PPRP OF FOOT AND ANKLE

by dr. giridhar boyapati

pg

dept. of orthopaedics

Foot and Ankle are the most dependent parts of the body subjected to significant amount of deforming forces

M.c deformities includes-1. Claw toes

2. Cavus deformity and claw toes3. Dorsal bunion4. Talipes Equinus5. Talipes Equino Varus6. Talipes Equino Valgus7. Talipes Calcaneus

PEABODY’S CLASSIFCATION

1. Limited extensor invertor insufficiency

2. Gross extensor invertor insufficiency

3. Evertor insufficiency

4. Triceps surae insufficiency

LIMITED EXTENSOR INVERTOR INSUFFICIENCY

- Tibialis Anterior muscle paralysis produces slowly

progressive deformity

1. Equinus

2. Cavus

3. Varying degree of plano values

Muscle power is redistributed by transferring the EHL tendon

to base of 1st metatarsal + plantar fasciotomy.

GROSS EXTENSOR INVERTOR INSUFFICIENCY

TYPE A

-Paralysis of Extensors of toes and Tibialis Anterior in the

presence of relatively normal Tibialis Posterior muscle. Produces

-Equinus

-Equino Valgus

• Transfer of Peroneus Longus to dorsum of 1st

cunieform bone.

• Talo-navicular arthrodesis is combined if deformity is

fixed.

TYPE B

Paralysis of both Tibialis Anterior & Tibialis

Posterior and toe extensors

Transfer of both Peroneals to dorsum of foot.

Hoke arthrodesis is combined in severe deformity

EVERTOR INSUFFICIENCY

Paralysis of Peroneal muscles producing

- Varus foot

• Deformity produce Slight to moderate impairment:

Transfer of EHL to base of 5th MT.

• Severe:- Tibialis anterior to cuboid

EHL to base of 5th MT

TRICEPS SURAE INSUFFICIENCY

Calcaneo-Varus deformity- Tibialis posterior,FHL are

transferred.

Calcaneo-Valgus deformity- both peroneals attached

to calcaneum

Calcaneo-Cavus in which both invertors and

overtures are strong. transfer of peroneals,tibialis

posterior tendons to calcaneus.

when to operate

1. wait for atleast 1 1/2 years after paralytic attack.

2. tendon transfers done in skeletally immature

3. Extra articular arthrodesis 3-8 years

4. Tendon transfer around ankle and foot after 10yr of age can be

supplimented by arthrodesis to correct the deformity

5. Triple arthrodesis >10-11 years

6. Ankle arthrodesis >18 years

PRE-OPERATIVE CONSIDERATIONS

AGE:

bony procedures after skeletal maturity.

tendon transfers better after 10 yrs

TYPE OF DEFORMITY:

static deformity require bony procedures

dynamic deformity require both tendon transfer and bony

procedures.

CLAW TOE

Hyperextension of MTP and flexion of IPSeen when long toe extensors are used to substitute dorsiflexion of ankle

Treatment: For lateral 4 toes :

Procedure 1: division of extensor tendon by z-plasty incision,dorsal capsulotomy of MTP joint.

Procedure 2:

Girdlestone- Taylor tendon transforDorsolateral incision. Divide the long flexor tendon and suture them to lateral side of proximal phalanx to extensor expansion.

Dickson and Diveley procedure

For insufficiency of the planter flexors of the ankle-EHL tendon is divided proximal to IP joint.-Proximal end is attached to taut flexor tendons.-Distal part of extensor tendon sutured to soft tissues on dorsum of proximal phalanx to assist maintain opposition of raw surfaces of IP joint.-Arthrodesis of interphalangeal joint.

Modified Jone’s procedure

Division of EHL proximal to IP joint

Proximal slip fixed to neck of 1st metatarsal

Distal slip fixed to soft tissues

Arthrodesis of IP joint by K wire fixation

CAVUS AND CLAW FOOT

Primary deformity is forefoot Equinus resulting in clawing of

toes.

Clawing disappear if mild cavus of short duration is

corrected.

In severe cavus large callosities or even ulcerations may

develop beneath the metatarsal heads.

Clawing may lead to dorsal dislocation of MTP joint

In severe cases all plantar stuctures may contract

MILD CAVUS WITH CLAWING

Conservative : metatarsal bar on the shoe, metatarsal pads.

Surgical measures:

Division PL tendon and imbricate to PB assuming that the

deformity is due to imbalance of Tibialis Anterior and PL.

Arthrodesis of all IP joints assuming clawing is caused by

disturbance of function of intrinsic muscles of foot.

MODERATE

young children : Steindler’s fasciotomy

older children : Dwyers calcaneal osteotomy.

Japas V osteotomy

SEVERE DEFORMITY

Steindler’s fasciotomy

stripping of fat and muscles from both superficial and

deep surfaces.

Transverse division of fascia close to calcanea

attachment.

Release of long plantar ligament extending from

calcaneus to cuboid.

Cole’s Anterior wedge osteotomy

indicated in cavus without various or calcaneus or

gross muscle imbalance.

Advantage : preserves mid tarsal and sub-talar joints

Disadvantage: shortens the dorm of foot.

Osteotomy of the navicular and cuboid and defect is closed by

elevating the forefoot.

Japas V osteotomy.

apex of v is proximal at highest point of cavus

lateral limb extends to cuboid

medial limb through intermediate cuneiform to medial border

of foot.

no bone is excised

proximal border of distal fragment is pressed plantarwards,

while metatarsal heads are elevated correcting the

deformity.

Hibb’s operation

EDL tendons is divided and proximal end is inserted to 3rd

cuneiform.

EHL tendon is divided and fixed to neck of 1st metatarsal.

Interphalangeal joint arthrodesis.

DORSAL BUNION

Shaft of 1st MT is

dorsiflexed and graet toe

is plantar flexed resulting

in prominent head of 1st

metatarsal. If severe may

result in subluxation of

MTP joint.

Pathogenesis :

Imbalance between TA and PL : normally TA raises the 1st

cuneiform and 1st MT and PL opposes this action. Unopposed

action of TA causes this deformity. Thus before the transfer of

PL, the effect of its loss on 1st MT must be considered. Every

transfer of PL should be accompanied with midline transfer of

TA to 3rd cuneform.

Weakness of Anterior and lateral compartment muscles.

unopposed action of posterior compartment muscles causes

excessive plantar flexion of great toe.

LAPIDUS TECHNIQUE

Wedge of bone is removed from metatarso-cuneform and

naviculo-cuneform joint.

If TA is overactive, transfer it to 2nd or 3rd cuneiform.

FHL is detached and brought dorsally and attached to 1st

metatarsal, converting it into a plantar flexor of metatarsal

rather than great toe.

Subcutaneous plantar tenotomy

capsulotomy of 1st MTP joint.

HAMMOND TECHNIQUE

any deforming tendon except

the FHL is divided and

transferred to dorsum of foot to

correct MT displacement.

Fusion of joint.

TALIPES EQUINUS

Commonest deformity

Planter flexors are stronger than dorsiflexors and tight TA.

If lateral imbalance is there Equinuovarus or Equinovalgus may

result.

MANAGEMENT :

1. No intervention : mild equinus

2 Conservative management: exercises, serial casting, orthosis

and molded shoe wear.

3 Surgical management:

a) soft tissue procedures

b) bony procedures

Contraindications for surgery in equinous foot.

In children : children who will never walk due to week

arms.

minimal deformity and child is managing well

Infection

In adults : Equinus foot is stabilizing n unstable foot.

Equinus foot is compensating for shortening.

Lengthening of Tendo-achillis

1. Percutaneous Tenotomy

2. Z- plasty

Tendon transfer

1. Anterior transfer of TP

2. Anterior transfer of PL, PB

Cambells Posterior bone block operation

Usually combined with triple arthrodesis to correct lateral

instability.

A mechanical bone block is constituted on posterior aspect

of talus and superior aspect of calcaneus in such a manner

that it will impinge on posterior lip of distal tibia and prevent

plantar flexion.

Dorsiflexion is preserved.

Complications: Recurrence of deformity, degenerative

arthritis, flattening of talus, ankylosis of ankle

LAMBRINUDI PROCEDURE Talonavicular and Calcaneocuboid joint arthrodesis

Wedge of bone removed from distal and plantar parts of talus, so

that talus remains in equines but rest of foot is brought to

corrected position.

Complications : recurrent of deformity

residual deformity

degenerative tarsal athritis

pseudoarthrosis of talonavicular joint

flattening of talus

PANTALAR ARTHRODESIS

Surgical fusion of Tibio-talar, subtalar, talo-

navicular,calcaneo-cuboid joints.

Indications:

Calcaneous or Equinus deformity combined with lateral

instability of foot and whose leg muscles are strong enough

to control the foot and ankle.

Reccurance of deformity after post. bone block or

lambrinudis

Foot deformity with unstable knee due to quadriceps palsy.

Contraindications:

If full extension of knee is not possible

Insufficient hamstrings or triceps to prevent genu

recurvatum

When there is Equinus / Calcaneous deformity in addition to

unstable knee, whether pantalar arthrodesis will effectively

stabilize the knee may be determined before surgery by

applying a short leg walking cast.

TALIPES EQUINO VARUS

Deformity: equinus at ankle, inversion of heel at mid tarsal

joint, adduction of forefoot. Cavus and clawing may develop

in long standing cases.

Weak peroneals

Weak Tibialis anterior

Normal triceps surae

Equinus thus produced increases mechanical advantage of

TP which in turn encourages the fixation of hind foot

inversion and forefoot adduction and supination.Cavus and

clawing develop when toe extensors help to dorsiflex the

ankle.

Treatment:

Young children4-8 yrs:

Double bar brace with ankle stopStretching of plantar fascia and posterior ankle structure with wedging castingTA lengtheningPosterior capsulotomyAnterior transfer of tibialis posterior or Split transfer of tibialis anterior to insertion of p.brevis (if tibialis posterior is weak)Anterior transfer of medial half of tendo-calcaneous( Caldwell)

Children >8yrs:

Steindlers fasciotomyTriple arthrodesisAnterior transfer of tibialis posteriorModified jones procedure When TP is weak TA is transferred laterally to midline.

TALIPES EQUINO VALGUS

Tibialis anterior and Tibialis

posterior are weak and

Peroneal longus and brevis

are strong and the triceps sure

is strong and contracted.

Triceps surae pulls the foot

into equinus and the

Peroneals into valgus.

Treatment: skeletally immatureDouble bar brace with ankle stopShoe with an arch support and medial heel wedge

Repeated stretching and wedging cast TA lengtheningAnterior transfer of peronealsSubtalar arthrodesis and anterior transfer of peroneals(Grice and green arthrodesis)

Skeletally mature :TA lengtheningTriple arthrodesis followed by anterior transfer of peronealsModified Jones

TALIPES CAVOVARUS

Seen due to imbalance of extrinsic muscles or by unopposed short toe flexors and other intrinsic muscle

Plantar fasciotomy , Release of intrinsic muscles and resecting motor branch of medial and lateral plantar nerves before tendon surgeryPeroneus longus is transferred to the base of the second MTEHL is transferred to the neck of neck of 1st MT

TALIPES CALCANEUS

Due to unopposed action of

dorsiflexors

Plantar fasciotomy ,intrinsic muscle release before tendon transferTransfer of TP and PL and FHL tendons to calcaneous. Green and Grice

Posterior transfer of TA ( Peabody )

When EHL and EDL strength is good, both tibials and peroneials can be transferred posteriorly and EHL, EDL transferred proximally to act as dorsiflexors of ankle.

If adequate muscles are not available, Tenodesis of Tendoachiles to fibula is done ( Westin )

FLAIL FOOT

All muscles paralised distal to the kneeEquinus deformity results because passive plantar flexion andCavoequinus deformity because – intrinsic muscle may retain some function.

Radical plantar release TenodesisIn older pt mid foot wedge resection may be requiredANKLE ARTHRODESIS

Indian Journal of Orthopaedics ,

October 2004, Vol 38: Number 4. p 226-232

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