Arthri&s of the Forefoot, Hindfoot and Ankle: OA, RA, Post- Trauma&c

Transcription

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2 Arthri&s of the Forefoot, Hindfoot and Ankle: OA, RA, Post- Trauma&c Oct 20, 2010 Alex

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4 Case L.S. 82 male with ankle pain over 15 years What is your clinical approach?

5 Case L.S. Hx: Ankle twist 17 yrs ago, lateral pain, no treatment, walked it off Progressively gelng worse Walking on side of foot, lateral foot pain Medial ankle pain Difficulty filng into shoes Wants to know what s wrong with his ankle

6 Case L.S. Phx: HTN, Diabetes, Cholesterol, ETOH, Hep C, MH Psx: CABGX4 All: ancef, vanco, clinda, cephlosporins Meds: Altace, Metoprolol, Insulin, Lipitor, Xeralto Smoker = 1.5 packs/day x 25 yrs ETOH = 10 beers / week

7 Case L.S. What would you like to do next? What do you think happened to his foot/ ankle?

8 O/E Case L.S. Gait = Antalgic with Varus Ankle No open lesions, Insensate (SW test poor) Pulses weak Ankle moaon minimal, <5 degrees, mild equinus HF moaon limited, but not painful Painful sites: Base 5 th MT, Ant- Medial Tibia, Peroneals Medial arch increased compared to other side FF normal

9 Case L.S. What is your differenaal diagnosis? What is your next step?

10 Case L.S.

11 Case L.S.

12 Case L.S. What is your diagnosis? What are your management opaons?

13 Arizona Brace Case L.S. AFO + Rocker Boiom

14 Someames it snows in Dallas

15 Case D.B. 57 year old female CC: Foot and Ankle Pain HPI: Worsening Pain in Foot and Ankle over 2 years Failed shoe modificaaon + Orthoacs RA meds not working for this pain Narcoacs are helpful, but wants to stop them

16 Case D.B. PHx: Rheumatoid Arthrias No allergies No bleeding issues No surgical complicaaons

17 Case D.B. What is your differenaal at this ame? What is your next step?

18 Case D.B. O/E Gait = Antalgic Standing = Ankle neutral, HF Valgus, PPV Pulses palpable, DNV good, No Open Lesions FF Abducaon Very Tight Gastrocnemius complex 1 st MTPJ ROM 20/5 degrees Ankle ROM 15 degrees HF Rom 5 degrees + Pain TN pain with osteophyte dorsal

19 Case D.B.

20 Case D.B.

21 Case D.B. What is your diagnosis? What is your management of this paaent?

22 Case D.B. How should you manage the RA? = List the major issues you need to consider: PRE- OP INTRA- OP POST- OP

23 Case D.B. What surgery are you offering this paaent? What is your surgical approach? Describe your skin incision(s) Describe structures at risk during approach Describe orthopaedic preparaaon Describe orthopaedic fixaaon

24 Case D.B.

25 Case D.B.

26 Case D.B. What is your Post- Operaave Protocol? Would you allow the pain service to give her NSAID s?

27 Case D.B. Post Op Day 1 Falls on Opposite Hip During Physiotherapy Unable to put weight on hip, ++ Pain What is your suspicion? What should you do?

28 Case D.B.

29 Case D.B. What is the Diagnosis? What is your plan?

30 Case D.B.

31 5 Min Brake Take a load off your heels

32 Case R.O. 25 yo male in a dirt bike 5pm Hyper dorsi- flexion of Leo Ankle Leo foot/ankle painful + swelling ER called 9pm for consult You are at dinner with your family What is your next step? What do you ask the ER doc?

33 Case R.O. Isolated Injury, non- ATLS All = none Meds = none Phx = numerous motorbike accidents, non- surgical management Psx = none ETOH = 2-3 beers/day Smoker = 1 pack/day x 5 yrs

34 Case R.O. What is your next step? What is your differenaal so far? What are your concerns?

35 Case R.O. Clinical Exam Isolated injury No Open Lesions Swelling moderate, wrinkle test negaave Pulses weak, cap refill < 2 sec Tip of toes and plantar foot has no sensaaon 1 st webspace, Dorsal Foot, Medial and Lateral Border sensaaons intact Motor fxn not possible, ++ pain

36 Case R.O.

37 Case R.O.

38 Case R.O.

39 Case R.O. What is your diagnosis? What is your management? What is the blood supply of the Talus?

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41 Case R.O. What do you need to have in the OR? What is your surgical approach? What is your preferred fixaaon for this paracular case?

42 Anteromedial Approach

43 Anteromedial Approach with Medial Mal Osteotomy

44 Anteromedial Approach

45 Anterolateral Approach

46 Anterolateral Approach?

47 Anterolateral Approach

48 Case R.O.

49 Case R.O. If you were to plate this fracture, where would you place the plate?

50 Case R.O.

51 Case R.O.

52 Case R.O. What is your post- operaave protocol? What concerns will you inform this paaent about?

53 Case R.O. Major Issues Soo- Tissue / Swelling / Infecaon Osteonecrosis Post- traumaac Arthrias (HF, Ankle, TN) Non- union Malunion (medial talus shortening/varus)

54 Case R.O.

55 I like shooang

56 Case K.L. 41 female CC: Pain in Ankle and walking on toes HPI: age 18, with Talus # ORIF Chronic Pain Failed Non- Op treatment Wants to walk more normal

57 Case K.L. PHx: Non- smoker No allergies No bleeding disorders SHx: Mother of Triplets Very home and Hiking for recreaaon

58 Case K.L. What is your differenaal diagnosis? What is your next step in her management?

59 Case K.L.

60 Case K.L.

61 Case K.L. What is your diagnosis? What are your opaons?

62 Case K.L. Pre operaave consideraaons? Intra operaave consideraaons? Post- Operaave protocol?

63 Case K.L.

64 Case K.L.

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66 Case V.L. 35 year old male CC: Foot and Ankle swelling HPI: Over past 2 months, increasing swelling in foot and ankle Not much pain, but difficulty gelng into shoes

67 Case V.L. PHx: No previous surgeries IDDM since young age = well controlled No bleeding disorders Otherwise healthy SHx: Acave with sports and recreaaon Married with children Non- Smoker, but chews tobacco

68 Case V.L. What would you like to do now? Indicate features of the clinical exam that are going to help you in decision making?

69 Case V.L.

70 Case V.L.

71 Case V.L. What is your diagnosis? What is your plan?

72 Eichenholz classificaaon Charcot Foot

73 Brodsky classificaaon Charcot Foot

74 Charcot Management Stage 1 and 2 General Surgical Principles TCC for Charcot Shoe modificaaon Pre- op medical opamizaaon Bracing Surgery (Controversial) Soo- assue protecaon Realignment Fusion Remove bony prominences Stage 2 and 3 Shoe modificaaon Bracing Surgery Exostosis vs. Fusion Ankle/HF beier with fusion MF/FF beier with exostosis Amputaaon always opaon

75 Case K.W. 29 year old female CC: Foot Pain and Deformity HPI: MVA 2 years ago Mulaple MSK injuries, and Brain Injury Sustained foot fracture ORIF All other fractures/dislocaaons dealt with

76 Case K.W. PHx: Overweight, Smoker Depression SHx: Office worker Hiking

77 Case K.W. What is your next step in management? What is your workup?

78 Case K.W.

79 Case K.W.

80 Case K.W. What is your diagnosis? What is your plan?

81 K.W.

82 K.W.

83 K.W. = Uni- CP Plates by Integra

84 Quesaons F/A in General

85 Most common malignant tumor of foot? 1. Chondrosarcoma 2. Synovial Sarcoma 3. Osteosarcoma 4. Clear Cell Sarcoma 5. Melanoma Ref: OKU F/A #2

86 Weil osteotomy of lesser metatarsal, what is the desired angle of saw cut? 1. Perpendicular to shao of metatarsal 2. Parallel with the inclinaaon of the metatarsal 3. Parallel with the plantar surface of the foot degrees to the shao of the metatarsal degrees to the shao of the metatarsal Ref: FAI 2006; 27:

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88 Most frequent locaaon of entrapment of the DPN? 1. EHB tendon 2. Inferior Extensor Reanaculum 3. Osteophytes of the TNJ 4. OS Intermetatarseum 5. Base of the 5 th MT Ref: NEJM 1960; 262:56-60

89 Anterior Tarsal Tunnel Most common in Runners Dx via symptoms of pain/numbness/ weakness of EDB Tx is release of tunnel + osteophyte excision

90 What type of physical therapy is most effecave for chronic Non- Inseraonal Achilles Tendinopathy? 1. Stair climbing 2. Eccentric strengthening 3. Concentric strengthening 4. Isometric strengthening 5. Rope jumping Ref: FAC 2005;10:

91 24 male with foot drop aoer knee dislocaaon 1 yr ago. Does not want AFO, what is the best opaon? 1. Repeat neurolysis of knee level 2. Repeat neurolysis of CPN with cable graoing 3. EHL transfer to distal 1 st MT 4. Tib- Post transfer through interosseous membrane 5. Ankle fusion Ref: FA 1988;8:

92 f/u quesaon If you use Tib- Post as a transfer for Foot- Drop, do you get a residual Flat Foot Deformity? What is the underlying pathology in paaents with flat- foot deformity known as Posterior Tibial Tendon Dysfuncaon (PTTD)?

93 18 male, pain+swelling in midfoot aoer direct injury to plantar flexed foot. Non- wb xrays were normal, what is the next step in 1. Gradual return to play 2. Physio 3. Orthosis 4. NWB Cast 5. WB Xray management? Ref: OKU F/A #2

94 Which one has been found to affect rate of perioperaave infecaons in f/a surgery? 1. Methotrexate 2. Gold 3. Hydroxychloroquine 4. TNF- alpha inhibitors 5. Smoking Ref: Ann Surg 2003;238:1-5

95 Flexible vs. Fixed A liile about Cavus Fixed Does not correct with coleman block test Tx = Osteotomy + Fusion Flexible Corrects with coleman block test Tx = shopping list

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97 Flexible Cavus Tx Shopping List Non- Surgical = MOST common treatment - Orthosis with LATERAL Wedge (acts like a coleman block test) + Physio for stretching Calf Surgical Shopping List Plantar Fascia Release PL to PB transfer Tib- Post Lat Cueinform transfer Lat CWO of Calcaneus 1 st MT Dorsal CWO MF Dorsal CWO Triple Arthrodesis

98 Example CMT with flexible cavovarus equinus + failed non- op Corrects with coleman block test Pathology = Tight Gastroc, PB is weak, Tib- Ant is Weak Tx - Surgical 1) Strayer 2) PL to PB transfer 3) 1 st MT Dorsal CWO 4) Lateral CWO of Calcaneus

99 Type 1 Diabeac with deep non- healing ulcer on plantar 1 st MTPJ. What objecave findings are indicaave of paaents ability to heal wound post- op 1. Absolute toe pressure 55 mm Hg 2. TcO2 20 mm Hg 3. ABI = level of surgery 4. ABI = level of surgery 5. Albumin 2.5 Ref: OKU F/A #2