Foot and ankle update Mr Ian Garnham Consultant Foot and Ankle Surgeon Whipps Cross University Hospital
Hallux Rigidus Symptoms first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe shoe irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to paresthesias pain becomes less severe as the disease progresses Physical exam limited dorsiflexion pain with grind test
Hallux Rigidus Coughlin and Shurnas Classification Exam Findings Radiographic Findings Grade 0 Stiffness no pain Grade 1 mild pain at extremes of motion Grade 2 moderate pain with range of motion increasingly more constant Grade 3 significant stiffness, pain at extreme ROM, no pain at mid-range Grade 4 significant stiffness, pain at Extreme ROM, pain at mid-range of motion Normal mild dorsal osteophyte, normal joint space moderate dorsal osteophyte, <50% joint space narrowing severe dorsal osteophyte, >50% joint space narrowing same as grade III
Hallux Rigidus Coughlin and Shurnas Classification Grade 1 Grade 2
Hallux Rigidus Coughlin and Shurnas Classification Grade 3 Grade 4
Hallux Rigidus Nonoperative NSAIDS, activity modification & orthotics Operative Joint debridement and synovectomy patients with acute osteochondral or chondral defects MRI Dorsal cheilectomy grade 1 and 2 disease (controversial) pain with dorsiflexion is an indicator of good results with dorsal cheilectomy shoe wear irritation from dorsal prominence and pain (ideal candidate) contraindicated when pain located in the mid-range of the joint during passive motion
Cheilectomy Technique remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively
Moberg procedure Hallux Rigidus dorsal closing wedge osteotomy of the proximal phalanx runners with reduced dorsiflexion (60 is needed to run) failure of cheilectomy to provide at least 30 to 40 degrees of motion technique increases dorsiflexion by decreasing the plantar flexion arc of motion
Hallux Rigidus Keller Procedure (resection arthroplasty) indications elderly, low demand patients with significant joint degeneraion and loss of motion technique involves removing the base of the first proximal phalanx risk of hyperextension (cock-up deformity) weakness with push-off transfer metatarsalgia (decreased with capsular interposition)
Hallux Rigidus MTP arthroplasty indications controversial capsular interpositonal arthroplasty gaining popularity silicone implants are not recommended due to poor long-term results silicone implants may have a good short term satisfaction rate osteolysis and synovitis cause mid to long term pain and joint destruction
Hallux rigidus MTP joint arthrodesis indications grade 3 and 4 disease (significant joint arthritis) most common procedure for hallux rigidus surgery outcomes 70% to 100% fusion rate 15% of patients experience degeneration of IP joint after (mostly asymptomatic)
Cartiva Interposition arthroplasty 8-10mm implant PVA polyvinyl alcohol Synthetic polymer
Cartiva Prospective randomised trial Canada and UK 2 yr follow up 1 st MTP fusion v cartiva 236 pts 152 implants
Cartiva Equivalent outcome for pain relief and function <10% revision to fusion at 2 years
Management of heel pain Plantar fasciitis Posterior heel pain
Plantar fasciitis Pathophysiology Clinical presentation Clinical assessment Differential diagnosis Imaging Medical management
Plantar fasciitis >90% success from conservative treatment NSAIDS Modification of footwear Modification of activity Physical therapy Night splints Steroid injection ECSWT PRP
Indications for surgical treatment Confirmed diagnosis on imaging MRI Failed medical management in compliant patient Symptoms > 1yr
Surgical treatment of plantar fasciitis Open fasciectomy Endoscopic fasciotomy Gastrocnemius/soleus complex release/lengthening
Open fasciectomy
30-50% release +/- excision calcaneal spur Release 1 st branch lateral plantar nerve Literature Few studies Retrospective 70%+ good/excellent outcome Open fasciectomy
Similar reported outcomes to open surgery Endoscopic release
Proximal medial gastrocnemius release Gastrocnemius / soleus contracture Multiple lengthening techniques Silfverskoid +ve patients Proximal medial gastrocnemius release if failure medical treatment
Posterior heel pain Achilles tendonosis Insertional tendonosis Haglund deformity Pump bump Posterior heel spur
Achilles tendonosis Eccentric stretches High volume injection ECSWT PRP Surgery - tenolysis
Insertional tendonosis Haglund deformity Insertional tendonosis Inflamed retro calcaneal bursa
Insertional tendonosis Physiotherapy NSAIDS Injection of bursa ECSWT (non-calcific)
Surgical treatment of insertional tendonosis Open surgery Resection of posterosuperior calcaneus (Haglund deformity) Excision retro-calcaneal bursa Debridement achilles tendonopathy
Surgical treatment of insertional tendonosis Endoscopic calcaneoplasty Minimally invasive Medial/lateral portals Coblation bursa/tendon
Endoscopic calcaneoplasty
Posterior heel spur
Posterior heel spur
Posterior heel spur Posterior approach Achilles split Excision bony prominence Repair Arthrex speed bridge Accelerated rehab with boot and wedges
Ankle arthritis Open fusion Arthroscopic fusion TAR total ankle replacement
Ankle arthritis arthroscopic fusion
Total Ankle Replacement Contributing to NJR since 2010 2,554 cases in total Around 500 cases/yr 49 revisions (12 to fusion) Revision at 90 days 0.08% At 1yr 0.45% 2yrs 1.85% 3yrs 2.52% 4yrs 3.28%
Ankle arthritis Mobility TAR total ankle replacement
TAR Market leader withdrawn last year (40+%) 10 different implants listed +20 unknown cases More onto market since 2 designs Mobile or fixed bearing
Lateral ligament injury Grade 1-3 RICE Functional bracing Lateral gutter pain Instability OCD
Lateral ligament injury Lateral gutter pain
Ankle instability History of inversion injury and giving way Stress test Anterior drawer test
Brostrom Gould Repair
Ankle instability Free hamstring graft Non anatomic repair (peroneal tendons) Internal brace
Ankle arthroscopy Soft tissue impingement Bony impingement Loose body OCD osteochondral defect
Ankle arthroscopy
Ankle arthroscopy Anterior impingement Pain on forced dorsiflexion of ankle Soft tissue or bony
Bony impingement Ankle arthroscopy
Anterior osteophyte Ankle arthroscopy
Soft tissue impinge ment Ankle arthroscopy
Os trigonum
Ankle arthroscopy Loose body History of locking and giving way
OCD
5-7% IN OCD
OCD
OCD
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OCD
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Acquired flat foot edial a kle sprai Tibialis posterior dysfunction Grades 1-4
Acquired flat foot Grade 1 Arch maintained Single toe stance Conservative v surgical
Acquired flat foot Grade 2 Flat foot deformity Unable to initiate single toe stance Hindfoot and midfoot corrects passively Degenerate changes in tibialis posterior tendon Conservative Rx
FDL transfer + calcaneal osteotomy
Acquired flat foot Grade 3 Fixed deformity Bony fusion
Acquired flat foot Grade 4 Subtalar and ankle arthritis