Foot & Ankle. Mr Peter Black, FRCSEd. Specialist Orthopaedic Surgeon Anglesea Clinic Orthopaedics

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Arnold Andrews
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1 Foot & Ankle Mr Peter Black, FRCSEd Specialist Orthopaedic Surgeon Anglesea Clinic Orthopaedics

2 Foot & Ankle Problems - Myths and Leg-ends All foot and ankle surgery is cripplingly painful There s no point having bunions operated on Heel spurs are associated with plantar fasciitis All big toe problems are bunions All lesser toe problems are hammer toes All ankle sprains are ligamentous I ve got my Granny s feet there s nothing I can do

3 What s the problem Foot and ankle surgery is plagued with myths Surgery outcomes are historical Modern surgery has specialised kit and techniques Anaesthesia has progressed to give control to the patient Let s move into the 21 st century

4 Anaesthesia Important Minimise post op pain and give patients control Minimise risks of CRPS Regional Whole leg Below knee Local Specific

5 Post op mobilisation Minimise time in casts Minimally invasive surgery Early weight bearing Offloading footwear Supportive boots allowing compressive stability Early ROM, quicker return to normal

6 Controllable factors SMOKING Cessation prior to surgery REDUCES risk Diabetes Optimisation Bleeding dyscrasias Stop warfarin, plavix, aspirin, omega-3, etc Pre-operative swelling Compressive hosiery, diuretics, etc

7 Pre-op assessment X rays Ultrasound scans MRI scans Patient preparation Practice with crutches/footwear/boots Follow up plans Expectations

8 X rays Weight bearing Unless so painful it s impossible Standard views AP & Lateral obliques are NOT standard Prior to referral within 3 to 4 months Specialist views Leave for the specialist Minimise radiation exposure

9 Ultrasound scans What does it add? What will you do with the results? What to scan Soft tissue injury Does it help? Can be useful Very operator dependent Best done by dedicated MSK unit Can be used to guide injections

10 MRI scans Useful but should be restricted to specialist requests Negative scans can be very helpful Can change plans for surgery Diagnostic not therapeutic

11 Patient preparation and expectations Foot surgery is NOT associated with a speedy recovery no Lazarus effect! Pain management Swelling will be an issue for 3 to 6 months Driving, footwear, etc Normal Practice with kit before you HAVE to!

12 Follow-up plans We make sure patients are given all predicted follow-up appointments pre-op X rays Open door policy Face up to all questions honestly PPPPPP

13 Outcomes More predictable More acceptable More reliable Surgeon/Anaesthetist/GP/Patient team Physiotherapy helpful Strive to return to normality within a realistic timeframe

14 Specific Problems Forefoot

16 Bunions Common Often asymptomatic Cosmetic or functional? Limiting? Progressive? Surgery or shoes Prognosis

19 Forefoot articular surface damage Hallux rigidus Common Trauma or wear? Flat MTPJ Freiberg's infraction Overload Trauma? Osteochondritis desiccans

$Stress fractures March fracture Unexplained swelling and pain after$

22 Stress fractures March fracture Unexplained swelling and pain after exercise X rays normal at first Callus develops later If in doubt, USS

24 Neuromas Most commonly 2 nd and 3 rd WS electric shocks into toes Worse shod Worse coming down stairs Digital nerve crushed between MT heads

26 Hindfoot Mysteries

27 Heel pain Spurs are NOT plantar fasciitis Plantar fasciitis occurs WITHOUT spurs Not all heel pain is plantar fasciitis

28 TA insertional enestheseopathy Hagalund s deformity Calcaneal stress fracture

29 Plantar fasciitis Self-limiting Plantar, medial heel pain Origin of plantar fascia Exaccerbated by tight TA 1 st foot and start-up pain Poor research studies

31 Treatment Use everything you can! NSAIDS 6 weeks TA stretches In line stretches (not off the edge off stairs) Side-specific GEL heel cups Softspot silipos Deep massage Rolling pin or golf ball Night splints Dubious value great contraception!

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