Foot & Ankle Disorders
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1 Foot & Ankle Disorders Hillingdon PGMC Htwe Zaw FRCS (Tr&Orth) Consultant Foot & Ankle and Trauma Surgeon Hillingdon Hospitals NHS Foundation Trust
2 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
3 Divide the Foot into Thirds Hindfoot Midfoot Forefoot
4 Anatomy Forefoot Midfoot Hindfoot
5 Anatomy Forefoot Midfoot Hindfoot
6 Anatomy Forefoot Midfoot Hindfoot
7 Anatomy Medial column Lateral column Hindfoot
8 Anatomy Medial column Lateral column Hindfoot
9 Anatomy
10 Anatomy
11 Anatomy
12 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
13 Assessment Symptoms mechanical vs non-mechanical neuropathic (spinal origin) shoewear related activity related (sports) functional deficit (stairs)
14 Assessment Examination (look, feel, move) site of maximal tenderness dorsal/plantar callosities hammer/claw/mallet toes flatfeet/ cavus examine gait & footwear gastrocnemius tightness (Silfverskiold s test)
15 Gastrocnemius-soleus complex
16 Silfverskiold s positive
17 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
18
19
20 Radiography 3 views of foot (AP, oblique, lateral) 2 views of ankle (mortise, lateral) weight-bearing views (if possible) LATERAL
21 Radiography Ankle arthritis
22 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
23 Hallux Valgus (bunion) bunion : lay term for enlarged medial prominence over 1 st MTPJ lateral deviation of big toe congenital or acquired end result of unstable 1 st ray bilateral, 6 th decade, females, familial secondary lesser toe deformities bunionette (prominent 5 th MT head)
24 Hallux Valgus: assessment patient expectations & compliance flatfeet, splayed foot, hallux pronation ROM, correctable? callosities? metatarsalgia 1 st TMTJ instability inflammatory arthropathy
25 Hallux Valgus: treatment Non-operative: wide toe box to accommodate bunion high toe box to accommodate hammertoes orthotics (arch support, metatarsal bar) physiotherapy (calf stretches,?taping) Operative: failure of above patient demands informed consent
26 Operative Treatment Soft tissue procedures Distal metatarsal osteotomies Proximal metatarsal osteotomies Phalangeal osteotomies (Akin) 1 st TMT joint fusion (Lapidus) Transmetatarsal osteotomy (Scarf) Fusion of 1 st MTP joint Resection arthroplasty
27 Operative Treatment 100+ types of surgical techniques exist for HV! 4 key steps: distal lateral soft tissue release first metatarsal osteotomy medial capsular plication Akin osteotomy MICA: minimally-invasive chevron-akin MICA DMO: distal metatarsal osteotomy
28 Hallux Rigidus (1 st MTPJ arthritis) hallux limitus presents with stiffness & swelling dorsal spur palpable/ X-ray confirmed start-up or toe-off pain pain at extremes or mid-arc pain grind test positive
29 Hallux Rigidus
30 Hallux Rigidus cheilectomy arthrodesis
31 Hallux Rigidus arthroplasty
32 claw hammer mallet
33 Clawed Hallux
34 Clawed Hallux
35 Jones procedure on EHL tendon trasnfer to 1 st MT head + IPJ fusion
36 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
37 Midfoot arthrtitis Midtarsal degenerative disease common Increasing age, repetitve trauma, post-traumatic OA Non-op therapy: arch support, rocker shoes, analgesia Operative: steroid injections Midfoot arthrodesis
38 Lisfranc injuries TMTJ (Lisfranc) articulation is an osseous + capsulo-ligamentous complex 3 cuneiforms/ cuboid/ metatarsal bases series of self-locking wedges making the transverse (Roman) arch Keystone is 2 nd metatarsal base Lisfranc fracture-dislocations: axial load on PF foot +/-rotational (RTA, fall, sports)
39 Lisfranc injuries
40
41 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
42 Flatfeet abnormally low medial arch congenital: constitutional (flexible), coalition (rigid) acquired: posterior tibial tendon dysfunction Charcot Rheumatoid Fracture Polio Infection
43 Flexible flatfeet bilateral, FHx ligamentous laxity presentation: asymptomatic foot strain, recurrent falls shoes wears badly may see os naviculare on X-ray (as shown) treatment: reassurance insoles, physiotherapy rarely operative unless acquired (PTTD)
44 Rigid flatfeet (in paediatrics) Tarsal coalition abnormal separation of 2 bones bony, cartilagenous, fibrous bridge presents in adolescents Talocalcaneal C sign restriction in hindfoot-midfoot movement significant deformity producing symptoms operative treatment may be required resection/ arthrodesis
45 Posterior Tibialis Tendon Dysfunction (PTTD) most common cause of adult acquired flatfoot deformity PTT is powerful invertor & dynamic arch stabiliser "locks TNJ promoting a more efficient toe-off PTTD results in abnormal loading of midtarsal joints excess stresses lead to midfoot collapse & forefoot abduction unopposed peroneus brevis causes heel valgus & tight Achilles
46 Posterior tibial tendon dysfunction
47 arch collapse pes planus valgus heel deformity too-many toes sign medial sided pain lateral subfibular impingement pain tight Achilles tendon unable to single heel rise
48 flexible vs fixed planovalgus deformity flexible: corrective orthotics US-guided steroid injection (Stage1 only) flatfoot reconstruction
49 flexible vs fixed planovalgus deformity fixed: accommodative orthotics arthrodesis triple fusion
50 Peroneal tendon disorders Peroneus brevis hindfoot eversion Peroneus longus 1 st ray plantarflex Disorders: Tenosynovitis Dislocation Tendinopathy/Tears Entrapment Os peroneus
51
52 Achilles tendon rupture
53 Hindfoot arthroscopy Anterior ankle arthroscopy Posterior hindfoot endoscopy Subtalar arthroscopy Tendonoscopy
54 Anterior Ankle Arthroscopy Debridement of synovitis/ impingement Anterior cheilectomy Microfracture of OCDs Syndesmotic debridement Arthroscopic ankle arthrodesis
55 Talar dome osteochondral defect
56 39 male fell down stairs
57 CT: talar neck and 2x osteochondral #s
58 5 months post-op
59 Posterior Hindfoot Endoscopy Excision os trigonum Tendon release (FHL/peroneals) Endoscopic calcaneoplasty (Haglund s) Subtalar arthrodesis Tendoscopy (tibialis posterior/peroneals) Endoscopic Achilles tendon debridement Mini-open Arthroscopically-assisted Calcaneal Osteosynthesis (MACO)
60 Subtalar Arthroscopy
61 Intra-articular: ORIF
62 Pre-op
63 Pre-op CT
64 Post-op MACO
65 Post-op
66 Post-op
67 Overview Anatomy: hindfoot-midfoot coupling Assessment of the foot & ankle patient Foot & ankle examination Common forefoot disorders Common midfoot disorders Common hindfoot disorders Hindfoot arthroscopy
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