Foot and ankle issues in collagen disorders
• Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, VA
• Director, Eastern Virginia Medical School podiatry education
• Past President ACFAPediatrics
• Captain, (SCWO), MSC, USNR-R
Previous research
• Common foot problems identified by survey, Seattle, WA
• Xrays taken at Detroit Children’s Hospital evaluated
• Footmax scans collected, Philadelphia, PA
Some collagen disorders
• Ehlers-Danlos Syndrome
• Marfans Syndrome
• Osteogenesis imperfecta
• Etc….
Special considerations
• Soft tissue handling
• Vascular fragility?
• Bone fragility?
• Over pronation or sagging
• Achilles may still be tight!
Common foot problems
• Hypermobility
• “Flat feet” with or without over pronation
Common foot problems
• Uncommon manifestations
• “Bunions” with joint fluid leak (ganglion cyst/”pseudo tumor”)
Principles of podiatric intervention
• Align and maintain functional anatomy
• Avoid skin injury
• Don’t rely on ligaments
• Select and time invasive intervention carefully
Align and maintain functional anatomy
• Foot orthoses-> controversial • Arthrodesis -> anecdotally mediocre results • Osteotomies -> more reliable, much experience • Arthroresis -> controversial but promising • Ligament replacement -> new devices
Sub talar arthroresis
Subtalar Arthroresis
• History/variations
• goals
• Disadvantages
• Advantages
HISTORY
• Chambers 1946: bone block
• Subotnick 1974 silastic carved plug
• Current: Metal implants, Absorbable implants
HISTORY
• Polymers
• Metals
• absorbable
Goals of STA
• Relief of pain
• Improved joint alignment and function
• Interruption of patho-mechanical progression
• “correction” of “deformity”???
STATE OF THE ART
State of the art
Size matters!
• CT measurements of sinus tarsus
• Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable sub talar arthroeresis, JFAS, 2007
Metatarsus Adductus
• From: Agnew, P in: McGlamery’s comprehensive textbook of foot and ankle surgery. Lippincott Williams and Wilkins, 3rd and 4th editions
Diagnosis • Infancy
• Toddler hood
• Childhood
• Adults
• From: Agnew, P in: McGlamery’s
comprehensive textbook of foot and ankle surgery. Lippincott Williams and Wilkins, 3rd and 4th editions
Multiplanar deformities From: Agnew, P in: McGlamery’s comprehensive textbook of foot and ankle surgery. Lippincott Williams and Wilkins, 3rd and 4th editions
Prognosis • No reliable method
• Uncompensated: styloid process, HAV?, ankle injuries, lateral knee?, claw toes…
• Compensated: complex over pronation, HAV?, hammertoes
Management
• Observation(?)
• “stretching”(?)
• Casting
• Splinting
• Shoes(?)
• Surgery
External fixation
•Mini rails
•May obviate second surgeries, may result in less bone surgeries
Good solutions for bad ligaments
• Strong: absorbable vs non absorbable
• Minimally invasive (small incisions)
• May obviate some bone surgeries
• May permit weight bearing immediately
Suture and button procedures by permission
Pre operative
Post operative
Minimally invasive techniques in development
Internal brace Replaces commonly injured ligaments with strong suture webbing
Small incision
Doesn’t rely on native collagen for reinforcement
Please pray for our troops
US NAVY SEA BEES
Top Related