Lecture 27 parekh pttd3 and 4

1. Operative Care Stage 3 and 4 PTTD Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd

2. Stage 3 and 4 PTTD • Stage 3 • Rigid flat foot deformity • Stage 4 • Rigid foot deformity with ankle arthritis

3. Introduction • Triple arthrodesis • Fusion of the three hindfoot articulations • Subtalar or talocalcaneal • Talonavicular • Calcaneocuboid joints. • Responsible for • Supination and pronation of the foot;

4. 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.

5. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid COUPLED MOTION • Talonavicular • 6 degrees of freedom • Ab/adduction forefoot • Varus/valgus forefoot • Dorsiflexion/plantarflexion

6. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid • Talonavicular • 6 degrees of freedom • Ab/adduction forefoot • Varus/valgus forefoot • Dorsiflexion/plantarflexion

7. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid • Subtalar • Inversion/eversion • Calcaneocuboid • Dorsiflexion/plantarflexion • Ab/adduction

8. 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

9. Hindfoot Arthritis Presentation • Swelling • Tenderness • Decreased inversion/eversion motion • Crepitus • Malalignment

10. Hindfoot Arthritis Radiographs • Radiographs • Standing A/P, Lateral and Oblique foot • Standing A/P ankle • Possibly axial heel view (Harris)

11. Hindfoot Arthritis Radiographs • Radiographs • Standing A/P, Lateral and Oblique foot • Standing A/P ankle • Possibly axial heel view (Harris)

12. Hindfoot Arthritis PE and Radiographs • Possibly (rare) • CT scan for Coalition/Assess degree of arthritis of adjacent joints

13. 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

14. 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

15. 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.

16. Preoperative Evaluation • Sensation should be documented preoperatively • The presence of peripheral neuropathy must be identified to avoid potential complications of postoperative Charcot arthropathy.

17. 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.

18. 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.

19. 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

20. 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.

21. Case

22. Case

23. 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

24. 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

25. Lateral Incision • Tip of fibula to base of the 4th • Careful of sural

26. Lateral Incision • Final peroneals and trace distally to CC jt • Elevate extensors of anterior process • Enter subtalar and CC jts • Prepare joints

27. Medial Incision • Between ATT and PTT • Inferior to saphenous vein

28. Medial Incision • Open capsule • Distract joint • Prepare joint

29. Joint Preparation

30. 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

31. Stage 4 • Ankle arthritis • Ankle fusion • At same time • Pantalar fusion with TTC rod

32. Stage 4 • Ankle arthritis • Ankle replacement • Staged by 4-6 wks

33. 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

34. 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

35. Complications

36. 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

37. 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

38. 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

39. Complications • Nerve injury or entrapment of the sural nerve at the lateral incision • Require a neurolysis or nerve resection if the symptoms become severe

40. Complications • Failure to address an Achilles Tendon contraction • Lead to excessive midfoot stresses • Lengthened to achieve no more than 10 degrees of dorsiflexion

41. 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

42. Complications • Avascular necrosis of the talus reported • If present and symptomatic • Initial treatment employ bracing • Unsuccessful then consideration of ankle fusion

43. Complications • If a triple arthrodesis is being done as a stage procedure for a later total ankle or as part of a pantalar 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

44. 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

45. RE ECT the ankle the foot

Lecture 27 parekh pttd3 and 4

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