Foot & Ankle Disorders - PDF Free Download

Foot & Ankle Disorders Hillingdon PGMC 6-7-2013 Htwe Zaw FRCS (Tr&Orth) Consultant Foot & Ankle and Trauma Surgeon Hillingdon Hospitals NHS Foundation Trust

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

Divide the Foot into Thirds Hindfoot Midfoot Forefoot

Anatomy Forefoot Midfoot Hindfoot

Anatomy Medial column Lateral column Hindfoot

Anatomy

Anatomy www.aofoundation.org

Anatomy

Assessment Symptoms mechanical vs non-mechanical neuropathic (spinal origin) shoewear related activity related (sports) functional deficit (stairs)

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)

Gastrocnemius-soleus complex

Silfverskiold s positive

Radiography 3 views of foot (AP, oblique, lateral) 2 views of ankle (mortise, lateral) weight-bearing views (if possible) LATERAL

Radiography Ankle arthritis

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)

Hallux Valgus: assessment patient expectations & compliance flatfeet, splayed foot, hallux pronation ROM, correctable? callosities? metatarsalgia 1 st TMTJ instability inflammatory arthropathy

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

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

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

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

Hallux Rigidus

Hallux Rigidus cheilectomy arthrodesis

Hallux Rigidus arthroplasty

claw hammer mallet

Clawed Hallux

Jones procedure on 18-03-2013 EHL tendon trasnfer to 1 st MT head + IPJ fusion

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

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)

Lisfranc injuries

Flatfeet abnormally low medial arch congenital: constitutional (flexible), coalition (rigid) acquired: posterior tibial tendon dysfunction Charcot Rheumatoid Fracture Polio Infection

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)

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

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

Posterior tibial tendon dysfunction

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

flexible vs fixed planovalgus deformity flexible: corrective orthotics US-guided steroid injection (Stage1 only) flatfoot reconstruction

flexible vs fixed planovalgus deformity fixed: accommodative orthotics arthrodesis triple fusion

Peroneal tendon disorders Peroneus brevis hindfoot eversion Peroneus longus 1 st ray plantarflex Disorders: Tenosynovitis Dislocation Tendinopathy/Tears Entrapment Os peroneus

Achilles tendon rupture

Hindfoot arthroscopy Anterior ankle arthroscopy Posterior hindfoot endoscopy Subtalar arthroscopy Tendonoscopy

Anterior Ankle Arthroscopy Debridement of synovitis/ impingement Anterior cheilectomy Microfracture of OCDs Syndesmotic debridement Arthroscopic ankle arthrodesis

Talar dome osteochondral defect

39 male fell down stairs

CT: talar neck and 2x osteochondral #s

5 months post-op

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)

Subtalar Arthroscopy

Intra-articular: ORIF

Pre-op

Pre-op CT

Post-op MACO 28-08-2012

Post-op 28-08-2012

Post-op 25-09-2012