Foot and Ankle. in the Primary Care Setting. September 29, 2018 WOJCIECH L CZOCH, MD COHEN CHILDREN S MEDICAL CENTER LONG ISLAND, NY

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1 Foot and Ankle in the Primary Care Setting September 29, 2018 WOJCIECH L CZOCH, MD COHEN CHILDREN S MEDICAL CENTER LONG ISLAND, NY

2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation

3 Congenital Congenital Talipes Clubfoot Equinovarus

4 What is clubfoot? Most common musculoskeletal birth defect 1:1,000 live births Highest prevalence in Pacific Islanders ~1:250 live births More common in males than females 50% of cases are bilateral

5 What is clubfoot? More than 75% of cases are idiopathic with clubfoot as isolated deformity Environmental factors In utero mechanical forces/exposures Genetics now strongly indicated Recent link to PITX1 (guides limb development) 25% of new diagnoses have a family history Unaffected parents have 3-7% chance of having second child with clubfoot

6 Genetics Twin studies: 40 monozygotic (identical) and 134 dizygotic (fraternal) twin pairs in which at least one of the paired siblings had a clubfoot 32.5%: Incidence of clubfoot in other monozygotic (identical) twin 2.9%: Incidence of clubfoot in other dizygotic (fraternal) twin Idelberger K. Gesellschaft 1939;33:

7 Anatomy of Clubfoot Dislocation of the foot medially in relation to the ankle

8 Key Physical Exam C avus (high arch) A Forefoot A dduction V Hindfoot V arus E Ankle E quinus

9 Clubfoot Imaging Largely a clinical diagnosis Minimal ossification limits utility of radiographs Prenatal Ultrasound (Caution!) Deformity seen on early scans can resolve during pregnancy 29% false positive rate in unilateral clubfoot 7% false positive rate in bilateral clubfoot

10 Clubfoot Natural History Untreated clubfoot results in severe deformity Callus on dorsum of foot Ulcers/infection Severe arthritic changes/pain Extremely modified shoe wear

11 Treatment Pearls Goal is to provide a stable and relatively painless platform for ambulation The foot and ankle will never be normal or symmetric Can expect the foot/leg Shorter Stiffer Weaker Degree of residual abnormality is patient specific

12 Treatment Extensive history Dates back to some of the earliest Egyptian paintings Hippocrates initially wrote about it in 400 B.C. Modern Times Kite s Method (1939) Extensive Surgical releases Ponseti Method (1963, repopularized in 1990s)

13 Kite s Method J. H. Kite treated >800 patients non-operatively with his method of casting ( ) If casting started before 1 year of age, the usual treatment ranged from weeks Technique Limitations Undercorrection Lenghty treatment Low success rate (11-58%) Frequently required surgical intervention

14 Extensive Surgical Release Aggressive surgical approaches Number of new problems Many more problematic than those seen with the non-operative or limited operative approaches

15 Poseti Technique Ignacio Ponseti ( ) was a Spanish born orthopaedic surgeon Faculty member at University of Iowa Generally disillusioned with the outcomes of clubfoot treatment Convinced that treatment should be largely non-operative with limited surgical intervention

16 Landmark Article Published in 1992 (JBJS) The goal of treatment is a functional, pain free, plantigrade foot with good mobility and without calluses, that does not necessitate the wearing of modified shoes The goal is not to attain a perfect anatomical result

17 Ponseti Technique Serial weekly manipulation and casting Sequence of correction CAVE Talar head as fulcrum 1st cast corrects cavus Supinates forefoot, dorsiflexion of first ray Subsequent casts correct adduction and varus 90% of pts will require percutaneous Achilles tenotomy Duration of casting is ~6-8 weeks

18 Ponseti Technique

19 Ponseti Technique Post-cast bracing Imperative to decrease recurrence Full-time for 3 months Nights and naps 3 years Success rate >90% in avoiding an extensive surgical release Children can be expected to walk, run, and be fully active

20 Congenital Vertical Talus

21 Congenital Vertical Talus Irreducible dorsal dislocation of navicular on talus Rigid flatfoot present at birth Uncommon 1:150,000 births 50% idiopathic 50% associated with neuromuscular and syndromic conditions Myelomeningocele Arthrogryposis Spinal Muscular Atrophy Neurofirbromatosis Perform careful neurologic exam due to frequent comorbid associations

22 Congenital Vertical Talus 50% bilateral M:F ratio 2:1 Pts will demonstrate a Peg-leg gait Awkward with limited push-off Positive family history in ~20% of patients Poor prognosis in untreated cases Stiff Painful Difficulty with shoe wear

23 Congenital Vertical Talus Talar head is prominent medially Sole is convex Forefoot is abducted and in dorsiflexion Hindfoot is in equinovalgus

24 Congenital Vertical Talus Rigid Rocker Bottom Deformity - Irreducible dorsolateral navicular dislocation - Vertically oriented talus - Calcaneal equinus Soft Tissue Contractures - Displacement of peroneal longus and posterior tibialis tendon - Contracture of Achilles tendon - Contracture of anterior tibialis, EHL, and EDL tendons

25 Congenital Vertical Talus Navicular does not reduce on forced plantar flexion lateral radiograph

26 Treatment Historically Extensive surgical approach Performed at 6-12 months of age Pantalar release Lengthening of peroneals, Achilles, and toe extensors Pinning of talonavicular joint Concomitant tib ant transfer to talar neck Reconstruction of Spring ligament Complicated by high rates of talar osteonecrosis

27 Treatment Ponseti Casting Serial manipulation and casting Limited surgery Percutaneous Achilles tenotomy Minimal talonavicular capsulotomy TN pin fixation

28 Early manipulation and casting followed by minimal surgery Neuromuscular patient population Serial cast applied average of 5 casts Check TN joint on lateral radiograph after first several casts Perc TAL followed by occasional fractional lengthening of TA and PB and pinning of TN joint Proceed with open reduction of TN joint if unable to obtain complete TN reduction Corrective procedures are better in younger children but the upper age limit for success in unknown More extensive surgery if child is greater than 3 JBJS 2012 **Preserves subtalar and ankle motion in kids with CVT associated with NM or genetic syndromes

29 Metatarsus Adductus

30 Metatarsus Adductus Adduction of forefoot Normal hindfoot alignment 1:1,000 live births 1:1 ratio M:F 50% bilateral Packaging disorder Intra-uterine positioning Associated conditions DDH Torticollis

31 Metatarsus Adductus Increased incidence First pregnancy Late pregnancy Twin pregnancy oligohydramnios Classified based on severity (Bleck) Normal Bisector 2 nd /3 rd websapce Mild Moderate Severe

32 Treatment Benign condition that resolves spontaneously in 90% of cases by age 4 Flexible deformity actively correct to midline No treatment Flexible deformity passively correct to midline Serial stretching at home Rigid deformity with medial crease Off-the-shelf orthoses/serial casting Goal is to obtain straight lateral border

33 Treatment Surgery Only in refractory cases Abductor hallucis longus recession Osteotomies Rare Older children (>5 years old) Lateral column shortening with medial column lengthening

34 Adolescent Hallux Valgus

35 What is Hallux Valgus? Complex deformity of the first ray Varus deviation of metatarsal Valgus deviation of phalanx Sesamoids laterally translated relative to metatarsal head Less common/less severe than adult form Often bilateral Frequent positive family history Females >> Males Associated with Ligamentous laxity Hypermobile first ray

36 Treatment Non-operative Mainstay therapy Modification of shoe wear Wide toebox Arch supports Operative Generally avoided due to high recurrence Severe refractory cases Should wait until skeletal maturity Limitation of surgical techniques with open physes

37 Night splints were not found to have an effect on painful HV deformity Insoles with toe separators significantly decreased pain intensity Neither option showed lasting improvement in HV angles

38 Growth Plate Injury Wuerz TH, Gurd DP. Pediatric Physeal Ankle Fracture. JAAOS Apr;21(4):

39 Physis Bone growth is achieved by adding newly synthesized bone to existing bone by two mechanisms Enchondral ossification Intramembranous ossification Bone forms via a cartilaginous intermediate The child s physis best reflects this process From ~ 9 weeks gestational age to skeletal maturity, physes are responsible for the longitudinal growth of bone

40 Epidemiology of Physeal Injuries 20-30% of all childhood fractures The incidence varies with age and has been reported to peak in adolescents Most commonly in phalanges (43%)

41 Anatomy 4 zones of physis organized from center of epiphysis to metaphysis Germinal Proliferative Hypertrophic Provisional calcification (or enchondral ossification).

42 Anatomy Abundant extracellular matrix Great deal of mechanical integrity

43 Anatomy Scant extracellular matrix Mostly apoptotic cells Weakest area of physis Site of most physeal fractures

44 Hormonal Effects Growth hormone increases the number of cells in the physeal columns Thyroid hormone potentiates cytoplasmic proliferation Estrogens play an important role in triggering physeal closure

45 Etiology of Physeal Injuries Direct- Fracture Indirect- ischemia, compression, infections, radiation, repetitive stress, tumors

46 Classification Systems Many different ones: Salter-Harris most commonly used in US (1963) Poland earliest scientific approach (1895) Bergenfeldt later modified by Salter & Harris (1933) Aitken standard from 1930 s until S-H proposed (1936) Peterson newer and more thorough, but more complicated (1994)

47 Salter-Harris I: Straight (entirely within the physis) II: Above (Physis to metaphysis) III: below (epiphysis to physis) IV: Through (epiphysis through physis to metaphysis) V: crusher (Crush injury)

48 Case Example 10M, jumped into river, landed on uneven surface, twisted ankle Images: Tx:

49 Goals of Treatment Goal of treatment of all physeal fractures is to maintain function and normal growth Need anatomical reduction open or closed All reductions should be gentle to prevent damage to the delicate physeal cartilage Forceful, repeated manipulations should be avoided!

50 Physeal Growth Disturbance Angular deformity, limb length diff, epiphyseal distortion Direct and indirect etiologies Growth disturbance vs. frank arrest XR/CT/MRI: thinner or thicker physeal area with an indistinct metaphyseal border. Assymetric growth arrest lines do NOT taper to physis indicates GD rather than frank arrest

51 Frank Arrest vs. Growth Disturbance

52 Management/Treatments Prevention Epiphysiololysis/physiolysis Physeal distraction Repeated osteotomies during growth Completion of epiphyseodesis Contralateral epiphyseodesis

53 Physeal Arrest Resection Indications: Etiology: trauma, infantile Blount s Anatomic type: central or linear Physis affected: distal tibia Extent of arrest: <25% Amount of growth remaining: >2 years Likelihood of resumption of growth

54 Thank You!

55 References Chell J, Dhar S. Pediatric Hallux Valgus. Foot Ankle Clin N Am (19): Hurn SE, Vicenzino BT, Smith MD. Non-surgical treatment of hallux valgus: a current practice survey of Australian podiatrists. Journal of Foot and Ankle Research. 2016, Volume 9. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int Mar;32(1): Wuerz TH, Gurd DP. Pediatric Physeal Ankle Fracture. JAAOS Apr;21(4):