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Need advice from the Pod surgeons please.

Have just consulted a 64 yr old male, T2DM (12 yr onset, fluctuant control - last HbA1c 8mmol/L), 120kg's, 6.4ft tall. Presents with chronic painful feet. Primarily during weight-bearing and activity.

Clinically, neuropathy was well present. As was PVD. The x-ray attached confirm my MSK exam of marked limitation, just about everywhere.

My concern is around his inability for ankle dorsiflexion and his high pressure (seen on WinPod) at his 1st MPJ left and plantar hallux right + his almost complete loss of sensation at these (and other) points.

Conservative Mx includes orthotics and footwear. The former to off-load and redistribute pressure and force. The latter to accommodate his size UK13 feet and orthotics and of course to increase comfort.

But what about any surgical options? Would any of you discourage an Achilles lengthening to allow for improved dorsiflexion and reduced pressure at the fore-foot?
The rest of the foot seems too rigid for much else in as far as functional intervention, but what about prophylaxis? Especially around the rear-foot (talo-navicular, navicular-cuneiform, STJ)?

Any thoughts/ advice greatly appreciated.

Regards

Brandon

 

Brandon

Your patient, based on the limited views available, has severe DJD throughout the hindfoot and ankle. He also has neuropathy and a poor recent HbA1c.

At this point your diagnosis is unclear. Is the chronic pain due to his arthritis? Or is it due to painful neuropathy.

If it is the former, doing a tendo Achilles lengthening in isolation is pointless. He has anterior ankle impingement/OA, plus marked TN osteophytosis/OA. This is a bony equinus. I would be looking to Richie Brace/AFO conservatively first. His surgical options, depending further imaging, would be centered around ankle fusion/ TN fusion etc.

If it is neuropathic pain that is his chief complaint, then better glycaemic control first, followed by pain management such as gabapentin or pregabalin.

LL

 

Hi LL

Thank you. And I agree with all. Of concern is that in this case, it's just about impossible to differentiate between purely neuropathic and OA pain. It is most likely both.

Optimal glycaemic control is being pursued. My chief concern is to limit the possible chances for fore-foot ulceration based on the radiological findings plus the neuropathy.

I also thought perhaps ankle fusion as an option, but the benefit long term to the reduction of fore-foot pressure is of course limited.

A Richie Brace is of course an outstanding conservative option but patient compliance may rule this option redundant.

the more I think about this the more I reckon a non-surgical approach is better suited - to include footwear, orthotics, Richie Brace, regular check-ups and of course strict glycaemic control.

regards

Brandon

 

Until, or if, there is ever any neuropathic forefoot ulceration, I would not make this the goal of treatment.

I would try to continue to pursue the basis of his symptoms, and try to resolve this.

A simple technique is to place him in a removable walking cast for a few weeks. This would emulate an ankle/triple arthrodesis. If his symptoms are largely improved, then his pain is arthritic in nature. If it is neuropathic pain (due to diabetes, B12, etc) I would doubt it would improve (unless it is tarsal tunnel). Simple diagnostic test. Treat accordingly from there.

Hope this helps,

LL