Advice on foot surgery

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Here's a question for the surgery bofs

I have a patient, male 56 years old, who 15 years ago fractured both ankles in a motor bike accident. He now suffers severe 'ankle' pain during ambulation bilateral but worse l/f.
He has recently been thru the medical route and only has analgesia and anti imflammatories as a result.

In his biomechanical exam I noted that the left STJ was rigid and the right was reasonably normal in quality and range of movement. Left and right mid foot rom was restricted in both feet but worse l/f. I ordered x rays, which showed complete degeneration of the l/f STJ and substantial degeneration of the r/f stj. Right mid foot had mild degeneration and left mid foot had severe degeneration with no distiction of joint space in any joint. Both talo-crural joints are in good condition and have good clinical presentation and RoMs.


I propose to fit soft accomodative orthoses to reduce moments about the STJ and increase shock attenuation in addition to rocker type shoes to reduce dorsiflexion moments about the midtarsal joint.

I have advised referal to orthopaedics with a view to surgery in the future, possibly arthrodesis. What type of surgery would you envisage, if any.

Cheers Dave Smith

 

David

So, to read into what you are saying...your diagnosis is?

The most objective information you provide relates to likely post-traumatic degenerative joint disease affecting the subtalar joints and "midfoot" (whatever that is).

Post the x-rays, but reading between the lines this person might end up requiring bilateral triple arthrodesis...not an enviable thought.

I would ditch the accomodative route in preference to deep UCBL devices to immobilise the hindfoot as much as possible. Rocker-boots are not indicated if there is no sagittal block (ie ankle and 1st MTPJ function is normal).

LL

 

LL

I was thinking of a ucbl type shape but in EVA for increased shock attenuation.
The rocker shoe would not be a surgical or orthopaedic type but instead a walking shoe or boot with a rockered sole. This will reduce dorsiflexion moments about the the midfoot, which includes all joints from talo navicular and calcaneo-cuboid to met-cuneiforms. If the customer will wear boots then this would help to reduce STJ moments in the frontal plane.

Thanks for the input all the best Dave Smith

 

Hi David:
Sounds as though the original injury was a fall or MVA causing compression (B) ?
It also sounds as though he had a Fx of the STJ as well as the ankles.

As you probably are aware it's better to have no motion in the STJ then a small amount of painful motion. It sounds as though (unless the Midtarsals were injured as well) that the compensatory forces from decreased STJ motion has caused degenerative changes in the Midtarsal joints.

If the arthritis is as bad as I envision, STJ/Ankle fusion via intermedullary pin is available (when all else fails).

Can you upload an xray?

Steve

 

Dr Sarbes

Absolutely

Yer tis!





Thanks for your interest Steve

Cheers Dave

 

Steve

Amazingly the reproduction on the Arena page is better than on the computer I read it on

Due to the CD format supplied I was only able to read the x rays on a very old computer. I copied the images and uploaded them to my computer via email then posted them via tiny pic.

Nowt's easy eh!

Dave

 

Hi Dave:

Looks like your patient had a compression (i.e. joint depression type) fracture of the calcaneus, worse on the left.

The ankle looks good (B)
He's getting secondary arthritis in the TN and CC joints left.

As always happens when not treated with ORIF the body of the calc widened and now he has an obvious impingement of the distal Fib head, Lt.

It looks as though he might (big might) have gotten away with a simple Fx posterior process on the right talus - although there is evidence of a depression Fx of the posterior facet as well (healed fracture line in the body of the calcaneus)

TREATMENT:
Depending on his symptoms, he's a candidate for a triple on the left.
Tx for the right most likely orthotic control (for now).
If he had ankle symptoms I would guess it's simple synovitis. His left TNJ will get worse with time is not fused.

This is probably all pretty obvious.
Good luck.

Steve

 

Steve

Like everything its obvious when your familiar with the problem, which is why I require your expert assistance here. Thanks for your help.

All the best Dave

 

ORIF - what's this

 

ORIF = open reduction internal fixation

 

Steeve,
even in after ORIF, we are having problem of
collapse of the calcaneum and the secondary
degenerative changes in sub talar joint.

how do you select the pt for surgical management,?
are you using bone graft?
what type of plate are you using?

suresh