Foot and ankle update

Transcription

1 Foot and ankle update Mr Ian Garnham Consultant Foot and Ankle Surgeon Whipps Cross University Hospital

2 Hallux Rigidus Symptoms first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe shoe irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to paresthesias pain becomes less severe as the disease progresses Physical exam limited dorsiflexion pain with grind test

3 Hallux Rigidus Coughlin and Shurnas Classification Exam Findings Radiographic Findings Grade 0 Stiffness no pain Grade 1 mild pain at extremes of motion Grade 2 moderate pain with range of motion increasingly more constant Grade 3 significant stiffness, pain at extreme ROM, no pain at mid-range Grade 4 significant stiffness, pain at Extreme ROM, pain at mid-range of motion Normal mild dorsal osteophyte, normal joint space moderate dorsal osteophyte, <50% joint space narrowing severe dorsal osteophyte, >50% joint space narrowing same as grade III

4 Hallux Rigidus Coughlin and Shurnas Classification Grade 1 Grade 2

5 Hallux Rigidus Coughlin and Shurnas Classification Grade 3 Grade 4

6 Hallux Rigidus Nonoperative NSAIDS, activity modification & orthotics Operative Joint debridement and synovectomy patients with acute osteochondral or chondral defects MRI Dorsal cheilectomy grade 1 and 2 disease (controversial) pain with dorsiflexion is an indicator of good results with dorsal cheilectomy shoe wear irritation from dorsal prominence and pain (ideal candidate) contraindicated when pain located in the mid-range of the joint during passive motion

7 Cheilectomy Technique remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively

8 Moberg procedure Hallux Rigidus dorsal closing wedge osteotomy of the proximal phalanx runners with reduced dorsiflexion (60 is needed to run) failure of cheilectomy to provide at least 30 to 40 degrees of motion technique increases dorsiflexion by decreasing the plantar flexion arc of motion

9 Hallux Rigidus Keller Procedure (resection arthroplasty) indications elderly, low demand patients with significant joint degeneraion and loss of motion technique involves removing the base of the first proximal phalanx risk of hyperextension (cock-up deformity) weakness with push-off transfer metatarsalgia (decreased with capsular interposition)

10 Hallux Rigidus MTP arthroplasty indications controversial capsular interpositonal arthroplasty gaining popularity silicone implants are not recommended due to poor long-term results silicone implants may have a good short term satisfaction rate osteolysis and synovitis cause mid to long term pain and joint destruction

11 Hallux rigidus MTP joint arthrodesis indications grade 3 and 4 disease (significant joint arthritis) most common procedure for hallux rigidus surgery outcomes 70% to 100% fusion rate 15% of patients experience degeneration of IP joint after (mostly asymptomatic)

12 Cartiva Interposition arthroplasty 8-10mm implant PVA polyvinyl alcohol Synthetic polymer

13 Cartiva Prospective randomised trial Canada and UK 2 yr follow up 1 st MTP fusion v cartiva 236 pts 152 implants

14 Cartiva Equivalent outcome for pain relief and function <10% revision to fusion at 2 years

15 Management of heel pain Plantar fasciitis Posterior heel pain

16 Plantar fasciitis Pathophysiology Clinical presentation Clinical assessment Differential diagnosis Imaging Medical management

17 Plantar fasciitis >90% success from conservative treatment NSAIDS Modification of footwear Modification of activity Physical therapy Night splints Steroid injection ECSWT PRP

18 Indications for surgical treatment Confirmed diagnosis on imaging MRI Failed medical management in compliant patient Symptoms > 1yr

19 Surgical treatment of plantar fasciitis Open fasciectomy Endoscopic fasciotomy Gastrocnemius/soleus complex release/lengthening

20 Open fasciectomy

21 30-50% release +/- excision calcaneal spur Release 1 st branch lateral plantar nerve Literature Few studies Retrospective 70%+ good/excellent outcome Open fasciectomy

22 Similar reported outcomes to open surgery Endoscopic release

23 Proximal medial gastrocnemius release Gastrocnemius / soleus contracture Multiple lengthening techniques Silfverskoid +ve patients Proximal medial gastrocnemius release if failure medical treatment

24 Posterior heel pain Achilles tendonosis Insertional tendonosis Haglund deformity Pump bump Posterior heel spur

25 Achilles tendonosis Eccentric stretches High volume injection ECSWT PRP Surgery - tenolysis

26 Insertional tendonosis Haglund deformity Insertional tendonosis Inflamed retro calcaneal bursa

27 Insertional tendonosis Physiotherapy NSAIDS Injection of bursa ECSWT (non-calcific)

28 Surgical treatment of insertional tendonosis Open surgery Resection of posterosuperior calcaneus (Haglund deformity) Excision retro-calcaneal bursa Debridement achilles tendonopathy

29 Surgical treatment of insertional tendonosis Endoscopic calcaneoplasty Minimally invasive Medial/lateral portals Coblation bursa/tendon

30 Endoscopic calcaneoplasty

31 Posterior heel spur

32 Posterior heel spur

33 Posterior heel spur Posterior approach Achilles split Excision bony prominence Repair Arthrex speed bridge Accelerated rehab with boot and wedges

34 Ankle arthritis Open fusion Arthroscopic fusion TAR total ankle replacement

35 Ankle arthritis arthroscopic fusion

36 Total Ankle Replacement Contributing to NJR since ,554 cases in total Around 500 cases/yr 49 revisions (12 to fusion) Revision at 90 days 0.08% At 1yr 0.45% 2yrs 1.85% 3yrs 2.52% 4yrs 3.28%

37 Ankle arthritis Mobility TAR total ankle replacement

38 TAR Market leader withdrawn last year (40+%) 10 different implants listed +20 unknown cases More onto market since 2 designs Mobile or fixed bearing

39

40 Lateral ligament injury Grade 1-3 RICE Functional bracing Lateral gutter pain Instability OCD

41 Lateral ligament injury Lateral gutter pain

42 Ankle instability History of inversion injury and giving way Stress test Anterior drawer test

43 Brostrom Gould Repair

44 Ankle instability Free hamstring graft Non anatomic repair (peroneal tendons) Internal brace

45 Ankle arthroscopy Soft tissue impingement Bony impingement Loose body OCD osteochondral defect

46 Ankle arthroscopy

47 Ankle arthroscopy Anterior impingement Pain on forced dorsiflexion of ankle Soft tissue or bony

48 Bony impingement Ankle arthroscopy

49 Anterior osteophyte Ankle arthroscopy

50 Soft tissue impinge ment Ankle arthroscopy

51 Os trigonum

52 Ankle arthroscopy Loose body History of locking and giving way

53 OCD

54 5-7% IN OCD

55 OCD

56 OCD

57 OCD

58 OCD

59 OCD

60 OCD

61 OCD

62 OCD

63 OCD

64 OCD

65 OCD

66 OCD

67 OCD

68 OCD

69 OCD

70 OCD

71 OCD

72 Acquired flat foot edial a kle sprai Tibialis posterior dysfunction Grades 1-4

73 Acquired flat foot Grade 1 Arch maintained Single toe stance Conservative v surgical

74 Acquired flat foot Grade 2 Flat foot deformity Unable to initiate single toe stance Hindfoot and midfoot corrects passively Degenerate changes in tibialis posterior tendon Conservative Rx

75 FDL transfer + calcaneal osteotomy

76 Acquired flat foot Grade 3 Fixed deformity Bony fusion

77 Acquired flat foot Grade 4 Subtalar and ankle arthritis