT JNTS STILL UNLOCKED/FLEXIBLE 14

15 STANDING EXAM SYMMETRY VS ASYMMETRY SINGLE LEG HEEL RISE SPECTRUM OF DISEASE ACUTE TENDINITIS / NO DEFORMITY TENDON ATTENUATION / FLEXIBLE DEFORMITY RIGID DEFORMITY / ARTHRITIC RIGID / ARTHRITIC / ANKLE DEFORMITY EARLY DIAGNOSIS CRITICAL ONCE POSTERIOR TIBIAL TENDON ATTENUATED / NON-FUNCTIONAL: FOOT ~ NEVER THE SAME 15

16 ACUTE TENDINITIS BOOT IMMOBILIZATION X 3-4 WKS WEAN TO SHOE / SOFT ORTHOTIC GASTROC STRETCHING FLEXIBLE DEFORMITY NON-SURGICAL TREATMENT: SOFT ORTHOTIC GASTROC STRETCHING LACE UP BRACE FLEXIBLE DEFORMITY SURGICAL TREATMENT CALCANEAL OSTEOTOMY (-IES) TENDON DEBRIDEMENT FDL TENDON TRANSFER ACHILLES LENGTHENING SPRING LIGAMENT RECONSTRUCTION P BREVIS LENGTHENING SELECTIVE MIDFOOT ARTHRODESIS 16

17 FLEXIBLE DEFORMITY FLEXIBLE DEFORMITY FIXED DEFORMITY NON-SURGICAL TREATMENT: LACE UP BRACE GASTROC STRETCHING ARIZONA BRACE BOOT IMMOBILIZATION PRN 17

18 FIXED DEFORMITY SURGICAL TREATMENT TRIPLE ARTHRODESIS ACHILLES LENGTHENING P BREVIS LENGTHENING TRIPLE ARTHRODESIS SALVAGE PROCEDURE ESSENTIAL HF JOINTS SACRIFICED (3-D) TECHNICALLY DIFFICULT TRIPLE ARTHRODESIS 95% UNION RATE PREDICTABLE PAIN RELIEF (IF PROPERLY ALIGNED / HEALED) RISK OF COMPENSATORY ARTHRITIS 18

19 FIXED DEFORMITY FIXED DEFORMITY MIDFOOT ARTHRITIS 19

20 ATYPICAL FLATFOOT / MIDFOOT ARTHRITIS DEFORMITY THRU MIDFOOT DRIVEN BY ACHILLES / GASTROC PTT OFTEN STILL FUNCTIONAL PATHOANATOMY NEUTRAL-VALGUS ALIGNED FOOT ACHILLES/GASTROC CONTRACTURE PLANTAR LIGAMENTS OF MEDIAL COLUMN EXPOSED TO ACHILLES FORCES / BODY WT: ATTENUATE PATHOANATOMY MEDIAL COLUMN BECOMES UNSTABLE ABDUCTION / SAG THRU MIDFOOT EXCESSIVE LOAD / WORK ON PTT PTT ULTIMATELY BECOMES NON- FUNCTIONAL: AAF / PTT 20

21 NON-SURGICAL TREATMENT CARBON/STEEL SHANK SOFT ORTHOTIC GASTROC STRETCHING SURGICAL TREATMENT MIDFOOT ARTHRODESIS ACHILLES LENGTHENING MIDFOOT ARTHRODESIS BEST OF BOTH WORLDS DEFORMITY CORRECTED PREDICTABLE PAIN RELIEF ESSENTIAL JOINTS PRESERVED 21

22 SURGICAL TREATMENT HALLUX RIGIDUS ETIOLOGY LOSS OF MOTION FROM ARTHRITIS HISTORY OF TRAUMA OR REPETITIVE MICROTRAUMA 22

23 PATHOANATOMY CHRONIC INFLAMMATORY PROCESS DORSAL MT HEAD & PROX PHALANX MECHANICAL IMPINGEMENT CAPSULAR THICKENING / SYNOVITIS EVALUATION AXIAL GRIND TEST ASSESS GASTROC FLEXIBILITY STANDING RADIOGRAPHS 23

24 NON-OP TREATMENT NSAIDS / STEROID INJX CARBON / STEEL SHANK VS MORTON S EXTENSION GASTROC STRETCHING SURGICAL TREATMENT AXIAL GRIND TEST & EXTENT OF ARTHRITIC CHANGE ON XR: DORSAL CHEILECTOMY +/- GASTROC RECESSION 1ST MTP ARTHRODESIS +/- GASTROC RECESSION DORSAL CHEILECTOMY ~ DORSAL 1/3 OF MT HEAD EXCISED / EXIT AT ARTICULAR MARGIN 24

25 1ST MTP ARTHRODESIS SUMMARY LIVING ANATOMY GOOD PHYSICAL EXAM & PLAIN XR: DIAGNOSIS IN >90% OF CASES TREATMENT BASED ON EXTENT / SEVERITY OF SYMPTOMS 25