DEFORMITIES OF THE FOOT &ANKLE AND THEIR MANAGEMENT

POLIOMYELITIS-

 Acute anterior poliomyelitis is an infectious disease caused by a neurotropic virus which initially invades the GIT & respiratory tracts & subsequently spreads to the CNS.

POLIO VIRUS

 The disease usually passes through the following stages: Acute stage Stage of recovery or convalescence Stage of residual paralysis

Clinical presentations to the orthopaedician in the current context

Patients usually in the stage of post polio residual paralysis present with various deformities Some may come asking for a change from long-standing braces & calipers Post polio syndrome Some with flail & unstable joints seeking upgrading in their ambulatory status

Pre operative considerations

Selection of the correct procedure at the correct time Problem identification
Muscle imbalance Joint deformity Joint instability Limb length discrepancy

Goals of treatment
Preventing or correcting deformities Reestablishing muscle power Stabilising flail joints Eliminating the need for such external supports such as braces & corsets

Causes of skeletal deformity

Muscle imbalance Unrelieved muscle spasm Habitual faulty posture (aided sometimes by gravity) Dynamics of activity Growth

Stabilisation of relaxed or flail joint

Joint instability can be static or dynamic Stabilisation can be achieved by partially or completely restriting ROM of the joint or by eliminating an abnormal motion

Static instability can be stabilised indefinitely by Orthoses Tenodesis Fixation of ligaments or artificial ligaments BONY PROCEDURES- BONE BLOCKS OR ARTHRODESIS

 Dynamic instability is one in which there is muscle imbalance around the joint. Operations to correct a joint deformed as a result of muscle imbalance will not prevent recurrence of deformity unless the muscle imbalance is also corrected.(Sharrard) The most effective method of reestablishment of muscle power is tendon transfer

Tendon Transfer
Shifting of a tendinous insertion from its normal attachment to another location so that its muscle may be substituted for a paralysed muscle in the region

Principles of tendon transfer

The muscle to be transferred must be strong enough to accomplish what the paralysed muscle did or to supplement the power of a partially paralysed muscle. A transferred muscle loses at least one grade in power after transfer. The freed end of the tendon should be attached close to the insertion of the paralysed tendon & should be routed in a direct line b/w its origin & new insertion

 The transferred tendon should be retained in its own sheath or of another tendon;it should be passed throgh tissues that will allow it to glide. The nerve & blood supply to the transferrecd muscle must not be impaired. The joint on which the muscle is to act must be in a satisfactory position.

 The transferred tendon must be securely attached to bone under tension slightly greater than normal. Agonists are preferred to antagonists. The tendon to be transferred should have, when possible, a range of excursion similar to the one it is replacing.

Non phasic transfers & Phasic conversion

Often a non phasic muscle must be trained to assume the proper phase of the walking cycle after transfer. The mixing of swing phase & stance phase transfers should not be done. Phasic conversion is not related to the time from onset of the disease to transfer Bracing or splinting after surgery seems to have no effect on phasic conversion

Considerations in timing procedures

AGE of the patient is most important Arthrodesis should be done near skelatal maturity Tendon transfer should be done in children only when they are old enough to cooperate in muscle reeducation

FOOT AND ANKLE

Since the foot & ankle are the most dependent parts of the body and are subjected to greater strain than other parts, they are especially susceptible to deformity from paralysis.

Basic anatomy

Movements at the ankle

The aim of treatment of the paralysed foot in poliomyelitis is to obtain a foot which is plantigrade during stance,which can push off well at the initiation of swing, and which can dorsiflex actively during the swing phase.

A plantigrade foot implies that there is no varus or valgus deformity with normal distribution of weight under the heel and metatarsal heads

 To achieve a powerful push off, there must be adequate power (grade 4/5 ) of plantarflexion A dorsiflexor power of at least grade 3 is required to achieve active dorsiflexion during swing

Deformities around the foot & ankle

Deformities of the foot may be Supple and passively correctable or Rigid and fixed

 Supple deformities can be very effectively corrected by performing a suitable muscle transfer. Rigid deformities require soft tissue release operations, tissue distraction with Ilizarov, osteotomies or resection of bone

Patterns of muscle paralysis & resultant deformities

Tibialis anterior+ toe extensors Triceps surae Equinus

Calcaneus Planovalgus Equnovarus

Equinovalgus Valgus Calcaneovalgus Calcaneovarus

Tibialis posterior Tib ant+ peronei

Tib ant+ tib post +toe extensors Tib ant+ Tib post Triceps surae+ tib post Triceps surae+ peronei

PEABODY CLASSIFICATION
Limited extensor- invertor insufficiency Gross extensor-invertor insufficiency Type A Type B Evertor insufficiency Triceps surae insufficiency

1)Paralysis of the tib ant; normal toe extensors-eqinus & cavus or planovalgususually requires only transfer of EHL to the base of first metatarsal 2)Type A- paralysis of tib ant+ toe extensors; normal tib post-equinus or equinovalgus-PL to dorsum of foot Type B paralysis of all 3 muscles-transfer of peronei

POLIO VIRUS

3)When slight, EHL is transferred to the base of fifth metatarsal When gross, tib ant to cuboid & EHL to first metatarsal 4)Calcaneovalgus-peronei are transferred to the calcaneum Calcaneovarus-tib post + FHL are transferred Calcaneocavus-peronei+tib post to calcaneus

 Tendon transfers around the foot & ankle after the age of 10/11 are usually supplemented by stabilisation procedures to 1)Spare a tendon for transfer 2)To correct fixed deformities 3)To establish enough lateral stability for weight bearing 4)To compensate for the loss of power in the invertor and evertor muscles

 When tendon transfer and bone stabilisation are contemplated in the same patient, THE LATTER IS DONE FIRST.

STABILISATION OF THE JOINTS OF FOOT AND ANKLE

Triple arthrodesis; it is the surgical fusion of talocalcaneal, talonavicular& calcaneocuboid joints

 Whitman layed down the principles of arthrodesis on a sound basis Concept of posterior displacement of the foot : transfers its fulcrum (the ankle) anteriorly to a position near its centre & lenghtens its posterior lever arm;this is of particular advantage when the triceps surae is weak He advised talectomy for the same

HOKE in 1921 and DUNN in 1922 suggested removing bone from b/w the cuneiform & talus to produce posterior displacement

 1n 1923 RYERSON advised inclusion of calcaneocuboid joint to the other two joints for added stability

The two important modifications of triple fusion are the LAMBRINUDI technique & the ELMSLIE technique

Lambrinudi- for equinus deformity. Here an anteriorly based wedge is resected from the talus & calcaneum while the foot is held fully plantarflexed. Elmslie Cholmeley-for calcaneus deformity. Here a posteriorly based wedge is resected while the foot is held in full dorsiflexion

LAMBRINUDI ARTHRODESIS

Sub talar arthrodesis

Subtalar arthrodesis
Only arthrodesis permissible in the skeletally immature foot (b/w 3-8 years) Green & Grice developed an extra articular subtalar fusion by packing the sinus tarsi with cortical tibial grafts fashioned so as to prise open the sinus tarsi

Modifications
A fibular strut graft is passed in the axis of the subtalar joint from the neck of the talus across the sinus tarsi into the calcaneum (Brown & Batchelor 1968) A screw is placed the sinus tarsi in the axis of the subtalar joint and the sinus tarsi is packed with cancellous graft (Dennyson and Fulford 1976)

Green & Grice extraarticular subtalar arthrodesis

Dennyson Fulford arthrodesis

Pantalar arthrodesis
This operation is indicated as follows
For patients who have calcaneus or equinus deformities combined with lateral instability of the foot. For patients whose deformity has recurred after a bone block or a Lambrinudi procedure Some times for patients with an unstable knee from paralysis of the quadriceps muscle

Orthotic stabilisation
Ankle foot orthoses are the mainstay AFOs are modified to control various instabilities of the foot & ankle in poliomyelitis

Modifications
Instability Upright
Equinus Double irons

T-strap
Lateral Medial

Joint
90 degree foot drop stop or toe raising spring Free motion joint Free motion joint

Varus Valgus

Medial iron Lateral iron

Calcaneus
Flail foot

Double iron
Double iron

Reverse foot drop stop

Limited motion joint

Common deformities in poliomyelitis

CLAW TOES CAVUS DEFORMITY & CLAW FOOT DORSAL BUNION TALIPES EQUINUS TALIPES EQUINOVARUS TALIPES CAVOVARUS TALIPES EQUINOVALGUS TALIPES CALCANEUS

CLAW TOES
Occur in 2 situations When long toe extensors are used to substitute weakened ankle dorsiflexors When long toe flexors substitute weakened triceps surae

The responsible mechanism can be identified by careful analysis of the foot In the first case during the swing phase toe extensors actively contract producing the deformity.During stance phase it disappears In the second case,clawing of the toes occurs only when propulsion or push off is attempted

 When claw toes are associated with cavus, the latter should be corrected first, since clawing will then usually correct spontaneously

Treatment of clawing of the great toe

Modified Jones operation: EHL

is attached to the neck of first metatarsal;interphalangeal joint is arthrodesed

Clawing of lateral toes

The long toe flexors are divided at their insertion & attached to theplantar aspect of theproximal phalanx. Clawing is corrected by interphalangeal capsulotomies

CAVUS DEFORMITY & CLAW FOOT

 Deformity caused by a poorly understood weakness or imbalance of intrinsic or extrinsic muscle groups of the foot, or both. The primary deformity is a drop or equinus of the forefoot Secondary deformity is clawing of the toes In severe cavus all the plantar structures contract

Treatment of mild cavus

Conservative measures:metatarsal bar on the shoe or an insole with a metatarsal pad Several operations have been recommended, each based on a theory of muscle imbalance Bentzon-the cause is an imbalance b/w tib ant & PL. So he recommends division of PL& imbrication of its proximal stump into PB

 Garceau & Brahms-imbalance of abductor hallucis, flexor hallucis brevis, flexor digitorum brevis & quadratus plantae. They described selective denervation of these muscles

Treatment of severe cavus

Steindler plantar fasciotomy Dwyer osteotomy of calcaneus Cole anterior tarsal wedge osteotomy Japas V osteotomy Tendon transfers-Jones operation for the great toe & Hibbs operation for clawing of the lateral toes

Steindler stripping operation

Along a short medial approach, the long plantar ligament & origins of the short plantar muscles are subperiosteally stripped

Dwyer osteotomy

Wedge of bone with its base lateral is resected inferior & posterior to the PL & parallel to it. Medial borer of the calcaneus is not divided, but broken manually to close the gap

 Dwyers is done when there is a cavovarus Dwyer contends that rendering the varus foot plantigrade by the above operation, weight bearing exerts a corrective influence in progressive decrease of the deformity More effective before structural deformity develops & before skeletal maturity

Cole anterior tarsal wedge osteotomy

Japas V osteotomy

 Advantages- no bone is excised; no shortening Lenghtening of the plantar surface of the foot along with better deformity correction Recommended for children 6 years or older

DORSAL BUNION
In this deformity the shaft of the first metatarsal is dorsiflexed & the great toe is plantar flexed

Two types of muscle imbalance may cause a dorsal bunion

M.c. is b/w Tib ant & PL. Normally tib ant raises the base of the first metatarsal;the PL opposes this action When the PL is weak, first metatarsal is dorsiflexed by the unopposed tib ant &the great toe plantar flexes to establish a point of weight bearing Many bunions develop after ill advisedtransfer of the PL

 The second & less common mechanism is a paralysis of all muscle groups except triceps surae & long toe flexors This causes the great toe to be constantly flexed to sustain push off The first metatarsal head is then displaced upward to accomodate

LAPIDUS operation to correct dorsal bunion

Shaded areas show the fused joints FHL has been converted to depressor & dorsiflexor action of tib ant is abolished by transferring it posteriorly

TALIPES EQUINUS
Causes 1)Muscle imbalance-plantar flexors are stronger than the dorsiflexors 2)A flail foot under the influence of gravity develop tendo calcaneus & posterior capsular contracture

Treatment
When not responding to conservative measures, tendo Achilles lenghtening is indicated. After correction has been obtained, one of the following stabilising operations should be done to prevent recurrence

Posterior bone block Lambrinudi procedure Pantalar arthrodesis Arthrodesis of the ankle joint

Techniques of TA lenghtening[
Whites percutaneous TA lenghteningbased on the observation that the tendon rotates about 90 degrees b/w its origin & insertion; the rotation is from medial to lateral Hauser developed a similar method based on the observation that the rotation begins about 12-15 cm proximal to the insertion

 Z- plastic tenotomy of TA & posterior capsulotomy Either in the lateral or AP plane.Lateral plane is preferred because the width of the tendon is maintained In equinovarus deformity, lenghtening in AP plane that leaves the lateral half attached to the calcaneum is preferred to prevent hindfoot varus

A word of caution-Do not correct equinus in an ambulant patient with quadriceps paralysis

Campbell posterior bone block

Here a bone block is constructed on the posterior aspect of talus & superior aspect of calcaneum in such a manner that it will impinge on the posterior lip of the distal tibia & prevent plantar flexion of the ankle

 The operation has been modified by Gill, Inclan and others It is usually combined with a triple arthrodesis Fibrous or bony ankylosis of the ankle must be guarded against.

TALIPES EQUINOVARUS
Is characterised by equinus deformity at the ankle, inversion at the heel, adducton at the midtarsal joints & supination of the forefoot

 When the deformity is of long standing duration, a cavus deformity of the foot develops; clawing of the toes may develop secondarily

Pathogenesis
The peroneal muscles are paralysed or severely weakened The tibialis posterior is usually normal The tibialis anterior may be weakened or it may be normal The triceps surae is comparatively strong & gets contracted

 The equinus position thus produced increases the mechanical advantage of the tib post; this in turn encourages hind foot inversion & forefoot adduction and supination

Treatment of talipes equinovarus

Depends on Age of the patient Forces causing deformity Severity of the deformity Its rate of increase

Treatment in a skeletally immature foot

A brace may help to prevent deformity If deformity increases, wedging cast technique is employed Rarely Steindlers operation,TA lenghtening & posterior capsulotomy may be necessary

 Once the deformity has been corrected, surgery is indicated to prevent recurrence The tibialis posterior is usually the main deforming force, & unless its influence is removed, the deformity will recur

 Barr & Blount procedure- Transfer of the tib post anteriorly through the interrosseous membrane to the anterolateral tarsal area is the most effective procedure

Ober modification- rerouting the tendon subcutaneously

Split tibialis anterior transfer

Hoffer described this technique when the tib post is weak & tib ant is strong enough

Treatment in a skeletally mature foot

Foot is stabilised by a triple arthrodesis & cavus is corrected at the same sitting by Steindlers release 4-6 weeks later TA is lenghtened combined with a modified Jones operation & a Barr transfer External tibial torsion is corrected by derotational osteotomies of tibia & fibula

TALIPES CAVOVARUS

TALIPES EQUINOVALGUS
Usually develops when The tib ant & tib post are weak The peronei are weak The triceps surae is strong & contracted Triceps surae pulls the foot into equinus Peronei pull into valgus The weight bearing thrust shifts to the medial border of the foot

Treatment in a skeletally immature foot

A double bar brace with a 90 degree ankle stop & inside T- strap, a shoe witharch support & a medial heel wedge, and repeated stretching exercises are needed. If correction is not obtained, TA lenghtening may haveto be done

 After correction surgery is needed to prevent recurrence. Subtalar arthrodesis of Green & Grice and anterior transfer of of the PL & PB tendons is the procedure of choice

Peroneal tendon transfer for equinovalgus

Described by Fried & Hendel The new site of insertion depends on the severity of deformity & existing muscle power When EHL is working, transfer to third cuneiform When no functioning dorsiflexor,transfer to the midline of the foot anteriorly

 Peronus longus, FDL FHL or the EHL may be transferred to replace a paralysed tibialis posterior

TALIPES CALCANEUS
Is a vicious, rapidly progressing deformity caused by paralysis of the triceps surae

Pathogenesis
Weakness of TA- calcaneum cannot be stabilised & push off in walking is lost TA becomes thin & elongated When walking is attempted, calcaneum rotates dorsally due to the pull of long & short toe flexors &intrinsic muscles;cavus thus develops Gravity assists in development of forefoot equinus

 Treatment of talipes calcaneus is difficult because No appliance can replace a paralysed triceps surae Gross disparity b/w the strength of all other muscles of the leg & triceps surae. (Cross sectional area of TA far exceeds the sum of that of other muscles of the calf)

Treatment in skeletally immature foot

Tendon transfers are indicated early Tendons of tib post & peronei should be transferred to the calcaneum to restore plantar flexion If these muscles are weak, posterior transfer of the tibialis anterior is indicated.(Drennan)

 If adequate muscles are not available, Westin recommends tenodesis of the tendo Achilles to the fibula.

Westins calcaneal tenodesis to fibula

Treatment in skeletally mature foot

Plantar fasciotomy+ Hoke arthrodesis Alternatively Siffert, Forster & Nachamie described the beak triple arthrodesis for severe cavus 4 weeks later posterior transfer of the previously named tendons is done

Siffert, Forster & Nachamie beak triple arthrodesis