Successfully reported this slideshow.

Lecture 27 parekh pttd3 and 4

3

Share

Upcoming SlideShare
Lecture 26 parekh pttd2
Lecture 26 parekh pttd2
Loading in …3
×
1 of 45
1 of 45

More Related Content

Related Audiobooks

Free with a 14 day trial from Scribd

See all

Lecture 27 parekh pttd3 and 4

  1. 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. 2. Stage 3 and 4 PTTD • Stage 3 • Rigid flat foot deformity • Stage 4 • Rigid foot deformity with ankle arthritis
  3. 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. 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. 5. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid COUPLED MOTION • Talonavicular • 6 degrees of freedom • Ab/adduction forefoot • Varus/valgus forefoot • Dorsiflexion/plantarflexion
  6. 6. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid • Talonavicular • 6 degrees of freedom • Ab/adduction forefoot • Varus/valgus forefoot • Dorsiflexion/plantarflexion
  7. 7. Hindfoot Arthritis Subtalar/Talonavicular/Calcaneocuboid • Subtalar • Inversion/eversion • Calcaneocuboid • Dorsiflexion/plantarflexion • Ab/adduction
  8. 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. 9. Hindfoot Arthritis Presentation • Swelling • Tenderness • Decreased inversion/eversion motion • Crepitus • Malalignment
  10. 10. Hindfoot Arthritis Radiographs • Radiographs • Standing A/P, Lateral and Oblique foot • Standing A/P ankle • Possibly axial heel view (Harris)
  11. 11. Hindfoot Arthritis Radiographs • Radiographs • Standing A/P, Lateral and Oblique foot • Standing A/P ankle • Possibly axial heel view (Harris)
  12. 12. Hindfoot Arthritis PE and Radiographs • Possibly (rare) • CT scan for Coalition/Assess degree of arthritis of adjacent joints
  13. 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. 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. 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. 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. 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. 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. 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. 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. 21. Case
  22. 22. Case
  23. 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. 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. 25. Lateral Incision • Tip of fibula to base of the 4th • Careful of sural
  26. 26. Lateral Incision • Final peroneals and trace distally to CC jt • Elevate extensors of anterior process • Enter subtalar and CC jts • Prepare joints
  27. 27. Medial Incision • Between ATT and PTT • Inferior to saphenous vein
  28. 28. Medial Incision • Open capsule • Distract joint • Prepare joint
  29. 29. Joint Preparation
  30. 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. 31. Stage 4 • Ankle arthritis • Ankle fusion • At same time • Pantalar fusion with TTC rod
  32. 32. Stage 4 • Ankle arthritis • Ankle replacement • Staged by 4-6 wks
  33. 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. 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. 35. Complications
  36. 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. 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. 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. 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. 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. 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. 42. Complications • Avascular necrosis of the talus reported • If present and symptomatic • Initial treatment employ bracing • Unsuccessful then consideration of ankle fusion
  43. 43. 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
  44. 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. 45. RE ECT the ankle the foot

×