April 2016

4/4/2016 | BY Resident Review Contributors

Foot & Ankle Questions

Question 1:

A 15 year old running back presents with severe foot pain and inability to weight bear after a tackler lands on his heel.  The patient has significant midfoot pain, swelling and plantar ecchymosis.  Radiographs obtained upon presentation to the emergency department provided.  Initial treatment should include:
  1. Open reduction and midfoot arthrodesis.
  2. MRI imaging to evaluate the competency of the oblique interosseous ligament.
  3. Bulky Jones dressing splint immobilization followed by weight bearing AP foot radiographs as outpatient.
  4. Open reduction and internal fixation.
  5. Application of spanning external fixator for three months of maintenance of alignment.
Correct Answer: 4. Open reduction and internal fixation. 
Open reduction and internal fixation is the preferred treatment with the goal of anatomic restoration of Lisfranc and tarsometatarsal articulations (see figure below with post-operative imaging).  Implants are typically removed at 4-6 months post-operative.  Primary midfoot arthrodesis is not preferred in young, active patients unless significant chondral injury and / or intraarticular comminution is noted.  Weight bearing radiographs or MRI imaging are not required unless nondisplaced ligamentous injuries are suspected. 

References:
  • Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc Joint Injury: Current Concepts.JAAOS 2010;18(12):718-728.
  • Deol RS, Roche A, Calder JD. Return to training and playing after acute Lisfranc injuries in elite professional soccer and rugby players. Am J Sports Med. 2016 Jan;44(1):166-170.
  • Smith N, Stone C, Furey A. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic review and meta-analysis. Clin Orthop Relat Res. 2015 May 29. Epub.


 
 

 Question 2:

A 15 year old male presents with ankle pain and inability to ambulate following an inversion injury playing basketball.  Radiographs and CT images provided below demonstrate the injury. Treatment recommendations include:
  1. Arthroscopic removal of loose body with microfracture of osteochondral defect.
  2. Fibular osteotomy and open reduction and internal fixation of osteochondral fragment.
  3. Short leg cast immobilization followed by physical therapy.
  4. Removal of loose body with autologous osteochondral graft transfer from ipsilateral trochlea.
  5. Arthroscopic reduction and fixation of osteochondral fragment.
Correct Answer: 2. Fibular osteotomy and open reduction and internal fixation of osteochondral fragment.

This lateral talar shoulder osteochondral fracture is located posterior to the midsagittal plane of the talus and is not amenable to orthogonal bioabsorbable chondral screw fixation without a distal fibular osteotomy (intraoperative fluoroscopy image and 2 year postoperative image included below).  Given the large fragment of subchondral bone with intact overlying cartilage, fixation is preferred over resection and chondral regenerative procedures such as microfracture, autologous chondrocyte implantation, or osteochondral transfer procedures.  Large, displaced intraarticular loose fragments are not amenable to conservative treatment due to near certain likelihood of posttraumatic arthritis.

References:
  • Dunlap BJ, Ferkel RD, Applegate GR. The “LIFT” lesion: lateral inverted osteochondral fracture of the talus. Arthroscopy. 2013. Nov;29(11):1826-33.
 

 

Question 3:

Which of the following is not a late complication seen with traditional open clubfoot surgery.
  1. Dorsal bunion
  2. Osteonecrosis of the talus
  3. Tarsal tunnel syndrome
  4. Rigid pes planus
  5. In-toeing gate
  
Correct Answer: 3
Traditional surgical treatment of clubfoot deformity with wide release (in order to correct the cavus, adduction, varus, equinus) is notable for frequent complications, residual deformity, and secondary surgeries. Tarsal tunnel has not been correlated with previous clubfoot release surgery. Each of the remaining choices are known complications or deformities following clubfoot surgery. Kuo et al reviewed 134 cases of clubfeet who underwent surgical release.Late deformities included in-toeing gait, overcorrection, rotatory dorsal subluxation of the navicular, vascular insult to the talus with collapse, and dorsal bunion. Patients who underwent surgery prior to 6 months of age had poorer results.

 
Question 4:

Which of the following components of the clubfoot deformity should be addressed first when using the Ponseti method?
  1. < >Metatarsal Adduction
  2. < >< >Hindfoot alignment
  
Correct Answer: 1 
Cavus should be addressed first when using the Ponseti method to treat clubfoot.

Idiopathic clubfoot is characterized by forefoot adductus, hindfoot varus, ankle and subtalar equinus, and supination of entire foot. The forefoot is pronated relative to hindfoot. Correction of clubfoot requires an organized and sequential methodology. In the Ponseti method cavus is first corrected followed by adduction of the metatarsals, hindfoot varus, then finally equinus.

 
 Question 5: 

A child presents with unilateral foot deformity and this set of x-rays. Which of the following is true:
 
  1. This abnormality presents most commonly as clinodactyly.
  2. Earlier treatment, before the bracket epiphysis ossifies, is unlikely to prevent deformity long term.
  3. Excision of the bracket epiphysis is adequate treatment for this child.
  4. This abnormality has no known associations.
  5. Splinting should be the first line of treatment for this child.
  
Correct Answer: 1 
Longitudinal epiphyseal bracket presents most commonly as clinodactyly. It can be associated with polydactyly, cleft hand or foot, tibial hemimelia, Apert’s syndrome, Klinefelter’s syndrome, and other less common conditions.
 
Based on relatively limited published data, earlier treatment can potentially prevent or limit deformity longer term. Those children who present at a later age may require an osteotomy to correct deformity of the metatarsal.  At a younger age, the metatarsal deformity may be relatively mild, and a physiolysis (with appropriate follow-up) may provide adequate treatment.
 
Persistence of the bracket in a younger child and rigid metatarsal deformity in an older child preclude splinting as a viable treatment method.
 
References:
  • Longitudinal epiphyseal bracket. Choo AD, Mubarak SJ. J Child Orthop. 2013 Dec; 7(6):449-54. 
  • Preossified longitudinal epiphyseal bracket of the foot: treatment by partial bracket excision before ossification. Shea KG, Mubarak SJ, Alamin T. J Pediatr Orthop. 2001 May-Jun;21(3):360-5.

Question 6:

An 8 month old infant presents with a right foot deformity. Mother is concerned about cosmesis and requests surgical management. The child is noted to have six toes, with the second appearing relatively underdeveloped. She has a wide forefoot. The hindfoot is normal clinically and radiographically. This is an isolated abnormality and the rest of her examination is normal. This child would benefit from:
 

 
  1. An MRI of the foot.
  2. Excision of the right first ray.
  3. Excision of the right sixth ray.
  4. Excision of the smaller second ray, with reconstruction/repair of the intermetatarsal ligament.
  5. Shoe wear modification.
 
Correct Answer: 4 
Mother is requesting surgical management as the cosmesis of the child’s foot is unacceptable to her. Isolated shoe wear modification is thus inadequate treatment. An MRI is unlikely to provide any significant new information and could require an anesthetic.
 
It is reasonable to proceed surgically. The anatomy of a polydactyly can vary greatly. Generally, the most normal looking toes/rays are preserved and the smaller, more deformed toes are excised.
 
References:
  • Polydactyly of the foot. Literature review and case presentations. Galois L, Mainard D, Delagoutte JP. Acta Orthop Belg. 2002 Oct;68(4):376-80.
  • Polydactyly of the feet in children: suggestions for surgical management. Morley SE, Smith PJ. Br J Plast Surg. 2001 Jan;54(1):34-8.
  • Polydactyly and polysyndactyly of the fifth toe. Nogami H. Clin Orthop Relat Res. 1986 Mar;(204):261-5.

Question 7:

Metatarsus adductus is characterized by:
  1. An incidence of 1 in 5000 births.
  2. 90% bilaterality.
  3. Associated with torticollis and internal tibial torsion.
  4. The heel bisector line passes medial to the 2nd/3rd toe.
  5. Increased incidence in multiparous births (twins, triplets, etc).
 
Correct Answer: 5
The incidence is 1 in 1000, bilaterality occurs about 50% of the time, it can be associated with torticollis and DDH, it occurs equally for males and females.  The heel bisector line, used for diagnosis, passes lateral to the 2nd/3rd toe webspace in MTA.  There is an increased incidence in twin births, first births, births at greater then 40 weeks, and oligohydramnios.  This is consistent with the belief that it is most likely a packaging disorder.
 
References: 
  • Kumar S, MacEwen G.  The incidence of hip dysplasia with metatarsus adductus. Clin Orthop. 1982;164:234-235.
  • Kite H.  Congenital Metatarsus Varus.  J Bone Joint Surg. 1967;49(2):388-97. 

Question 8:

Koehler’s disease (osteochodrosis of the navicular) is:
  1. Seen equally in males and females
  2. Usually resolves spontaneously regardless of observation or immobilization treatment
  3. Frequently requires IV antibiotics
  4. Generally occurs in patients over the age of 10
  5. Usually occurs bilaterally
 
Correct Answer: 2
Koehler’s disease is more frequently seen in males, does not require IV antibiotics, is seen most commonly in kids ages 4-9 (average 6), and is mostly unilateral.  Studies evaluating methods of treatment including observation (skillful neglect), casting, shoe modifications or rest showed no difference in resolution regardless of type of treatment.  Casting may decrease the time of symptoms by a few weeks.
 
References:
  • Borges JLP, Guille JT, Bowen JR. Kohler’s Bone Disease of the Tarsal Navicular. J Ped Orthop. 1995;15:596-8.
  • Williams GA, Cowell HR. Kohler’s Disease of the Tarsal Navicular. Clin Orthop. 1981;158:53-8.

Question 9A:

The most typical natural history of untreated idiopathic toe walking includes:
  1. difficulty playing sports as a teenager.
  2. worsening over time.
  3. progressive pain in the feet.
  4. the development of midfoot or forefoot arthritis.
  5. gradual resolution, no pain, and no functional limitations.
Correct Answer: 5
 

Question 9B:

The treatment most likely to produce a noticeable improvement in idiopathic toe walkers is:
  1. the use of orthotics.
  2. serial Casting.
  3. Botox injection of the gastrocsoleus complex.
  4. physical therapy.
  5. Achilles tendon lengthening.
 Correct Answer: 5
 
Discussion:
The first step when evaluating a child who toe walks is to determine if there is an underlying neurologic cause, or if the condition can be considered “idiopathic”. Historical data, such as the birth history and the record of motor milestones, combined with a detailed neurologic exam, can exclude most neurologic abnormalities. If questions persist, a formal Neurology consultation can be initiated.
For cases considered idiopathic, the natural history suggests that most children will cease toe walking, at least noticeably, before reaching adulthood. Conservative treatments, including orthotics, stretching with physical therapy, and serial casting with or without Botox to the calves, may show legitimate short-term improvements. However, the toe-walking typically recurs when the acute conservative treatments are discontinued, and most studies show no significant lasting effect.

A small percentage of patients will continue toe walking into the teenage or adult years. This is likely due to preexisting Achilles tendon contractures, or perhaps the development of contractures over time from persistent plantarflexion of the ankles. Despite the persistent toe walking, there is no evidence that it causes an increased incidence of pain, arthritis, or dysfunction in the adult years. Therefore, this natural history, and the indications for surgical intervention in the childhood years need to be carefully evaluated, and clearly explained to patients and their parents.

Parents may wish to have idiopathic toe walking corrected for social reasons, (i.e., they may not want their child to be the only one among their peers who walks on their toes), or they may fear that it will cause future problems, even after a discussion of the natural history. If there is a strong desire for correction, Achilles tendon lengthening is the most likely treatment that will produce a noticeable change. Typically, the lengthening can be accomplished with simple, percutaneous, outpatient surgery. Though Achilles tendon lengthening does typically improve the symptoms, parents should be cautioned that children still have slightly abnormal gait kinematics, compared to normal controls.

References:  

Question 10:

A patient with Charcot-Marie-Tooth complains of gait problems with walking.  Formal gait analysis is performed to help guide treatment.  The kinematic plots suggest:
  1. Excessive cavus
  2. Excessive planus
  3. Plantar flexor weakness
  4. Cavovarus deformity and claw toes
  5. Heel cord contracture

 
Correct Answer: 3
A patient with Charcot-Marie-Tooth (hereditary sensory motor neuropathy) may present with a variety of complaints.  The most common objective finding is plantar flexor weakness. Patients may have other foot deformities, such as cavus, cavovarus, claw toes, or even a flail foot.  Some patients develop heel cord contractures and appear to be toe walkers, but they often fatigue easily and have difficulty intentionally rising higher on their toes.  The plots show a pale grey reference band with the patient’s data superimposed.  Note the delay in ankle in the timing of
push off as well as the excessive range of ankle motion and knee flexion in stance – all suggesting gastrocnemius weakness.  One needs strong plantarflexors to push off properly and support the plantarflexor-knee extension couple.   This patient also has a drop foot in swing and may benefit from an AFO.    
 
References:
  • Ounpuu S, Garibay E, Solomito M, Bell K, Pierz K, Thomson J, Acsadi G, DeLuca P: A comprehensive evaluation of the variation in ankle function during gait in children and youth with Charcot-Marie-Tooth disease. Gait Posture. 2013 Sep;38(4):900-6.
  • Faldini C, Traina F, Nanni M, Mazzotti A, Calamelli C, Fabbri D, Pungetti C, Giannini S: Surgical treatment of cavus foot in Charcot-Marie-Tooth disease: a review of twenty-four cases: AAOS exhibit selection. J Bone Joint Surg Am. 2015 Mar 18;97(6):e30
  • Dreher T, Wolf, SI, Heitzmann D, Fremd C, Klotz MC, Wenz W: Tibialis posterior tendon transfer corrects the drop component of cavovarus foot deformity in Charcot-Marie-Tooth disease. J Bone Joint Surg AM. 2014 Mar 19;96(6):456-62.
 

Question 11:

What has been reported as a risk factor for clubfoot relapse after Tibialis Anterior Tendon Transfer (TATT)?
  1. Family history
  2. Type of fixation of tendon transfer
  3. Tendon transfer before age 2½
  4. Transfer to cuboid
Correct Answer: 3
 TATT is used to correct clubfoot relapse associated with dynamic supination. Two studies(1, 2) have reported higher recurrence rate after TATT if the surgery is performed before 2 ½ years of age. Other answers (Family history, type of fixation, and transfer to cuboid) have not been reported as risk factors for recurrence after TATT.

References:
  • Luckett MR, Hosseinzadeh P, Ashley PA, Muchow RD, Talwalkar VR, Iwinski HJ, et al. Factors predictive of second recurrence in clubfeet treated by ponseti casting. Journal of pediatric orthopedics. 2015;35(3):303-6.
  • Masrouha KZ, Morcuende JA. Relapse after tibialis anterior tendon transfer in idiopathic clubfoot treated by the Ponseti method. Journal of pediatric orthopedics. 2012;32(1):81-4.

 Question 12:

  Which one is not found in complex idiopathic clubfeet?
  1. Hyper extended first ray
  2. Rigid equinus
  3. Cavus deformity of all metatarsals
  4. Dropped halux
 Correct Answer: 4 
Complex idiopathic clubfoot is a special type of idiopathic clubfoot that requires another type of treatment described by Dr. Ponseti (1)(besides the traditional Ponseti method). Hyper extended first ray, rigid equines, and cavus deformity of all metatarsals are all the deformities found in the complex idiopathic clubfoot. Dropped hallux is seen in some clubfeet associated with peroneal nerve palsy but is not seen in complex idiopathic clubfeet (2).
 
Refereces:
  • Ponseti IV, Zhivkov M, Davis N, Sinclair M, Dobbs MB, Morcuende JA. Treatment of the complex idiopathic clubfoot. Clinical orthopaedics and related research. 2006;451:171-6.
  • Edmonds EW, Frick SL. The drop toe sign: an indicator of neurologic impairment in congenital clubfoot. Clinical orthopaedics and related research. 2009;467(5):1238-42.