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Foot And Ankle Disorders An overview

Andrew Skyrme Lower Limb Surgeon Horder Centre Eastbourne District General Hospital

Common Presentations

· Forefoot disorders · Midfoot disorders · Hindfoot disorders · Soft tissue problems · Non-articular problems

Painful hindfoot

· · · · · Ankle arthrosis Subtalar arthrosis Talonavicular arthrosis Ankle injuries Rheumatoid hindfoot

Ankle arthritis

· Presentation

­ Solitary or combined ­ Significant deformity

· Varus or valgus

­ Pain, swelling ­ Reduced ROM

· Treatment

­ ­ ­ ­ ­ Conservative - brace Synovectomy if rheum Arthroscopic debridement Fusion Replacement

Ankle fusion

Advantages · Long-term solution · Correct deformity Disadvantages · Complications · 6/52 NWB · then 6/52 PWB aircast

Fusion versus ankle replacement

Ankle replacement - relative contraindications

1. 2. 3. 4. 5. 6. AVN Poor circulation Long-term steroid therapy Poor skin coverage Instability Hindfoot valgus / varus

STAR

Agility

Personal problem ­ complication rate, failure, loss of bone stock and restriction of options thereafter.

Subtalar Arthritis / Synovitis

· Presentation

­ ­ ­ ­ ­ Painful hindfoot Planovalgus Swelling Insufficiency fracture Rheumatoid commonly

· Treatment

­ fusion +/- graft

· Post-op

­ POP 6/52 NWB ­ 6/52 Aircast WB ­ Total 12 weeks !!

Mr JF - 63 y/o 2 previous failed fusions

Talonavicular arthritis

· Presentation

­ ­ ­ ­ Painful hindfoot Collapsing MLA Progressive planovalgus Rheumatoid

· Surgical Treatment

­ Early fusion

· delay progression of Forefoot abduction

Pantalar arthritis

· Presentation

­ Painful hindfoot ­ Planovalgus ­ Swelling

· Surgical treatment

­ Ankle OK - Triple fusion ­ Ankle RA ­ Talocalc F'n

· Post-op

­ 6/52 NWB POP ­ 8/52 PWB ­ FWB POP

Rheumatoid hindfoot

· · · · · Subtalar arthrosis Talonavicular arthrosis Midfoot disease Pantalar arthrosis Rarely ankle alone

· Usually have forefoot disease

Ankle injury

1. Acute lateral ligament injury 2. Post injury continued pain

­ Osteochondral injury ­ Soft tissue impingement

3. Chronic and recurrent instability

­ Lateral ligament instability

Lateral ligament injury

· Symptoms

­ History of inversion ­ Pain, swelling etc

· Treatment

­ Ice, elevate, rest ­ Early physio ­ Wobble board, brace ­ Advice re sports

Chronic ankle instability

· `I keep twisting my ankle' · Clinically unstable · MRI to confirm ATFL injury

­ ­ ­ ­ Brace Brostrom repair and POP 6/52 Brace 3/12 Return to jogging 3/12 and sports 6/12

Post injury continued pain

· Osteochondral injury

­ X-ray, MRI ­ Arthroscopy and debride

· Soft tissue impingement

­ Gutter pain ­ lateral and medial ­ Sharp pinching pain and giving way ­ Inject - depomedrone ­ Arthroscopy and debride (85%)

Midfoot disorders

· Rare · Arthrosis ­ treat accordingly · Foot fatigue syndrome

­ Vague pain after 20 miles !! ­ Walkers, runners ­ overuse ­ Podiatry and insoles ­ Activity reduction

Forefoot Disorders

Commonest site in foot 80% of RA patients

1. 2. 3. 4. 5.

Hallux valgus Hallux rigidus Claw toes Hammer toes Rheumatoid forefoot

MTP Disease

Dorsal subluxation of P1 Distal migration of plantar fat pad Metatarsalgia Callosities Hallux valgus, hammertoes, claw toes

Hallux Valgus

· Commonest

­ forefoot disorder (75%)

· Presentation

­ ­ ­ ­ ­ ­ Bunion Pronation of toe Valgus 2nd toe crossover Transfer metatarsalgia Callosities

Treatment of hallux valgus

· Keller

­ ­ ­ ­ Resection arthroplasty Elderly and unable to NWB Recurrence Cock-up deformity

· Osteotomy

­ Chevron, Wilson - POP ­ Multiplanar ­SCARF

· no POP · Maintain length

Hallux rigidus

· Painful

­ Tip toe, stairs, toe off ­ Reduced ROM ­ Arthritic osteophytes

· Treatment

­ ­ ­ ­ Kellers ­ elderly and frail Replacement ­ very selective few Fusion ­ gold standard ­ 95% happy Cheilectomy / Moberg osteotomy ­ 80% happy

Fusion For Hallux Valgus

· Position

­ 10° valgus ­ 20° dorsiflexion (M/F)

· Method

­ 2 screws, memory staple

· Post-op

­ POP 6-8/52 ­ NWB or heel WB ­ No movement but walk normally

Hammer Toe Correction

· Definition

­ Flexion PIP ­ Neutral MTP

· Treatment

­ PIP fusion / k wire ­ Release EDL, FDB ­ +/- prox hemi

Rheumatoid MTP Disease Pathophysiology

· Recurrent MTP synovitis

­ ­ Instability Deformity MTP DISLOCATION

·

Cartilage destruction by pannus

­ ­ Incongruity instability

·

Static stabilisers attenuated

­ Collateral ligaments, capsule,

Rheumatoid Forefoot Reconstruction

· Resection lesser MT heads

­ Adequate resection ­ K wire all lesser rays

· 1st ray fusion · Recreate the normal cascade · Post-op

­ NWB with crutches ­ K wires 6/52 ­ +/- antibiotics

Soft tissue problems

· PTTD · Plantar fascitis · Achilles tendinitis · Morton's · Lumps

Posterior tibial tendon dysfunction (PTTD)

· Who?

1. 2. 3. 4. 5. 6. Anyone Fat, female and forty Reiter's syndrome Ankylosing spondylitis Psoriatic arthropathy Rheumatoid

PTTD

· Presentation

­ ­ ­ ­ ­ ­ Medial hindfoot pain initially Swelling Planovalgus hindfoot Unable to tip-toe Lateral pain later Rigid hindfoot

· Treatment

­ Conservative - insoles ­ Surgical TPTR / MDCO / SPR

· Fusion

Mrs OS ­ Wheelchair bound Insufficiency fracture

Post-op Mrs OS talocalcaneal fusion

Plantar fascitis

· Symptoms

­ Pain mane ­ Following long periods of sitting

· Treatment

­ ­ ­ ­ ­ ­ Podiatry Injection Tx Heel cushion Stretching Night splinting NSAIDS

­ Recalcitrant ­ partial release

Achilles tendinitis

Who?

Anyone Overuse Reiter's Rheumatoid Crystal arthropathy

Treatment Ice / rest +/- POP Heel raise Dynamic AFO Avoid injection Tx Surgical treatment Nodule excision Rarely Need MRI

Symptoms Insertional pain Nodular disease

Morton's neuroma

· Clinically

­ Pain in forefoot ­ 3rd webspace 90% ­ Pins / needles ­ Numb ­ Clicking (Mulders click) / nodule

· Treatment

­ Conservative ­ injection depo 50% ­ Surgical ­ dorsal excision

Lumps in the foot and ankle

· Dorsally

­ Ganglion or osteophytes

· Medial

­ Accessory navicular

· Posterior

­ Heel bump, inflamed tendon

· Plantar

­ Fibroma or ganglion

Summary

Basic rules

1. 2. 3. 4. 5.

· ·

Only operate if painful Correction mainstay of treatment Fusion mainly in rheumatoids Soft tissue management Multi-disciplinary approach

Rheumatology, podiatry, orthotics Rehabilitation unit post-op

Painless Conservative therapy

6.

If it looks like a foot it will probably function like one

THANK YOU

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