FOOT PROBLEMS
From Canadian Orthopaedic Foot and Ankle Society Symposium,
sponsored by the University of British Columbia
Forefoot Pain with Bunion
| TIPS ON HISTORY AND PHYSICAL EXAMINATION óKevin
J. Wing, MD, Clinical Associate Professor, Department of Orthopaedics,
University of British Columbia Faculty of Medicine, Vancouver
|
| History: ask patient toósit and remove shoes
and socks before taking history; point to anatomic location of problems;
describe pain (quality; radiation; severity; timing; aggravating and
relieving factors); determineówhether pain under second
metatarsal head (indicates more severe problem); whether bunion problems
progressing; any steps taken to relieve problem |
| Physical examination: with patient standing,
considerówhether variation of normal or pathology requiring surgery;
weight-bearing position of foot (heel position; longitudinal arch;
forefoot shape and position); overall conditioning (single-leg balance;
basic gait assessment); patient on raised seat, knee flexed at
90ƒóexaminer on lower seat, with ready access to foot; begin
with knee, then move from hindfoot complex to forefoot; callosities
indicate weight-bearing pattern, whether foot or shoe transmitting force;
gastrocnemius equinus may be present; first ray
stabilityóhypermobility accompanies large deformities in older
patients; first metatarsophalangeal (MTP) jointódocument severity
of deformity; pronation of great toe indicates degree of rotation; signs
of arthritis in older patient; pulsesóassess and document;
neuropathyóif any suspicion, monofilament testing
|
| INVESTIGATIONS óTimothy P. Kalla, DPM,
Clinical Instructor, University of British Columbia Faculty of Medicine,
Operative Podiatrist, British Columbia Foot & Ankle Clinic, and
Division Head of Podiatry, Department of Orthopaedics, Providence Health
Care, Vancouver |
| Mechanical pain: distinguished from nonmechanical
pain (eg, rheumatologic or posttraumatic arthritis); primaryó
bunion, medial eminence, or joint pain; secondaryóalteration
in gait; weight-bearing starts at lateral aspect of heel through
mid-stance into arch area and out to great toe joint; lateral weight
transfer results in stress fractures and overload arthropathy around
lesser MTP joint, and painful sheer calluses |
| Physical examination: palpate MTP joints and
metatarsals; inspect pattern of callus, shoe wear (circular pattern under
forefoot), and toe length (long second and third metatarsals prone to
overload); assess range of motion of great toe joint, first ray, and ankle
joint (like ìteeter-totter,î pulled up when dorsiflexion limited, shifting
load to forefoot, leading to metatarsalgia) |
| Role of x-rays: to support clinical findings; for
preoperative planning; obtain standing views; do not ìtreat x-rayî (not
accurate index of pain); use to evaluateóintermetatarsal 1-2
angle; hallux abductus angle; metatarsal length pattern; calcaneal
inclination angle; relation of first and second metatarsals (elevatus
deformity) |
| CHEVRON OSTEOTOMY óMark Glazebrook, MD, Assistant
Professor, Division of Orthopaedic Surgery, Dalhousie University, Halifax,
Nova Scotia |
| Proper patient selection: essential to success;
condition must be painful; historyóshoe wear; previous surgery;
systemic health (eg, diabetes, rheumatoid arthritis); activity
level; referred patient may not want operation; clinical
examinationówhile weight-bearing; deformity not passively correctable
(indicates tight lateral complex or congruous joint, with different
treatment); pain with compression of MTP joint (indicates arthritis, with
different treatment); hypermobile first MTP and tarsometatarsal (TMT)
joint (treatment controversial); associated deformity (requires operation
on lesser toe) |
| Radiographic assessment: presence of arthritis;
angular measurements for surgery; sesamoid position for lateral complex;
hallux rigidus (uncommon) |
| Nonoperative treatment: must be attempted before
surgery |
| Further decisions: arthritis present (procedure
unlikely to be beneficial); arthritis absent and joint congruous (Aiken-
type osteotomy or other procedure to realign articular surface); not
congruous and not passively correctable (sesamoid lateral shift); not
congruous and passively correctable (most patients; chevron osteotomy
indicated) |
| Surgical procedure: patients need to
knowóìnot a simple bump removal,î involves foot realignment;
potential complications, eg, more pain, infection; intensive
postoperative care; potential hardware removal; techniqueó
straight medial approach; pyramidal distally based capsulotomy; visual
inspection; cooling with saline; initial limited bunion resection; chevron
osteotomy (at ≈60ƒ angle); lateral shift of distal
fragment; complete bunionectomy; pull on capsule for toe correction;
extensor hallucis longus (EHL) tendon tightness often requires Z-plasty
lengthening (warn patient of potential plantar flexion and strength loss)
|
Diabetes
| Risk factors in diabetic foot: history of problem;
foot deformity; peripheral vascular disease; peripheral neuropathy;
hemoglobin A1c (HbA1c
) >10% may be considered risk factor (indicates
nonadherence to therapy); reversible risk factorsófoot deformity
and peripheral vascular disease |
| Peripheral vascular disease:
assessmentóneuropathy makes pain poor indicator;
vascular calcification falsely elevates ankle brachial indices;
angiography gold standard for vascular assessment; speaker uses infrared
thermometer to compare foot temperatures (difference of 2-3ƒ celsius
indicates abnormality; when difference >5ƒ, consider infection or
Charcot arthropathy) |
| Peripheral neuropathy: involves sensory, motor, and
autonomic abnormalities; useful analogyófor patients to think of
foot neuropathy as broken alarm system in basement; shoe
sizeópatients choose shoes ≈1 size too small
(ìcrave tightnessî against foot); need professionally fitted shoes;
evaluationóask whether feet warm or numb; check sensations
(sharp; dull; vibratory; monofilament testing); ulcer diagnostic of
neuropathy |
| Deformities: include protruding bone, thick nail,
calluses, cheiroarthropathy; extrinsic causeóeg, tight
shoe against bony prominence; intrinsic causeóprotruding
bone-caused ulceration (requires surgery); hard thickened
callusesócaused by nonenzymatic glycosylation of soft tissue;
pressure cuts off underlying vascularity, leading to tissue breakdown and
ulceration; painless; presence indicated by dry intralesional hemorrhages;
debriding callus reveals ulcer; cheiroarthropathyósecondary to
nonenzymatic collagen glycosylation; 70% of ulcers under forefoot;
tightening of Achilles tendon overloads forefoot; ankle
motionóimportant to assess; heel cord lengthening reduces pressure on
forefoot |
| CHARCOT ARTHROPATHY AND THE ROLE OF ORIF óGregory
Pomeroy, Clinical Assistant Professor of Surgery, University of New
England, Biddeford, Maine, and Director, Portland Orthopaedic Foot &
Ankle Centre, South Portland, Maine |
| Main message: open reduction and internal fixation
(ORIF) plays limited role in treating Charcot arthropathy
|
| Eichenholtz staging: stage 1ófragmentation;
characterized by inflammation, erythematous appearance, dislocation,
resorption, and osteoclasis; confused with infection; stage
2ócoalescence; reparative; decreasing swelling, warmth, and erythema;
new bone formation on radiographs; stage 3óconsolidation;
inflammation resolved; bone consolidation on radiographs; often stable
|
| Anatomic staging: type 1ómidfoot; most
common; rocker-bottom sole frequent; ulcers possible; type
2óhindfoot; more unstable; type 3aóankle joint; very
unstable; type 3bócalcaneal tubercle; not unstable
|
| Osteomyelitis: rare in inflamed swollen foot without
ulcer; recommended testótechnetium-labeled white blood cell scan
(most sensitive and specific scan for osteomyelitis) |
| Goals of treatment: stable plantigrade foot;
braceable deformity; prevention of ulcers; maximization of function;
stage 1ócontrol swelling; stage 2óprovide stability;
stage 3óprovide even distribution of forces; postoperative
managementóspeaker works with orthotist who adjusts Charcot restraint
orthotic walker (CROW) as swelling recedes; finally, patient fitted with
custom shoes; commentóat no point in this process is ORIF
indicated |
| Surgical indications: ulcer unable to heal (bony
deformity and too much pressure); recurrent ulcer; unbraceable deformity;
impending ulcer (ìacute Charcotî); infection |
| Surgical options: exostectomy; fusion; rarely
neededóamputation; ORIF; aggressive managementófor acute
traumatic fractures in patients with neuropathy; anatomic fixation may
prevent Charcot |
| TRANSMETATARSAL AMPUTATIONó Alastair S. E.
Younger, MD, Clinical Associate Professor, Department of Orthopaedics,
University of British Columbia Faculty of Medicine, and St. Paulís
Hospital, Vancouver |
| Pathophysiology: elevated glucose leads to cross
linking of collagen; consequenceóabnormal nerve conduction;
reduced shear resistance in skin; stiff joint capsule or contracture;
tight heel cord; decreased vascular microcirculation; bone fractures;
results inóweak skin, loss of sensation, pressure areas, deep
ulceration, and finally, infection |
| Indications for surgery: ulcer probe goes through
skin (infection can spread to tendon); impending ulcer with tight heel
cord; skin necrosis with superinfection |
| Transmetatarsal amputation: ruled out by inadequate
skin coverage or necrotizing fasciitis; absence of pulses not
contraindication; deep posterior compartment infection also not
contraindication (debride deep tendons completely); surgical
procedureópatient must be medically stable with hemoglobin A1c (HbA1c )
under control; incision kept clear of necrotic tissue; percutaneous
Achilles tendon lengthening; sharp dissection (enhances soft tissue
healing); elevator in midfoot at level of amputation; cut foot and bevel
metatarsals, making broad weight-bearing surface (substituting for
metatarsal heads); develop plantar flap (loose; closes without wound-edge
tension); debride tendonsóbacterial spread in tendon sheath leads
to failure; follow infection to end of tendons, into all 4 compartments if
necessary; OsteoSet beadsóused liberally to prevent wound
breakdown, improve recovery time, and prevent bacterial recolonization of
dead space not reached by intravenous antibiotics; closureódeep
closure enhances microcirculation, preventing wound-edge necrosis;
resultsó65 procedures with 75% success rate |
| Importance of HbA1c
: comparison of transmetatarsal
amputation and below-knee amputation groups found only difference to be
quality of diabetic control measured by HbA1c
level; take-home messageómeasure HbA1c in every diabetic with ulcer or undergoing
any orthopaedic operation; HbA1c level
must be ≤8% before surgery (if HbA1c >10%, healing impossible;
if <6%, likely always to heal) |
| BELOW-KNEE AMPUTATION AND CALCANECTOMY óDr. Wing
|
| Introduction: requires strong team (vascular surgeon
for consultation; wound care; nursing care; family/home support)
|
| Calcanectomy: considerations in individual
patientówhether limb salvage expected to produce better result than
below-knee amputation; how many procedures patient willing to tolerate;
indicationsólongstanding diabetic heel ulcer with osteomyelitis;
adequate soft tissue for closure; procedureóremove enough bone
for manageable soft- tissue envelope; transect Achilles tendon; avoid
total calcanectomy (risk of midfoot instability); débridement (2- stage if
active infection); postoperativeósplint in equinus; custom
ankle-foot orthotic (AFO) |
| Below-knee amputation: long posterior
myofasciocutaneous flap preferable; consider prosthetic
needsómyodesis of gastrocsoleus onto anterior tibia; Ertl
osteomyoplasty closes medullary canal and creates osteoperiosteal flaps
for tibiofibular synostosis, optimizing stump stability; patient
motivationóessential for achieving functional prosthesis
|
Educational Objectives
| The goal of this program is to educate orthopaedists about current
management of forefoot pain with bunion and diabetic foot problems. After
hearing and assimilating this program, the surgeon will be better able to:
|
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1. Evaluate patients with forefoot pain with
bunion. |
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2. Perform chevron osteotomy.
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3. Manage Charcot arthropathy.
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4. Select patients for transmetatarsal
amputation and perform the surgical procedure. |
|
5. Identify surgical candidates for below-knee
amputation and calcanectomy. |
Suggested Reading
Cohen
MM: The oblique proximal phalangeal osteotomy in the correction of
hallux valgus. J Foot Ankle Surg 42:282, 2003; Crevoisier X et
al: The scarf osteotomy for the treatment of hallux valgus deformity: a
review of 84 cases. Foot Ankle Int 22:970, 2001; Donnelly RE et
al: Modified chevron osteotomy for hallux valgus. Foot Ankle
Int 15:642, 1994; Eichenholz SN: Charcot Joints.
Springfield, IL: Charles C. Thomas, 1966; Faber FW et al: Role
of first ray hypermobility in the outcome of the Hohmann and the Lapidus
procedure. A prospective, randomized trial involving one hundred and one feet.
J Bone Joint Surg Am 86-A:486, 2004; Kernozek TW et al:
Chevron (Austin) distal metatarsal osteotomy for hallux valgus:
comparison of pre- and post-surgical characteristics. Foot Ankle Int
23:503, 2002; Lin SS et al: Plantar forefoot ulceration with
equinus deformity of the ankle in diabetic patients: the effect of tendo-
Achilles lengthening and total contact casting. Orthopedics 19:465,
1996; Lin SS et al: Total contact casting and Keller
arthoplasty for diabetic great toe ulceration under the interphalangeal joint.
Foot Ankle Int 21:588, 2000; Okuda R et al: Surgical
treatment for hallux valgus with painful plantar callosities. Foot Ankle
Int 22:203, 2001; Olmos PR et al: The Semmes-Weinstein
monofilament as a potential predictor of foot ulceration in patients with
noninsulin-dependent diabetes. Am J Med Sci 309:76, 1995;
Pomeroy G et al: Feeling lumps and bumps in foot surgery.
Foot Ankle Int 16:452, 1995; Raja S: Turn-up bone flap
for lengthening the below-knee amputation stump. J Bone Joint Surg Br
86:150, 2004; Scranton PE Jr et al: Prognostic factors in
bunion surgery. Foot Ankle Int 16:698, 1995; Shi K et al:
Surgical treatment of hallux valgus deformity in rheumatoid arthritis:
clinical and radiographic evaluation of modified Lapidus technique. J Foot
Ankle Surg 39:376, 2000; Thordarson D et al: Correlation
of hallux valgus surgical outcome with AOFAS forefoot score and radiological
parameters. Foot Ankle Int 26:122, 2005. Erratum in: Foot Ankle Int
26(4), 2005; Veri JP et al: Crescentic proximal metatarsal
osteotomy for moderate to severe hallux valgus: a mean 12.2 year follow-up
study. Foot Ankle Int 22:817, 2001; Waldecker U:
Metatarsalgia in hallux valgus deformity: a pedographic analysis. J Foot
Ankle Surg 41:300, 2002.
Faculty Disclosure
In adherence
to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to
disclose any significant financial relationship with the manufacturer or
provider of any commercial product or service discussed. The following has been
disclosed: Dr. Pomeroyóconsultant (DePuy).
Drs. Wing, Kalla, Glazebrook, Pomeroy, and Younger were recorded at the
Canadian Orthopaedic Foot and Ankle Society Symposium, sponsored by the
University of British Columbia Department of Orthopaedics and held in Vancouver,
April 8-9, 2005. The Audio-Digest Foundation thanks the speakers and the sponsor
for their cooperation in the production of this program.
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