Complications following ankle arthrodesis - help please

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Have a patient who presented in clinic this week who following an accident 5 years ago ('jumped over a 12 foot fence and foot went in different direction') had surgical arthodesis attaching the right tibia to the talus.

He's not very impressed with the results and gets a intense deep burning pain in the lateral 1/3 of his fibula. This often occurs non-weightbearing.

He is planning on going back to the surgeon but is also considering having the foot removed altogether!

Main finding from a quick biomech assessment are LLD with left leg circumducting during gait and rigid feet - need to do a full assessment with more time.

Thinking of shoe modifications rather than orthotics at this stage such as heel raise and rocker bottom sole - he does find that he feels better in shoes (so with a slight raise) than without them.

Any surgeons out there got any opinions as to what may be causing the pain / ideas for further treatment? Let me know if you need any further info.

Pt seems to want immediate results - however have explained this may not be possible.

Cheers
Chloe

 

Not a surgeon (just a pedorthist) but; since you mentioned shoe mods..... I might suggest raise the left heel to the angle of plantarflexion plus fore-foot rocker sole, and use a SACH heel or undercut the heel about 30 degrees to reduce heel impact at contact. Then raise the right shoe with a mild rocker enough to eliminate any left toe drag which could be contributing to the need for circumduction of the left foot. Also, Out flaring or offsetting the left heel may reduce the fibula stress (if that is the case) without trying to laterally wedge the fused deformity.

I hope I am not overstepping by jumping in here.

 

Thanks - I shouldn't have put surgeons - I didn't mean them specifically - any opinions are welcome!

Just to confirm one point you make

'Also, Out flaring or offsetting the left heel may reduce the fibula stress (if that is the case) without trying to laterally wedge the fused deformity.'

He is getting pain in the right fibula - do you mean do this mod to the left or right shoe?

Cheers

 

Sorry for the confusion, I reversed the feet. Here is what I should have typed:

I might suggest raise the right heel to match the angle of plantarflexion plus fore-foot rocker sole, and use a SACH heel or undercut the heel about 30 degrees to reduce heel impact at contact. If the left foot is circumducting due to a rigid plantarflexion, raising the right heel a little more than the left may help. Of course, leg length has to be considered if the height correction is not minor. If I am right about the toe drag on the left, I would have the tip of the left sole replaced with a non-gripping surface like sole leather under the toe area. Also, Out flaring or offsetting the right heel may reduce the fibula stress (if that is the case) without trying to laterally wedge the fused deformity.

Unless you spot more inconsistencies in this reply, I'll butt out now.

 

Chloe

As pain is there when non weightbearing you need to consider following

1. CRPS type 1 or 2. Was there a trans fibula approach? Check for allodynia, Hyperpathia by light percussion. If +ve try some gabapentin and send to pain clinic
2. Non union. Check X-ray and consider CT scan
3. Low grade infection. Consider leucoscan
4. Metalwork problems. X-ray and or CT would help with this. For instance is the screw penetrating the STJ inadvertantly?

If all that is negative then really its orthotics/ shoes and live with it
or A BKA. Thats what a patient of mine chose as the pain was so intense! I would suggest this as a absolute last resort as it has to be pretty bad for that option!

Tony Wilkinson

 

Hello Chloe:
Perhaps we need more information on any x-ray, CT, or MRI findings. Was the arthrodesis done with residual malalignment? Is there any protuding hardware? Is there a limb lenght discrepancy causing lateral stress to the fibular malleolar area? Is there any neuropathy or paresthesias present?
Before you decide what biomechanical device to use, please evaluate him further.
Last, but not least, these type of traumas culd induce a regional pain syndrome to the affected area that may not respond to conservative measures.
Regards,
Narmo

 

Hi Chloe

One element I would look at is the LLD a chronic functional LLD as a result of the jump over the fence.

Whats psoas function like? Is it stuck in a chronic spasm
Whats the translation of interior and superior tib-fib joint like.
The burning in the lower third of fib could be a translation restriction in tib-fib joints. the arthodesis is a very specific resriction but that may not be the only injury when the landing occured.
could be irritation of the interosseus membrane and could work with needling that.
Also when you are checking translation at TIB-Fib joints check what the hamstrings are doing. If Lateral head of bicep fem is restricted then sup tib-fib and inferior tib-fib is going to have trouble working.

I think associated injuries are the key to this case and also the post surgical rehab.
Was the patient rehab in all body planes, he obviously had a bad injury but what else was injuried

Dave

 

Dave

Whilst I admire your enthusiasm and creativity in creating a differential diagnosis, in all liklihood the ongoing symptoms are directly related to the surgery and the common complications related to ankle arthrodesis.

That old chestnut, Occam's Razor - "the simplest explanation is usually the correct one"- comes to mind here.

LL

 

Hi Luckylisfranc

If the problems are simply post surgical then what is the complaint?
We have thrown a few ideas to chloe and numerous idea's are still awaiting answers.
Is the pain as a result to the LLD.
Why do we have the LLD, Was it a primary anatomical LLD or a functional LLD.
It's not about differential diagnosis but I have successfully rehabilitated numerous patients in a similar boat even with what were thought to be surgical post op complications.
When the injury took place I very much doubt that a single injury took place to the structure.
I think its more about looking at the whole picture and an accurate assessment.
That would allow us a more informed viewpoint.
I think The physical therapy view has been missed from options and orthotics and appliances seem to be the next port of call if an answer is not found. I am not saying that isn't right I also like the functional improvement view point.


cheers
Dave:drinks

 

Thank you for all the thoughts so far.

Sorry for being a bit slow in getting back to answer the questions - will hopefully be seeing the patient this week along with x-rays. As far as I know he hasn't had a CT scan. There is a functional LLD since the accident. I'm unsure of what exactly was done in the surgery - will investigate further once seen him.

Thanks again and I'll be back with more info

Chloe

 

More details please Chloe, was he on a pogo-stick?, was he on mind-altering 'super-human' nonprescribed medication, has he a younger brother / sister capable of same looking for a sports manager?, thanks, mark

 

Hi Chloe:
The original injury was five years ago. When was the fusion done? 5 years ago? Recently?
Why was the fusion done?
If he's within a few months post op I would consider different DDs than if he had the fusion 5 years ago and had been doing well until recently.

Like all fusions, the #1 complication is psuedoarthrosis.

Diagnosis before treatment!

Steve