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Advice on, hyprocure and early HAV surgery.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Nov 23, 2009.

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    A tricky one this. Would appreciate any help anyone can offer. Poor kid is in a lot of pain and I've not been able to offer much by way of comfort or optimism prognosis wise.

    Patient is in early 20's. Had surgery for a painless but substantial HAV in both feet around a year ago. Sorry, don't know the details of the operation. Returned to surgeon a few months later with substantial pain 2-4 MPJs both feet. Surgeon Diagnosed mortons neuroma 2-3 and 3-4 and carried out a double neurectomy. Both feet. Dorsal approach.

    I saw this patient about a month ago. She now presents with severe and sharp pain 2-4 PMA and recently developed pain 4-5 as well. Also presents with pain around medial and lateral ankle, around Tibialis anterior and peroneal muscles. Also reports recent onset knee pain. The pain is severely limiting the patients activity and the patient has plans to move to south east Asia (I think it was, somewhere far far away) first half of 2010.

    O/E patient presents with a shortened 1st ray which does not weightbear substantially on static stance, very limited dorsiflexion range at 1st MPj, no effective windlass function. Joint ranges are as one would expect and QOM is perhaps a little on the loose side.

    Gait is heavily antalgic and difficult to assess consistently as it changes based on the degree of pain in the various locations.

    Patient was referred to me for orthotics to "control the hypermobility". I'm at a bit of a loss with this one. I've started with a polyprop 2/3rds with no medial wedging cast a shade below neutral. I'm acutely aware of how "hot" all the muscles are and I don't want to aggravate the peroneals more than they already are. I have a view to making a more aggressive prescription with a deeper heel cup and higher medial flange if she tolerates the lower one.

    I considered a mortons extension to bring the ground up to the 1st met head but I'm also a little reluctant to exert more dorsi-flexion moment to the 1st met. I don't want to chase it higher into the foot than it already is!

    The Surgeon has also suggested using a hyprocure stent to block the sub talar joint. I've had no experience with these but I am instinctively cautious about this. The medial column is already well off the ground and the lateral part of the forefoot is taking a battering. Assuming the stent is up to the task, i'm not convinced supinating the foot like that is wise!

    So I'm interested in:-

    General thoughts

    Opinions on hyprocure in general and for this case in particular.

    Ideas for anything orthotic wise.

    Any other options at all.

    Sorry, the photos are a bit rubbish....


  2. drsarbes

    drsarbes Well-Known Member

    Hi Robert:

    Looks like the Surgeon shortened/dorsiflexed the first ray even more than they had been preoperatively, causing not only additional forefoot varus but sub lesser met pain from the transfered weight bearing. Probably never had neuromas.

    Some bunions NEVER hurt! Guess his preventive surgery didn't prevent much except a painless foot.

    The hypocure (or any arthroereisis procedure) only decreases STJ eversion, it's not a cure for flat feet, especially if they have a short heel cord and marked FF varus.
    Sounds like your surgeon has the Hammer/Nail syndrome.

    Prior to any additional surgery I would get some Orthotic suggestions from the arena.

  3. Thanks Steve. I was Hoping you'd pick this one up.

    I did wonder. Never been entirely happy with surgery based on a clinical DX alone, especially considering how long the recovery is from that op! The bits were sent to histology and reported "features consistant with Mortons Neuroma" but then I can remember reading a study, which i cannot now find:bang:, which reported pretty much identical histo reports between painful neuroma and painless control groups!

    Hammer and nail indeed.

  4. Which throws another big curve ball at treatment hot not wanting to wear shoes etc.

    Ive got something brewing pretty left field 1st some questions. How bad is her balance-proprioception. Whats the power of triceps surea like ?
  5. Triceps surae are pretty good. Patient did a lot of gymnastics before all this started. Balance ain't so good. Its still within a year or so of the surgery so I suspect she's still trying to reset her proprioceptive control. I'd have suggested a wii fit only the pain is rather too severe.

    I think the balance will improve over time and with it the peroneal / tibialis pain although I don't know how far it will go before it plateaus in the absence of 1st ray function (PCI anyone:pigs::eek:). Be good to accelerate the process but the real nasty bit is the lateral planter pain.

    Left field is good because all the options in the middle of the field stink. Hit me with it!

  6. Alrighty then.

    Here´s what I got. It appears the forefoot is mess. Function with Tib Ant and Peroneal sounds a bit messy too.

    So change the forces are acting on the foot .... Rocker bottom shoes/MBT´s with an ankle brace.
    You could make some changes to the insole in the shoe by fitting a D pad to support the navicular ie stop navicular drop.
    Also increase lateral column support. These could be from felt or ppt.

    Here why I came to this one.... Take away the importance of pronation- supination during gait, stabilize inversion-eversion of MTJ with padding, stabilize ankle inversion-eversion with bracing, soft cushioning rocker bottom will reduce bending moments on mets from GRF.

    what do you think ?
  7. Interesting...

    I did think of MBTs for the forefoot pain but dismissed it as an idea because of the increased muscle demand to stabilize the (already unstable) foot. MBTs in conjunction with an ankle brace... that I had'nt thought of.

    Stopping the nav drop is the trick. If I do that the 1st met don't weightbear and the lateral foot stays overloaded. If I let the nav drop the ankle suffers. If I force the 1st met to bear weight by putting a shaft under it I jeapordize that joint.:bang:.

    MBTs with an ankle brace. Hmmm.

    What If I took a garden variety reebok classic trainer and built a 20mm rocker into the sole. Be less destabilising than an MBT...

    Thanks for that. Its certainly something to mull.

    Anyone else got anything?

  8. Robert:

    I call patients like this "surgical cripples" since the surgeon has basically crippled this patient for life. This is why anyone doing foot surgery should be required to have excellent knowledge of foot and lower biomechanics. Unfortunately, many foot surgery training programs focus more on how to do the surgery, which instruments or tools to use, and on "making the angles on xray better" rather than the potential devastating biomechancal effects that improper foot surgery can have on patients.

    Unfortunately, I am referred many of these "surgical cripples" such as your patient in the hopes that I can salvage their foot with foot orthoses to make them somewhat functional again. The goal with this type of foot with surgically induced metatarsus primus elevatus deformity is to attempt to reestablish some weightbearing function to the overs-hortened/over-dorsiflexed first metatarsal.

    I would definitely use a Morton's extension combined along with an antipronation orthosis with a deep heel cup, well-formed medial longitudinal arch and medial heel skive in order to reduce the ground reaction force (GRF) plantar to the 2nd and 3rd metatarsals. You may also want to leave the anterior edge of the orthosis about 5-6 mm thick to further reduce the GRF plantar to the lesser metatarsal heads. The idea of an MBT or rocker sole may be a good option but I wouldn't use that as a first choice. The muscle pain in the leg is the likely result of the patient's antalgic gait pattern due to their trying to avoid forefoot loading during gait.

    The choice of a subtalar arthroereisis procedure is ridiculous since this would not do anything to reestablish the normal weightbearing function of the 1st metatarsal head. If any surgical procedure needs to be done, the first metatarsal should be lengthened and/or plantarflexed to allow it to bear weight again. This is a very difficult procedure and should only be carried out by someone who is familiar with this type of surgery. I definitely would tell this patient to avoid the surgeon who did these things to their feet like the plague!

    Hope this helps.
  9. Thanks Kevin. Strong and harsh words but sadly not untrue! I'm used to seeing severe deformity in elderly Rheumatoid patients. Its rather horrible to be having to think this way about somebody so young.

    I suppose bringing the 1st met off the bench and into play has got to happen hasn't it. To be perfectly honest I'm probably being overcautious about what I do here. I reeeeally don't want to add to this patients troubles and I'm acutely aware that I won't be able to monitor her for further complications if the post surgical joint is not up to weight bearing. I might be tempted to pad her up with SCF under the 1st met for a few days and see how she fares with that before I try it on an orthotic.

    And I think we have a consensus that an arthroereisis is well and truly off the table in terms of treatment options. Bit of a funny one that. :wacko:

    Thanks for the advice.

  10. Robert:

    The Morton's extension will not work by itself. You will need a custom foot orthosis of the design that I described earlier to do anything truly useful for this patient. I have seen numbers of these patients over the last 25 years and have tried many types of orthosis designs. If the orthosis is designed properly and the patient is willing to wear supportive shoes with the orthoses, then they will have some chance for a normal active life in the future. Otherwise, there is, unfortunately, little hope of the patient having any chance of painfree walking in the future with any other type of treatment.
  11. I would think if you do go down the Rockerbottom road, any shoe would work even a hiking boot.

    Good luck it looks like Kevins got some orthotic options for you to try 1st.
  12. The patient already has a custom orthotic along pretty much the lines you describe lacking only the mortons extension so it would'nt be by itself.

    The patient is more than willing to wear anything which will help!

    We'll see. The thing is, the neurectomies I see post op routinely take well over a year, sometime two, to settle down even with orthotics. If the muscle pain is caused by the antalgic gait then I can't see that improving until the op sites do. And offloading is a bit of a mare when 2 - 5 is all painful and 1 is hanging in mid air. Thats why I think Michaels idea for a rocker and Kevins Idea of a thick leading edge both have some merit. But I rather suspect / hope that the muscle pain is caused as much by instability as antalgic hypertonia.

    Nice ring to it. Reminds me of ice-cream. I think we will indeed be traveling that happy path!

    Thanks to both.

  13. Here is my biomechanical rationale for which such an orthosis works so well for these patients:

    The lack of ground reaction force (GRF) plantar to the 1st metatarsal head causes not only a transfer of excessive GRF to the 2nd and 3rd metatarsal heads, causing increased pressure and pain plantar to these metatarsal heads, but also causes a reduction in external subtalar joint (STJ) supination moment (or an increase in external STJ pronation moment). The foot orthosis must be designed to increase the external STJ supination moment to make up for the lack of STJ supination moment that would normally be caused by GRF acting on the plantar 1st metatarsal head since the 1st metatarsal head is the most medial metatarsal of the foot and, therefore, the one most capable of causing increased external STJ supination moments with increased GRF acting on its plantar aspect.

    The orthosis I used for these patients includes the following orthosis modifications:

    1) Morton's extension: to increase the GRF plantar to the first metatarsal head to not only increase the external STJ supination moment but also decrease the plantar pressure on the 2nd and 3rd metatarsal heads;

    2) Inverted heel cup: to increase the GRF plantar to the medial calcaneus to increase the external STJ supination moment (e.g. 4 mm medial heel skive);

    3) Higher and stiffer medial longitudinal arch: to shift the GRF toward the medial aspect of the midfoot which will decrease external STJ pronation moment/increase external STJ supination moment (e.g. minimal medial longitudinal arch fill, inverted cast balancing, stiffer orthosis plate);

    4) Thicker and longer anterior edge of orthosis: to reduce GRF and pressure plantar to 2nd and 3rd metatarsal heads so that during late midstance and propulsion these metatarsal heads have reduced plantar loads (e.g. make orthosis trim line distally to exactly at 2nd and 3rd metatarsal neck when patient is weightbearing on orthosis and make it 5-6 mm thick....I have called this the "internal metatarsal bar effect" in my first book).

    Hope this helps.
  14. mgates01

    mgates01 Active Member

    Is there an optimum time to begin orthotic therapy post surgery. I realise it will depend on the kind of surgery carried out but I'm probably thinking of those procedures that do take a while to settle.

    I always worry that I might undermine the patient's faith in the benefits of orthoses by prescibing too soon while the foot is still recovering from "normal" post op pain, leaving the patient assuming that orthoses have little or no benefitial impact on their foot health.

    It's probably an impossible time scale to quantify simply, but I'd be interested to hear how others determine the point at which to introduce orthoses post operatively.
    ps Kevin - don't suppose there are any plans to reprint your first book ??

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