Jacob Wynes DPM, MS, FACFASAssistant Professor, Department of Orthopaedics

Co-Director UMMC Limb Preservation Clinic

University of Maryland School of Medicine

Disclosures

Consultant: Orthofix

Consultant: Smith and Nephew

Sometimes Orthotics / Bracing is not

a Permanent Solution

“Faulty Attitude”

E.H. Bradford. JBJS 1910

Johnson and Strom (1989)

*Myerson Addition (1996)

Tendon

Condition

Peritendonitis;

tenosynovitis /

degeneration

Elongated Elongated;

complete rupture

Elongated:

complete

rupture

Rearfoot Flexible; normal

alignment

Flexible;

valgus RF

Rigid;

Valgus RF

Rigid;

valgus RF

Valgus ankle

Pain Focal (medial);

Mild – Mod.

Focal (medial);

Moderate

Medial and/or

Lateral;

Moderate

Med / Lat;

Moderate –

Severe

Single Heel

Test

TMT Sign

Pathology

Mild Weakness

Normal

Synovial

Proliferation; mild

degeneration

Marked Weakness

Positive

Mod Degeneration

Marked Weakness

Positive

Mod Degeneration

Complete Rupture

Marked

Weakness

Positive

Degeneration

Complete

Rupture

Treatment Conservative:

Tenosynovecomty

Debridement

FDL transfer

RF Arthrodesis /

osteotomy

Isolated RF (or)

Triple Arthrodesis

Tibiocalcaneal

(or) Pantalar

Fusion / Deltoid

Repair ?

TYPE I TYPE II TYPE III TYPE IV*

#GOALS

Relieve pain

Provide stability

Realign and maintain alignment

Axial (Long Leg Calcaneal Axial)

45º

+

Axial (Hindfoot Alignment)

20º

+

Cobey JC. Clin Orthop 1976

Saltzman and el-Khoury, Foot Ankle Int, 1995

Lamm BM et al. JAPMA 2005

Long Leg Calcaneal Axial Hindfoot Alignment

45

°

20

°

Lamm et al. JFAS 2016

Perioperative Considerations

Anatomic alignment (assessment of angles)

Use of adjunctive bone grafting

Fixation type (screws vs. plate vs. staples vs. steinman

pins)

Low energy joint preparation

Assessment of Equinus (gastroc vs. gastroc-soleal)

Assessment of extent of osteoarthritis and motion

TNJ arthrodesis limits STJ and CC to ~ 2

degrees

STJ lmits TN motion to 26% and CCJ to 56%

Astion et al. JBJS 1997

Preferred in absence of cuboid DJD

Mann et al. FAI 1998

EDB Flap

Above Peroneals

Avoid IDCN and Sural Branch

Evaluation by flurosocopy

Above Post Tib Tendon

Saphenous and Tib Ant

Arthrodiastasis of CCJ occurs (decreased subchondral sclerosis) with mild -moderate DJD

N= 20 /46 meeting inclusion criteria

Berlet et al. JFAS 2015

Greater arthrodiastasis of CCJ 32% to 62% when combined with Lapidus

Gali et al. JFAS 2015

Greater rates of nonunion / incomplete union for PTTD Stage 3+ (N=9 double arthrodesis vs. N=7 triple arthrodesis)

44% nonuion vs. 0% nonunion

Burrus et al .JFAS 2016

Schuh et al. J Orthop Research 2013

N=22 feet / 14 patients

Solid fusion at 12 weeks

25 degree AP / Lateral Meary’s angle maintained

Horton et al. FAI 1995

Courtesy of RIAO / ICLL

BMI with flatfoot 26.52 +/-5.24 vs. without

25.07 +/- 4.71 (Shibuya et al. JFAS 2010)

Reduction in pain frequency from 87.5% to

12.5% after bariatric surgery (Melo et al. Arg

Bras Cir Dig 2012)

Obesity may lead to failure of FDL tendon

transfer and may necessitate medial column

fusion (Hatic et al. Foot Ankle Clin 2012)

Level III retro cohort:

Overweight patients = worse preoperative

scores

No difference post operatively with respect to

BMI in Stage 2 AAFD @ 1 year follow up (<25,

25-30, >30kg/m2) (Soukup FAI 2016)

Labs

Prox

Distal

Alignment

Post Op Course

Follow Up

Lessons Learned - Triple

Arthrodesis

Release / Lengthen Peroneals to allow for STJ reduction

Provisional pinning of tibiotalar joint to maintain

stability (removal 6 weeks)

Calcaneal cuboid preparation may allow for ease of STJ

reduction

Hentges et al. JFAS 2016

Stage 4 PTTD

Lui et al. Foot Ankle Surg 2014

Hintermann et al. Foot Ankle Clin

2013

Colin et al. FAI 2013

Smith et al. Foot Ankle Clin 2012

Deland et al. FAI 2004

Pre Op

Stage 4: Triple / Calc Slide / Deltoid Repair

Arthrex

Recreation of Deltoid Complex

Arthrex

2 Years Post Op

Recommendation to avoid in cases of “advanced” tibiotalarosteoarthritis

Smith et al. Foot Ankle Clin 2017

Delay and prevent ankle arthritis

Oburu et al. Foot Ankle Clin 2017

Deltoid + Triple with success in 5/8 patients to maintain < 3 degrees of valgus and > 2mm LAT ankle displacement

6.4±2.9 degrees to 2.0±2.0 degrees correction of tibiotalar valgus

Jeng et al. FAI 2011

Use of FiberTape® construct with combined spring ligament and deltoid reconstruction without post op complications, stiffness or loss of correction (N=10)

Nery et al. FAI 2018

Retrospective cohort N= 21 patients

Improvement in radiographic parameters

Mean f/u 27.6 months

Tarsal osteotomies unable to correct translatory valgus

Eberhardt et al. Acto Orthop Trauma Surg2018

Supramalleolar osteotomy performed

N=14 mean f/u 50.6 months

Improvement in VAS 4.1 ± 1.7 to 2.2 ± 1.5 (p < 0.05)

Improvement in AOFAS 51.6 ± 12.3 77.8 ± 11.8 (p < 0.05)

Knupp et al. JBJS 2012

Gross et al. Arthritis Care Res 2011

Pes planovalgus associated with

medial tibiofemoral cartilage damage

1.3 x more likely to have knee pain

with rigid valgus

Preoperative MRI - 9/2015

In-111 Scan 9/2015

4/2015

1/28/2016

1/28/2016

1/28/2016

2/2016

2/2016

2/17/2016

6/15/2016

Post op Clinical

Take Home Points

Triple/ Double arthrodesis appear to be equally as effective

Maintenance of correction is paramount to success

Address arthritis joints through arthrodesis

BMI may play a role in procedure selection

Deformity principles help with evaluation and procedure selection

Avoid residual translation after STJ fusion

Rigid hindfoot can influence knee alignment

Thank You

An Interesting Case

S

Jacob Wynes DPM, MS, FACFAS

Assistant Professor, Department of Orthopaedics

Co-Director UMMC Limb Preservation Clinic

University of Maryland School of Medicine

S Assess for Complete vs. Incomplete coalitions

S Calcaneal axial view / medial oblique foot view

S Evaluate tolerance to Orthotics and unilateral pain phenomenon

S Pediatric Neurology consultation with spasticity / weakness (ie. Cerebral Palsy)

S Assess proximal segment - tibial torsion / femoral retroversion

S Assess compensation for Equinus

S Could be associated with fibular hemi-melia or other syndromicconditions as well

S Be suspicious with marrow edema on MRI

S Cerebral Palsy - Neuromuscular

S Tarsal coalition - structural abnormality

S Osteogenesis imperfecta - Collagen defect

S Downs Syndrome - Hypotonia / collagen defect

S Marfan Syndrome - Collagen defect

S Ehlers-Danlos Syndrome - Collagen defect

S Most Common Talocalcaneal > Calcaneonavicular

S Age of onset of symptoms varies

S TC and CN can exist together

S Richer et al. Clin Imaging 2016

General Approach:

Downey ClassificationJAPMA 1991

S Compensation at midtarsal joint

complex

S Mosca, Principles/Management

of Ped Foot/ Ankle Text 2015

S FHL > FDL > PT tendons >

Medial plantar nerve

S Alaia et al. Skeletal Radiol 2016

S Symptomatic in flat foot with co-existing tarsal tunnel

S Bhat et al. BMJ Case Rep 2017

S Garchar et al. JFAS 2001

S Combined fibrous coalitions reported

S Calcaneal-Navicular + Naviculocuneiform

S Calcaneal-Navicular + Metatarsocuneiform

S Vira et al. Bull Hosp Jt. Dis 2013

“C Sign” for STJ coalition

Lateur et al. Radiology 1994

Brown et al. Skeletal Radiology 2001

“ Anteater Sign” for Calcaneal Navicular

Coalition

Oestreich et al. JPO 1987

S Cuboid Lateral Cuneiform

S N=1 Babu et al. JAPMA 2017

S N=1 Renner et al. JAPMA 2017

S Cuboid Navicular

S N=4 with fat interposition with “excellent results”

S Sarage et al. JFAS 2012

S Persistent midfoot pain

S Kamiya et al. JBJS 2015

S Approx 10 reported cases

S Awan et al. Case Report Radiol 2015

S Soft tissue contractures (lateral ligaments, peroneals, and

gastroc-soleal complex)

S Recommendation for peroneal tendon release

S Gougoulias et al. Foot Ankle Clin 2014

Golano et al. Knee Surg Sports Traumatol Arthrosc 2010

S N=8 (13 feet)

S Non resectable coalition in

5/8 patients

S Follow up 2-15 years

S “Excellent deformity

correction” and pain relief in

rigid feet

Intra Op (Pre / Post LCL)

Pre Op: Calcaneal Navicular Bar

Post Badgley Interposition

Recurrence of Coalition

Re-Resection

S N=48 patients / 56 feet CN Bar resection

S Compared Fat grafting, bone wax, EDB

S VAS improvement in fat grafting / bone wax >> EDB

S AOFAS: 59 to 98; 50 to 90; 48 to 75 (P<0.001)

S RECURRENCE: 4% FAT, 6% bone wax, 40% EDB

S N=4

S 3 talocalcaneal coalitions (1 fibrous / 2 osseous)

S 1 cuboid navicular

S Xray / CT / MRI performed with no recurrence

S 40 month f/u

S AOFAS 93.5 / FFI 3.25% (0-13%)

• Calcaneal lengthening osteotomy

• Medial displacement calcaneal osteotomy

• Arthroereisis

• Fusion

• N=32 patients (46 feet) mean age 11

y/o

• Mean follow-up: 66 months

• Results:

• 30 feet achieved excellent /good

• Improved cosmesis in 37 feet

• Mild restriction of eversion in 34 feet

• NC sag persisted in 11/13 feet

• Complications

• 7 feet had recurrence of deformity

• 4 feet developed varus deformity

S N=75 CP patients m ean age 11 yo

S Mean follow-up 3.1 years

S Excluded medial column procedures

S Results:

• Improved radiographic parameters

(p<0.001)

• Additional procedures should be

considered if:

S >23° AP talus-1st met

S >36° lateral talus-1st met

S 72% NV-cuboid overlap

Sung et al. CORR 2013 Zaifang et al. FAI 2006

S N=21 (37 Feet)

S One-year follow up

S Improvement in

maintenance of

radiographic results

S Improved TN coverage

Intra-op

2 Months Post-op

Consider the Bauman in

Cerebral Palsy

https://thenewageparents.com/understanding-cerebral-palsy-and-muscular-dystrophy/

S Can be iatrogenic

S Midfoot break and

external tibial torsion

S Weakened gastroc-soleus

complex

S Excessive dorsiflexion /

Calcaneus gait

S Knee pain

S 134 children (195 procedures)

S 98 PTAL, 40 open lengthening, 57

Baker’s recession

S 42% satisfactory calf length

S 22% recurrent equinus

S 36% calcaneus gait

S Calcaneus gait

S Children ≤ 8 years old (44%)

S Quadriplegics (60%)

S 80% of quadriplegics with PTAL

Borton et al. JBJS Br 2001

S Saraph V. et al. JBJS 2000

S Use in diplegic CP without

weakening the triceps surae

S Herzenberg et al. FAI 2007

S Average 14 degrees increase in

Ankle DF with knee extended

S Lamm et al. JAPMA 2005

S 5-9 degrees per each score of the

fascia

S

Baumann

Procedure

S

Baumann Procedure

S

Baumann

Procedure

S

Baumann

Procedure

S Diagnosis is critical in treating this condition

S Obtain peds ortho / peds neurology consultations

S Assess proximal deformity

S Coalitions can be resected (use of fat grafting has been advocated to prevent recurrence)

S CN bar resections offers relief with restoration of alignment

S TC coalition offers relief with debated results with alignment restoration

S Adjunctive posterior muscle group lengthening, lateral column lengthening or cuneiform osteotomy can be helpful in maintaining correction

S Avoid achilles lengthening in cerebral palsy and consider medial column stabilization

Thank You