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Foot and ankle issues in Foot and ankle issues in collagen vascular disorderscollagen vascular disorders
• Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, VAVA
• Director, Eastern Virginia Medical School PMS 24Director, Eastern Virginia Medical School PMS 24
• Past President ACFAPediatricsPast President ACFAPediatrics
• Captain, (SCWO), MSC, USNR-RCaptain, (SCWO), MSC, USNR-R
Previous researchPrevious research
• Common foot problems identified by survey, Common foot problems identified by survey, Seattle, WA Seattle, WA
• Xrays taken at Detroit Children’s Hospital Xrays taken at Detroit Children’s Hospital evaluatedevaluated
• Footmax scans collected, Philadelphia, PAFootmax scans collected, Philadelphia, PA
Collagen vascular disordersCollagen vascular disorders
• Ehlers-Danlos SyndromeEhlers-Danlos Syndrome
• Marfans SyndromeMarfans Syndrome
• Osteogenesis imperfectaOsteogenesis imperfecta
• Etc….Etc….
Special considerationsSpecial considerations
• Soft tissue handlingSoft tissue handling
• Vascular fragility?Vascular fragility?
• Bone fragility?Bone fragility?
• Over pronation or saggingOver pronation or sagging
• Ankle may still be tight! Ankle may still be tight!
Common foot problemsCommon foot problems
• HypermobilityHypermobility
• ““Flat feet” with or without over pronationFlat feet” with or without over pronation
Common foot problemsCommon foot problems
• Uncommon Uncommon manifistationsmanifistations
• ““Bunions” with Bunions” with joint fluid leak joint fluid leak (ganglion cyst)(ganglion cyst)
Principles of podiatric Principles of podiatric interventionintervention
• Align and maintain functional anatomyAlign and maintain functional anatomy
• Avoid skin injuryAvoid skin injury
• Don’t rely on ligamentsDon’t rely on ligaments
• Select and time invasive intervention carefullySelect and time invasive intervention carefully
Align and maintain functional Align and maintain functional anatomyanatomy
• Foot orthoses-> controversialFoot orthoses-> controversial• Arthrodesis -> anecdotally mediocre Arthrodesis -> anecdotally mediocre
resultsresults• Osteotomies -> more reliable, much Osteotomies -> more reliable, much
experienceexperience• Arthroresis -> controversial but promisingArthroresis -> controversial but promising• Ligament replacement -> new devicesLigament replacement -> new devices
Sub talar arthroresisSub talar arthroresis
Subtalar ArthroresisSubtalar Arthroresis
• History/variationsHistory/variations
• goalsgoals
• DisadvantagesDisadvantages
• AdvantagesAdvantages
HISTORYHISTORY
• bone proceduresbone procedures
• Chambers 1946: bone blockChambers 1946: bone block
• Subotnick 1974 silastic carved plugSubotnick 1974 silastic carved plug
• Current:Current:
• Metal implantsMetal implants
• Absorbable implantsAbsorbable implants
HISTORYHISTORY
• PolymersPolymers
• MetalsMetals
• absorbableabsorbable
Goals of STAGoals of STA
• Relief of painRelief of pain
• Improved joint Improved joint alignment and alignment and functionfunction
• Interruption of Interruption of patho-mechanical patho-mechanical progressionprogression
• ““correction” of correction” of “deformity”???“deformity”???
STATE OF THE ARTSTATE OF THE ART
State of the artState of the art
Size matters!Size matters!
• CT measurements of sinus tarsus CT measurements of sinus tarsus
• Preliminary radiographic findings and sizing Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable sub implications on patients undergoing bioabsorbable sub talar arthroeresis, JFAS, 2007talar arthroeresis, JFAS, 2007
Metatarsus AdductusMetatarsus Adductus
DiagnosisDiagnosis• InfancyInfancy
•Toddler Toddler hoodhood
•ChildhooChildhoodd
•Adultery Adultery ;);)
Multiplanar deformitiesMultiplanar deformities
PrognosisPrognosis• No reliable methodNo reliable method
• Uncompensated: Uncompensated: styloid process, styloid process, HAV?, ankle injuries, HAV?, ankle injuries, lateral knee?, claw lateral knee?, claw toes…toes…
• Compensated: Compensated: complex over complex over pronation, HAV?, pronation, HAV?, hammertoeshammertoes
ManagementManagement
• Observation(?)Observation(?)
• ““stretching”(?)stretching”(?)
• CastingCasting
• SplintingSplinting
• Shoes(?)Shoes(?)
• SurgerySurgery
Good solutions for bad Good solutions for bad ligamentsligaments
• Strong: absorbable vs non absorbableStrong: absorbable vs non absorbable
• Minimally invasive (small incisions)Minimally invasive (small incisions)
• May obviate some bone surgeriesMay obviate some bone surgeries
• May permit weight bearing immediately May permit weight bearing immediately
External fixationExternal fixation
•Mini railsMini rails
•May obviate May obviate second second surgeries, may surgeries, may result in less result in less bone surgeriesbone surgeries
Please pray for our troopsPlease pray for our troops
US NAVY SEA US NAVY SEA BEESBEES