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Challenging case.

Discussion in 'Foot Surgery' started by Ryan McCallum, Jan 8, 2010.

  1. Ryan McCallum

    Ryan McCallum Active Member

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    Hi all,
    We recently had a difficult case of a 30ish female patient who had been referred to our department. Her complaint was mainly that of an unstable ankle with frequent episodes of "going over" on her ankle.

    The relevant history in this case was a traumatic accident when she was 5 years old where her "ankle was severed". I believe this was from a car accident. She required surgery to repair the ankle two years following the accident. She was unsure exactly what had been done, only that she had two or three operations within one or two years of each other. The only details we had from the GP was that a split tibialis anterior tendon transfer was performed (surgery was carried out in Belfast so we had no records). Over the years, the lady had been treated with orthoses, physiotherapy and various ankle straps and braces. The only relief she had was from a lace up brace.

    On presentation, the patient's foot adopted a supinated attitude in stance with a notable varus alignment of the hindfoot. the affected leg was slimmer than the contralateral side with atrophy of the peroneal muscles. It was difficult to palpate the peroneal tendons and the patient had no peroneal muscle strength. There was no other muscle weakness noted in either leg.
    It turns out, the patient had ruptured peroneus brevis (or it had been severed) and this was missed at the time and therefore not repaired.

    MRI results reported torn ATFL, CFL and peroneus brevis. Ankle joint synovitis with mild degenerative changes to the ankle and also a complete tib ant tendon transfer to the base of the 5th metatarsal or the cuboid I cannot remember exactly. Initially a split transfer was performed then subsequently the remaining tib ant was transferred across. Peroneus brevis tendon and muscle were unidentifiable on the MR.

    We discussed various options with the patient and tried researching different surgical options.

    I found one paper which reported two similar cases:
    Bordon et al, 1998: Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis. JBJS, 80-B (5) 781-784.

    We eventually ended up performing a FDL transfer to the base of the 5th met along with repair of the lateral ankle ligaments and a lateral displacement osteotomy of the calcaneus. Intra operativley, there wasn't much to be seen of p.longus.
    The patient is only a few weeks post op.

    Couple of questions.
    Is anyone aware of any literature supporting lateral displacement osteotomies of the calc for lateral ankle instability? (obviously not in isolation).
    Would anyone have done anything different?
    I am not entirely sure how the FDL is actually going to function so would like to hear what others think.
    Any other opinions welcome.

    Unfortunately I cannot get a hold of the pre op x-rays but hopefully should be able to get some photos.


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