management of the adult flatfoot

Transcription

Instructional Course Lecture
9th EFORT Congress
Nice - 30 may 2008
Management
of the
Adult flatfoot
Docteur E. Toullec
Polyclinique de Bordeaux –Tondu / BORDEAUX - France
[email protected]
Moderator : Dr. Eneroth
Instructional course lecture
Management of the
adult flatfoot
Dr E Toullec
What’s flatfoot ?
A static tridimentional deformity of the foot
Introduction
Classifications :
clinical examination
imaging
aetiologies
Flatenning of the medial arch
Treatments :
Stage 1 : medical
Stage 2 : conservative
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Forefoot abduction
Hindfoot valgus
Management of the
adult flatfoot
Dr E Toullec
What’s flatfoot ?
A dynamic default of the lock mechanism
of the midfoot with an apropulsive gait
( Meehan – Foot ankle clinics sept 2005)
Introduction
Classifications :
imaging
aetiologies
Treatments :
Lateromedial force index ( novel)
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Double heel rise test
Specific treatments
Conclusion
Nice , 30 may 2008
E. Toullec ( 2005) : Evaluation par baropodométrie dynamique de la force latéro-médiale
dans le pied plat valgus sévère avant et après chirurgie, RCO , 91 : 3S129.
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
For the management =
Clinical and radiographic examination
to know :
the stage
the type of deformity
all the pathologic joints & tendons
the aetiology
Indication and drawbacks of the
different medical and surgical
treatments
Conclusion
The combined surgical procedures
Nice , 30 may 2008
Management of the
adult flatfoot
1 - Location of the pain
Dr E Toullec
Medial :
Introduction
Classifications :
imaging
aetiologies
* posterior tibialis t. dysfunction
* ankle medial ligament lesion
* coalition
* arthritis ( subtalar, talonavicular ,
cuneonavicular,Lisfranc)
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Lateral :
- calcaneofibular conflict
- calcaneocuboid overpressure
( abduction)
- lateral malleolar stress fracture
- peroneal muscle spasms
Management of the
adult flatfoot
2 - The deformities : different types & stages
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
abduction
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
flattening
Nice , 30 may 2008
Valgus : too many toes sign ( Johnson)
Management of the
adult flatfoot
2 - The deformities
Dynamic pedobarography classification
Dr E Toullec
E.Toullec , LS Barouk : La baropodométrie dans la chirurgie du pied
plat valgus (2004 ) - Revue de Médecine et chirurgie du pied :
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Flatfoot
abductus
Flatfoot
valgus
Management of the
adult flatfoot
Dr E Toullec
2 - The deformities
Axis of the lower limb & flatfoot
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Genu valgum++
Nice , 30 may 2008
Genu varum
Management of the
adult flatfoot
Dr E Toullec
2 - The deformities
Hallux valgus
& flatfoot
Introduction
Classifications :
imaging
aetiologies
17.3% PPV if HV / 1-3 % normal population
Relationship between M1P1 angle and
Calcaneus valgus on X ray ( V Staquet)
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Why ? : - overload on the medial side
- passive great toe valgus on heel rise
- 1srt ray hypermobility ( Mueller )
- FHL desaxation
Recurence in HV surgery if flatfoot :
1/3 of cases by overload above the first ray
(Groulier )
3 - The reductibility of the deformity
Management of the
adult flatfoot
Valgus of the hindfoot
Dr E Toullec
Heel rise tests = dynamic reductibility by PTT
Introduction
Classifications :
imaging
aetiologies
Double heel rise test : no HF inversion
1
= fixed
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
2
+
Double heel rise normal
+ single single : no inversion
= supple with PTT
elongation or rupture
Specific treatments
Conclusion
3
Nice , 30 may 2008
Painful PTT or no inversion only after repetitive
monopodal test = PTT weakness
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Valgus reductibility when passive correction
ankle medial laxity
or sometimes subtalar laxity
Management of the
adult flatfoot
Dr E Toullec
The laxity of the joint
Chopart hypermobility = instable flatfoot
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Abduction – adduction in stress
Management of the
adult flatfoot
Dr E Toullec
3 -The reductibility of the deformity
Sometimes , valgus fixed by
achille tendon contracture
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Dorsal flexion of the ankle
after correction of the valgus of the hindfoot
knee flexed and in extension ( Silverskiold test)
gastrocnemius or achille retraction
Management of the
adult flatfoot
Dr E Toullec
The posterior tibialis tendon (PTT) strenght
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Inversion against resistance
from plantar flexed & everted position
Management of the
adult flatfoot
Dr E Toullec
Chopart joint stifness
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Passive inversion impossible:
tendon ( peroneus tendon contracture )
or joint ( arthritis ) ?
Management of the
adult flatfoot
Dr E Toullec
Valgus of hindfoot in stand position
sometimes due to forefoot supination
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Partial reductibility
No reductibility
Specific treatments
Conclusion
Nice , 30 may 2008
Reductibility when forefoot not in charge
( Caroll test)
Management of the
adult flatfoot
Dr E Toullec
Introduction
Supination ( varus) of forefoot :
First metatarsal rise sign ( Hinterman)
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Supination of the forefoot after correcting
the valgus of the hindfoot
rising of the 1rst ray head
if varus fixed
Management of the
adult flatfoot
Dr E Toullec
The laxity of the joint
TMT1 hypermobility (often multiplanar)
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Elevation of the 1srt metatarsal
reductible forefoot varus
X ray TMT1 collapse ( plantar gap)
Reductible metatarsus varus
Hallux valgus
Specific treatments
Conclusion
Nice , 30 may 2008
radiographic squeeze test
Management of the
adult flatfoot
Imaging
X ray = 3 views in weightbearing
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Forefoot abduction
Dorso-plantar view
Flatenning medial arch
lateral view
Specific treatments
Conclusion
Nice , 30 may 2008
Hindfoot valgus
Meary view
Management of the
adult flatfoot
1 – dorso-plantar view
Dr E Toullec
1 Talo1srt metatarsal angle
Mann and Thompson:
N= 0, mild<15° ,severe >15°
Introduction
2 Talocalcaneal angle
Classifications :
imaging
aetiologies
N= 25-35°
3 Talonavicular uncoverage
Treatments :
N=0%
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
2
1
Specific treatments
Conclusion
Nice , 30 may 2008
3
Management of the
adult flatfoot
2 – lateral view
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Talocalcaneal angle
N= 25-35°
Calcaneal pitch : N= 15-20°
Conclusion
Talo1srt metatarsal (Méary) ++ : N= 0°
Nice , 30 may 2008
Management of the
adult flatfoot
2 – lateral view
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Break of the medial arch
Specific treatments
Conclusion
Nice , 30 may 2008
Gap above the TMT1, NC joint
with sometimes arthritis
Management of the
adult flatfoot
3 – Meary view
Dr E Toullec
Normal
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
or 2 ankles frontal view ( anglo-saxons)
Conclusion
Axis of hindfoot : N= 4-8°
Nice , 30 may 2008
Measure of the valgus
localisation of the valgus
Management of the
adult flatfoot
3 – Meary view
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Tibiotarsal joint shape
Lateral malleolar stress fracture
Medial laxity: talar tilt
Arthritis in tibiotarsal or subtalar joint
Management of the
adult flatfoot
X ray in stress if laxity
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stress in valgus
Stress in varus
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Stress in abduction
Stress in adduction
Management of the
adult flatfoot
Ultrasound
Dr E Toullec
Cost effective
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
posterior tibialis tendon
(tenosynovitis , splits ,..)
Interest in stage 1 dysfunction
Specific treatments
Conclusion
Nice , 30 may 2008
dynamic tests : laxity
Management of the
adult flatfoot
MRI
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Spring ligament
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
PTT rupture, split,
tenosynovitis,
intratendinous degeneration
Conti classification (tears)
Management of the
adult flatfoot
CT scan
Specific aetiologies
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
3D
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Subtalar arthritis
Specific treatments
Conclusion
Nice , 30 may 2008
coalition
aetiologies
Management of the
adult flatfoot
Dr E Toullec
Introduction
poliomyelitis
Coalition
Acquired flatfoot
( PTT dysfunction)
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Medial TN & TT laxity
tumor
Congenital flatfoot
Specific treatments
Conclusion
Nice , 30 may 2008
Lisfranc injury
Rheumatoid arthritis
Management of the
adult flatfoot
Rheumatoid foot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
severe deformity
Joint arthritis
Knee often impaired
Tendon weakness
or rupture
osteoporosis
Management of the
adult flatfoot
Charcot disease
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Diabetes
or peripheral neuropathy
Major risq of infection
Bone necrosis at different level
Management of the
adult flatfoot
Hyperlaxity ( Marfan syndrome,
Ehlers-Danlos)
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Global hyperlaxity
Congenital
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Tumor of the foot or the leg
Man 21 years old Anterolateral leg tumor
( peroneus muscles compression)
since 5 years old
Management of the
adult flatfoot
Dr E Toullec
Neurologic flatfoot
Neuromuscular imbalance
( closed head injury , cerebral palsy,
poliomyelitis, nerve injury)
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Poliomyelitis with equinovalgus
PTT and ATT insufficiency
Management of the
adult flatfoot
Dr E Toullec
Traumatic flatfoot
PTT tendon, spring ligament injury
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Woman 70 years old : flatfoot 1 year after ankle sprain
with rotation on the foot in charge ( Chopart laxity)
Management of the
adult flatfoot
Dr E Toullec
Traumatic flatfoot
Ankle collateral medial ligament injury
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Chronic medial laxity of the ankle
after ankle injury
Subtalar fusion= a bad solution
Management of the
adult flatfoot
Traumatic flatfoot
Bone & joint injuries
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
After Lisfranc’s fracture
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
After calcaneus fracture
Abduction/ lateral compression
Nice , 30 may 2008
Management of the
adult flatfoot
Dr E Toullec
Introduction
congenital
Coalition= Rigid flatfoot in young adult
Talar beak
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
C sign
Accessory navicular bone
The most frequent
Management of the
adult flatfoot
Congenital flatfoot
Dr E Toullec
Achilles retraction
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Acquired flatfoot
Subtalar dislocation
Specific treatments
Conclusion
PTT dysfunction
Nice , 30 may 2008
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Classification of the posterior tibialis tendon dysfunction :
Johnson KA , Strom DE : tibialis posterior tendon dysfunction .
Clin Orthop 1989
Stage 1 : TP tenosynovitis , no or a few deformity
Stage 2 : flexible flatfoot , tendinous strenghtening or prerupture
Stage 3 : severe deformity with rigid hindfoot
Myerson M, Solomon G, Shareff M : posterior tibial tendon
dysfunction : its association with seronegative inflammatory
disease . Foot Ankle Int 1989.
stage 4 : medial laxity with lateral ankle arthritis
Specific treatments
Conclusion
Nice , 30 may 2008
Bluman E , Craig T , Myerson M : Posterior tendon rupture :
a refined classification system .
Foot Ankle Clinics . 12(2007): 233-249
Management of the
adult flatfoot
Stage I ( Bluman)
Tenosynovitis without deformity
Dr E Toullec
IA:
normal anatomy, tenderness along PTT
X ray : normal
PTT inflammatory
IB:
normal anatomy , tenderness along PTT
X ray normal
partial PTT tear
IC:
slight hindfoot valgus, tenderness PTT
X ray : slight valgus ( less 5°)
partial PTT tear
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Tests :
normal inversion strenght
single heel rise test normal
Management of the
adult flatfoot
Medical treatment
Dr E Toullec
Introduction
The means :
Specific shoes
Arizona brace
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
DAFO
( semirigid,extradepth)
Insoles
Brace, walking boot, cast
physiotherapy ( cryotherapy)
NSAIDs
The indications :
stage 1
surgery contraindication
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Medical treatment
In acute PTT tenosynovitis :
below knee cast or boot
6 to 8 weeks
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Removable stirrup brace
non sufficient
Management of the
adult flatfoot
Stage 1 : sometimes surgery
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Tenosynovectomy
PTT suture (splint)
Medial calcaneal osteotomy ( I-C)
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 2 ( Bluman)
Ruptured PTT, flexible flatfoot
Inversion weakness
Inhability to single or multiple
single heel rise test
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
3 categories
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Stage 2 ( Bluman) :Ruptured PTT, flexible flatfoot
II A
supple hindfoot valgus
X ray: hindfoot valgus
Meary’s line dysruption
loss of calcaneal pitch
Management of the
adult flatfoot
Dr E Toullec
II A
Introduction
Classifications :
imaging
aetiologies
A1 flexible forefoot supination
A2 fixed forefoot supination
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
First metatarsal rise sign ( Hinterman)
Nice , 30 may 2008
Management of the
adult flatfoot
II A = Medial calcaneal osteotomy
tibia
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
calcaneus
Translation of achilles tendon
The medial translation protect
the medial collateral ligament
Oblique osteotomy 45° & translation of 1cm
Management of the
adult flatfoot
II A = Medial calcaneal osteotomy
Increase the forefoot abduction
Dr E Toullec
( Toullec – EFAS Seville march 2003)
Introduction
Classifications :
imaging
aetiologies
Pulling procedure
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Always associated with PTT repairing or transfert
+ spring ligament suture
Specific treatments
Conclusion
Nice , 30 may 2008
FDL transfert
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
If fixed forefoot varus (IIA2)
1srt ray lowering
by osteotomy or fusion
Navicular plantar
soustraction
1srt meta dorsal addition
TMT1 fusion
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Lowering scarf ost.
Specific treatments
Conclusion
Nice , 30 may 2008
1srt cuneiform plantar
soustraction
or dorsal addition (Cotton)
TMT1 & CN fusion
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
II B
forefoot abduction
X ray : forefoot abduction
talonavicular uncovering
hindfoot valgus
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
II B
supple hindfoot valgus & forefoot abduction
But different kind of abduction
35°
26°
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Transverse tarsal joint
1srt tarsometatarsal
Abduction location in dynamic pedobarography
Nice , 30 may 2008
Management of the
adult flatfoot
Stage IIB : lateral column lenghtening
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
To push = Evans
1 to 1.5 cm/ CC joint
Specific treatments
Conclusion
Nice , 30 may 2008
The best situation for the osteotomy
direction of the center of the talus head
Management of the
adult flatfoot
Dr E Toullec
No deformity of the head to turn
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Failure because no possibility of rotation
(congenital flatfoot)
Interest of peroperative X ray with correction
Nice , 30 may 2008
Management of the
adult flatfoot
Dr E Toullec
The weak point = the graft :
Introduction
- tricortical iliac crest
- size from 8 to 10 mm
- stable fixation
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Drawbacks :
Specific treatments
Conclusion
overcorrection
Nice , 30 may 2008
= clubfoot
Undercorrection /
Compressed graft
migration
Management of the
adult flatfoot
Dr E Toullec
Increase peroneus tendon contracture
CC joint overpressure
Introduction
Classifications :
imaging
aetiologies
( 65% for Philipps, Mosier LaClair 14%)
but without peroneus tendon lenghtening
Treatments :
Fusion = a solution ?
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Not around the center
of the talus head
Specific treatments
Conclusion
CC fusion with lenghtening
but sometimes non healing ( 47% for Conti)
Nice , 30 may 2008
Management of the
adult flatfoot
Combined osteotomies = a solution?
Dr E Toullec
Evans + MCO
Introduction
Classifications :
imaging
aetiologies
Mosier LaClair ( 2001), Catanzariti ( 2005)
Arthrose CC 14% à 5 ans
Z osteotomy or calcaneal scarf ost. ( Malerba –Weil )
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Weil LS, Roukis T(May-june 2001) : the calcaneal scarf osteotomy :
Operative technique. J. Foot Ankle Surg .
Specific treatments
Conclusion
from LS Weil
Nice , 30 may 2008
Management of the
adult flatfoot
II C
Dr E Toullec
fixed forefoot varus
medial column instability
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
X ray : hindfoot valgus
medial plantar gaping
Management of the
adult flatfoot
Stage II C
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Medial arch arthrodesis
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Medial cuneiform opening
wedge osteotomy ( Cotton)
Cotton FJ.Foot statics and surgery.
N Engl J Med 1936;214
From Myerson
Man 71 years old – PTT dysfonction & Lisfranc abduction
Evans + achilles & peroneus lenght. + TMT1 fusion
1 year later
Sono validi gli
interventi tipo Evans ?
26°
0°
Dr Toullec
Introduction
Indications
The procedure
osteotomy & graft
achille tendon
peroneus tendon
tibialis posterior
forefoot supination
Conclusion
Torino , 30 novembre 2007
before
1 year
Lateromedial force index
in dynamic pedobarography
lateral force
Medial force
time
Normal curve
Force on the medial side
during all the step
before
Force
on the lateral side
1 year
E Toullec : Evaluation par baropodométrie dynamique de la force latéro-médiale
dans le pied plat valgus sévère avant et après chirurgie .
Suppl au N°6 ,Rev Chir Orthop,2005,91 : 3S129.
Management of the
adult flatfoot
The place of arthroereisis
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
In stage II , to correct the collapse of the talus head
In conjonction with FDL transfert ( minimal deformity)
or MCO & FDL transfert (moderate deformity)
& if necessary , achille tendon lenghtening and
opening wedge medial cuneiform osteotomy ( Cotton)
( Schon L : Foot Ankle Clinics –2007:329-339)
! Sinus tarsi pain
implant removal
Management of the
adult flatfoot
Tendons imbalance
PTT stretching
Dr E Toullec
Peroneus
contracture
Tenosynovectomy
Introduction
PTT tightening = Kidner
Classifications :
imaging
aetiologies
Tendon transfert :
Achille
contracture
FDL
or FHL
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
lenghtening
Evans
Specific treatments
Conclusion
Nice , 30 may 2008
Cobb ( half TA)
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Stage III ( Bluman)
rigid hindfoot valgus
Rigid hindfoot valgus
Pain in sinus tarsi
X ray : hindfoot valgus
subtalar joint space loss
angle of Gissane sclerosis
IIIA
IIIB : forefoot abduction
Tests : inability to perform double heel rise test
Management of the
adult flatfoot
Dr E Toullec
Stage III ( Bluman) : rigid hindfoot valgus
The gold standart = Triple arthrodesis
Introduction
Classifications :
imaging
aetiologies
Sagittal view
: correction of the medial arch flattening
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Meary view :
Nice , 30 may 2008
Valgus corrected
in subtalar fusion
:
Fixed varus corrected
in Chopard fusion
Dorsoplantar view
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Triple arthrodesis : procedure
The approach :
- classical : lateral ( ST & CC) and medial (TN)
- only medial approach ( wound healing)
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Associated procedures if necessary:
- Achilles lenghtening
- Medial displacement osteotomy
- Lateral column lenghtening
- Plantar flexion osteotomy 1srt ray (Cotton)
Management of the
adult flatfoot
Dr E Toullec
Is partial arthrodesis sometimes useful ?
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Arthrodesis with lenghtening of the lateral
side of the foot if abduction + arthritis
Nice , 30 may 2008
Management of the
adult flatfoot
Stage 3 with arthritic TN joint & subtalar subluxation
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Sometimes , PTT repairing necessary
Management of the
adult flatfoot
Dr E Toullec
Introduction
Stage IV ( Bluman) : ankle valgus
4A = flexible ankle valgus
Surgery for hinfoot valgus
+ deltoide reconstruction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
X ray stress in varus
4B = rigid ankle valgus
Tibiotalocalcaneal fusion
or pantalar fusion
or triple arthrodesis +
ankle prosthesis
ANKLE VALGUS
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Rigid
Pantalar or
Tibiotalocalcaneal
fusion
Flexible
Multiplanar
instability
Mild arthritis
Severe arthritis
No instability
Plantigrade foot
+ ankle prosthesis
+ deltoid reconstruction
Multiplanar
instability
Lateral& medial
ligament
reconstruction
No instability
Deltoid & foot
reconstruction
Bluman E , Myerson M : Stage IV posterior tibial tendon rupture
Foot Ankle Clinics 12(2007): 341-362.
Management of the
adult flatfoot
Stage IV ( Bluman) : ankle valgus
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Stage 4B without instability :
Pantalar fusion ?
Management of the
adult flatfoot
Specific treatment = often fusion
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
Traumatic ankle arthritis with valgus
tibiotalar & syndesmosis fusion
Specific treatment = often fusion
Management of the
adult flatfoot
Dr E Toullec
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Subtalar arthritis joint with lateral subluxation
Specific treatments
Conclusion
Nice , 30 may 2008
Subtalar fusion with graft
Management of the
adult flatfoot
Dr E Toullec
But not always…
Medial collateral instability
+ sometimes lateral instability
Introduction
Classifications :
imaging
aetiologies
No fusion but
Medial col. Ligt suture
+ MCO
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
FU 1 year : excellent
but what prognosis ?
Management of adult flatfoot
Management of the
adult flatfoot
Dr E Toullec
1
What kind of flatfoot is it ?
Joints , tendons , aetiologies
clinical tests
X ray in weightbearing
dynamic pedobarography
2
How to correct all these deformities ?
a box of surgery tools
ankle and foot axis
muscle imbalance
arthritic joints
Introduction
Classifications :
imaging
aetiologies
Treatments :
Stage 1 : medical
Stage 3 : fusion
Stage 4 : the ankle
Specific treatments
Conclusion
Nice , 30 may 2008
woman 65 years old –
PTT rupture ( left foot):
Evans ost. & scarf ost.
Achille & peroneus length.
without repairing the tibial. post
2 years later
6 years later
Dynamic pedobarography
before
8 months
2 years
4 years
6 years
Thank you

management of the adult flatfoot

Transcription

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