FOOT AND ANKLE SURGERY
Selections from Canadian Orthopaedic Foot and Ankle Society Symposium
| FOREFOOT PAIN IN PATIENT WITH BUNION: INVESTIGATIONS —Stephen J. Pinney, MD, Associate
Professor of Clinical Orthopaedics and Chief, UCSF Foot and Ankle Service, Department of Orthopaedics,
University of California, San Francisco, School of Medicine
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| Elements of condition: lateral deviation of great toe; prominent medial eminence; symptoms aggravated by
restrictive shoe wear; positive family history; overload symptoms related to second toe
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| Symptoms and deformity: little correlation; be clear about source of patient’s complaint
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| History and physical examination: gain understanding of symptoms and complaint; assess first metatarsophalangeal
(MTP) motion
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| Key x-rays: anteroposterior (AP) and lateral weight-bearing views gold standard; weight-bearing necessary
for assessing alignment; look for arthritic changes in first MTP joint; second ray—look for evidence of hypertrophy
and stress fractures
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| Alignment on x-rays: helps establish extent of deformity and potential treatment
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 | Hallux valgus angle: between long axis of first MTP and long axis of proximal phalanx of great toe;
normal—<15°; mild deformity—15° to <20°; moderate deformity—20° to 40°; severe deformity—>40°;
reasonable intra- and interobserver reliability
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| Intermetatarsal angle: between long axis of first and second MTP; normal—<9°; mild deformity—9° to
<12°; moderate deformity—12° to 15°; severe deformity—>15°
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| Sesamoid subluxation: on AP view; relation between sesamoids and MTP head; actually MTP subluxed off
sesamoids; mild deformity—<50%; moderate deformity—50% to 75%; severe deformity—>75%
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| Distal metatarsal articular angle (DMAA): relation between lateral slope of articular surface and long axis
of first MTP joint; speaker does not find particularly helpful; poor intra- and interobserver reliability, but
represents important principle (visualize joint before and after surgery)
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| HALLUX VALGUS SURGERY —Timothy R. Daniels, MD, Associate Professor, Department of Surgery,
Division of Orthopaedic Surgery, University of Toronto Faculty of Medicine, Toronto, ON
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| Introduction: speaker’s practice mostly referral (often salvage surgery); experience performing many types
of osteotomy, eg, distal chevron, distal medial closing wedge chevron, proximal chevron, Lapidus, Ludloff,
scarf (Z); “still looking for that magic solution”; recurrence rate—long-term outcome unknown due to limited
follow-up (1-2 yr average); frustrating complication rate—eg, nonunion and malunion; level of patient
dissatisfaction—≈15% in speaker’s practice (may be lower in recent years); procedure technically
complex—not “just a bunion”
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| Why recurrence rate high: combination of fault of surgeon, pathology, and procedure
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| Typical patient: mostly women (more ligament laxity); strong hereditary component; middle-aged and elderly;
no strong correlation with mid- or hindfoot deformity
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| Patient example: first presentation—25-yr-old woman; requests surgery for bunions; has “terribly flat feet,”
but point straight forward; on x-ray, mild ples planus deformity; “can’t do anything about”—broad forefoot;
mild degree of metatarsus adductus; constant repetitive forces; cosmesis; patient elected not to have
surgery after discussion; second presentation—now 46 yr of age; all toes drifted into valgus; obtaining shoe
to wear difficult; complains of metatarsalgia; first surgery—leaves patient extremely dissatisfied; had “rip-
roaring” metatarsalgia under second and third toes; second surgery—fusion; shortened first to fourth toes;
patient satisfied
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| Pay attention to pathophysiology: ligamentous laxity; forefoot adduction; wide forefoot; natural process
of aging (soft tissue less resilient, cannot tolerate same forces as when younger); educate patient
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| Surgical considerations: clinical examination primary; look for pronation of first toe; significant deformity
with no pronation—consider congruent deformity; measure DMAA; patient underwent triple osteotomy
(medial-based closing wedge [to realign joint]; chevron [at base]; Akin proximal phalangeal); clinical
examination—stabilize metatarsal and try to pull toe over; if difficulty with reducing hallux valgus deformity,
consider whether congruent, arthritic, or long-standing deformity with severe soft-tissue contractures;
in any event, patient needs proximal metatarsal osteotomy; intraoperative difficulty in elderly may necessitate
fusion; choice of proximal osteotomy—depends on surgeon’s comfort level; must reduce sesamoid sling;
do not shorten first metatarsal unless others shortened to corresponding length
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| Key points: be aware of factors you cannot do anything about—reason for extensive counseling before surgery;
ligamentous laxity; wide forefoot; forefoot adductus; unrealistic patient expectations; careful clinical
assessment for—pronation of first toe; flexibility of deformity; significant mid- or hindfoot deformities;
perform distal osteotomy when—soft-tissue imbalance minimal; deformity minimal; hallux varus deformity
congruent; perform proximal osteotomy when—significant soft-tissue imbalance; need to reduce sesamoid
sling; always—minimize shortening of first metatarsal (unless combining with shortening of lesser metatarsals);
Lapidus procedure—not indicated for first ray instability; relative indication for relative radiographic
instability; absolute indication for midtarsal arthritis
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| OCD LESIONS OF THE TALUS —Dr. Pinney
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| Terminology: osteochondritis dissecans (OCD) now more commonly called osteochondral lesions (OCL) of
talus
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| History: ankle pain; crepitation; ankle sprain 2 to 4 mo previously; persistent symptoms; mechanism of injury—
often inversion/plantar flexion; causes central-medial lesion (from compression; more common) and lateral
lesion (from shearing; more often symptomatic); history of instability—recurrent ankle sprains or “giving
way”; lateral symptoms; instability may require treatment during surgery
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| Physical examination: understanding surface anatomy expedites diagnosis; source of pain may be from ankle-joint
line on anterolateral side, anterior talofibular ligament, sinus tarsi, peroneal tendons, or sural
nerve; alignment—neutral or varus (suggests instability); with hindfoot varus, load goes through medial aspect
of ankle (acute injury may be absent); also consider—ankle range of motion; crepitation (often requires
surgery); increased inversion; tests—anterior drawer for instability; stress fluoroscopy
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| Imaging studies: ankle weight-bearing series; osteochondral lesions often invisible on plain x-ray; magnetic
resonance imaging (MRI)—indicated if no improvement in symptoms during previous month; look for bone
edema and cartilage damage
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| Classification: made by direct vision; grade 0—normal; grade 1—superficial fissures; grade 2—involves
transitional zone, extending down 50%; grade 3—extending past 50%, into radial zone; grade 4—
subchondral bone exposed
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| Lateral vs medial lesions: history—lateral, acute injury; medial, more often chronic loading; mechanism—
lateral, shear; medial, compression; symptomatic—lateral, usually; medial, often asymptomatic
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| Diagnosis: consider sources of pain other than lesion—posterior tibial tendon; anterior ankle impingement
(injury to inferior fibers of anterior tibiofibular ligament; not usually visible on MRI); anterior impingement
(if diagnosis confirmed during arthroscopic debridement, can then perform reconstruction for instability)
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| Treatment: surgery indicated after symptoms fail to improve
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| Arthroscopic debridement and microfracturing: debride flap of cartilage interfering with joint motion; microfracturing
encourages bleeding and growth of fibrocartilage; determine that joint moving smoothly;
postoperative management—after 2 wk, begin gentle physical therapy for ≈4 wk, followed by more aggressive
therapy; results—good in 75% to 90% of cases; better for lateral than for medial lesions
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| Osteochondral grafting: indications include failure of debridement and microfracture, and larger lesion (eg,
20 mm/15 mm); grafting fills gap with bone and cartilage; obtain autograft from knee (lateral femoral
condyle; sometimes from groove); possibly allograft (eliminates graft site morbidity; requires ≈30 days
for screening tests; remaining viable cartilage problematic); graft should be somewhat larger than site of
placement; postoperative protocol—non-weight-bearing for ≈6 wk; followed by range-of-motion exercises;
results—studies report good-to-excellent results in 80% to 90% of patients
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| ACHILLES’ TENDON DISEASE: BASIC SCIENCE AND CLINICAL CARE —Mark Glazebrook, MD,
PhD, Assistant Professor, Division of Orthopaedic Surgery, Dalhousie University Faculty of Medicine, Halifax,
NS
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| Review of literature on treatment of Achilles’ tendon rupture: level 1 and level 2 studies; grade A treatment
recommendations
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| Survey of treatment results: open repair (vs nonopen)—decreased rerupture; increased complications and
infections in wound healing; faster return to activity; percutaneous (vs open)—increased rerupture; decreased
complications (especially wound healing); functional rehabilitation (vs casting)—faster return to
activity; improved function
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| Represents continuum: microtendinopathy—silent stage; tendinitis—inflammation; pain; clinical signs; repair
response—after repeated inflammation; tendinosis—repair response gone awry; mass of scar tissue;
rupture—after sufficient weakening
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| Rupture: extent of preexisting disease determines magnitude of force necessary to rupture Achilles’ tendon;
low-energy rupture indicates preexisting disease; speaker offers as theory based on his work
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| Laboratory study: equivalent of Achilles’ tendon disease produced in rat model; rats ran on treadmill 1 hr
per day, 5 days per week, for 12 wk; equivalent to human running marathon same length of time; findings
in runners (vs nonrunners)—decreased collagen organization; more intense collagen staining; increased
nuclear numbers; findings in cells—no leukocytes; cells either fibroblastic or endothelial; not inflammatory;
repair response; collagen—immature cross-linking (new tissue, probably collagen type 3)
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| Final comments: literature—divided over whether process inflammatory or degenerative; agreement that
clinical Achilles’ tendon disease “exactly what we showed in our rat model”; conclusion—disease represents
continuum of pathology; healing response gone awry; evidence that pathobiology may be repair or remodeling
response; rupture = force + preexisting disease
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Suggested Reading
Coughlin MJ et al: Angular measurements in the evaluation of hallux valgus deformities: a report of the ad
hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int
23:68, 2002; Coughlin MJ et al: Arthrodesis of the first metatarsophalangeal joint for idiopathic hallux valgus:
intermediate results. Foot Ankle Int 26:783, 2005; Coughlin MJ et al: Hallux valgus in men. Part II:
First ray mobility after bunionectomy and factors associated with hallux valgus deformity. Foot Ankle Int
24:73, 2003; Coughlin MJ et al: Proximal metatarsal osteotomy and distal soft tissue reconstruction as
treatment for hallux valgus deformity. Keio J Med 54:60, 2005; Elias I et al: Osteochondral lesions of the talus:
change in MRI findings over time in talar lesions without operative intervention and implications for
staging systems. Foot Ankle Int 27:157, 2006; Giannini S et al: Surgical treatment of osteochondral lesions
of the talus in young active patients. J Bone Joint Surg Am 87 Suppl 2:28, 2005; Grebing BR et al: Evaluation
of Morton's theory of second metatarsal hypertrophy. J Bone Joint Surg Am 86-A:1375, 2004; Grimes JS et
al: First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery. Foot Ankle Int
27:887, 2006; Jones CP et al: First metatarsophalangeal joint motion after hallux valgus correction: a cadaver
study. Foot Ankle Int 26:614, 2005; Kopp FJ et al: The modified Lapidus procedure for hallux valgus:
a clinical and radiographic analysis. Foot Ankle Int 26:913, 2005; Leach RE et al: Long-term results of surgical
management of Achilles tendinitis in runners. Clin Orthop Relat Res:208, 1992; Mittal D et al: The spike
osteotomy for hallux valgus: a clinical and radiological evaluation. J Foot Ankle Surg 45:261, 2006; Richardson
EG et al: First metatarsal head-shaft angle: a method of determination. Foot Ankle 14:181, 1993; Rosenberger
RE et al: Computer-assisted minimally invasive treatment of osteochondrosis dissecans of the talus.
Oper Orthop Traumatol 18:300, 2006; English, German. Sanhudo JA: Correction of moderate to severe hallux
valgus deformity by a modified chevron shaft osteotomy. Foot Ankle Int 27:581, 2006; Schepsis AA et
al: Achilles tendon disorders in athletes. Am J Sports Med 30:287, 2002; Schepsis AA et al: Surgical management
of Achilles tendinitis. Am J Sports Med 15:308, 1987; Schepsis AA et al: Surgical management of
Achilles tendon overuse injuries. A long-term follow-up study. Am J Sports Med 22:611, 1994; Tanaka Y et
al: Vascularized bone graft from the medial calcaneus for treatment of large osteochondral lesions of the medial
talus. Foot Ankle Int 27:1143, 2006.
Educational Objectives
| The goal of this program is to encourage orthopaedic surgeons to implement recent developments in foot and ankle
surgery. After hearing and assimilating this program, the surgeon will be better able to:
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| 1. Evaluate forefoot pain in a patient with a bunion.
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| 2. Identify forefoot abnormalities that cannot be changed with bunion surgery.
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| 3. Perform procedures involved in the surgical treatment of bunions.
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| 4. Diagnose and treat osteochondritis dissecans (OCD) lesions of the talus.
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| 5. Explain the pathophysiology of Achilles’ tendon disease.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to
disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, the following has been
disclosed: Dr. Glazebrook — DePuy Johnson and Johnson; Arthrex, Inc (research funding in form of an unrestricted
grant)
Acknowledgements
Drs. Pinney, Daniels, and Glazebrook were recorded at the Canadian Orthopaedic Foot and Ankle Society Symposium,
held March 30-31, 2007, in Vancouver, BC, and sponsored by the Canadian Orthopaedic Foot and Ankle Society
and the University of British Columbia, Faculty of Medicine, Department of Orthopaedics. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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