rod hammett consultant orthopaedic surgeon musgrove park
Post on 04-Oct-2021
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Rod Hammett Consultant Orthopaedic Surgeon Musgrove Park Hospital
What patients does the surgeon want to see?
What patients does the neurologist want the surgeon to see??
What does the surgeon need to know???
What does the patient want????
“CMT commonly presents to orthopaedic surgeons with lower and upper limb symptoms including ankle sprains, cavus feet, and weakness of intrinsic hand muscles. More rarely, they present with spinal and hip manifestations. It is not usually a life threatening or painful condition and therefore lends itself to the FRCS (Tr & Orth) exam.”
Ankle and hindfoot
Instability, recurrent sprains
Peroneal tendon pain
Insertional Achilles problems/plantar fasciopathy
Secondary degenerative joint disease
Tibial stress syndrome
Knee pain/genu varum/ITB syn
Mid and Forefoot 5th metatarsal
▪ Fracture(s)
▪ Non union
▪ Basal overload
Metatarsalgia
Midfoot OA
Claw toes
Neuropathic ulceration
Shoe breakdown
Diffuse/ multiple complaints
Any combination of the above
Beware pain fibre neuropathy
Neuromuscular until otherwise proven
Neuromuscular
Peripheral neuropathy CMT (HMSN)
Spinal Cord Disease Poliomyelitis/ neoplasia /syringomyelia
CNS disease Freidrich’s ataxia, cerebral palsy
Myopathy Muscular dystrophy Congenital
Arthrogryposis
Residual Club Foot deformity Trauma
Post compartment syndrome
Peroneal nerve palsy Idiopathic
70% have neurological diagnosis
CMT (HMSN) 50% of patients
30% Idiopathic
Importance of full neurological assessment Especially ▪ FH, bilateral, gait impairment / muscle atrophy
▪ Sensory / motor disturbance
Described 1886
Spectrum of genetic disorders that affects peripheral nerves
Slows action potential transmission or amplitude
Usually present with
Lower limb
▪ Cavus feet / ankle sprains
Upper limb
▪ Intrinsic weakness
Strong genetic component FH (spontaneous genetic mutation) Lots of subtypes of CMT
Inheritance pattern
What part of nerve cell is affected
Genes affect nerve proteins Progressive disease Management
Maintain mobility and independence
Lower limb pain 90% Rubbing toes 60% Metatarsalgia 50% Ankle instability 30% Lateral border pain 10% Ankle/hindfoot pain 10% Ulceration 1%
Pes cavus
Latin “hole / pit”
“hollow foot”
“A foot with a high arch that fails to flatten with
weight bearing”
Prevalence 10%
Cavovarus (HSMN)
Forefoot plantarflexed
Hindfoot varus
(1st ray > others – pronated)
Calcaneocavus (POLIO)
Dorsiflexion of calcaneus
Fixed equinus of forefoot
No pronation of forefoot – therefore no varus deformity
Plantaris
Plantarflexion of forefoot
Calcaneus
Dorsiflexion of hindfoot
Cavovarus
Varus deformity of hindfoot
Cavus
Equino –Cavo-Varus
Calcaneo-Cavo -Varus
A – Meary’s Angle N = 0 – 5 Degrees B – Calcaneal Pitch Angle N = 30 degrees C – Hibbs Angle N = <45 degrees D – Weight Bearing Tibioplantar Angle N = 90 degrees
Peroneus longus (1st MT and adj cuneiform)
Plantarflexion first ray / evertor
Tibialis anterior (1st MT and adj cuneiform)
Dorsiflexion
Peroneus Brevis (5th MT)
Evertor
Tibialis posterior (Navicular tuberosity)
Invertor / Flexor
Intrinsics
Flex the MTP / extend IP
Posterior muscles normal
Anterior weak (variable)
Weak Tib Ant – Relatively strong Peroneus Longus Forefoot equinus
Peronus Brevis weak / Tib Post normal Hindfoot varus
Hypothesis
Normal anatomy and function
Intrinsic and extrinsic muscle balance
▪ Acting on normal soft tissues and bones / joints
Muscular imbalance
Deformity and impaired function
Disorder differentially affects extrinsic muscles
CONTROVERSIAL
Tib post >peroneus brevis
▪ Adduction of forefoot and inversion of hindfoot
Peroneus longus > Tib ant
▪ Plantar flexion of first metatarsal
Tib ant weak – EHL and EDL aid dorsiflexion
▪ MTP dorsiflexion Tib ant> gastrocnemius / soleus (Polio)
Disorder affects foot Intrinsic muscles
CONTROVERSIAL
(Deformity can pre-date extrinsic weakness + MRI findings)
Long extensors - Dorsiflexion of MTP
Long flexors – IP joint flexion
Intrinsic shortening + windlass - Plantar aponeurosis tensioned - shortening of medial longitudinal arch
Cavus can progress without clawing!
Theory 1 and 2 are correct
Probably not a single problem in all cavus feet
“Windlass effect”
Plantar plates of MTP attached to plantar fascia
MTP extension tightens plantar fascia
Increase arch - cavus
Medial band largest – medial calcaneus - varus
“Tripod effect” Heel, 1st MT head, 5th MT
head
Plantigrade / no varus or valgus
1st ray plantarflexed ▪ 3 points can only rest on
ground if heel – varus
▪ (Coleman 1977 – “block test”)
“Plunger effect” (Stainsby)
MTP extension forces MT heads plantarward
MT plantarflexion
Bony Deformity
Bone growth affected by deforming forces
Altered bone shape
Variable Toes
PIP rubbing / tips of claw toes
Metatarsal Heads
Metatarsalgia
Hindfoot varus
Ankle instability (peroneus brevis)
Lateral foot pain
Stiff hindfoot
▪ Unable to absorb forces
▪ Fatigue
▪ Ankle / hindfoot pain
General
Shoe fitting /wear
Non specific foot pain (50% of CMT – not responsive to surgical measures)
Weakness
Ulceration
Most autosomal
dominant Demyelination of
nerves Presents in second
decade Diagnosed by
decreased nerve conduction velocities
Weakness Ataxia Distal sensory loss Areflexia Equinus/Calcaneus Cavus Varus
Autosomal Dominant
Neuronal form
Later presentation
Mildly Impaired Nerve Conduction Velocities
Onset in 20s and 30s
Profound limb weakness
As Type I or Stork leg appearance
Flail foot
Calcaneo varus or Flat foot
Autosomal recessive Includes Dejerine
Scottas syndrome (hypertrophic neuropathy of infancy)
Presents in infants Demyelination with
decreased conduction
Sensory loss (Glove and stocking)
Muscle weakness and contracture
Spinal deformity common
Type IV – Refsum disease Type V - Inherited spastic paraplegia
with distal weakness Type VI - Peroneal muscular atrophy with
optic atrophy Type VII – Atrophic muscle weakness with
retinitis pigmentosa
Explanation
Reassurance
Natural history & inheritance
Neurology/Genetics
Orthoses Insoles ▪ Metatarsalgia, accomodative, FFO
▪ Total contact insole
Shoes ▪ Lateral wedge & flare
▪ Extra depth toebox
AFO, ankle brace, caliper
Put the Foot below the leg Put the Foot square to the ground BALANCE THE MUSCLE POWERS
À la carte approach
Stepwise correction starting proximally and working distally
Balance the forces to maintain bony correction (even with fusions)
Flexible deformities – tendon transfers +/- axial realignment
Fixed deformities – osteotomies and soft tissue releases
Degenerative joint disease – arthrodesis (or replacement)
Patients with Charcot Marie Tooth have neuropathic pain
Surgery may introduce or exacerbate pain
Treat structural problems, not pain
After Surgery Change the shoes!
Careful examination and weightbearing XR
Supramalleolar osteotomy?
Achilles lengthening
Avoid over lengthening
Isolated gastroc?
ATFL reconstruction
Peroneal tendons
Brevis to longus tenodesis
Corrects calcaneal pitch
Not for plantaris correction
Beware medial and lateral plantar nerves
Chevron or ‘Z’ Correction of
calcaneus deformity Minimally invasive
surgery possible
Stiff subtalar/Chopart
Symptomatic DJD
Paralytic deformity
Peroneal LMN
polio
Calcaneal osteotomy
1st MT osteotomy
Gastroc/ Achilles release
Tendon transfers
Soft tissue releases
Adjunct procedures Talectomy
Wedge resections
Frame
Severe cavus
Dorsal bump
Foot realignment
Ankle fusion
TTC/ pantalar fusion
Ankle replacement
Foot realignment
Ankle fusion
TTC/ pantalar fusion
Ankle replacement?
Foot realignment
Ankle fusion
TTC/ pantalar fusion
Ankle replacement
Three components
Cavus
Adductus
Pronation
First ray Composite midfoot (wedge) osteotomies Triple fusion – Chopart’s joints correct
pronation
Coleman block test
Correctable hindfoot driven by 1st MT plantarflexion
Plunger effect
Windlass effect
Peroneus longus> tibialis anterior
Secondary fixed contracture
Treat claw hallux Transfer EHL
MT neck > tib ant>lateral
Elevate 1st MT dorsal closing wedge
TMT fusion
Longus to brevis transfer?
Plan from Coleman
block test
Restore dynamic balance for correctable deformities
Prevent recurrence after osteotomy or arthrodesis
Tibialis posterior and triceps surae
overpower
Tibialis anterior and
peroneus brevis
Invertors and flexors
overpower
Extensors and evertors
Tibialis posterior
Peroneus longus to brevis
Tibialis anterior laterally
Jones procedure
Mallet Hammer Claw
PF Flexors & intrinsics
PF Flexors
Dorsal callus
Dorsal ulceration
Nail walking and tip callous
“Plunger” effect
metatarsalgia
Type 1 Flexible MTP and IPJ Rarely present
Type 2
Stiff IPJ flexible MTP (+/- subluxation)
Type 3 Stiff IPJ &MTP
Type 1
FETT
MTP capsulotomy
PIP arthroplasty
Type 2
PIP fusion/arthroplasty +/- MTP release
Type 3
PIP fusion/arthroplasty +/- radical MTP release
& Kwire Or Stainsby
hemiphalangectomy
Flexible
Rarely present
FHL transfer to P1
Stiff
Jones procedure
IPJ fusion
EHL transfer to MT
History
Establish patient’s problem
Treat the patient not x-ray
Simple non-operative Mx first
Forefoot balancing if forefoot driven
Osteotomy and tendon transfer for mobile hindfoot joints
Fusion for fixed deformities/OA/paralysis
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