6/5/2018. Forefoot Disorders. Highgate Private Hospital (Royal Free London NHS Foundation Trust (Barnet & Chase Farm Hospitals) Hallux Rigidus

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Samuel Nigel Watts
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Forefoot Disorders Mr Pinak Ray (MS, MCh(Orth), FRCS, FRCS(Tr&Orth)) Highgate Private Hospital (Royal Free London NHS Foundation Trust (Barnet & Chase Farm Hospitals) E: ray.

1 Forefoot Disorders Mr Pinak Ray (MS, MCh(Orth), FRCS, FRCS(Tr&Orth)) Highgate Private Hospital (Royal Free London NHS Foundation Trust (Barnet & Chase Farm Hospitals) E: Our ethos Total Orthopaedics ethos is excellence through innovation, quality and commitment to our patients, delivered by teamwork. Why are we different? Multi-specialty in Orthopaedics, MSK and Spine Foot and Ankle, Hip and Knee, Spine, Hand & Wrist, Elbow & Shoulder, Trauma & Sports. six days a week service same day appointments & diagnostics Service now in multi locations throughout central and north London 5 star service with affordable self-pay packages Hallux Rigidus Freibergs Hallux Valgus Morton's Neuroma Topics Hallux Rigidus Davis Colley first reported it in 1887 Named Hallux Rigidus by Coterrill Other names like Hallux Limitus, dorsal bunion, metatarsus elevates. Incidence 2 distinct age group adolescent and adult 1 in 40 patients older than 50 develop hallux rigidus 80% bilateral disease. Male> Female over the age of 30 Family history in 50% of patients 1

Biomechanics Biomechanics Normal gait 40 60% of body weight Athletic

Supports twice the weight of each lesser toe Normal dorsiflexion required

compensated Etiology Trauma one episode or multiple repetitive microtrauma

Congenital flattened or squared metatarsal head Long first metatarsal

Tight intrinsic muscles Pes planus Hindfoot pronation and first ray

Painful Plantarflexion Lateral foot pain Significant discomfort with

2 Biomechanics Biomechanics Normal gait 40 60% of body weight Athletic activity 2to 3 times the body weight Running jump 7 fold body weight Supports twice the weight of each lesser toe Normal dorsiflexion required for running degrees Upto 50% reduction in dorsiflexion can be compensated Etiology Trauma one episode or multiple repetitive microtrauma In adolescent patient with HR we usually find a Osteochondral defect Congenital flattened or squared metatarsal head Long first metatarsal Short first metatarsal. Tight intrinsic muscles Pes planus Hindfoot pronation and first ray hypermobility Signs and Symptoms Pain Swelling Restricted Dorsiflexion Painful Plantarflexion Lateral foot pain Significant discomfort with constricting footwear Inability to wear heels Tingling sensation Radiographic Evaluation Conservative Treatment Standing AP and Lateral and oblique and sesamoid views 2

3 Insoles with Morton's Extension Taping Injection Chilectomy Osteotomies Replacement Arthrodesis Surgical treatment Chilectomy Osteototomies Early stages with dorsal osteophytes Good plantar flexion Proximal Phalangeal Osteotomy Moberg Usually for adolescent patients and running athlete Creates a pseudodorsiflexion and this produces less stress with push off 3

Cartiva Joint Replacement Cartiva Joint Replacement The Cartiva is a

polymer, consists of water in similar proportion to human tissue.

repetitive loading typical of normal walking conditions, and its

Results 93% reduction of pain 168% functional Improvement 23% improvement

100% good results 90 95% fusion rate Plates can cause soft tissue

4 Cartiva Joint Replacement Cartiva Joint Replacement The Cartiva is a polymer based viscoelastic hydrogel biomaterial implant This hydrated polymer, consists of water in similar proportion to human tissue. This organic polymer based biomaterial is capable of withstanding repetitive loading typical of normal walking conditions, and its mechanical properties are similar to articular cartilage. Results 93% reduction of pain 168% functional Improvement 23% improvement of motion Gold standard End stage arthritis Fusion Procedure Results % good results 90 95% fusion rate Plates can cause soft tissue irritation and has a 10% hardware removal rate The IOFIX is unique as its low profile, compression screw It provides stability and compression 4

jumping On examination there may be redness, swelling fullness of the joint X ray findings can be subtle or obvious Non Operative Treatment Non steroidals Activity modification. Stiff post op shoe.

5 Freibergs Clinical Findings Deterioration and collapse of the articular surface of lesser metatarsals. Usually the 2 nd (70%) Common in adolescents when epiphysis is still present It s a type of osteochondrosis Female 75% Forefoot pain getting worse with impact activities Specifically sprinting and jumping On examination there may be redness, swelling fullness of the joint X ray findings can be subtle or obvious Non Operative Treatment Non steroidals Activity modification. Stiff post op shoe. Orthotics Injections Debridement Dorsiflexion osteotomy Surgery Joint replacement Hallux Valgus (Bunion) Etiology High heeled shoes with a small toe box or tight fitting footwear can exacerbate the problem by keeping the hallux in an abducted position. Bio mechanical instability is the another common etiology and is associated with flat feet, gastrocnemius contracture, excessive flexibility of ligaments, forefoot varus, and abnormal bone structure Family history in 50% 5

Pain Redness Bursa Footwear problem Clinical presentation Investigation Non

Mortons Neuroma Morton's neuroma is a painful foot condition that affects one of

It's also known as Morton's metatarsalgia or interdigital neuroma.

can cause severe pain. The condition can occur in one foot or both feet.

6 Pain Redness Bursa Footwear problem Clinical presentation Investigation Non operative management Operative correction Chevron Scarf Post op and results Mortons Neuroma Morton's neuroma is a painful foot condition that affects one of the nerves between the toes. It's also known as Morton's metatarsalgia or interdigital neuroma. In Morton's neuroma, a nerve in the foot becomes irritated and thickened, which can cause severe pain. The condition can occur in one foot or both feet. Morton's neuroma is named after Dr Morton who first described this condition in 1876 Most commonly affects the plantar digital nerve between the 3 rd and 4 th toe 6

7 Etiology Clinical findings It is thought to develop as a result of long standing (chronic) stress and irritation of a plantar digital nerve Anatomy predisposes Shoes 3 out of 4 in women Pain Mulder s test Investigation Treatment Footwear modification Orthotics Injection Surgery Ultrasound guided 7

8 Post op and results Thank You Recovery time about 6 weeks 8

Common Foot and Ankle Pathology DOTS 17th April Nick Savva Orthopaedic Foot and Ankle Surgeon. Monday, 29 April 13

Common Foot and Ankle Pathology DOTS 17th April 2013 Nick Savva Orthopaedic Foot and Ankle Surgeon Monday, 29 April 13 Topics Forefoot pain Hindfoot/Ankle pain Hallux rigidus Bunions Toe deformity Mortons