Upload
selene-g-parekh-md-mba
View
728
Download
0
Embed Size (px)
Citation preview
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
Stage 3 and 4 PTTD
• Stage 3• Rigid flat foot deformity
• Stage 4• Rigid foot deformity with ankle arthritis
Introduction• Triple arthrodesis
• Fusion of the three hindfoot articulations• Subtalar or talocalcaneal• Talonavicular• Calcaneocuboid joints.• Responsible for
• Supination and pronation of the foot;
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.
Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
COUPLED MOTION• Talonavicular
• 6 degrees of freedom• Ab/adduction forefoot• Varus/valgus forefoot• Dorsiflexion/plantarflexion
Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
• Talonavicular• 6 degrees of freedom
• Ab/adduction forefoot• Varus/valgus forefoot• Dorsiflexion/plantarflexion
Hindfoot ArthritisSubtalar/Talonavicular/Calcaneocuboid
• Subtalar • Inversion/eversion
• Calcaneocuboid• Dorsiflexion/plantarflexion• Ab/adduction
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
Hindfoot Arthritis Presentation
• Swelling• Tenderness• Decreased inversion/eversion motion• Crepitus• Malalignment
Hindfoot Arthritis Radiographs
• Radiographs• Standing A/P, Lateral and Oblique foot• Standing A/P ankle• Possibly axial heel view (Harris)
Hindfoot Arthritis Radiographs
• Radiographs• Standing A/P, Lateral and Oblique foot• Standing A/P ankle• Possibly axial heel view (Harris)
Hindfoot Arthritis PE and Radiographs
• Possibly (rare)• CT scan for Coalition/Assess degree of arthritis of
adjacent joints
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
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
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.
Preoperative Evaluation• Sensation should be documented preoperatively
• The presence of peripheral neuropathy must be identified to avoid potential complications of postoperative Charcot arthropathy.
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.
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.
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
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.
Case
Case
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
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
Lateral Incision
• Tip of fibula to base of the 4th
• Careful of sural
Lateral Incision
• Final peroneals and trace distally to CC jt
• Elevate extensors of anterior process
• Enter subtalar and CC jts
• Prepare joints
Medial Incision
• Between ATT and PTT
• Inferior to saphenous vein
Medial Incision
• Open capsule
• Distract joint
• Prepare joint
Joint Preparation
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
Stage 4
• Ankle arthritis• Ankle fusion
• At same time• Pantalar fusion with TTC rod
Stage 4
• Ankle arthritis• Ankle replacement
• Staged by 4-6 wks
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
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
Complications
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
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
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
Complications• Nerve injury or entrapment of the sural nerve at the
lateral incision
• Require a neurolysis or nerve resection if the symptoms become severe
Complications• Failure to address an Achilles Tendon contraction
• Lead to excessive midfoot stresses
• Lengthened to achieve no more than 10 degrees of dorsiflexion
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
Complications• Avascular necrosis of the talus reported
• If present and symptomatic• Initial treatment employ bracing
• Unsuccessful then consideration of ankle fusion
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
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
RE ECT
the ankle
the foot