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FOOT & ANKLE. MOHAN LAL Consultant Orthopaedic & Foot/Ankle Surgeon Surrey & Sussex NHS Trust Spire Gatwick Park Hospital North Downs Hospital. Presentation by Chandar Lal. SUBCATEGORIES. FOOT AND ANKLE EXAMINATION COMMON FOOT DISORDERS ANKLE DISORDERS TENDON DISORDERS.
Consultant Orthopaedic & Foot/Ankle Surgeon
Surrey & Sussex NHS Trust
Spire Gatwick Park Hospital
North Downs Hospital
Presentation by Chandar Lal
Lateral deviation of great toe
HV + Claw toes
Medial exostosis (bunion)
Lateral displacement proximal phalanx
Degenerative changes in 1st MTP/IP Joint
Intermetatarsal & Hallux Valgus angles
Aim: Relieve pressure over painful bunion prominence
Factors to be considered before surgery
Soft tissue surgery - rarely indicated in adolescent cases
Bone/joint procedure remains the gold standard
Painful limitation of motion at 1st MTP joint
Pathogenesis: synovitis, cartilage destruction, osteophyte proliferation, subchondral cysts and sclerosis
Clinical presentation: pain, limited dorsiflexion and dorsal osteophyte, dorsal tenderness
Aetiology: Trauma, Repeated microtrauma, osteochondritis dissicans and abnormally long first metatarsal
Grade I: Mild osteophytes, joint space preserved
Grade II: Moderate osteophyte formation, joint space narrowing & subchondral sclerosis
Grade III: Severe arthritis
Flexible (99%) or Rigid (1%)
Pathology - Loss of normal medial longitudinal arch in combination with valgus posture of heel, mild subluxation of subtalar joint & eversion of calcaneum
Arch develops till the age of 7-10 years so there is no treatment required
15-20% of adults have asymptomatic pes planus
3-9 years: symptomatic - arch support
10-14 years require investigation
Symptomatic patient - rule out accessory navicular or incomplete tarsal coalition and treat accordingly.
Adults with painful pes planus not responding to conservative management will benefit with surgery
Commonly affected tendons:
Fatigue of foot with limited activity, medial and lateral pain
Flat foot on weight bearing
Standing tip toe – heel will go into valgus
Clinical examination confirms tenderness, weak/ruptured tendon, hindfoot valgus (flexible/fixed) and a lack of heel varus on tiptoeing
Pathogenesis: tenosynovitis, incomplete tear, complete disruption
Two groups of patients:
Younger patients with inflammatory arthropathy/traumatic rupture
Older, typically female patients with degenerative tearsPATHOLOGY/PRESENTATION
Imaging: X-ray (degeneration), MRI
Peroneus longus & brevis are posteolateral tendons originating from fibula and interosseous membrane and are inserted at base of I & V MT respectively.
Tenosynovitis- common in high arch foot because of increase in excursion.
Sprain/ subluxation - inversion ankle injuries.
Symptoms: pain in the outer part of the ankle or just behind the lateral malleolus. This pain commonly worsens with activity and eases with rest.
Examination - tenderness/subluxation
X-rays to exclude fracture
MRIPERONEAL TENDONS (CONTD.)
Rest, short-leg walking cast/brace, lateral heel wedge, physical therapy, NSAIDs and Cortisone injection
Tenosynovectomy and repair of split
Stabilisation of dislocating tendons by groove deepening, peroneal retinaculum reconstruction and bone block proceduresPERONEAL TENDONS (CONTD.)