FOOT AND ANKLE SYMPOSIUM
Educational Objectives
| The goal of this program is to improve medical and surgical management of disorders of the foot and ankle. After
hearing and assimilating this program, the participant will be better able to:
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 | 1. Perform an optimal clinical examination of gait, symmetry, and range of motion of the foot.
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| 2. Describe the proper movements of the calcaneus, cuboid, navicular, and metatarsal bones, and the Chopart and
other joints of the foot and ankle.
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| 3. Identify and treat abnormalities such as cavovarus foot and equinus contracture.
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| 4. Determine appropriate nonsurgical and surgical treatments for stages of Achilles tendon disease.
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| 5. Evaluate cases of hallux valgus and determine likelihood of success with various surgical options.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, Drs. Daniels and Glazebrook and the
planning committee reported nothing to disclose.
Acknowledgments
Lectures given by Drs. Daniels and Glazebrook were recorded at The 8th Biennial Canadian Orthopaedic Foot & Ankle
Symposium, held April 12-13, 2008, in Toronto, ON, and cosponsored by the Canadian Orthopaedic Foot & Ankle
Society, and the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Faculty of
Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
| FOOT AND ANKLE HISTORY AND EXAMINATION —Timothy R. Daniels, MD, Associate Professor, Department
of Surgery, Division of Orthopaedic Surgery, Saint Michael’s Hospital, University of Toronto Faculty of Medicine,
Toronto, ON
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| Gait analysis: important first step in evaluation of patients; observe cadence, equal lengths of stride, and heel-to-
toe progression (many patients come down on midfoot, toes, or laterally, indicating, eg, rigidity, spasticity, equinus
contracture of ankle); energy efficiency of gait results from eccentric muscle contraction that controls rate of falling
forward and progression of tibia during stance phase
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| Symmetry: asymmetry suggests pathology; most patients (80%) have pathology on single side; feet should point
straight forward, internal rotation or abduction indicates inefficient use of rockers of heel, ankle, and forefoot;
forefoot abduction often indicates flatfoot deformity; alignment of hindfoot—Achilles tendon should bisect bimalleolar
axis, following posterior tuberosity; helps determine whether hindfoot (calcaneus) in varus or valgus;
inverting foot slightly reveals less of median and more of lateral malleolus; symmetry may override other factors
(eg, if calcaneus closer to lateral malleoli on both sides, and foot points forward, symmetric anatomy suggests
lack of pathology
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| Heel raise: hindfoot should invert when patient raises heel to stand on toes; patient may have dysfunctional posterior
tibial tendon and still rise onto toes by leaning forward and bending knee; hindfoot inverts if posterior tibial
tendon, Achilles tendon, and gastrocsoleus complex function normally; posterior tibial tendon functions
similarly to rotator cuff in glenohumeral joint (ie, by locking subtalar and midtarsal joints) so entire lever arm of
foot used by Achilles tendon to lift with gastrocsoleus complex; when energy efficiency of gait impaired (eg,
with dropfoot or flexure contractures of knees), pain from fatigue may appear to involve entire leg
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| Range of motion: all bones (from calcaneus, cuboid, and navicular, to metatarsals [MTs]) move as unit around talus
because talonavicular, calcaneocuboid, and subtalar joints work as unit; movement rotational (ie, circular, linear,
or combination)
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| Subtalar joint: grasp foot at fourth MT head and rotate foot around talus; patient may have no motion of subtalar
joint but can appear to move because of Chopart joints (ie, talocalcaneonavicular and calcaneocuboid joints); to
distinguish this, feel movement of calcaneus during range of motion test
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| Talonavicular joint: largest arc of motion of any joint in hindfoot; subtalar joint constrained—depends on motion
through talonavicular joint; however, if subtalar joint stabilized, motion can occur through Chopart joints to give
plantar and dorsiflexion
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| Plantar and dorsiflexion: ability to move foot up and down (plantar and dorsiflexion) indicates combined movement
of ankle, subtalar, and Chopart joints, not range of motion of ankle; up to 40% of plantar flexion occurs
through Chopart joints; only 60% of sagittal range of motion comes from ankle joint; ankle may contribute only
10° of arc; reassure patients who undergo ankle fusion that they will not lose all range of motion
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| Arc of motion of subtalar joint complex: especially important to assess in flatfoot deformity; in close-packed position,
joints have optimal contact (hindfoot in valgus), and forces distributed through widest possible surface area
in posterior, anterior, and middle of subtalar joint
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| Flatfoot deformity: when standing, normal patient’s foot automatically flattens; normally, foot should show 15° of
eversion and twice as much inversion; in flatfoot deformity, patient has twice as much eversion as normal but no
inversion; extra-articular corrections (eg, lateral column lengthening) decrease arc of eversion but do not increase
arc of inversion; consider performing triple arthrodesis; make sure arc of motion functional (15° eversion);
otherwise, talar head driven into floor during stride, no rigid lever arm created between hindfoot and
midfoot, and patient rolls off medial aspect of foot, losing MT break and efficiency of gait
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| Cavovarus foot: place hindfoot into neutral position by cupping hand around back and observe orientation of forefoot
(supination or pronation) due to plantar flexion; not necessary for experienced clinician to perform Coleman
block test for flexibility; if hindfoot cannot be everted to neutral position, deformity rigid; if neutral, observe valgus
of MT and rotate forefoot externally while holding heel; if this corrects valgus, extra-articular correction or plantar
fascia release and dorsiflexion osteotomy of first MT may help patient more than triple fusion
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| Assessment for tendo Achilles contracture: gastrocnemius inserts above knee; position hindfoot under tibia
with knee extended, dorsiflex foot, and bend knee gently to look for more dorsiflexion; if equinus contracture
present, determine whether entire gastrocsoleus complex contracted or only soleus, and treat with tendo Achilles
slide or tendo Achilles lengthening, respectively
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| ADVANCES IN ACHILLES TENDINITIS: TENDON TRANSFER, ALLOGRAFT, CALCANEAL
OSTEOTOMIES —Mark Glazebrook, MD, Assistant Professor, Department of Surgery, Division of Orthopaedics,
Dalhousie University Faculty of Medicine, Halifax, NS
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| Spectrum of Achilles tendon disease: acute inflammation (tendinitis), tendonosis, rupture, insertional Achilles
tendon disease (most difficult to treat)
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| Nonoperative treatment: attempt in all patients; success rate ≤75%; 2 stages of treatment; stage 1 (decrease
inflammation)—walking cast or cast for 1 to 2 wk; provide orthotics; rigid hindfoot support from shoe; spacers
if local irritation present; heel lift; treatment with analgesic and anti-inflammatory medications orally or by injection
in and around tendon; stage 2 (reconditioning)— eccentric strengthening effective
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| Surgical treatment: remove diseased areas of tendon; use “pie crust” technique to reset healing response because
tendonopathy may represent abnormal healing response; case example 1—showed healing mass in tendon composed
of disorganized collagen matrix (mass stains intensely with hematoxylin and eosin [H&E] because of denaturation
of collagen), immature cross-links, and increased cellularity (endothelial cells or tenocytes, not
inflammatory cells)
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| Continuum of tendon disease: microtendonopathy—overuse causes breakdown of cross-links; tendinitis—
inflammation; tendonosis—nonhealing or immature healing and (unorganized) repair response; rupture—if
tendon subjected to force; case example 2—history of pain and swelling, palpable gap in Achilles tendon, excessive
ankle dorsiflexion; magnetic resonance imaging (MRI) showed extensive intrasubstance disease in tendon;
patient expected to evolve quickly from nonoperative to surgical treatment; with small defects, possible to
debride or remove diseased portions and repair; case example 3—medium-sized defect, end-to-end repair not
possible; actually represents autograft because piece of proximal portion of tendon removed and vascular supply
stripped; when sewed together, revascularization occurs; case example 4—large defect in tendon; detach flexor
hallucis longus (FHL) in midfoot, pull through hindfoot incision, tunnel through calcaneus, and tie back on itself
to reconstruct; rupture—end stage of disease; studies show ≥30% of cadavers have signs of Achilles tendon disease;
extent of disease determines force necessary to cause rupture; case example 5—patient had negative plantar
flexion response; complete rupture (ends usually frayed)
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| Review of evidence-based treatment: level 1 and 2 evidence (grade A treatment recommendations) showed that,
compared to nonoperative treatment, open surgery had decreased rate of rerupture, increased rate of complications,
and faster rate of return to activity; comparison of percutaneous vs open repair showed percutaneous had
increased rate of rerupture and decreased rate of complications (other than nerve injuries); comparisons of functional
rehabilitation vs prolonged casting show that functional rehabilitation gives better results in patients who
do not undergo surgery; repair of rupture—end-to-end reproximation; intraoperative testing of strength of repair
to estimate time needed before beginning physical therapy
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| Insertional disease: case example—obese sedentary man, 54 yr of age, with pain and swelling in Achilles tendon
and insertion; x-ray showed calcific deposits in tendon (treatment requires detachment of tendon), and deformity
from Haglund’s disease; imaging showed cyst in Haglund’s region; treatment included Haglund’s resection and debridement
of tendon (without complete detachment), but patient’s symptoms did not improve; subsequent calcaneal
osteotomy performed (wedge closed with superior base to shorten lever arm for insertion of tendon) and some
bone removed; patient improved after second surgery
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| SURGICAL MANAGEMENT OF HALLUX VALGUS: PLENTY OF OPINIONS, PLENTY OF TECHNIQUES —
Dr. Daniels
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| Issues with hallux valgus surgery: high rates of recurrence (eg, pins may break) and complications; due to current
plates and screws, nonunion no longer problem; malunion, however, remains issue; literature review indicates
15% to 20% of patients dissatisfied with outcome of surgery
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| Background: women comprise 85% of patients undergoing forefoot surgery; strong hereditary component; most
patients ≥35 yr of age; no strong clinical correlation with midfoot and hindfoot deformity in literature
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| Findings on examination: feet pointed straight forward; decreased but adequate height to medial arch (no pathologic
flatfoot deformity); no fixed supination; subtle range of motion in subtalar joint complex; no equinus contracture;
15° talar-first MT angle; no evidence of decompensated flatfoot; ligaments somewhat loose; x-ray
showed increased intermetatarsal angle; forefoot adducted, not abducted (likely compensatory change); in flatfoot
with forefoot abduction, line drawn down second MT should transect medial side of apex of calcaneal-talar
angle; further clinical examination showed slight laxity of medial ray (patient had 7 mm of motion in dorsal
translation [10 mm considered lax])
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| Treatment options: difficult to decrease width of forefoot (making first MT parallel to second decreases width by
<5 mm; substantial forefoot adduction (often missed in younger patients) limits extent to which MT can be
shifted over; presence of mild pes planus creates forces that push toe into valgus direction; surgery may not satisfactorily
correct
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| Etiology: in general, women have more tendon laxity, and therefore more likely than men to have wider forefoot
and bunions; speaker considers width of forefoot (not shoe wear) primary factor
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| Surgical outcomes: many patients who have attempted surgical management of hallux valgus dissatisfied; difficult
to correct factors such as laxity of ligaments, wide forefoot, forefoot adductus, and unrealistic expectations of patient;
case example with poor outcome—patient with subtle pes planus and forefoot adduction; surgeon performed
medial-based closing wedge osteotomy; initial surgery did not relieve symptoms (eg, metatarsalgia from shortening
of first MT); second (salvage) surgery involved first metatarsophalangeal (MTP) fusion and shortening osteotomies
of lesser MT
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| Physical factors that determine type of surgery
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| Pronation of first toe: if present, soft tissue release necessary at level of first MTP via scarf procedure or proximal
osteotomy; case example—after previous bunionectomy, patient still has substantial pronation of first toe, requiring
osteotomy to correct; patients who have pain in subtle bunion may have neuritis of dorsal sensory hallucal
nerve; to relieve, decompress nerve, remove bump, and add distal osteotomy
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| Correctability of hallux valgus deformity: if not correctable, evaluate whether deformity congruent; in patient <30
yr of age with shelf of bone, observe distal MT articulating angle; joint may be arthritic or have soft tissue contractures;
surgery more difficult in such patients
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| Type of osteotomy to correct bunion: many (>50) surgical options; important to pay attention to soft tissues;
perform adequate release of sesamoid sling (beneath MT head) to decrease risk for recurrence; correct intermetatarsal
angulation; avoid shortening first MT if possible (if not, shorten lesser MTs at same time); proximal first MT
osteotomy—shown sufficient to stabilize first ray by realigning first MT and sesamoid sling; Lapidus operation—
not indicated for instability of first ray; speaker performs proximal chevron and scarf osteotomies; Lapidus operation
possibly indicated for radiographic instability (although publication reported correction of MT cuneiform instability
after proximal osteotomy); absolutely indicated for midtarsal arthritis
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| Summary of surgical options: distal osteotomy—in cases of minimal soft tissue imbalance, minimal deformity,
and congruent deformities; proximal osteotomy—to balance soft tissues, reduce sesamoid sling, and minimize
shortening of first MT; Lapidus—not indicated for first ray instability alone; consider if radiographic instability
present; use for midtarsal arthritis
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Suggested Reading
Chhaya SA et al: Understanding hallux valgus deformity: what the surgeon wants to know from the conventional radiograph.
Curr Probl Diagn Radiol 37:127, 2008; DeOrio MJ, Easley ME: Surgical strategies: Insertional Achilles tendinopathy.
Foot Ankle Int 29:542, 2008; DiGiovanni CW, Langer P: The role of isolated Gastrocnemius and combined Achilles
contractures in the flatfoot. Foot Ankle Clin 12:363, 2007; Easley ME, Trnka HJ: Current concepts review: hallux valgus
part II operative treatment. Foot Ankle Int 29:464, 2008; Elliot RR, Calder JD: Percutaneous and mini-open repair of acute
Achilles tendon rupture. Foot Ankle Clin 12:573, 2007; Hennessy MS et al: Noninsertional Achilles tendinopathy. Foot
Ankle Clin 12:617, 2007; Jacobs AM: Soft tissue procedures for the stabilization of medial arch pathology in the management
of flexible flatfoot deformity. Clin Podiatr Med Surg 24:687, 2007; Janisse DF, Janisse E: Shoe modification and the use
of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg 16:152, 2008; Kennedy JF, Collumbier
JA: Bunions in Dancers. Clin Sports Med 27:321, 2008; Glasoe W et al: Arch height and first metatarsal joint axis orientation
as related variables in foot structure and function. Foot Ankle Int 29:647, 2008; Lee MS: Medial approach to the severe
valgus foot. Clin Podiatr Med Surg 24:735, 2007; Lipscombe S et al: Scarf osteotomy for the correction of hallux valgus:
midterm clinical outcome. J Foot Ankle Surg 47:273, 2008; Maffulli N, Ajis A: Management of chronic ruptures of the
Achilles tendon. J Bone Joint Surg Am 90:1348, 2008; Marks RM: Midfoot and forefoot issues Cavovarus foot: assessment
and treatment issues. Foot Ankle Clin 13:229, 2008; Marx RC, Mizel MS: What’s new in foot and ankle surgery. J Bone
Joint Surg Am 90:928, 2008; Maskill MP et al: Triple arthrodesis for the adult-acquired flatfoot deformity. Clin Podiatr
Med Surg 24:765, 2008; Meszaros A, Caudell G: The surgical management of equinus in the adult acquired flatfoot. Clin
Podiatr Med Surg 24:667, 2007; Pfeffer GB: The forgotten joints. Am J Orthop 37:241, 2008; Sands AK, Tansey JP:
Lateral column lengthening. Foot Ankle Clin 15:301, 2007; Siapkara A, Duncan R: Congenital talipes equinovarus: a review
of current management. J Bone Joint Surg Br 89:995, 2007.
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