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Severe ankle equinus and diastasis

Discussion in 'General Issues and Discussion Forum' started by Mark Russell, Aug 2, 2011.


  1. Members do not see these Ads. Sign Up.
    I have a very active sixty-one year-old female with severe ankle equinus following failed soft tisue release as a child for asymetrical TEV. Rx to date has been a variety of compressed felt crescent pads which fit over the bursae on her lateral mallelous on which she weighbears. I have an interesting set of radiographs which I will try and upload later, but as can be seen, there is gross deformation of the rearfoot with a relatively normal forefoot anatomy. Weighbearing is on the lateral malleolus with the calcaneus lying on its lateral side parallel to the ground.

    The ankle deformation is progressive and the LLD is now having an impact on her left knee and hip. The only surgical opinion she has had recommended a BK amputation with prosthetic limb - which may yet prove to be the best option. However my patient would be keen to consider some form of reconstructive surgical program - TJR or arthrodesis - with a suitably specialist surgeon. Any recommendations - UK preferably.

    Many thanks

    Mark Russell

    Attached Files:

  2. While I can't offer anything of help - looking forward to seeing the x-rays.

    Thanks for posting - tough one.
  3. efuller

    efuller MVP

    Wow, very active? What does she put on the bottom of her legs when she is active? What does the weight bearing skin look like? How rigid is the foot? (How rigid in the sagittal and frontal planes?) It looks like there is some pressure on the lateral forefoot from the picture. What is the angle of the forefoot to the ground when weight bearing? Will the medial forefoot accept load with a reasonable angle of forefoot wedging? Does it hurt?
    Does she want her foot wear to look nice? >>> BK/ terminal symes

    I'm imagining setting the whole mess into a foam box and creating a healing sandal that brings the ground up to the foot in as many locations as possible.

    Last edited: Aug 2, 2011
  4. Eric,

    The forefoot is fully plantargrade and has a fairly normal load pattern at late midstance through push-off. There is no heel strike as such, rather its a lateral malleolus strike then a rocker over the base of the 5th Metatarsal then push off through the hallux. The forefoot anatomy is, as previously stated, relatively normal with no degenerative changes at the MTPJs. There is a substantial malleolar bursa on which she weightbears and this is surprisingly asymptomatic - in fact, given the gross rearfoot deformation - the whole foot is remarkably pain free, with the other leg being the primary cause of discomfort.

    I have made her a poron ankle shield similar to the felt pads she has been wearing, which cups the bursa and provides a cushioned platform with a protected graphite plate, which she walks upon - I'll upload some more photos later with the radiographs. This she wears in a neoprene ankle cuff with he crocs - the only footwear she can use.

    Clearly the aim is to stabilise this foot, but because of the rearfoot alignment, any AFO will make the equinus more progressive, therefore surgery really is the only show in town here - the question being salvage or reconstructive?



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  5. Ryan McCallum

    Ryan McCallum Active Member

    You are more likely to get a useful surgical opinion if there are any x-rays available?
    Ideally, a weightbearing DP, latera of the foot and AP of the ankle. Without, it is very difficult to be any way specific or even helpful I really.

    Is the deformity at all reducible?

  6. Some weightbearing with padding in situ.

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  7. That's why I mentioned in the first post that I would upload radiographs in the next few days - I had a set done but unfortunately the CDRom was unavailable. I would say that they are of limited value insofar as there is much soft tissue calcification which makes indentification of the usual structures challenging, to say the least. For example there is a 3cm horn of new bone at the distal end of the fibula.

    I think we might need to do some additional 3D vol CT scans to give a better picture of what's going on in there, but in the meantime I'll upload the radiographs when I've scanned them tomorrow.

  8. drsarbes

    drsarbes Well-Known Member

    Looks like a candidate for an ankle and possibly STJ fusion.
    I see the Achilles incision. Obviously not Tx properly.
    In retrospect this should not have been allowed to get this bad.
  9. Mark looking forward to the x-rays ( if looking forward to is the right thing)

    Been thinking - Re Eric idea - and had a patient with a similar problem yesterday, but not near as bad - not even close.

    The patient foot (mine) was left with the styloid Process of the 5th as the most plantar aspect so as she strikes ( midfoot) the styloid process position means a very effective pronation moment.

    Her heel I don´t think has come in contact with the ground in 50 years.

    So what I am considering is a full contact device made out of Plastazote or the like to distribute the GRF over the whole foot, especially to bring the ground up to the heel in my patients case are reduce loads from the Styloid process of the 5th, and use a midfoot rocker in her shoes.

    This got me thinking about you patient.

    If you use Eric´s idea in supper soft material - for comfort and combine it with a full foot and ankle orthoses with a rocker sole you may have some positive outcomes.

    The foot and ankle device would allow the patient to use knee flexion to help to create forward progression - though the use of the plastic flex of the device, the rocker sole would reduce the amount of force required to move the CoP proximal to distal, the full contact soft device would distribute the GRF over the whole plantar surface and the Foot and Ankle device would provide energy and the same time if you use a light weight boot, with soft rocker sole the foot and ankle orthoses and boot would provide a better feed back to the patient on where the leg and foot are in relation to the Ground.

    Hope thats an idea and makes sense

    (seem to be having a really bad spelling day, sorry I know they are wrong and so does my spell check but no help)
  10. sarahhemsley

    sarahhemsley Member

    What was the final outcome for this lady? Did she have surgery or were you able to keep her off the operating table for a while? Can you post photos of any device you may have made?
  11. Hi Sarah if you look on the top left corner you will see the date the post was made.

    Mark only started the thread this week.
  12. Apologies for the quality of these plates - they don't scan particularly well.

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  13. efuller

    efuller MVP

    Now we are really opening up a can of worms. Essentially we are treating the grossly abnormal foot to make the other, symptomatic, limb better. Before you attempt to treat the "pain free" foot you should establish if your potential treatment will make the symptomatic side better. If you think the dramatic difference in leg length is contributing to contralateral symptoms, then you should have her walk with a lift for a while to see if balancing the limb length will help the "normal" symptomatic side.

    I'm not so sure that is the aim if the contralateral side is what's bothering her. Clearly, the picture of the foot says treat me, but what are her goals. She's had this for over 60 years and has coped quite well, I'm guessing, to this point. Did she walk into the office and say my foot and leg hurt and by the way on the other side I had a failed club foot surgery?

    There are so many questions for a potential reconstructive surgery. If you brought the heel underneath the leg, would the heel that has not born weight for 60 years be able bear weight now? Would moving bones that far compromise the blood vessels to the moved parts. Would moving the rearfoot keep the forefoot plantigrade. By the way, the callus in the picture of the bottom of the foot makes it look that there is more lateral than medial load. Is the mid foot rigid enough to accept weight when the forefoot is off of the ground?

    It makes me think of a patient I met in my residency who was a 17 year old boy who had bi lateral club foot. This was at the Baja crippled childrens project in Mexico. I saw him several times, the last time was after he got the cast off his second foot post tripple arthorodesis and reconstructive surgery. It was the first time he had been able to bear weight on the bottoms of both feet and walk without crutches. The look on his face was priceless. He had ridden on a bus for 3 days and 2 nights for each of the visits that we had seen him. The pain he must have been in after the surgery going back home must have been incredible. I was looking at him and thinking wow 17 and tripple arthrodesis of both feet. What are his ankles going to look like in 20 years. On the other hand, not having to use crutches just to get around is a huge upside.

    There is some benefit to cosmetic surgery. However, 17 year old is much different than a 60 year old. His initial deformity was not as bad as this patient's. Well, it's not quite cosmetic because there is significant deformity. What is the potential benefit verus the potential risk?

    What other questions can people think of that need to be asked. Osteopenia?

  14. efuller

    efuller MVP

    We were posting at the same time.

    Clearly some osteopenia. Perhaps someone who has done more suregery than I have can comment on the quality of the bone seen in the x-ray versus being able to hold together with fixation.

  15. Ryan McCallum

    Ryan McCallum Active Member

    Thanks for the x-rays Mark.

    I appreciate what you meant about the limited value but interesting nonetheless!

    I would imagine the only salvagable procedure in this case would be an ankle joint fusion (and as Steve said +/- subtalar joint depending on clinical assessment and repeated x-rays). Eric makes a very valid point in that the bone stock does appear to be quite poor however this may just be a reflection on the quality of the pictures or how the x-rays were taken (wishful thinking maybe!)
    That notwithstanding, I am not sure it would actually stand in the way of offering a fusion provided there was a good understanding on the patient's part about the associated risks and complications related to this- especially taking into consideration the alternative she has been offered!
    We have sucessfully performed subtalar joint fusions in rheumatoid patients with dreadful bone stock so I wouldn't rule fusion out as an option.

    I'm not sure that helps much but essentially, I would certainly advise of seeking a second surgical opinion looking at a salvage rather than opting for the amputation.

  16. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I have a similar patient, with not quite so severe deformity.

    He had a peroneal nerve injury, which went on to cause severe ankle varus and lateral instability. He now gets chronic neuropathic ulceration lateral to the calcaneus.

    He is not a surgical candidate for ankle fusion due to co-morbidities.

    With the help of a good orthopaedic bootmaker, we have stabilised the deformity quite well. The posterior tibial is in spasm and the deformity is only somewhat reducible.

    I hope the following images might be of help in assisting this woman.

    Good bracing and orthotic design are perhaps the only option if she won't/can't undergo fusion.


    Attached Files:

  17. I'm not certain it is a can of worms, Eric and I don't see it as clearly as one limb versus the other. One also has to consider the rate of deterioration on the abnormal foot - even though it is relatively asymptomatic with the short term padding she has had to use over the past 20+ years. Also, in the event of a fairly simple accident - say a fall from her motorcycle or a trip on a step - given the ankle anatomy, even a minor trauma could potentially be disastrous, structurally. What choice then facing the trauma surgeon who may be unfortunate to face such a presentation? I'm trying to plan ahead for this lady and give her the best options available - and I take your point about the complexity of reconstructive surgery and this is the nub of what I'm trying to get at. Obviously it is a major task. Is it a risk worth taking? Do we leave as it is - I don't think it is sustainable even with a good AFO and there's the aforementioned trauma risk - what then? Or do we consider an elective BK amputation with a good prosthetic.

    I had a patient 20 years ago - who had polio as a child and had an atrophic underdeveloped limb with the usual poliomyelitic lesions. He was a saddler and shoe maker and had made his own surgical footwear most of his life. Eventually - at 73 years old, he elected for a BK amputation as his other hip was deteriorating rapidly. He underwent concurrent procedures and it made a fantastic difference to his quality of life -he even took up bowling again - 7 months post op.

    Interesting comment about osteopenia. I didn't think you could determine that from radiographs - only MRI. But obviously bone density is a primary consideration. Thanks for the input - would be grateful for some more surgical opinions, please.

  18. RobinP

    RobinP Well-Known Member

    What is the likely loss of leg length from reconstuctive surgery, if any?

    A a dual qualified prosthetist/orthotist(although it is many years since I have done prosthetics) I am acutely aware of quality of life with regards to reconstructive surgery versus amputation.

    I have seen an increasing trend toward partial foot amputations in my diabetic population which are incredibly difficult to manage. Patients are left with a non functional foot and everthing from their enrgy expenditure to their self esteem at having to wear (frankly) pretty cosmetically poor boots even in summer is really knocked around.

    Clearly, this is not the case here and post reconstruction, the foot and ankle may well be reaonably functional. But what are the chances following the reconstruction, given the degree of deformity and the atypical structures as a result of the TEV that the patient will not require orthopaedic footwear and bespoke foot orthoses(total contact style). Pretty low would be my guess.

    What will be the rehab time for that type of surgical intervention especially when there may be questions over bone density? What are the chances of having a gait pattern post operatively that would be considered "normal"?

    A trans tibial elective amputation where the length of the stump/residuum can be determined and chosen for maximum lever arm and best componentry fitting would allow the patient to be walking with a reasonably definitive limb within 4-6 weeks. Over a 6 month period progression on to a limb with some top notch componentry, appropriate for an active 60 year old, should be possible. If this person wants to pursue sports etc, this should present no problems.

    Clearly a trans tibial amputation is a step not to be taken lightly and some serious pre op councelling/meeting with other prosthetic users/meeting with the prosthetic team will be critical to the success of the amputation. However, i think it is always viewed as a last resort where, in some cases, it should be considered a quickest route to an active and fullfilling life.

    Just my 2p

  19. Ryan McCallum

    Ryan McCallum Active Member

    Hi Robin,
    Good post.

    I think you make a number of interesting points. I suppoe if it was an easy decision then we wouldn't be discussing it!

    You mention about the energy expenditure and self esteem of those patients with partial foot amputations in comparison to BK amputees. I have to disagree with you on that point. There is an abundance of evidence supporting the fact that energy expenditure levels increases as the level of amputation becomes more proximal. Morbidity and mortality also increase the higher the level of amputation. Admittedly, this is of course a comletely different category of patients.

    As for the chances of being able to avoid wearing orthopaedic footwear following reconstruction, I can't answer that one. I suspect I am on the same boat as yourself and doubt this patient would be wearing footwear of choice post op but I suspect they would be considerably more acceptable than she has been wearing to date.

    I can only speak for our post op regimes but as standard, following ankle joint fusion (or hindfoot fusion) the patient is non weightbearing for 8 weeks then x-ray. If happy at that point, into an aircast walker for a further 4 weeks then x-ray and decide whether the patient can return to a supportive hiking boot or alternatvely another 4 weeks in the aircast. If of course, intra operatively it was noted that the bone stock was poor, we would amend this regime accordingly. We always tell the patients that the overall recovery will be approximately 9 months.

    As for when the gait pattern being normal? Never. Improved? Hopefully pretty much as soon as they are in footwear.
    As with fusion of any joint, I always stress to patients that they are not going to have a 'normal foot' again. The intention is to improve upon what they have and realistically, there should be no limitations post op that weren't there pre op (hopefully less!)
    Your point about the amputation having the quicker recovery and ability to return to sporting activity is certainly very important. I am unsure about how many patients would use this as justification for having their leg amputated though.

  20. efuller

    efuller MVP

    Is the rate of deterioration much greater than a normal foot? Are the choices facing the trauma surgeon much different than the choices that we are facing now? It may be fragile, but are we really worrying about an injury creating a severe deformity? I agree that it is important to give her the best options available so that she can make an informed decision. It is also important not to color that information with our biases. I haven't seen her walk, so I can't see how happy she is about how she if forced to get around. If she has lived with this all her life then she has no idea what walking normally is like. That potential upside will be hard for her to grasp when she makes her decision.

    If you look at it like what would I do if that were my foot, it is still a hard decision. I doubt you are going to find a surgeon who has done 10 of these in the last year. As a surgeon, it would be a very interesting challenge and technically difficult, but the surgeon doesn't live with the results. Although, after it's all healed, the chances of it looking worse are small. Tough call.

    The cortices of the metatarsals are very thin and this correlates with osteopenia.

  21. Thanks for the comments and advice - any suggestions for a reputable surgeon who secialises in ankle reconstruction/replacements in the UK?
  22. RobinP

    RobinP Well-Known Member

    Nicholas Geary in Liverpool. Generally a pretty good foot ankle surgeon. PM me if you want details. I send people to him from the IOMan because he can see them in the morning, have imaging done during the day and do the consultation later in the day. - 1 day trip for the patient. Not such a big deal where you are from but handy that he can do it quickly if time is a factor

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