Exostosis and Symptomatic Ossicles of the Foot and Ankle 2024 PDF

Exostosis, and Symptomatic Ossicles of the foot and Ankle John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University 4/9/24 1 objectives Recognize the accessory ossicles and prominences of the foot, symptomatic and asymptomatic. Recognize and apply Conservative measu...

Exostosis, and Symptomatic Ossicles of the foot and Ankle John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University 4/9/24 1 objectives Recognize the accessory ossicles and prominences of the foot, symptomatic and asymptomatic. Recognize and apply Conservative measures and surgical treatments for each given deformity. Medial foot Prominences Soft tissue: bursitis, tendonitis, neuritis, fibroma, granuloma, ganglionic cyst Bone: arthritis, periosteal rxn., osteoma, congenital deformity, pathomechanical deformity MEDIAL ASPECT OF THE FOOT TALAR PROMINENCE Prominence produced by the head of the talus Prominence is exaggerated with stj pronation Prominence is reduced with stj supination NAVICULAR PROMINENCE The prominence is located just distal to a possible talar head prominence, which is virtually unaffected by subtalar joint motion. With or without the presence of an accessory navicular The accessory navicular is the most common accessory ossicle Becomes apparent at age 9-11 radiographically THREE TYPICAL PRESENTATIONS TYPE I: Represents a small ossicle just proximal to the navicular tuberosity, classified as a true sesamoid because it is within the tendon. TYPE II: True accessory scaphoid appears radiographically as an extension of the navicular (its connection to the navicular is represented by a radiolucent zone which measures (1-3 mm.) The zone may be fibrous, cartilaginous, fibrocartilaginous, or partially osseous. TYPE III: Represents a true carnuate navicular or enlarged navicular tuberosity. (May be type II with an osseous bridge.) TREATMENT OF A TALAR PROMINENCE CONSERVATIVE Functional orthoses AFO Shoe modification Steroid injection Steroids Nsaids Surgical Arthrodesis of the subtalar or midtarsal joint or both, tend to be the primary procedure of choice. adjunctive procedures may need to be considered: TN fusion, CC fusion, PCDO TREATMENT FOR NAVICULAR PROMINENCES Conservative initial treatment may consist of immobilization, Nsaids, & non-weight bearing Shoe modification and shielding the prominence If secondary to severe pronation, functional orthosis may reduce symptoms AFO SURGERY FOR TYPE I Involves removal of the ossicle from the tendon which is achieved by: Tendon splitting approach Reflection of the posterior tibialis from the talonavicular joint capsule & then removing the ossicle Fluoroscopy may be warranted SURGERY FOR TYPE II Adequate osseous exposure so that the entire tuberosity is visualized. Radiolucent zone not visualized. Intro-op. (Need to probe the area to find the mobile piece of bone) Use fluoroscopy to isolate location] Excision of the fragment is performed May result in weakening of the tendon and capsule. SURGERY FOR TYPE III Requires talonavicular joint exposure. The subtalar joint should be supinated in order to protect the articular surface of the talar head Resection of the tuberosity is performed following the normal contour of the bone. Boney prominences of the dorsal foot Choparts joint Lesser tarsus -navicular cuneiform joint -tarsometatarsal joint DORSAL BOSSING Dorsal bossing of the 1st tarsometatarsal joint is a common acquired disorder of the foot presentation at the 1st met-cuneiform joint may be a medial or dorsal prominence. May be secondary to hallux limitus or hallux valgus (hypermobility) Another etiological agent may be charcot arthropathy CLASSIFICATION TYPE I: dorsal exostosis formation located at the 1st met. cuneiform. (secondary to intermittent compression of bone) etiology: forefoot valgus plantarflexed 1st ray (flexible or semirigid) TYPE II: characterized by 1st-met cuneiform joint exostosis located circumferentially (dorsal, plantar, medial) associated arthritic component of the joint itself (secondary to a history of trauma) patient may have a history of arthritis. TYPE III: characterized by dorsal exostosis of the 1st met.-cuneiform angular malalignment present: dorsiflexed (tendon imbalance, hallux limitus) plantarflexed (pes cavus) adducted (hallux abducto valgus) TYPE IV: characterized by dorsal exostosis of the 1st met.-cuneiform and involves lis franc’s joint as well. associated arthritis within the tarsometatarsal joint TYPE V: characterized by a pseudo exostosis at the 1st met-cuneiform etiology is (secondary to pes cavus) the position of the forefoot will accentuate the joint. resulting in shoe irritation treatment Conservative -shoe gear modification -orthosis -Nsaids -steroids Surgical -resection of osteophytic changes -Fusion of articular surface if involved Midfoot fusion http://www.aofas.org https://musculoskeletalkey.com 6 months post –op, arthrodesis of the midfoot. https://musculoskeletalkey.com Navicular cuneiform joint prominence treatment Conservative -shoe gear modification -orthosis -Nsaids -steroids Surgical -resection of osteophytic changes -Fusion of articular surface if involved Choparts joint prominence https://www.footeducation.com How should this patient be approached ACCESSORY BONES OF THE FOOT accessory bones of the foot are either normal parts or prominences of the tarsal bones that are abnormally separated from the main structure COMMON SYMPTOMATIC OSSICLES: OS VESALIANUM OS PERONEUS OS TRIGONUM OS TIBIALE EXTERNUM OS VESALIANUM located at the base of the 5th metatarsal. pain is usually characteristic in patients with an extremely large tuberosity in children pain tends to be related to activity in adults pain tends to be related to shoe gear irritation Treatment: -initiate conservative care -surgical intervention Excision of fragment Possible re-attachment of peroneus brevis OS PERONEUS accessory bone located inferior to the peroneal groove of the cuboid. encompassed within the tendon of the peroneus longus Actually considered a sesamoid. Functions to assist movement of the peroneus longus (acts as a fulcrum) Usually is not symptomatic Treatment Excision of ossicle Tendon repair Possible graft Tendon transfer OS TRIGONUM accessory boney process located on the lateral process of the posterior aspect of the talus usually unites or fuses with the talus by age 18 irritation is usually caused by the flexor hallucis longus secondary to prolonged activity, trauma Os Subfibulare Os Subtibiale Accessory Sesamoids Case study 32 year old male presents with a chief complaint of a painful left ankle of 6 months duration. Pmh: Htn, ankle sprains meds: lisinopril, advil NKDA Vasc: dp & pt +2/4 Neuro: epicritic sensation intact Musc: +5/5 extrinsic muscles no talar tilt, no ankle instability Derm: no erythema, +edema lateral ankle Treatment: immobilization in Camboot 4 weeks Nsaids Physical therapy Patient returns 1 year later, with a new injury to the same location. Conservative care initiated, patient unresponsive. Surgical intervention: -removal of accessory ossicle -Brostrom of the lateral ankle CASE #2 47 year old male with a chronic ulcer sub IPJ. Approx. 2cm in diam. PMH: DM w/ neuropathy HTN Hyperlipidemia Radiographs: Demonstrate an accessory ossicle sub IPJ Interphalangeal sesamoid 1 week post op 55 year old female with a malunited medial malleolar ankle fracture with exostosis + Tinel and Valleix sign at medial malleolus along saphenous nerve Case #3 Medial Malleolar Exostosis Exostosis Resected Medial Malleolus Post Exostosis Case #4 Dorsal Medial cuneiform exostosis causing deep peroneal entrapment neuropathy 20 year old healthy female Deep Peroneal Entrapment Deep Peroneal Entrapment Deep Peroneal Entrapment Case #5 45 year old male with painful neuritis to hallux due to hallux exostosis