Foot and ankle issues in Foot and ankle issues in collagen vascular disorderscollagen vascular disorders

• Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, VAVA

• Director, Eastern Virginia Medical School PMS 24Director, Eastern Virginia Medical School PMS 24

• Past President ACFAPediatricsPast President ACFAPediatrics

• Captain, (SCWO), MSC, USNR-RCaptain, (SCWO), MSC, USNR-R

Previous researchPrevious research

• Common foot problems identified by survey, Common foot problems identified by survey, Seattle, WA Seattle, WA

• Xrays taken at Detroit Children’s Hospital Xrays taken at Detroit Children’s Hospital evaluatedevaluated

• Footmax scans collected, Philadelphia, PAFootmax scans collected, Philadelphia, PA

Collagen vascular disordersCollagen vascular disorders

• Ehlers-Danlos SyndromeEhlers-Danlos Syndrome

• Marfans SyndromeMarfans Syndrome

• Osteogenesis imperfectaOsteogenesis imperfecta

• Etc….Etc….

Special considerationsSpecial considerations

• Soft tissue handlingSoft tissue handling

• Vascular fragility?Vascular fragility?

• Bone fragility?Bone fragility?

• Over pronation or saggingOver pronation or sagging

• Ankle may still be tight! Ankle may still be tight!

Common foot problemsCommon foot problems

• HypermobilityHypermobility

• ““Flat feet” with or without over pronationFlat feet” with or without over pronation

Common foot problemsCommon foot problems

• Uncommon Uncommon manifistationsmanifistations

• ““Bunions” with Bunions” with joint fluid leak joint fluid leak (ganglion cyst)(ganglion cyst)

Principles of podiatric Principles of podiatric interventionintervention

• Align and maintain functional anatomyAlign and maintain functional anatomy

• Avoid skin injuryAvoid skin injury

• Don’t rely on ligamentsDon’t rely on ligaments

• Select and time invasive intervention carefullySelect and time invasive intervention carefully

Align and maintain functional Align and maintain functional anatomyanatomy

• Foot orthoses-> controversialFoot orthoses-> controversial• Arthrodesis -> anecdotally mediocre Arthrodesis -> anecdotally mediocre

resultsresults• Osteotomies -> more reliable, much Osteotomies -> more reliable, much

experienceexperience• Arthroresis -> controversial but promisingArthroresis -> controversial but promising• Ligament replacement -> new devicesLigament replacement -> new devices

Sub talar arthroresisSub talar arthroresis

Subtalar ArthroresisSubtalar Arthroresis

• History/variationsHistory/variations

• goalsgoals

• DisadvantagesDisadvantages

• AdvantagesAdvantages

HISTORYHISTORY

• bone proceduresbone procedures

• Chambers 1946: bone blockChambers 1946: bone block

• Subotnick 1974 silastic carved plugSubotnick 1974 silastic carved plug

• Current:Current:

• Metal implantsMetal implants

• Absorbable implantsAbsorbable implants

HISTORYHISTORY

• PolymersPolymers

• MetalsMetals

• absorbableabsorbable

Goals of STAGoals of STA

• Relief of painRelief of pain

• Improved joint Improved joint alignment and alignment and functionfunction

• Interruption of Interruption of patho-mechanical patho-mechanical progressionprogression

• ““correction” of correction” of “deformity”???“deformity”???

STATE OF THE ARTSTATE OF THE ART

State of the artState of the art

Size matters!Size matters!

• CT measurements of sinus tarsus CT measurements of sinus tarsus

• Preliminary radiographic findings and sizing Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable sub implications on patients undergoing bioabsorbable sub talar arthroeresis, JFAS, 2007talar arthroeresis, JFAS, 2007

Metatarsus AdductusMetatarsus Adductus

DiagnosisDiagnosis• InfancyInfancy

•Toddler Toddler hoodhood

•ChildhooChildhoodd

•Adultery Adultery ;);)

Multiplanar deformitiesMultiplanar deformities

PrognosisPrognosis• No reliable methodNo reliable method

• Uncompensated: Uncompensated: styloid process, styloid process, HAV?, ankle injuries, HAV?, ankle injuries, lateral knee?, claw lateral knee?, claw toes…toes…

• Compensated: Compensated: complex over complex over pronation, HAV?, pronation, HAV?, hammertoeshammertoes

ManagementManagement

• Observation(?)Observation(?)

• ““stretching”(?)stretching”(?)

• CastingCasting

• SplintingSplinting

• Shoes(?)Shoes(?)

• SurgerySurgery

Good solutions for bad Good solutions for bad ligamentsligaments

• Strong: absorbable vs non absorbableStrong: absorbable vs non absorbable

• Minimally invasive (small incisions)Minimally invasive (small incisions)

• May obviate some bone surgeriesMay obviate some bone surgeries

• May permit weight bearing immediately May permit weight bearing immediately

External fixationExternal fixation

•Mini railsMini rails

•May obviate May obviate second second surgeries, may surgeries, may result in less result in less bone surgeriesbone surgeries

Please pray for our troopsPlease pray for our troops

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