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Jacob Wynes DPM, MS, FACFASAssistant Professor, Department of Orthopaedics
Co-Director UMMC Limb Preservation Clinic
University of Maryland School of Medicine
Disclosures
Consultant: Orthofix
Consultant: Smith and Nephew
Sometimes Orthotics / Bracing is not
a Permanent Solution
“Faulty Attitude”
E.H. Bradford. JBJS 1910
Johnson and Strom (1989)
*Myerson Addition (1996)
Tendon
Condition
Peritendonitis;
tenosynovitis /
degeneration
Elongated Elongated;
complete rupture
Elongated:
complete
rupture
Rearfoot Flexible; normal
alignment
Flexible;
valgus RF
Rigid;
Valgus RF
Rigid;
valgus RF
Valgus ankle
Pain Focal (medial);
Mild – Mod.
Focal (medial);
Moderate
Medial and/or
Lateral;
Moderate
Med / Lat;
Moderate –
Severe
Single Heel
Test
TMT Sign
Pathology
Mild Weakness
Normal
Synovial
Proliferation; mild
degeneration
Marked Weakness
Positive
Mod Degeneration
Marked Weakness
Positive
Mod Degeneration
Complete Rupture
Marked
Weakness
Positive
Degeneration
Complete
Rupture
Treatment Conservative:
Tenosynovecomty
Debridement
FDL transfer
RF Arthrodesis /
osteotomy
Isolated RF (or)
Triple Arthrodesis
Tibiocalcaneal
(or) Pantalar
Fusion / Deltoid
Repair ?
TYPE I TYPE II TYPE III TYPE IV*
#GOALS
Relieve pain
Provide stability
Realign and maintain alignment
Axial (Long Leg Calcaneal Axial)
45º
+
Axial (Hindfoot Alignment)
20º
+
Cobey JC. Clin Orthop 1976
Saltzman and el-Khoury, Foot Ankle Int, 1995
Lamm BM et al. JAPMA 2005
Long Leg Calcaneal Axial Hindfoot Alignment
45
°
20
°
Lamm et al. JFAS 2016
Perioperative Considerations
Anatomic alignment (assessment of angles)
Use of adjunctive bone grafting
Fixation type (screws vs. plate vs. staples vs. steinman
pins)
Low energy joint preparation
Assessment of Equinus (gastroc vs. gastroc-soleal)
Assessment of extent of osteoarthritis and motion
TNJ arthrodesis limits STJ and CC to ~ 2
degrees
STJ lmits TN motion to 26% and CCJ to 56%
Astion et al. JBJS 1997
Preferred in absence of cuboid DJD
Mann et al. FAI 1998
EDB Flap
Above Peroneals
Avoid IDCN and Sural Branch
Evaluation by flurosocopy
Above Post Tib Tendon
Saphenous and Tib Ant
Arthrodiastasis of CCJ occurs (decreased subchondral sclerosis) with mild -moderate DJD
N= 20 /46 meeting inclusion criteria
Berlet et al. JFAS 2015
Greater arthrodiastasis of CCJ 32% to 62% when combined with Lapidus
Gali et al. JFAS 2015
Greater rates of nonunion / incomplete union for PTTD Stage 3+ (N=9 double arthrodesis vs. N=7 triple arthrodesis)
44% nonuion vs. 0% nonunion
Burrus et al .JFAS 2016
Schuh et al. J Orthop Research 2013
N=22 feet / 14 patients
Solid fusion at 12 weeks
25 degree AP / Lateral Meary’s angle maintained
Horton et al. FAI 1995
Courtesy of RIAO / ICLL
BMI with flatfoot 26.52 +/-5.24 vs. without
25.07 +/- 4.71 (Shibuya et al. JFAS 2010)
Reduction in pain frequency from 87.5% to
12.5% after bariatric surgery (Melo et al. Arg
Bras Cir Dig 2012)
Obesity may lead to failure of FDL tendon
transfer and may necessitate medial column
fusion (Hatic et al. Foot Ankle Clin 2012)
Level III retro cohort:
Overweight patients = worse preoperative
scores
No difference post operatively with respect to
BMI in Stage 2 AAFD @ 1 year follow up (<25,
25-30, >30kg/m2) (Soukup FAI 2016)
Labs
Prox
Distal
Alignment
Post Op Course
Follow Up
Lessons Learned - Triple
Arthrodesis
Release / Lengthen Peroneals to allow for STJ reduction
Provisional pinning of tibiotalar joint to maintain
stability (removal 6 weeks)
Calcaneal cuboid preparation may allow for ease of STJ
reduction
Hentges et al. JFAS 2016
Stage 4 PTTD
Lui et al. Foot Ankle Surg 2014
Hintermann et al. Foot Ankle Clin
2013
Colin et al. FAI 2013
Smith et al. Foot Ankle Clin 2012
Deland et al. FAI 2004
Pre Op
Stage 4: Triple / Calc Slide / Deltoid Repair
Arthrex
Recreation of Deltoid Complex
Arthrex
2 Years Post Op
Recommendation to avoid in cases of “advanced” tibiotalarosteoarthritis
Smith et al. Foot Ankle Clin 2017
Delay and prevent ankle arthritis
Oburu et al. Foot Ankle Clin 2017
Deltoid + Triple with success in 5/8 patients to maintain < 3 degrees of valgus and > 2mm LAT ankle displacement
6.4±2.9 degrees to 2.0±2.0 degrees correction of tibiotalar valgus
Jeng et al. FAI 2011
Use of FiberTape® construct with combined spring ligament and deltoid reconstruction without post op complications, stiffness or loss of correction (N=10)
Nery et al. FAI 2018
Retrospective cohort N= 21 patients
Improvement in radiographic parameters
Mean f/u 27.6 months
Tarsal osteotomies unable to correct translatory valgus
Eberhardt et al. Acto Orthop Trauma Surg2018
Supramalleolar osteotomy performed
N=14 mean f/u 50.6 months
Improvement in VAS 4.1 ± 1.7 to 2.2 ± 1.5 (p < 0.05)
Improvement in AOFAS 51.6 ± 12.3 77.8 ± 11.8 (p < 0.05)
Knupp et al. JBJS 2012
Gross et al. Arthritis Care Res 2011
Pes planovalgus associated with
medial tibiofemoral cartilage damage
1.3 x more likely to have knee pain
with rigid valgus
Preoperative MRI - 9/2015
In-111 Scan 9/2015
4/2015
1/28/2016
1/28/2016
1/28/2016
2/2016
2/2016
2/17/2016
6/15/2016
Post op Clinical
Take Home Points
Triple/ Double arthrodesis appear to be equally as effective
Maintenance of correction is paramount to success
Address arthritis joints through arthrodesis
BMI may play a role in procedure selection
Deformity principles help with evaluation and procedure selection
Avoid residual translation after STJ fusion
Rigid hindfoot can influence knee alignment
Thank You
An Interesting Case
S
Jacob Wynes DPM, MS, FACFAS
Assistant Professor, Department of Orthopaedics
Co-Director UMMC Limb Preservation Clinic
University of Maryland School of Medicine
S Assess for Complete vs. Incomplete coalitions
S Calcaneal axial view / medial oblique foot view
S Evaluate tolerance to Orthotics and unilateral pain phenomenon
S Pediatric Neurology consultation with spasticity / weakness (ie. Cerebral Palsy)
S Assess proximal segment - tibial torsion / femoral retroversion
S Assess compensation for Equinus
S Could be associated with fibular hemi-melia or other syndromicconditions as well
S Be suspicious with marrow edema on MRI
S Cerebral Palsy - Neuromuscular
S Tarsal coalition - structural abnormality
S Osteogenesis imperfecta - Collagen defect
S Downs Syndrome - Hypotonia / collagen defect
S Marfan Syndrome - Collagen defect
S Ehlers-Danlos Syndrome - Collagen defect
S Most Common Talocalcaneal > Calcaneonavicular
S Age of onset of symptoms varies
S TC and CN can exist together
S Richer et al. Clin Imaging 2016
General Approach:
Downey ClassificationJAPMA 1991
S Compensation at midtarsal joint
complex
S Mosca, Principles/Management
of Ped Foot/ Ankle Text 2015
S FHL > FDL > PT tendons >
Medial plantar nerve
S Alaia et al. Skeletal Radiol 2016
S Symptomatic in flat foot with co-existing tarsal tunnel
S Bhat et al. BMJ Case Rep 2017
S Garchar et al. JFAS 2001
S Combined fibrous coalitions reported
S Calcaneal-Navicular + Naviculocuneiform
S Calcaneal-Navicular + Metatarsocuneiform
S Vira et al. Bull Hosp Jt. Dis 2013
“C Sign” for STJ coalition
Lateur et al. Radiology 1994
Brown et al. Skeletal Radiology 2001
“ Anteater Sign” for Calcaneal Navicular
Coalition
Oestreich et al. JPO 1987
S Cuboid Lateral Cuneiform
S N=1 Babu et al. JAPMA 2017
S N=1 Renner et al. JAPMA 2017
S Cuboid Navicular
S N=4 with fat interposition with “excellent results”
S Sarage et al. JFAS 2012
S Persistent midfoot pain
S Kamiya et al. JBJS 2015
S Approx 10 reported cases
S Awan et al. Case Report Radiol 2015
S Soft tissue contractures (lateral ligaments, peroneals, and
gastroc-soleal complex)
S Recommendation for peroneal tendon release
S Gougoulias et al. Foot Ankle Clin 2014
Golano et al. Knee Surg Sports Traumatol Arthrosc 2010
S N=8 (13 feet)
S Non resectable coalition in
5/8 patients
S Follow up 2-15 years
S “Excellent deformity
correction” and pain relief in
rigid feet
Intra Op (Pre / Post LCL)
Pre Op: Calcaneal Navicular Bar
Post Badgley Interposition
Recurrence of Coalition
Re-Resection
S N=48 patients / 56 feet CN Bar resection
S Compared Fat grafting, bone wax, EDB
S VAS improvement in fat grafting / bone wax >> EDB
S AOFAS: 59 to 98; 50 to 90; 48 to 75 (P<0.001)
S RECURRENCE: 4% FAT, 6% bone wax, 40% EDB
S N=4
S 3 talocalcaneal coalitions (1 fibrous / 2 osseous)
S 1 cuboid navicular
S Xray / CT / MRI performed with no recurrence
S 40 month f/u
S AOFAS 93.5 / FFI 3.25% (0-13%)
• Calcaneal lengthening osteotomy
• Medial displacement calcaneal osteotomy
• Arthroereisis
• Fusion
• N=32 patients (46 feet) mean age 11
y/o
• Mean follow-up: 66 months
• Results:
• 30 feet achieved excellent /good
• Improved cosmesis in 37 feet
• Mild restriction of eversion in 34 feet
• NC sag persisted in 11/13 feet
• Complications
• 7 feet had recurrence of deformity
• 4 feet developed varus deformity
S N=75 CP patients m ean age 11 yo
S Mean follow-up 3.1 years
S Excluded medial column procedures
S Results:
• Improved radiographic parameters
(p<0.001)
• Additional procedures should be
considered if:
S >23° AP talus-1st met
S >36° lateral talus-1st met
S 72% NV-cuboid overlap
Sung et al. CORR 2013 Zaifang et al. FAI 2006
S N=21 (37 Feet)
S One-year follow up
S Improvement in
maintenance of
radiographic results
S Improved TN coverage
Intra-op
2 Months Post-op
Consider the Bauman in
Cerebral Palsy
https://thenewageparents.com/understanding-cerebral-palsy-and-muscular-dystrophy/
S Can be iatrogenic
S Midfoot break and
external tibial torsion
S Weakened gastroc-soleus
complex
S Excessive dorsiflexion /
Calcaneus gait
S Knee pain
S 134 children (195 procedures)
S 98 PTAL, 40 open lengthening, 57
Baker’s recession
S 42% satisfactory calf length
S 22% recurrent equinus
S 36% calcaneus gait
S Calcaneus gait
S Children ≤ 8 years old (44%)
S Quadriplegics (60%)
S 80% of quadriplegics with PTAL
Borton et al. JBJS Br 2001
S Saraph V. et al. JBJS 2000
S Use in diplegic CP without
weakening the triceps surae
S Herzenberg et al. FAI 2007
S Average 14 degrees increase in
Ankle DF with knee extended
S Lamm et al. JAPMA 2005
S 5-9 degrees per each score of the
fascia
S
Baumann
Procedure
S
Baumann Procedure
S
Baumann
Procedure
S
Baumann
Procedure
S Diagnosis is critical in treating this condition
S Obtain peds ortho / peds neurology consultations
S Assess proximal deformity
S Coalitions can be resected (use of fat grafting has been advocated to prevent recurrence)
S CN bar resections offers relief with restoration of alignment
S TC coalition offers relief with debated results with alignment restoration
S Adjunctive posterior muscle group lengthening, lateral column lengthening or cuneiform osteotomy can be helpful in maintaining correction
S Avoid achilles lengthening in cerebral palsy and consider medial column stabilization
Thank You
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