Lecture 27 parekh pttd3 and 4
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Transcript of Lecture 27 parekh pttd3 and 4
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Operative Care Stage 3 and 4 PTTD
Selene G. Parekh, MD, MBAAssociate Professor of Surgery
Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery
Adjunct Faculty Fuqua Business SchoolDuke University
Durham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
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Stage 3 and 4 PTTD
• Stage 3• Rigid flat foot deformity
• Stage 4• Rigid foot deformity with ankle arthritis
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Introduction• Triple arthrodesis
• Fusion of the three hindfoot articulations• Subtalar or talocalcaneal• Talonavicular• Calcaneocuboid joints.• Responsible for
• Supination and pronation of the foot;
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Indications• Goal
• Achieve a stable, painless, and plantigrade foot.
• When possible, a procedure that preserves normal hindfoot motion and mechanics should be considered.
• In instances where this would be inappropriate• Triple arthrodesis valuable salvage procedure.
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Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
COUPLED MOTION• Talonavicular
• 6 degrees of freedom• Ab/adduction forefoot• Varus/valgus forefoot• Dorsiflexion/plantarflexion
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Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
• Talonavicular• 6 degrees of freedom
• Ab/adduction forefoot• Varus/valgus forefoot• Dorsiflexion/plantarflexion
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Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
• Subtalar • Inversion/eversion
• Calcaneocuboid• Dorsiflexion/plantarflexion• Ab/adduction
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Hindfoot Arthritis Presentation
• History• Trauma: Calc., talus fx, disloc.• Inflammatory arthritis
• Pain location “One Finger”• Sinus tarsi (subtalar)• Just below ankle (T-N)
• Swelling• Malalignment
• Flatfoot, Cavus foot• Antalgic gait
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Hindfoot Arthritis Presentation
• Swelling• Tenderness• Decreased inversion/eversion motion• Crepitus• Malalignment
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Hindfoot Arthritis Radiographs
• Radiographs• Standing A/P, Lateral and Oblique foot• Standing A/P ankle• Possibly axial heel view (Harris)
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Hindfoot Arthritis Radiographs
• Radiographs• Standing A/P, Lateral and Oblique foot• Standing A/P ankle• Possibly axial heel view (Harris)
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Hindfoot Arthritis PE and Radiographs
• Possibly (rare)• CT scan for Coalition/Assess degree of arthritis of
adjacent joints
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Hindfoot Arthritis: Non-op Treatment
• Non-operative– Lose Weight (5lbs = 20lbs foot)– Activity Modification
– Biking– Swimming
– NSAIDS– Glucosamine
– AAOS position paper said as effective as ibuprofen
– Bracewear– Cortisone injection AND Bracewear
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Hindfoot Arthritis Non-op Treatment
• Non-operative• Stiff Shoe Heel Counter
– Bracewear• Decrease motion• Shift load
• OTC Ankle brace• Custom Ankle brace
• Arizona, Richie• University of California Biomechanics Laboratory (UCBL)• AFO +/- anterior clamshell
Ankle Brace
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Preoperative Evaluation• All patients should have adequate circulation.
• If pedal pulses are not palpable• Arterial Doppler evaluation for ankle brachial
indices, dorsalis pedis indices and normal wave forms should be performed.
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Preoperative Evaluation• Sensation should be documented preoperatively
• The presence of peripheral neuropathy must be identified to avoid potential complications of postoperative Charcot arthropathy.
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Preoperative Evaluation• A complete understanding of the relationship
between the forefoot and hindfoot in supination and pronation deformities of the foot is essential for proper positioning of triple arthrodesis.
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Preoperative Evaluation• Pes planus deformity - a pronated foot
• Heel in valgus
• Forefoot is both abducted at TN jt and in varus
• Proper positioning of the foot at surgery• Heel - five degrees of residual valgus• Forefoot abduction - bringing the navicular
medially cover the head of the talus• Can be assessed by palpation of the medial
side of the foot at the talonavicular joint to identify any residual subluxation.
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Preoperative Evaluation• Long standing pes planus deformities
• Secondary contracture of the GSC
• Assessed by reducing the talonavicular joint to neutral and then dorsiflexing the ankle
• If contracture present • TAL• Recession
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Preoperative Evaluation• Valgus angulation of talus in the ankle
mortise suggestive of deltoid ligament insufficiency
• May promote degenerative arthritic changes in the ankle joint following triple arthrodesis secondary to increased load on the lateral portion of the joint.
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Case
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Case
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Surgical Technique• Multiple techniques
• Basic principles• Surgical incisions placed to avoid injury
to the sensory nerves of the dorsum of the foot
• Anatomic realignment • Hindfoot to 3-5 degrees of residual
heel valgus• Neutral alignment of the forefoot
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Surgical Technique• Preparing joint surfaces
• Remove all the residual cartilage and subchondral bone to the level of exposed cancellous surfaces
• Rigid fixation with compression of the joint surfaces• Maintain corrected position• Promote fusion
• Bone graft needed if significant bony defect
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Lateral Incision
• Tip of fibula to base of the 4th
• Careful of sural
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Lateral Incision
• Final peroneals and trace distally to CC jt
• Elevate extensors of anterior process
• Enter subtalar and CC jts
• Prepare joints
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Medial Incision
• Between ATT and PTT
• Inferior to saphenous vein
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Medial Incision
• Open capsule
• Distract joint
• Prepare joint
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Joint Preparation
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Position
• Take the heel out of valgus• Pin from neck to calcaneus• Place hardware
• Reduce TN joint• Correct abduction and supination• Place hardware
• Place hardware over CC joint
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Stage 4
• Ankle arthritis• Ankle fusion
• At same time• Pantalar fusion with TTC rod
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Stage 4
• Ankle arthritis• Ankle replacement
• Staged by 4-6 wks
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Post-operative Management• NWB in a compressive dressing with plaster splints
• 10-14 days
• NWB in SLC 2-4 wks• X-rays at six weeks demonstrate adequate bony
healing, immobilize in a walking cast/boot for an additional eight to ten weeks
• Immobilization is continued until there is radiographic evidence of solid union with consolidation of the fusion sites
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Complications• Malalignment
• Significantly increase the forces on the ankle joint
• Excessive hindfoot valgus• Increase the stress on the deltoid
ligament by as much as 76% increasing force across the ankle joint
• May lead to continued lateral subfibular impingement and continued lateral pain
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Complications
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Complications• Residual hindfoot varus
• Cause overload of the lateral column of the foot causing pain at the cuboid or base of the fifth metatarsal
• Lead to lateral ankle instability and secondary ankle arthritis
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Complications• Significant residual varus or valgus of the
forefoot• Abnormal gait pattern • Cause excessive forces across the ankle
joint• May require revision of the triple arthrodesis
• Extensive calcaneal varus or valgus of the calcaneus • Corrected by utilizing a Dwyer type
calcaneal osteotomy
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Complications
• Loss of motion remains a problem• Produces secondary arthrosis of the ankle and tarso-
metatarsal joints over time• These changes are often not apparent clinically• Radiographic changes have been reported in over
fifty percent of patients
• This problem remains unsolved and the long term implications unclear
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Complications• Nerve injury or entrapment of the sural nerve at the
lateral incision
• Require a neurolysis or nerve resection if the symptoms become severe
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Complications• Failure to address an Achilles Tendon contraction
• Lead to excessive midfoot stresses
• Lengthened to achieve no more than 10 degrees of dorsiflexion
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Complications• Secondary degenerative arthritis of the ankle
and midfoot reported 14-20%• More common with residual malalignment
• Ankle symptoms can often be treated with the use (MAFO)
• Midfoot pain can be treated with a UCBL
• If bracing unsuccessful• Consider fusion/replacement of these
effected joints
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Complications• Avascular necrosis of the talus reported
• If present and symptomatic• Initial treatment employ bracing
• Unsuccessful then consideration of ankle fusion
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Complications• If a triple arthrodesis is being done as a stage
procedure for a later total ankle or as part of a pan-talar arthritis then a limited subtalar fusion should be considered
• Only the posterior facet should be approached
• Do not violate the arterial supply of the talus from the inferior neck
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Complications• Nonunions occur
• TN joint• Theorized to stem from inadequate
exposure and preparation of the joint surfaces
• If nonunion is asymptomatic no treatment is required
• If nonunion produces symptoms then revision of the nonunion with internal fixation and bone grafting is generally effective
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RE ECT
the ankle
the foot