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Case Study #3

Kristen Biel
Eric Gervelis
Sean Hodson
Patient History
 25 y.o. male PTC with pain in heel.
 N - sharp, nagging pain
 L - medial and lateral sides of heel
 D-?
 O-?
 C-?
 A - pain increases when on his feet for
prolonged periods of time
 T-?
 S - “reconstruction of left foot and ankle” for
treatment of flatfoot
History (continued)

 PMH - non contributory


 Social History - unemployed, normal
activity level, wears worn out gym shoes,
denies any tobacco/EtOH/drug use
 Family History - non contributory
 ROS - arthritis in left shoulder, ankle and
thumb
Pertinent Findings on PE

 BP 145/88, Height 6’0’’, Weight 380 lbs.

 Integument - diffuse HPKs sub 1st and 5th meta


heads right foot, diffuse plantar-medial heel
bilateral, pinpoint/nucleated plantar-posterior
left heel. Surgical scars 5 cm dorsomedial
foot/ankle left and 3 cm lateral calcaneus left.

 Vascular - DP/PT 1/4 bilateral, CFT <3 sec


bilateral, minimal non-pitting edema left ankle
Pertinent Findings on PE (continued)

 MS – decreased medial arch left>right, POP at


medical and lateral aspects of left heel,
prominent styloid process of 5th meta bilateral,
pain at anterior aspect of left ankle with AJ DF

 Gait – Adductory twist left foot with decreased


angle of gait bilateral, marked pronation
bilateral, left 1st MPJ and IPJ PF during
midstance, apropulsive
Biomechanical Exam
Right Left
STJ 30 IN/ 0 EV 8 IN/ 0 EV
Neutral STJ 4 IN 2 IN
Calc STJ 10 IN Tarsal coalition

MTJ 10 IN (FF 12 IN (FF


supinatus) supinatus)

Ankle – Knee -4/-4 (Bony block 4/5 (Gastro-soleal


Ext/Knee Flex maybe?) equinus)

Ist ray 2 DF/5 PF 2 DF/5 PF

Ist MPJ 28 unloaded (HL) 25 unloaded (HL)

RCSP 4 EV 6EV
NCSP 0 4 EV
Tibial Influence 4 EV 6 EV
D/DX before X-rays
 Iatrogenic
 Infection secondary to internal fixation
 Self induced – walked on foot too early after SX
 AVN of calcaneus
 Stress Fx
 Arthritis
 STJ Coalition
 Plantar Fasciitis
Radiography Findings of Left Foot
 ST – slight edema ankle, left>right
 Bone - Well healed fusion (sclerotic line) of
calcaneal osteotomy with partial threaded
cancellous screw which is not purchasing the
bone, “backing out”
 Bone - Talar beaking, Os trigonum, and
hypoplatic fibular sesamoid
 Joint - Well healed fusion of TN jt with cortical
screw
 Joint - Bony fragments between 1st CN jt, lack of
screw purchase
Radiography Findings of Both Feet

 Decreased medial arches


 “C” foot type due to metatarsus adductus
 Biomechanics - signs of pronation
 Anteriordisplaced cyma line, decreased
calcaneal inclination angle, increased talar
declination angle
D/DX after X-rays
 Iatrogenic left heel pain posteriorly and plantarly
secondary to calcaneal screw not purchasing,
iatrogenic malunion of 1st CN jt, left foot.
 Medial heel pain bilateral secondary to
biomechanics
 Anterior left ankle pain upon DF (and decreased
ROM upon DF) secondary to talar beaking
 STJ coalition
 Metatarsus Adductovarus, possible undiagnosed
congenital talipes equinovarus
Past “Corrective” SX
 The previous doctor tried to raise the medial column by
performing a calcaneal osteotomy and fusing the TN and
1st CN joints.
 However the dx of a “C” shaped foot, or metarsus
adductovarus, “clubfoot” was missed, which was the
original reason for his pes planus.
 By doing this procedure, he shortened the medial
column and further adducted the metatarsals.
 This decreased his medial arch even further.
 The posterior screw that was not purchasing was the
etiology behind the nucleated HPK on the plantar-
posterior left heel.
Non-surgical Corrective Procedures of
the “Corrective Procedure”
 Thank the doctor for referring the pt.
 Discuss your findings with the previous
doctor of how to fix this problem – see
who wants to do revisional SX.
 Treatment today without SX - Debride
HPKs. The patient will not be compliant
with crutches and he will not be able to fit
in most wheelchairs…….so, what do you
do....?
 Naproxen 500mg tab, PO BID.
 CAM walker left, heel to toe rocker right
Bracing Before SX

 The patient must be casted before


receiving any of these braces.

 Arizona AFO (articulated)


 Marzano Brace
 Richie Brace (articulated)
Arizona AFO
 Custom made leather brace designed to
hold AJ complex similar to a well molded
cast (articulated)
Before and After
 Application of Arizona Brace – this will
make the ankle and foot look great but
will cause the patient too much pain since
it will limit eversion.
Marzano Brace
 A UCBL incorporated into an AFO
(unarticulated)
Richie Brace
 A pronated device incorporated into an
AFO (articulated)
Recommendations
 Articulated devices would be the best, because we do
not want to stop the ROM at his ankle joint….if the AFO
is not articulated the muscles proximal to the AJ will
atrophy, causing more problems.

 The Marzano AFO (nonarticulated) is an option for the


patient, but not very likely.

 The Arizona AFO (articulated) is a more likely device.

 However, the Richie AFO with an incorporated pronated


device would be the best recommendation after the arch
correcting SX is completed.
Rocker Bottom Shoes

 Toe Rocker
 Heel Rocker
 Forefoot Rocker
 Double Rocker
 Heel to Toe Rocker
Recommendation
 Heel to Toe Rocker
Recommendations
 LisFranc’s Rocker
Surgical Correction
 SX – clean the necrotic bone from the 1st CN jt, and insert a base
wedge osteotomy (allogenic from a bone bank or allograft) between
the 1st CN jt and fuse – this will raise the medial arch.
 The Ganley and Ganley open base wedge procedure can also be
done to lengthen and raise the medial column in the 1st cuneiform,
and possibly shorten the lateral column with a closed wedge
procedure if the foot is rigid – however this is probably not the 1st
choice for our pt.

 Remove the posterior screw to alleviate the nucleated HPK


secondary to the screw not purchasing the bone.
Metatarsus Adductovarus Correction
 This patient is too heavy for this procedure, therefore this
procedure is for the ideal patient.
 The wedge osteotomy in the 1st CN jt will correct the
metatarsus adductus only by a few degrees, so he will still
have an adducted forefoot after SX.

A – Peabody and Muro. B – McCormick and Blount. C – Steytler and Van Der Walt,
D – Berman and Gartland procedure – good for meta adductus of residual clubfoot
and also congenital metatarsus varus
Orthoses
 Depending on his ROM after surgery, functional
orthoses may be in order for the ideal patient.
However, our patient will probably still need a
pronated device, with or without an AFO. The
nucleated HPK and any incisions should first be
healed.

 The only definite orders/modifications we would


give for a pair of orthoses would be to have a
width wider than normal and a deep heel cup.
The rest will be dependent on his biomechanical
exam after SX.
References
 Banks, Downey, McGlamry, 1992. Metatarsus adductus
deformity. In McGlamry, E.D. Comprehensive textbook of
foot surgery (volume one, second edition). Williams and
Wilkins, Baltimore. pp. 842-843, 847.
 Elftman, Nancy. “Shoe Modifications.”
http://bignwideshoes.com/old_website/Shoe%20Modific
ation.pdf#search=%22double%20rocker%20shoe%20m
odification%22
 Manifis, Tracey. Surgery of Metatarsus Adductus, 1999.
Curtin Health Science, Department of Podiatric
Encylopedia.
http://podiatry.curtin.edu.au/encyclopedia/metadd/
 “Marzano Brace.” http://www.customfootwear.com
 “Richie Brace.” http://www.richiebrace.com

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