e received a lot of excellent responses from YOU regarding the management of the challenging patient, which are posted below, along with the conclusion of this case presentation:
LETTERS TO THE EDITOR
(from Part I)
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Ryan Fitzgerald, DPM
PRESENT RI Asso. Editor
Washington Hospital Center
Washington, DC |
Sarah M. Fitzgerald, DPM
PGY-2 Podiatric Surgical Res.,
Washington Hospital Center
Washington, DC |
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When considering your surgical options for a patient such as this, one must consider what the ultimate goal is for the patient. In this situation you would want to decrease the patients pain and maintain a stable/braceable foot structure. Due to the progressive disease and soft-tissue contracture, I would consider reconstructive alignment and triple arthrodesis. If there is indeed a spastic equinus I would consider a murphy procedure (anterior advancement of the achilles tendon insertion), calcaneal-cuboid distraction arthrodesis and peroneus brevis tendon transfer to peroneus longus to correct for transverse plane deformity by lengthening the lateral column and removing the deforming force of the peroneus brevis, a medial calcaneal slide to correct for calcaneal valgus with subtalar joint fusion, and the talo-navicular wedge fusion with apex dorsal and base plantar to plantarflex and shorten the medial column. Taking into consideration the lifestyle, care needs/compliance, and the patients weight, this procedure might best be performed with external ring fixation or combination internal and external fixation. The digits should be brought into rectus by realigning the rearfoot and could be percutaneously pinned at this time to allow for soft-tissue adaptation while immobilized. It is likely additional procedures may be needed in the future but this would allow for adequate realignment of this severe deformity.
—Brandon R. Gumbiner, DPM, C. Ped.
PGY-2 Podiatric Surgical Resident
St. Joseph Hospital/North Chicago VAMC
This is certainly an extremely challenging case. First, in consideration of the mental impairment, you need to make sure of his daily supervision in order to remain compliant with post-op care. That aside, after reviewing the x-rays and the pictures along with the additional history, I would recommend the following: The misshaped navicular seems to be at the apex of the deformity therefore I would remove it in toto; secondly I would perform a triple arthrodesis with a talar cuneiform fusion; a calcaneal axial x-ray is needed to ascertain it's appearance in the coronal view since if in severe valgus, a calcaneal slide osteotomy may be needed; the articulation at the CC joint is also severely misaligned and would need to be corrected with a possible opening wedge osteotomy; use the navicular bone for any wedges and/or bone fillers; removal of the navicular should decompress the 1st MTP joint hopefully reducing the contracture deformity; lastly internal and external fixation should be used, most of which should allow compression along with stabilization. These procedures could also be done in stages if needed. Best of luck.
—Warren Mangel DPM
Chief of Podiatry, Virtua Health System
I am commenting on the patient with the bilateral pes plano valgus. This patient is the 16-year-old MR patient. First a couple of questions, is this a rigid deformity. Also is there an underlying neurological syndrome that needs addressed prior to working with this patient. Has bracing been tried? If we have exhausted all options, this patient would required a triple arthrodesis along with peroneus longus transfer to bring down the first metatarsal. At that point you could do a Jones tenosuspension for the hallux. But the main goal would be to restore his rearfoot and calcaneal valgus...
—Aaron J. Chokan, DPM, FACFAS
I treated a similar case this past year in an adolescent further complicated with spastic dyplegia. The treatment included triple arthrodesis with generous open lengthening of the triceps surae in lieu of the Murphy and external fixation with ilizarov frame to permit some modicum of movement/ weight bearing during the long convalescence.
The surgeries were performed sequentially (left foot healed, then right foot). I have found good success without issues of excess shortening via performing the triple with excision of the cartilage down to the subchondral bone and simply Manipulating the Bone into the correct anatomic position/ holding it with k-wires, then placing the internal hardware. Cutting wedges to correct the deformity frequently excessively shortens the foot and is not recommended, especially since it is possible to "dial-in" the correction by manipulation. One caveat is to avoid the bone correction until after the TAL as this will allow much easier control. Also, I typically wait to repair the achilles until AFTER the triple, as often the final position of repair differs from where I might have anticipated at first. Additionally, I do use platelet derived growth factors and external bone stimulators in most if not all of these reconstructions.
—William P. Grant, DPM, FACFAS
Tidewater Foot and Ankle Center |
Treatment Plan
This patient presents with multiple levels of deformity that need to be addressed as part of the pes planus reconstruction. The patient demonstrates collapse of the medial arch, rigid dorsiflexion 1st metatarsal, with fixed plantar flexion of the hallux, and more flexible contracture of the lesser digits. Additionally, the hallux is flexed in a position that is underlapping the second digit. The patient demonstrates a rigid calcaneal valgus rearfoot position, and shows soft tissue atrophy along the lateral aspect of the foot in the area of the sinus tarsi. Muscle strength is graded +5/5 in all muscle groups tested, and an equinus deformity was noted at the ankle. Deep tendon reflexes were noted to be hyper-reflexive at the Achilles and patella tendons, bilaterally.
After careful review of the patient’s radiographs and clinical findings, it was determined that the patient would benefit from a naviculectomy, to allow the foot to adduct into a more rectus position (fig. 1). The navicular was evaluated upon removal, and was noted to be atrophic and dysplastic (Fig 2). Following excision of the navicular, the patient’s foot was noted to adduct more freely, however, there was still significant tightness noted with residual deformity, and therefore a posterior capsulotomy with a tendo-achilles lengthening was performed to reduce the equinus deformity as well as to allow for soft tissue (Fig. 3). Once the foot could be appropriately reduced to a rectus position, a triple arthrodesis was performed (Fig 4). Following this part of the procedure, the rearfoot deformity was noted to be reduced, however the first metatarsal remained in a dorsiflexed position with a flexion contracture of the hallux. At this point, a plantarflexory osteotomy of the 1st metatarsal was performed as well as a flexor hallucis longus transfer the distal aspect of the 1st metatarsal to further bring it into proper alignment (Fig 5).
Following this procedure, the flexion contracture at the hallux was reduced, and the overall alignment of the foot was noted to be excellent as compared to preoperative assessment. The wound was then closed utilizing vicryl subcutaneous suture, and the skin was closed with nylon suture in vertical mattress suture technique (fig. 6).
Following the procedure, the patient was placed into a posterior split, which was changed to a short –leg, nonweight bearing cast at the first post operative visit. The patient is to remain non-weight bearing for 8-12 weeks, until radiographic evidence of osseous healing at the triple arthrodesis site is noted.
—Sarah M. Fitzgerald, DPM
PGY-2 Podiatric Surgical Resident,
Washington Hospital Center
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Figure 1: A medial approach was utilized to perform the naviculectomy in this patient. |
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Figure 2: The navicular was noted to be dysplastic, which was observed on radiographs. This deformity contributed to the overall abduction of the forefoot in this patient. |
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Figure 3: A Z-incision was utilized to perform a posterior capsular release to relax the soft tissues to allow the foot to be appropriately reduced. |
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Figure 4a: The triple arthrodesis was performed through the lateral incision... |
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Figure 4b: ...and rigid screw fixation was obtained with the rearfoot in slight valgus. |
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Figure 5: A plantarflexory osteotomy at the base of the first 1st metatarsal was performed as well as an FHL tendon transfer to the distal aspect of the 1st metatarsal to bring the 1st metatarsal into proper position and alignment. |
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Figure 6: The multiple deformities noted in the foot have been reduced, and the patient now demonstrates a medial arch, appropriate forefoot and rearfoot alignment. |
Editors Discussion
When managing complex lower extremity deformities, it is necessary that the surgeon utilize a step-wise approach to address each level of deformity to provide for the greatest overall outcome in lower extremity reconstruction of the patient. As part of the clinical exam, it is important to determine if the deformity is rigid or flexible, because this will guide your surgical options. In this case, the patient presented with a rigid deformity, with contracture of the soft tissues; therefore elements of soft tissue release, tendon transfer, and arthrodesis were utilized in combination to reduce the patient�s pes planus deformity and realign the forefoot and hindfoot.
Of additional concern in this patient is his mental status and the requisite compliance issues it belies. Significant reconstructive procedures require that the patient remain non-weightbearing for 8-12 weeks post-operatively. In this case, this reality was reinforced with the patient and the patient's care-givers, but this is still an area of concern.
I appreciate the many great responses we received from those of you who participated in this case presentation. As always I look forward to hearing from you, so please contact me if you have any comments, questions, or suggestions.
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