1. Determine the underlying pathology responsible for forefoot pain.

2. Perform a 9-point physical examination of the forefoot, leading to a diagnosis of the causes of forefoot pain.

3. Evaluate candidates for ankle fusion and replacement.

4. Manage severe nonreducible claw-toe deformity.

5. Salvage infected hindfoot fractures.

Diagnosing Forefoot Pain: Hallux Valgus, Arthritis, Sesamoiditis, Synovitis, Stress
Alastair S.E. Younger, MD, Clinical Associate Professor, Department of Orthopaedics, University of British Columbia Faculty of Medicine, and Ambulatory Care Physician Leader, Providence Health Care, Vancouver

Forefoot overload: from pressure areas; sesamoiditis (first ray overload); synovitis (overload of metatarsophalangeal [MTP] joints); stress fractures (when pressure increases to point metatarsal shafts fracture)

During examination: identify area of maximum tenderness in order to determine underlying pathology and anatomy; have patient: remove sox and shoes; point to area that hurts most; describe what pain prevents him or her from doing; point to where it hurts after walking as far as he or she can; ask—whether this is most disabling pain he or she has

Warning signs: disability patient (secondary gain issues); failed athlete (unrealistic expectations); previous failed surgeries

Regional pain syndrome: patient says whole foot hurts; ask about night pain, burning pain, pain from light touch pain out of proportion to injury; pain nonanatomic

Previous therapy: ask about medications, physical therapy, orthotics, and braces; avoided previous measures that failed

Nine-point physical examination: expose extremities; standing alignment; assess gait; inspect forefoot position, eg, hindfoot and forefoot varus; palpate; range of motion (ROM; side to side; compare to opposite foot); special tests; joints above and below area of complaint; neurovascular examination

Radiology: standing anteroposterior (AP) and lateral x-rays essential (enables measuring); look for—associated flat foot; long second ray; hallux valgus interphalangeus (in proximal metatarsal); subluxation of sesamoids; raised distal metatarsal articular angle (joint points in wrong direction); metatarsus adductus; elevated first ray (causes overload of second metatarsal head); measure various forefoot angles on standing view (gives indirect measure of soft-tissue contracture, thus aiding choice of surgical procedure)

Hallux valgus: subluxation of first MTP joint; patient sees as bunion; determine point of pressure and pain; look for—tight heel cord; elevated first ray (pain due to overload of second metatarsal head common presenting complaint); radiographic findings—primus varus; splay foot; wide forefoot; skew foot (hindfoot points in one direction, forefoot in other direction); metatarsus adductus; planovalgus foot; Morton’s foot (long second ray); claw toes (due to overload of lesser rays); subluxated second MTP joint; Morton’s neuroma (associated with overload of lateral border of foot); etiologic factors—family history of hallux valgus; clear association between hallux valgus deformity and shoe wear (shoes force MTP joint into valgus); some patients have combination of hallux rigidus and hallux valgus; trauma (eg, car accident); patients may have generalized ligamentous laxity (makes surgical and nonsurgical correction difficult)

Other causes of forefoot pain: Morton’s neuroma; synovitis; stress fracture; rheumatoid arthritis ([RA]; second tarsometatarsal [TMT] joint; combination of problems); sesamoiditis (often due to first metatarsal overload; offload first metatarsal head with orthotics)

Summary: localize pain; understand anatomy; diagnose pathoanatomy

Preoperative Evaluation for Ankle Fusion and Replacement
David G. Stevens, MD, Grand River and St. Mary’s Hospital, Kitchener, ON

Presurgical evaluation: general health status (look for diabetes, peripheral vascular disease, inflammatory disease); age; body mass index (BMI); medications; allergies; smoking (impedes fusion and healing of soft-tissue envelope); past surgery and anesthetic complications; employment; recreational activities

Past: causes of ankle problem—posttraumatic; inflammatory disease; “idiopathic” often posttraumatic; initial illness or trauma

Treatment: modality and complications; imaging and test results

Present: patients seek treatment for pain; assess pain—mild or severe; whether amenable to conservative management (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], bracing, orthotics); constant or occasional; nature of pain—mechanical (eg, grinding, clicking, locking); neuropathic (eg, burning, allodynia); claudicant; mixed degree of disability; treatments—current and past, eg, NSAIDs, orthotics, bracing, injections; other consultations— including Internet

Future: determine patient’s expectations (can tell patient walking reasonable); no “pain-free guarantee”

Physical assessment: begins at start of interview (general health; rheumatoid signs); general preoperative physical examination; ipsilateral hip and knee examination; limb lengths (expect shortening after correction of equinus contracture)

Aspects of foot and ankle examination: speaker takes “look, feel, move” approach; assess gait with both legs exposed; look at both legs circumferentially; assess static sagittal and coronal angular deformity

Skin examination: scars or sinuses from previous surgery; soft-tissue edema; trophic changes; soft-tissue ulceration

Additional evaluation: feel for maximal tenderness, swelling, and effusion; whether ankle actual problem (have patient point to source of pain); assess for pulses and capillary refill; careful neurologic examination (possible diabetes)

Movement: assess for dynamic deformity at knee, hindfoot, or midfoot; assess tibia; assess—ROM; stability and power; subtalar and Chopart joints; for gastrocsoleus contracture; strength of dynamic stabilizers

Imaging studies: radiography—standing views of ankle; AP and lateral views of foot (for cavus or planus); 3-ft standing view of leg; fluoroscopy—true ROM; correctable deformity; for diagnostic nerve blocks to isolate pain

Advanced imaging: computed tomography (CT)—for avascular necrosis (AVN), bony defects, cyst formation, involvement of subtalar and Chopart joints; magnetic resonance imaging (MRI)—talar AVN; periarticular tendons and ligaments; nuclear scanning—for possible sepsis in posttraumatic condition

Management of Severe Nonreducible Claw-Toe Deformity
Dr. Younger

Associated pathology: always present in forefoot; must be addressed for good result; identify pathology with history and physical examination

Look for: tight heel cords; hallux valgus deformity; long second ray; many toes to be affected; systemic disorder, eg, RA

Evaluation: history—where patient hurting; previous treatment; physical examination—observe walking and standing; identify calluses on plantar foot and pinpoint tenderness in area; heel cord; pulses; sensation

Radiography: standing x-rays essential; determine length of second metatarsal compared with first metatarsal; indicates surgical options for length of rays

Pathoanatomy: “claw-toe deformity is all about the intrinsics”; extrinsic overload combined with intrinsic malfunction; normally—intrinsic muscles stabilize MTP joint by bringing tip of toe to ground and straightening whole phalanx; intrinsics keep plantar pad in place, protecting metatarsal head and allowing force-transfer through tip of toe

Underlying etiologies: overload of metatarsal head; inflammatory disease causing synovitis; either one or both combine with gravity to cause subluxation and dislocation of toes (destroying structures maintaining toes in joint); result—feedback loop; increasing damage to plantar plate causes more loss of function; dislocation or subluxation of toe shortens intrinsics (10%-15%); extrinsic muscles remain strong; flexor tendons subluxate around metatarsal heads, increasing deformity; patient presentation—complaint of pressure and pain

Treatment

Nonoperative treatment: requires reducing pressure in order to lessen pain; stiff-soled shoe with wide toe box to accommodate deformity; orthotics with metatarsal pad; physical therapy—exercises to strengthen intrinsic muscles; additional option—removing callus provides temporary relief of pain

Surgical therapy: goal—to restore function by alleviating pain; restoring intrinsic muscle function maintains MTP stability, broadening forefoot and transferring load; deformity in one toe may require operating on all four; common muscle in extrinsics (long flexors and extensors; one muscle with four tendons); operating on 2 toes may cause deformity in other toes

Metatarsal head resection: for older patients or those with inflammatory disease; transverse cut stabilizes MTP joint; interphalangeal joint (IP) fusion transfers load from long flexor tendons, substituting for intrinsic muscle; avoid excessive metatarsal head resection (shortens ray; weakens intrinsic muscle; further toe dislocation possible); try to preserve metatarsal heads and stabilize first ray; take extensor tendon to lateral border of foot, off-loading extensor tendon and preventing toes from being pulled out of joint again; this restores intrinsic function, maintains stability of MTP joint, and broadens forefoot, transferring load; treat lesser toes through second and fourth web space incision; fixation—2 cross screws to stabilize first ray; may need to fuse first MTP joint; IP fusion with bone excision; MTP joint releases; to get MTP joint back in, cut long extensor proximally and short extensor distally; this lengthens brevis tendon, which is then transferred to longus stump; Kirschner (K) wires to stabilize IP joints and MTP joints (bring MTP joints into plantar flexion so that when K wires removed, toes drift back to neutral position rather than dorsiflexion)

Potential complication: failure of blood supply to return to toe after tourniquet removed (requires removal of more bone; amputation possible); inform patient about risk for dysvascular toe before surgery

Salvage of Infected Hindfoot Fractures
Dr. Younger

Incidence of fractures: calcaneal—2% of all fractures (2% of those open); 39% of open fractures develop osteomyelitis; talar—1% of all fractures; navicular—<1% of all fractures; osteomyelitis—can develop in 2% of open reduction and internal fixation (ORIF) cases

Factors affecting healing: soft-tissue compromise; damaged vessels in watershed zones of perfusion; poor soft- tissue attachment to bones; difficulty visualizing bones during ORIF, requiring extensive soft-tissue dissection; prolonged recovery following multiple surgeries

Evaluation: determine residual ROM; nature of injury; extent of damage; assess skin coverage; determine vascularity (may require ankle-brachial index [ABI]); test sensation (for nerve injury and to rule out neuropathy); check ROM and alignment

Laboratory tests: C-reactive protein; erythrocyte sedimentation rate; white blood cell count; when diabetes present— obtain hemoglobin (Hb)A1c ; avoid operating on patient with HbA1c >8% (limits healing of skin and bone)

Treatment: debridement—remove all infected tissue; stabilization—external fixation or internal fixation after infection eradicated; amputation—possibility requires early discussion with patient

Points on procedure: resect infected skin, soft tissue, and sinus tracts; remove all infected hardware; resect bone to healthy margin ≤5 mm; assess viability of remaining tissue using laser Doppler imaging

Infection management: obtain intraoperative blood cultures; antibiotic therapy—6 wk intravenous (IV); 6 wk oral; alternative protocol—5 to 7 days IV; 6 wk oral (if organism susceptible); irrigation and debridement as needed; delayed bone grafting and fixation when necessary; results—91% successful limb salvage rate; 100% successful when bone resected to >5 mm margin; variables affecting outcome—smoking; virulence of organism; duration of osteomyelitis; quality of diabetic control

Consider calcanectomy: for complete resection of bone in infected cases in primary closure; allows limb salvage when unsalvageable otherwise; orthosis required

Summary: salvage of hindfoot infections all about—debridement; correct choice of antibiotics; optimizing host factors