Paeditric Orthopaedic Focus on practice

Complex Foot & Ankle Deformities, Current PracticeDr Samir Zahed Professor of Orthopedic Surgery, Benha University Monday Educational Program 2016, semester IIFoot Deformities, Current Practice

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Outline

Anatomy & Biomechanics Grounds

Deformity Assessment

Equinus, Cavus, Varus, Equinocavovarus

Toes Deformities

Valgus, Planus, Hyper-pronation, planovalgus

Diabetic Foot

Anatomy & Biomechanics Grounds

Anatomy & Biomechanics grounds

Foot Construction & shape 26 bones (One-quarter of bones in human body); 33 joints; 20 muscles.

Foot loading Heel 50-60% Forefoot 40-50% Peak forefoot pressure under 2nd MT

Foot FunctionsBase of support/weight distributionThe human foot combines mechanical complexity and structural strength.The foot can sustain enormous pressure (several tons over the course of a one-mile run) and provides flexibility and resiliency. Conformity to changing terrainFootwear helps to distribute pressures more evenlyShock AbsorptionPropulsionFoot acts as a rigid lever at push-offThe ankle serves as foundation, shock absorber, and propulsion engine

Anatomy & Biomechanics grounds

Three ArchesOne Transverse Two LongitudinalMedial-shock absorberLateral-transmits wt. Weight Support & Conformity functions need adequate & pliable platformPropulsion Function needs a strong levers (2nd class)Anatomy & Biomechanics grounds

Foot Functions

Foot Functions

Muscle mainly active in propulsion (dynamic) Tibialis posterior Triceps surae

Ligaments active in standing (static): 2- Spring (calcaneo-navicular ligament) 3- Short plantar (calcaneo-cuboid ligament) 1- Long plantar (calcaneo-cuniform- metarasal ligament)4- Plantar aponeurosis

Anatomy & Biomechanics grounds

Dorsiflexion of proximal phalanx raises the arch through traction on the plantar fascia & mid foot locks in a rigid position to act as a lever armAnatomy & Biomechanics grounds

Windlass Effect

Early Heel Strike= Contact Made on the Lateral Border of the Heel= Foot is Supinated= Foot is Rigid (locked)

Integrated Function of Foot/Ankle JointsLateral SideMedial SideAnatomy & Biomechanics grounds

Early to Mid- Stance= Foot goes to poronation= Foot is Mobile (unlocks)= Shock absorption, increases support on the ground, and enhances balance Late Stance to Toe-Off= Foot goes again to supination= Foot turns rigid (locks)= Force transfer from Achilles tendon to toes through contracted planter fascia= Enhances Propulsion

Left Foot

SupinationCalcaneal inversion (Varus)Dorsiflexion + External Rotation of talar HeadCompensatory Forefoot Supination (Varus)PronationCalcaneal Eversion (Valgus)Plantar Flexion + Internal Rotation Of Talar HeadCompensatory Forefoot Pronation (Valgus)Heel RiseShortening and tightness of planter fascia Supinated inverted footLocked transverse tarsal jointHindfoot inversion

Integrated Function of Foot/Ankle JointsAnatomy & Biomechanics grounds

Main Movers of foot

Muscle imbalance in foot deformity

MuscleMainTib postAdductorPeronus previsAbductorTib AntSupinatorPeronus longusPronator

DeformityStrong MuscleWeak MuscleequinusTriceps sureAnkle dorsiflexorscavusplantar fascia, intrinsicsAnkle dorsiflexorsvarustib post & tib ant peroneal brevis flatfootperoneus brevistibi postsupinationTibi antperoneus longus

Anatomy & Biomechanics grounds

Deformity Assessment

Deformity AssessmentClassic foot & ankle examinationSpecific for deformity assessment look for the patient walking (gait), then examine the components of the deformity while the patient lying supine & prone, then again look for the patient putting weight walking again and againComponents of deformity in hind mid, forefoot, & toesFlexibility (correctability) deformity changes on weight bearing during walking (dynamic elements)Special tests, block test & its dynamic version

Equinus, Cavus, Varus, Equinocavovarus

Equinus, Cavus, Varus, EquinocavovarusCommonly seen in combinationsHind foot is varus, or equinus or equinovarusMidfoot in cavus (high arch) Lateral border may be longForefoot may be inverted Dropping first rayClawing of the toes +/- Flexibility (Block test)

Equinus, Cavus, Varus, EquinocavovarusMostly seen inCongenital (since birth)Clubfoot: persistent, neglected, relapsedDeveloped in childhood, adolescence or adulthood idiopathicParlyticCPCMT (herditary somatosensory neuropathy)Freidreich ataxiaMuscular dystrophyPolioSpinal cord affections (eg. spinal dysraphism or tumors)

Equinus, Cavus, Varus, EquinocavovarusStages1. Flexible cavus / Flexible 1st MT - plantarflexion corrects with pressure on 1st MT2- Fixed 1st MT equinus / hindfoot mobile varus - hindfoot corrects with Coleman block test3. Fixed lesser MT's equinus / fixed hindfoot varus - hindfoot does not correct with Coleman block test4. Joint degenerative changesX RaySee through sinus tarsi, evident both talar domes, calcaneal height 20-25, Maerys angle 4 dorsal

Equinus, Cavus, Varus, EquinocavovarusSurgical principles1. Flexible cavus / Flexible 1st MT - semi-rigid insole orthotic with a depression for first ray and a lateral wedge2- Fixed 1st MT equinus / hindfoot mobile varus - Steindler release (plantar fascia release) - Jones, 1st TMT fusion/ 1st MT osteotomy - Shortening lateral border - Tib post transfer if weak dorsiflexion - PL to PB transfer if weak eversion3- Fixed lesser MT's equinus / fixed hindfoot varus - Above + - Lateral slide Calcaneal Osteotomy - T Achilles lengthening4. Joint degenerative changes - Arthrodesis for salvage of rigid deformity - Frame may be of help to maintain size of foot

A 32 year-old male complains of lateral foot pain and a progressively awkward gait. He has a family history of "foot problems" and reports some minor burning and numbness in both feet. Physical exam reveals bilateral cavus feet with clawing of the toes and intrinsic muscle wasting of the hands. A clinical photograph is shown in Figure Which of the following is responsible for the patients initial symptoms and awkward gait?

1. Weak gastrocnemius-soleus complex2. PB overpowering the tib post tendon3. Tib ant overpowered by PL4. Plantar flexion of the first ray5. Clawing of the toes

Quiz

An 18-year-old male presents with recurrent ankle sprains of the left ankle. During Coleman block testing the hindfoot is positioned in 3of valgus. The PB & tib ant have 4/5 strength compared to 5/5 strength in PL, gastrocsoleus complex, & tib post Using a semi-ridged orthotic with a recess for the head of the first ray and lateral hindfoot posting has failed to improve symptoms. Which of the following surgical interventions is most appropriate?1.PL to PB transfer + medial calcaneal slide osteotomy2.Triple arthrodesis3.1st ray dorsiflexion osteotomy + plantar fascia release4.Subtalar arthrodesis5.First TMTjoint arthrodesis & MTP capsular release

Quiz

A 14-year-old male child presents with the increasing foot deformity shown in Figure . On physical exam, it is noted that he is unable to walk on his heels and has decreased Achilles reflexes bilaterally. Coleman block testing reveals correctable hindfoot deformity.Which procedure is associated with improved clinical outcomes in patients with the above described condition? 1. Transfer of PB to PL2. Split tib ant transfer to lateral column3. Triple arthrodesis4. Tib post transfer to dorsum of the foot5. Lateral column lengthening calcaneal osteotomy

Quiz

A 42-year-old woman with Charcot-Marie-Tooth disease complains of longstanding foot pain. Orthotics, bracing, and NSAIDs no longer provide relief. She has cavovarus hindfoot deformity that does not correct with Coleman block testing.Radiographs are notable for degenerative changes within the talocalcaneal and calcaneocuboid joints. Which of the following is the most appropriate treatment? 1. Split tibialis posterior transfer2. Triple arthrodesis3. Lateral closing wedge calcaneal osteotomy with peroneus longus to brevis transfer4. First metatarsal dorsal closing wedge osteotomy5. Achilles tendon lengthening

Quiz

What is the preferred orthotic device for a symptomatic adult foot deformity that is shown in Figure ?He has no arthritis on radiographs, and responds to Coleman block testing as shown in Figure?

1.Short walker boot2.Accommodative custom orthotics3.Lace up soft ankle brace4.Medial hindfoot posting with arch support5.Lateral hindfoot posting with recessed first ray

Quiz

QuizA 3-year-old boy has been treated in the past with Ponseti casting now presents with dynamic supination during gait. You're planning to perform an anterior tibialis transfer to the lateral cuneiform. All of the following are true except1. This transfer is required in 10-20% of children who undergo the Ponseti treatment2. Weak peroneals are counteracted by overpull of the anterior tibialis3. Grade 4 or 5 strength of the anterior tibialis is needed prior to transfer4. Subtalar rigidity supplements the transfer5. Dynamic supination includ

QuizA 4-year-old boy demonstrates excessive supination occuring during the swing phase of gait following Ponseti casting for an isolated right clubfoot.

Which of the following sites identified in Figure shows the correct destination for the transferred tendon in order to balance the foot and eliminate the supination? 1. A2. B3. C4. D5. E

Toes Deformities

Lesser Toes DeformitiesClaw toesFlexible painful deformity (no contracture)FDL flexor-to-extensor transfer (Girdlestone) Fixed contractureGirdlestone (above), MTP capsulectomy, and PP head resectionFixed claw toe deformity of all four lesser toesGirdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy) Hammer toesEDL lengthening or tenotomy (flexible)Excision of head of PP (most common surgery)Mallet toes Percutanous tenotomy of FDLExcision of the head of middle phalanx

A 34-year-old woman presents with right foot pain and a callus over the 1st TMT joint. Accommodative shoe wear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures. The distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity?

1.Closing wedge osteotomy of the proximal phalanx (Akin)2.Distal soft-tissue release3.Distal metatarsal osteotomy4.Medial eminence resection and exostectomy (Silver)5.Scarf osteotomy

Quiz

A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work.Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st MTP joint deformity that passively corrects. The hallux valgus angle (HVA) is measured at 25 degrees and the intermetatarsal angle(IMA) is measured at 12 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities?

1.Distal metatarsal osteotomy (Chevron)2.Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride)3.Resection of medial eminence (Silver bunionectomy)4.Proximal metatarsal osteotomy and first MTP arthrodesis5.Metatarsal cuneiform fusion (Lapidus)

Quiz

Hallux Valgus Patho-anatomyTypesAdult hallux valgusJuvenile and Adolescent Hallux valgusfactors that differentiate juvenile / adolescent hallux valgus from adultsoften bilateral and familialpain usually not primary complaintvarus of first MT with widened IMA usually presentDMAA usually increasedoften associated with flexible flatfootcomplicationsrecurrence is most common complication (>50%), also overcorrection and hallux varus

Hallux Valgus Radiographic Measurements in Hallux Valgus (weight bearing AP , lateral & oblique views)Hallux valgus (HVA)Long axis of 1st MT and prox. phalenxIdentifies MTP deformityNormal< 15Inter metatarsal (IMA)Between long axis of 1st and 2nd MT < 10

Distal metatarsal articular (DMAA)Between 1st MT long. axis and line through base of of distal articular capIdentifies MTP joint incongruity< 15

Hallux valgus interphalangeus (HVI)Between long. axis of distal phalanx and proximal phalanx< 10

Hallux Valgus

ProcedureTechnique1- Modified McBrideIncludes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication (original McBride included lateral sesamoidectomy)2- Chevron /Biplanar Chevron/ MitchellDistal 1st MT osteotomy (intra-articular).Biplanar Chevron (corrects DMAA) 3- Scarf / Ludloff / MauMetatarsal shaft osteotomies.4- Proximal crescentric osteotomy/ Broomstick osteotomyProximal metatarsal osteotomies. (plus modified McBride)5- Akinproximal phalanx medial closing wedge osteotomy

Hallux Valgus

ProcedureTechnique6- Keller resection arthroplastyInclude medial eminence removal and resection of base of proximal phalanx7- MTP arthrodesis8- Lapidus procedurefirst TMT joint arthrodesis with distal soft tissue procedures (Modified McBride)9- First Cuneiform OsteotomyOpening wedge osteotomy (often requires autograft)

Hallux Valgus

Surgical Indications for Various Techniques to treat Hallux ValgusHVAIMAModifierProcedureMild< 25< 13Distal osteotomyChevron or Mitchell osteotomy. usually with mod McBrideModerate26-4013-15Shaft osteotomy or Proximal osteotomy Scarf/ Ludloff/ Mau or crescent/ Bromestick. + mod McBrideSevere41-5016-20Double osteotomy Proximal osteotomy + biplanar Chevron (if DMAA > 15) + mod McBride

Hallux Valgus Surgical Indications for Specific ConditionsJuvenile/Adolescent with open physis First cuneiform open wedge osteotomy

1- Hypermobile 1st MT2- Recurrence with pain in 1st TMT joint Lapidus procedure1- DJD, gout, RA2- CP3- Down's syndrome, Ehler-DanlosMTP Arthrodesis

Hallux Valgus

Procedure IndicationsComplicationsModified McBride - 30-50 y/o female with - HVA 15-25 - IMA 20 - HVA > 50 - hallux varus - dorsal malunion with transfer metatarsalgia - recurrence

Hallux Valgus

ProcedureIndicationsComplicationsKeller resection arthroplasty - largerly abandoned due to complications. - indicated only in older patients with reduced functional demands - cock-up toe deformity - poor potential for correction of deformityMTP arthrodesis - DJD of 1st MTP - CP - painful callosities beneath lesser MT headsLapidus procedure- moderate or severe deformity- hypermobility of first ray - Nonunion (may or may not be symptomatic) - dorsiflexion of the 1st MT with transfer metatarsalgiaFirst Cuneiform Osteotomy- children with ligamentous laxity, flatfoot, and hypermobile first ray-adolescent with an open physis - Nonunion (may or may not be symptomatic)

A 34-year-old woman presents with right foot pain and a callus over the 1st TMT joint. Accommodative shoe wear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures. The distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity?

1.Closing wedge osteotomy of the proximal phalanx (Akin)2.Distal soft-tissue release3.Distal metatarsal osteotomy4.Medial eminence resection and exostectomy (Silver)5.Scarf osteotomy

Quiz

A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work.Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st MTP joint deformity that passively corrects. The hallux valgus angle (HVA) is measured at 25 degrees and the intermetatarsal angle(IMA) is measured at 12 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities?

1.Distal metatarsal osteotomy (Chevron)2.Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Mod Mcbride)3.Resection of medial eminence (Silver bunionectomy)4.Proximal metatarsal osteotomy and first MTP arthrodesis5.Metatarsal cuneiform fusion (Lapidus)

Quiz

Which of the following clinical scenarios regarding hallux valgus could be appropriately treated with a modified McBride procedure?

1.35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint2.40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint3.70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray4.65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus5.85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA

Quiz

A 67-year old female presents with the bilateral foot deformity shown in Figures. All of the following contribute to the risk of recurrence after surgery EXCEPT:

1.Resection of the lateral sesamoid2.Lack of lateral capsular release3.Lack of medial metatarsophalangeal joint capsule closure4.Use of an Akin procedure alone for a moderate to severe deformity5.Under correction of the widened 1-2 intermetatarsal (IMA) angle

Quiz

Complex Foot Deformities

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Valgus, Planus, Hyper pronation, Planovalgus

Valgus, Planus, hyper pronation, planovalgus; Overview Presentation Evaluation Selected Types Congenital Vertical TalusFlexible Flat FootTarsal CoalitionPTTD

Valgus, Planus, hyper pronation, planovalgus; Overview PresentationFlexibleIdiopathic, Neonatal calcaneovalgus of uterine packingPhysiologic (morphologic),Infants & childrenLigamentous hyper laxityAcquired (Secondary to)Tibialis posterior tendon affection as in PTTD & accessory navicularFaulty foot loading as in obesity, valgus external rotation tibiaParalytic problems as in spinal dysraphism, muscular dystrophy, CPRigidCongenital vertical talusTarsal coalitionCharcoat arthropathyExterno Peroneal Spasm secondary to: Subtalar arthrosis; trauma, RA, non specific inflammationSubtalar arthritis as a late stage of PTTD, # calacaneus, ect

Functional

Valgus, Planus, hyper pronation, planovalgus; OverviewEvaluationFamily and Clinical HistoryClinical ExaminationFlexible vs rigidMorphologic vs functional (if flexible)Tiptoe testToe raise (Jack test)RadiologySeverity (meary,s angle) & talocalcaneal angle & calcaneal height, talar uncoverageTarsal coalitionSubtalar arthritis

CT

Valgus, Planus, hyper pronation, planovalgus; OverviewCongenital Vertical TalusDates since birthDDCongenital oblique talusFibular hemimelia, absent fibula &possible lateral raysIdiopathic calcaneovalgus, flexibleTTEarly peroneal & extensors lengtheningProlonged splinting

A 12-year-old boy has 2 years of right foot pain that prevent participation in athletic activities and is symptomatic with walking. He has attempted UCBL and custom made orthoses for 1 year with no relief of symptoms. His hindfoot is supple and he has full dorsiflexion. Clinical images of the foot & a lateral radiograph are shown. A surgical plan to address the deformity would most appropriately include which of the following?

1. Lateral calcaneal slide osteotomy2. Transfer of the peroneus longus to the peroneus brevis3. 1st metatarsal dorsiflexion osteotomy4. Calcaneal neck lengthening osteotomy5. Posterior tibial tendon transfer to dorsum of the foot

Quiz

Valgus, Planus, hyper pronation, planovalgus; OverviewFlexible Flat Foot (Non PTTD)Treatment AlgorithmClinical pictureDiagnosis & initial treatmentClinical response & final treatmentShoes and Orthotics Orthotics do not alter underlying structural fault, moreover they may negatively affect footOrthotics do not encourage redevelopment of the archRunning sports shoes have been found to be as effective as medical shoes and are more socially acceptable They reduce shoe wear and are said to be more effective in treating shoes rather than feet

Valgus, Planus, hyper pronation, planovalgus; OverviewFlexible Flat Foot (Non PTTD)Treatment AlgorithmClinical pictureDiagnosis & initial treatmentClinical response & final treatmentShoes and Orthotics SurgeriesSubtalar ArthroeresisNot in subtalar arthritis, paralytic, or severe ligamentous laxitySoft tissue procedures Alone or in combinations with othersETA +/- tib post advancementOsteotomy lateral calcaneal lengtheningMedial sliding calcaneal osteotomyCombination of bothFusionArthrodesis of the medial column, including N-C joint &MT- C jointDistraction arthrodesis of C-C jointSubtalar or triple in degen. cases

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Valgus, Planus, hyper pronation, planovalgus; OverviewTarsal CoalitionDiagnosisCanale & keley oblique viewHarris-Beath axillary viewCTDDSubtalar inflammation with spasmodic valgus footTTResection with or without other proceduresRealignment OsteotomiesEvans lateral calcaneal lengtheningMedial slide calcaneal osteotomyFusionSubtalarTrible

Controversial except in cases with degenerationMore in late adolescence and adults

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Valgus, Planus, hyper pronation, planovalgus; Overview

Tibialis Posterior Tendon Dysfunction Deformity Radiographs

Stage ITenosynovitis No deformityNormalStage IIAFlatfoot deformity Flexible hindfoot valgusNormal forefootArch collapse deformityStage IIB Flatfoot deformity Flexible hindfoot valgusForefoot abduction("too many toes", >40% talonavicular uncoverage)Stage IIIFlatfoot deformityRigid hindfootvalgusRigid forefoot abduction Arch collapse deformitySubtalar arthritisStage IV Flatfoot deformityRigid hindfootvalgusRigidforefoot abductionDeltoid ligament compromise Arch collapse deformitySubtalar arthritisTalar tilt in ankle mortise

Tibialis Posterior Tendon Dysfunction Nonoperativeimmobilization in walking cast/boot for 3-4 months

Indications: first line of treatment in stage I disease

custom-molded in-shoe orthosisIndications: stage I patients after a period of immobilization, and stage IIpatientsTechnique: UCBLwith medial postingankle foot orthosisIndications: stage II, III, and IV patients who are not operative candidates, and low demand (age > 60-70)

techniqueAFO found to be most effectivewant medial orthotic post to support valgus collapse

Tibialis Posterior Tendon Dysfunction OperativeTenosynovectomyIndications: in stage I disease if immobilization fails

FDL transfer, calcaneal osteotomy, TAL,+/- forefoot correction osteotomy [plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy], +/- lateral column lengthening,+/- PTT debridement

Indications: stage II diseaseContraindications: hypermobility, neuromuscular conditions, severe subtalar arthritis: obesity (relative), age >60-70 (relative)Triple arthrodesis and TALIndications: stage III disease, and stage II disease with severe subtalar painTriple arthrodesis and TAL+ deltoid ligament reconstructionIndications: stage IV disease with passively correctable ankle valgusTibiotalocalcaneal arthrodesisIndications: stage IV disease with arigid hindfoot, valgus angulation of the talus, and tibiotalar and subtalar arthritis

Tibialis Posterior Tendon Dysfunction TreatmentStage IImmobilization walking cast for 3-4 months, followed by UCBL orthosisTenosynovectomy if immobilization fails

Stage IIAFDL transfer, calcaneal osteotomy, TAL, +/- lateral column lengthening,+/- PTT debridement

Stage IIB The same as IIA +/-forefoot correction osteotomyStage IIITriple arthrodesis and TALStage IV triple arthrodesis and TAL+ deltoid ligament reconstruction in correctable ankle valgusTibiotalocalcaneal arthrodesis in non correctable ankle valgus

An obese 65-year-old woman has a chronic painful flatfoot with a rigid valgus hindfoot deformity. Radiographs reveal subtalar joint degenerative changes but no signs of ankle joint degenerative changes or abnormal talar tilt. She is unable to single-leg heel raise and has a "too many toes" sign. What stage of posterior tibial tendon dysfunction is she best classified as?

1.IIB2.IV3.III4.IIA5.I

Quiz

A 53-year-old female has a 20 month history of left hindfoot pain that has failed to respond to AFO bracing and physical therapy. She has a unilateral planovalgus deformity, shown in Figure which is flexible. She is unable to do a single leg-heel rise.

Which of the following surgical options is most appropriate?

1.Triple arthrodesis2.Isolated FDL transfer to the navicular3.Dorsiflexion osteotomy of the 1st ray with peroneus longus-to-brevis transfer4.Lateralizing calcaneal osteotomy with FDL to navicular transfer5.Lateral column lengthening, medializing calcaneal osteotomy, and FDL transfer to the navicular

Quiz

A 70-year-old female complains of progressive pain of the medial ankle and foot over the past 10 years. Orthotics no longer provide relief of her pain. The hindfoot deformity is unable to be passively corrected on physical exam. Figure A is a posterior view of the patient's foot upon standing and a current radiograph is provided in Figure B. Which of the following is the best treatment option?

1.Posterior tibialis tendon debridement2.FDL transfer to navicular and calcaneal slide osteotomy3.FDL transfer to navicular, calcaneal slide osteotomy, and lateral column lengthening through the cuboid4.Talocalcaneal arthrodesis5.Triple arthrodesis

Quiz

A 54-year-old female has a painful flatfoot that has not improved with over 8 months of conservative management with orthotics. Preoperatively, she was unable to perform a single-heel rise and her hindfoot was passively correctable. Figures A and B are radiographs of the affected left foot. She undergoes FDL tendon transfer to the navicular, medial slide calcaneal osteotomy, and tendoachilles lengthening procedures. Following these procedures, the appearance of the foot is demonstrated in Figure What is the next most appropriate intraoperative procedure to be performed during her foot reconstruction?1.Dorsiflexion dorsal closing wedge medial cuneiform osteotomy2.In-situ 1st-3rd tarsometatarsal joint arthrodesis3.Plantar flexion dorsal opening wedge medial cuneiform osteotomy4.Lateral column closing wedge shortening osteotomy5.Subtalar arthrodesis

Quiz

A 50-year-old male with long-standing type 1 diabetes presents with redness, swelling and crepitus in his foot two weeks after a twisting injury. Elevation of the extremity reduces the hyperemia. A radiograph is shown in Figure . What is the most likely diagnosis? 1.Osteomyelitis2.Charcot-Marie-Tooth disease3.Lisfranc fracture-dislocation4.Charcot arthropathy5.Freiberg's Disease

Quiz

Diabetic Foot

Diabetic Foot Charcot NeuropathyBrodskyClassificationType 1 Involves tarsometatarsal and naviculocuneiform joints Collapse leads to fixed rocker-bottom foot with valgus angulation60%

Type 2 Involves subtalar, talonavicular or calcaneocuboid jointsUnstable, requires long periods of immobilization (up to 2 years)10%

Type 3AInvolves tibiotalar joint Late varus or valgus deformity produces ulceration and osteomyelitis of malleoli20%Type 3BFollows fracture of calcaneal tuberosity Late deformity results in distal foot changes or proximal migration of the tuberosity< 10% Type 4Involves acombination of areas< 10%Type 5Occurs solely within forefoot< 10%

Diabetic Foot Charcot Neuropathy Nonoperative TreatmentIndications: first line of treatmentTechnique:Total contact castingcasts changed every 2-4 weeks for 2-4 months in acute charcotOrthoticsPatellar bearing brace in types II, III, & IVCharcot restraint orthotic walker (CROW) boot can be used after contact casting especially in type II & IIIShoe modifications: in type 1Wound care shoes (WCS) to relieve ulcerated areasDouble rocker shoe modifications will best reduce risk for ulceration at the plantar apex of the deformity

Medicationsbisphosphonatesneuropathic pain medicationsantidepressantstopical anestheticsOutcomes75% success rate

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Diabetic Foot Charcot Neuropathy

Operative TreatmentResection of bony prominences (exostectomy) and TALIndications: "braceable" foot with equinus deformity and focal bony prominences causing skin breakdownGoal is to achieve plantigrade foot that allows ambulation without skin compromiseDeformity correction, arthrodesis +/- osteotomiesindicationssevere deformity that is not "braceable"outcomesvery high complication rate (up to 70%)Amputationsindicationsfailed previous surgery (unstable arthrodesis)recurrent infection

A 50-year-old male with long-standing type 1 diabetes presents with redness, swelling and crepitus in his foot two weeks after a twisting injury. Elevation of the extremity reduces the hyperemia.A radiograph is shown in Figure .What is the most likely diagnosis? 1.Osteomyelitis2.Charcot-Marie-Tooth disease3.Lisfranc fracture-dislocation4.Charcot arthropathy5.Freiberg's Disease

Quiz

A 56-year-old male with uncontrolled diabetes presents for follow up of a recurrent midfoot ulceration. He has been placed into a total contact cast for extended periods without resolution of the ulcer. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. He has an equinus contracture. A clinical photo of the patient and lateral radiograph of the foot are provided in Figures. Radiographs are unchanged from prior evaluation.What is the next best option at this point?

1.External fixation2.Below the knee amputation3.Continued observation4.Exostectomy with placement into a protective brace5.Exostectomy & achilles tendon lengthening with placement into a protective brace

Quiz

A 62-year-old gentleman with a 10-year history of Type II diabetes complains of warmth, swelling, and pain in his right foot that has progressively worsened over the past 6 weeks. He denies fevers or chills, and states that the swelling and warmth dissipates each night after he sleeps with his foot elevated on pillows. A clinical photograph of the foot is provided . The midfoot is hot to touch and mildly tender with palpation. A radiograph is provided in Figure. Which of the following is the most appropriate management?1.Custom orthotics with first ray recession and lateral heel posting2.Total contact cast and non-weight bearing3.Intravenous antibiotics4.Talonavicular and tarsometarsal arthrodeses5.Transtibial amputation

Quiz

A 57-year-old woman with type 2 diabetes presents with right foot pain resulting in gait disturbance for the past 6 months. Medical comorbidities include renal insufficiency and hypertension. A radiograph is provided in Figure.

What initial management is most appropriate? 1. Carbon fiber shank insole2. Custom orthotic with Jones bar and medial posting3. AFO (ankle foot orthosis) with posterior leaf spring4. Total contact casting5. Accomodative plastizote insole with depression cut into the midfoot and extra-depth shoes

Quiz

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