The hindfoot and ankle

The hindfoot and ankle

Ankle arthritis The definitive operative treatment for arthritis of the ankle will usually be in the form of total ankle replacement (TAR) or - more commonly arthrodesis (fusion); the latter is often carried - out via an open approach but arthroscopic techniques have better outcomes, more rapid recovery and fewer complica - tions and almost all surgical units in the UK now o ff er such techniques. Such techniques are mandatory in the presence of a poor soft-tissue envelope or in the presence of a clotting diathesis. A UK national trial is cur rently under way to evaluate the relative outcomes of TAR versus arthrodesis (the TAR V A trial), which are as yet undefined; the trial has been complicated fur - ther by the withdrawal/failure of the two leading implants. The advantage of fusion is that it has a known track record, good outcomes (over 90% of patients do well) and minimal morbidity , especially with modern arthroscopic techniques, but not all do well with fusion. Function following isolated fusion is virtually normal f or most patients and this is probably due to increased mobility at other joints. However, this may precipi - tate arthralgia elsewhere. TARs were until recently three-component devices (except in the USA) but a two-component device is now the market leader in the UK by far. It is not yet known if this is relevant - but allows an easier regula tory pathway in the USA. Outcomes instrumentation may be a key factor; custom implants based on preoperative computed tomography (CT) scans are becoming mainstream. TARs allow preservation of joint mobility but at the expense of larger incisions and possible eventual failure. Revision rates of <1% to 7% per annum are reported, with most showing an approximately 3% failure rate per year. Sur vivorship analysis does not record patients who are doing badly but who do not have further surgery and a recent paper showed revisions are under-reported. The c hanges in the regulatory pathways in the UK/European Union relating to the develop ment of new implants may limit the development of TARs in these regions to the same levels of e ffi cacy seen by total hip replacements and total knee replacements. Hindfoot (excluding ankle) arthritis The triple complex refers to the subtalar (talocalcaneal), calcaneocuboid and talonavicular joints. These joints are often a ff ected by arthritis. Treatment options are limited and, if simple measures have failed, a fusion should be performed. Smokers and patients with diabetes have a massively increased non-union rate for all foot fusion procedures and should be warned of this when they give consent. Late presentation of coalitions usually requires fusion. Ankle combined with other hindfoot arthritis If surgical input is required, one option is to treat one set of joints and then see how the patient fares. For example, o ff er the patient an ankle fusion or replacement and then assess the outcome. Secondary surgery to the other joints can then be performed if required. The alternative is to treat all joints at once. The non-union rates of the ankle following a subtalar fusion or vice versa are high (up to 75%). For this reason, some clinicians advise TAR, not ankle fusion, following a previous subtalar/triple fusion. Modern techniques now use third-generation hindfoot fusion nails that fuse both the ankle and subtalar joints. These are inserted with an open or arthroscopic fusion technique. A pantalar fusion is quite disabling but may be necessary in patients with rheumatoid arthritis or with defor mities/stress fractures and in those with a failed arthroplasty with subtalar joint involvement, pantalar arthritis or A VN with collapse of the talus. Summary box 41.6 Midfoot and hindfoot /uni25CF /uni25CF /uni25CF /uni25CF Alan W Fowler , 1920–2013, orthopaedic surgeon, Bridgend Hospital, UK. The early presentations of rheumatological disease may include synovitis of the lesser MTP joints and widespread small joint disease, often in association with enthesopathy such as plantar fasciitis or Achilles tendinosis. However, the classic deformity is of hallux valgus with or without hallux rigidus deformity and - subluxation or even dislocation of the lesser MTP joints in the forefoot and arthritis and deformity in the mid/hindfoot. The patient may present with a bunion and prominent lesser metatarsal heads, which can often be felt to be dislo - - cated on clinical examination and are painful to palpation. Joint-sparing surgery is preferr ed, with preservation of the metatarsal heads if possible, often shortening and reloca ting the MTP joints. Destruction of the joints can be treated with proximal phalangeal partial excisions. Fusion of the first MTP joint is the usual requirement. Late recurrence can be man - aged with excision arthroplasty . Excision of the metatarsal heads produces an almost instan - taneous and gratifying relief of pain. If a plantar approach is used an ellipse of skin can be excised to move the metatarsal padding back over the end of the metatarsal. While most sur - geons avoid scar s on the plantar aspect of the foot wherever possible, this is one procedure where the results are good. How - ever, such surgery lea ves no room for revision in later years. The requirement for rheumatoid forefoot correction has fallen dramatically in the last 20 years with the advent of disease-modifying drugs; most trainee surgeons will now have never seen a Fowler’s procedure (or similar), whic h was once a mainstream and common procedure. Midfoot Rheumatological disease may also a ff ect the midfoot and here the outcome is usually just pain and sti ff ness. Options are limited to injections and fusion surgery if non-operative measures have failed. Hindfoot and ankle Rheumatological disease also a ff ects the hindfoot and ankle. Many patients require surgical hindfoot fusions and the options for the ankle are discussed in Ankle arthritis . Outcomes of TAR are favourable in patients with rheumatoid arthritis, although increased deformities may make the outcomes less predictable. The rheumatological diseases also a ff ect soft tissues. Patients are more prone to developing enthesopathy , tendinitis and tendinosis, and even tendon rupture. The Ac hilles tendon should never be injected with steroid for fear of rupture; simi - larly , the tibialis anterior and tibialis posterior tendons are risky for injection.

Joint disorders are degenerative or in /f_l ammatory The mainstay of surgical treatment remains fusion, although ankle replacements are becoming more successful Rheumatoid arthritis must be medically controlled as well as possible before surgery Knee deformities should be corrected before tackling foot problems

The hindfoot and ankle

Ankle arthritis The definitive operative treatment for arthritis of the ankle will usually be in the form of total ankle replacement (TAR) or - more commonly arthrodesis (fusion); the latter is often carried - out via an open approach but arthroscopic techniques have better outcomes, more rapid recovery and fewer complica - tions and almost all surgical units in the UK now o ff er such techniques. Such techniques are mandatory in the presence of a poor soft-tissue envelope or in the presence of a clotting diathesis. A UK national trial is cur rently under way to evaluate the relative outcomes of TAR versus arthrodesis (the TAR V A trial), which are as yet undefined; the trial has been complicated fur - ther by the withdrawal/failure of the two leading implants. The advantage of fusion is that it has a known track record, good outcomes (over 90% of patients do well) and minimal morbidity , especially with modern arthroscopic techniques, but not all do well with fusion. Function following isolated fusion is virtually normal f or most patients and this is probably due to increased mobility at other joints. However, this may precipi - tate arthralgia elsewhere. TARs were until recently three-component devices (except in the USA) but a two-component device is now the market leader in the UK by far. It is not yet known if this is relevant - but allows an easier regula tory pathway in the USA. Outcomes instrumentation may be a key factor; custom implants based on preoperative computed tomography (CT) scans are becoming mainstream. TARs allow preservation of joint mobility but at the expense of larger incisions and possible eventual failure. Revision rates of <1% to 7% per annum are reported, with most showing an approximately 3% failure rate per year. Sur vivorship analysis does not record patients who are doing badly but who do not have further surgery and a recent paper showed revisions are under-reported. The c hanges in the regulatory pathways in the UK/European Union relating to the develop ment of new implants may limit the development of TARs in these regions to the same levels of e ffi cacy seen by total hip replacements and total knee replacements. Hindfoot (excluding ankle) arthritis The triple complex refers to the subtalar (talocalcaneal), calcaneocuboid and talonavicular joints. These joints are often a ff ected by arthritis. Treatment options are limited and, if simple measures have failed, a fusion should be performed. Smokers and patients with diabetes have a massively increased non-union rate for all foot fusion procedures and should be warned of this when they give consent. Late presentation of coalitions usually requires fusion. Ankle combined with other hindfoot arthritis If surgical input is required, one option is to treat one set of joints and then see how the patient fares. For example, o ff er the patient an ankle fusion or replacement and then assess the outcome. Secondary surgery to the other joints can then be performed if required. The alternative is to treat all joints at once. The non-union rates of the ankle following a subtalar fusion or vice versa are high (up to 75%). For this reason, some clinicians advise TAR, not ankle fusion, following a previous subtalar/triple fusion. Modern techniques now use third-generation hindfoot fusion nails that fuse both the ankle and subtalar joints. These are inserted with an open or arthroscopic fusion technique. A pantalar fusion is quite disabling but may be necessary in patients with rheumatoid arthritis or with defor mities/stress fractures and in those with a failed arthroplasty with subtalar joint involvement, pantalar arthritis or A VN with collapse of the talus. Summary box 41.6 Midfoot and hindfoot /uni25CF /uni25CF /uni25CF /uni25CF Alan W Fowler , 1920–2013, orthopaedic surgeon, Bridgend Hospital, UK. The early presentations of rheumatological disease may include synovitis of the lesser MTP joints and widespread small joint disease, often in association with enthesopathy such as plantar fasciitis or Achilles tendinosis. However, the classic deformity is of hallux valgus with or without hallux rigidus deformity and - subluxation or even dislocation of the lesser MTP joints in the forefoot and arthritis and deformity in the mid/hindfoot. The patient may present with a bunion and prominent lesser metatarsal heads, which can often be felt to be dislo - - cated on clinical examination and are painful to palpation. Joint-sparing surgery is preferr ed, with preservation of the metatarsal heads if possible, often shortening and reloca ting the MTP joints. Destruction of the joints can be treated with proximal phalangeal partial excisions. Fusion of the first MTP joint is the usual requirement. Late recurrence can be man - aged with excision arthroplasty . Excision of the metatarsal heads produces an almost instan - taneous and gratifying relief of pain. If a plantar approach is used an ellipse of skin can be excised to move the metatarsal padding back over the end of the metatarsal. While most sur - geons avoid scar s on the plantar aspect of the foot wherever possible, this is one procedure where the results are good. How - ever, such surgery lea ves no room for revision in later years. The requirement for rheumatoid forefoot correction has fallen dramatically in the last 20 years with the advent of disease-modifying drugs; most trainee surgeons will now have never seen a Fowler’s procedure (or similar), whic h was once a mainstream and common procedure. Midfoot Rheumatological disease may also a ff ect the midfoot and here the outcome is usually just pain and sti ff ness. Options are limited to injections and fusion surgery if non-operative measures have failed. Hindfoot and ankle Rheumatological disease also a ff ects the hindfoot and ankle. Many patients require surgical hindfoot fusions and the options for the ankle are discussed in Ankle arthritis . Outcomes of TAR are favourable in patients with rheumatoid arthritis, although increased deformities may make the outcomes less predictable. The rheumatological diseases also a ff ect soft tissues. Patients are more prone to developing enthesopathy , tendinitis and tendinosis, and even tendon rupture. The Ac hilles tendon should never be injected with steroid for fear of rupture; simi - larly , the tibialis anterior and tibialis posterior tendons are risky for injection.

Joint disorders are degenerative or in /f_l ammatory The mainstay of surgical treatment remains fusion, although ankle replacements are becoming more successful Rheumatoid arthritis must be medically controlled as well as possible before surgery Knee deformities should be corrected before tackling foot problems

The hindfoot and ankle

Ankle arthritis The definitive operative treatment for arthritis of the ankle will usually be in the form of total ankle replacement (TAR) or - more commonly arthrodesis (fusion); the latter is often carried - out via an open approach but arthroscopic techniques have better outcomes, more rapid recovery and fewer complica - tions and almost all surgical units in the UK now o ff er such techniques. Such techniques are mandatory in the presence of a poor soft-tissue envelope or in the presence of a clotting diathesis. A UK national trial is cur rently under way to evaluate the relative outcomes of TAR versus arthrodesis (the TAR V A trial), which are as yet undefined; the trial has been complicated fur - ther by the withdrawal/failure of the two leading implants. The advantage of fusion is that it has a known track record, good outcomes (over 90% of patients do well) and minimal morbidity , especially with modern arthroscopic techniques, but not all do well with fusion. Function following isolated fusion is virtually normal f or most patients and this is probably due to increased mobility at other joints. However, this may precipi - tate arthralgia elsewhere. TARs were until recently three-component devices (except in the USA) but a two-component device is now the market leader in the UK by far. It is not yet known if this is relevant - but allows an easier regula tory pathway in the USA. Outcomes instrumentation may be a key factor; custom implants based on preoperative computed tomography (CT) scans are becoming mainstream. TARs allow preservation of joint mobility but at the expense of larger incisions and possible eventual failure. Revision rates of <1% to 7% per annum are reported, with most showing an approximately 3% failure rate per year. Sur vivorship analysis does not record patients who are doing badly but who do not have further surgery and a recent paper showed revisions are under-reported. The c hanges in the regulatory pathways in the UK/European Union relating to the develop ment of new implants may limit the development of TARs in these regions to the same levels of e ffi cacy seen by total hip replacements and total knee replacements. Hindfoot (excluding ankle) arthritis The triple complex refers to the subtalar (talocalcaneal), calcaneocuboid and talonavicular joints. These joints are often a ff ected by arthritis. Treatment options are limited and, if simple measures have failed, a fusion should be performed. Smokers and patients with diabetes have a massively increased non-union rate for all foot fusion procedures and should be warned of this when they give consent. Late presentation of coalitions usually requires fusion. Ankle combined with other hindfoot arthritis If surgical input is required, one option is to treat one set of joints and then see how the patient fares. For example, o ff er the patient an ankle fusion or replacement and then assess the outcome. Secondary surgery to the other joints can then be performed if required. The alternative is to treat all joints at once. The non-union rates of the ankle following a subtalar fusion or vice versa are high (up to 75%). For this reason, some clinicians advise TAR, not ankle fusion, following a previous subtalar/triple fusion. Modern techniques now use third-generation hindfoot fusion nails that fuse both the ankle and subtalar joints. These are inserted with an open or arthroscopic fusion technique. A pantalar fusion is quite disabling but may be necessary in patients with rheumatoid arthritis or with defor mities/stress fractures and in those with a failed arthroplasty with subtalar joint involvement, pantalar arthritis or A VN with collapse of the talus. Summary box 41.6 Midfoot and hindfoot /uni25CF /uni25CF /uni25CF /uni25CF Alan W Fowler , 1920–2013, orthopaedic surgeon, Bridgend Hospital, UK. The early presentations of rheumatological disease may include synovitis of the lesser MTP joints and widespread small joint disease, often in association with enthesopathy such as plantar fasciitis or Achilles tendinosis. However, the classic deformity is of hallux valgus with or without hallux rigidus deformity and - subluxation or even dislocation of the lesser MTP joints in the forefoot and arthritis and deformity in the mid/hindfoot. The patient may present with a bunion and prominent lesser metatarsal heads, which can often be felt to be dislo - - cated on clinical examination and are painful to palpation. Joint-sparing surgery is preferr ed, with preservation of the metatarsal heads if possible, often shortening and reloca ting the MTP joints. Destruction of the joints can be treated with proximal phalangeal partial excisions. Fusion of the first MTP joint is the usual requirement. Late recurrence can be man - aged with excision arthroplasty . Excision of the metatarsal heads produces an almost instan - taneous and gratifying relief of pain. If a plantar approach is used an ellipse of skin can be excised to move the metatarsal padding back over the end of the metatarsal. While most sur - geons avoid scar s on the plantar aspect of the foot wherever possible, this is one procedure where the results are good. How - ever, such surgery lea ves no room for revision in later years. The requirement for rheumatoid forefoot correction has fallen dramatically in the last 20 years with the advent of disease-modifying drugs; most trainee surgeons will now have never seen a Fowler’s procedure (or similar), whic h was once a mainstream and common procedure. Midfoot Rheumatological disease may also a ff ect the midfoot and here the outcome is usually just pain and sti ff ness. Options are limited to injections and fusion surgery if non-operative measures have failed. Hindfoot and ankle Rheumatological disease also a ff ects the hindfoot and ankle. Many patients require surgical hindfoot fusions and the options for the ankle are discussed in Ankle arthritis . Outcomes of TAR are favourable in patients with rheumatoid arthritis, although increased deformities may make the outcomes less predictable. The rheumatological diseases also a ff ect soft tissues. Patients are more prone to developing enthesopathy , tendinitis and tendinosis, and even tendon rupture. The Ac hilles tendon should never be injected with steroid for fear of rupture; simi - larly , the tibialis anterior and tibialis posterior tendons are risky for injection.

Joint disorders are degenerative or in /f_l ammatory The mainstay of surgical treatment remains fusion, although ankle replacements are becoming more successful Rheumatoid arthritis must be medically controlled as well as possible before surgery Knee deformities should be corrected before tackling foot problems