Midfoot & Rearfoot Arthritis (Dikis 2024) PDF

ARTHRITIS OF THE MIDFOOT & REARFOOT Ashley M. Dikis, DPM, FACFAS Assistant Professor College of Podiatric Medicine & Surgery 2 OBJECTIVES » Recognize the clinical presentation and imaging findings of arthritis in the midfoot and rearfoot » Demonstrate knowledge of conservative treatment options for...

ARTHRITIS OF THE MIDFOOT & REARFOOT Ashley M. Dikis, DPM, FACFAS Assistant Professor College of Podiatric Medicine & Surgery 2 OBJECTIVES » Recognize the clinical presentation and imaging findings of arthritis in the midfoot and rearfoot » Demonstrate knowledge of conservative treatment options for arthritis of the midfoot and rearfoot » Demonstrate knowledge of surgical treatment for arthritis of the midfoot and rearfoot 3 Midfoot Tarsometatarsal Intercuneiform Naviculocuneiform 4 Rearfoot AKA Hindfoot Midtarsal » Talonavicular » Calcaneocuboid Subtalar 5 Goals Painless Plantigrade Functional 6 1. Clinical Presentation & Imaging 7 Etiology Degenerative joint disease » Osteoarthritis » Post-traumatic arthritis » Neuropathic arthritis » Rheumatoid arthritis » Tarsal coalition 8 Clinical Presentation » Often history of trauma ⋄ Midfoot – Lisfranc injury ⋄ Rearfoot – Calcaneal fracture » Deep, aching pain » Exacerbated with activity » Nerve impingement ⋄ Osteophytes 9 Clinical Presentation » Pain on palpation » Rigid vs. Flexible ⋄ Pain with range of motion? ⋄ Grinding, clicking, popping, etc.? » Weightbearing and nonweightbearing exam ⋄ Compensation ⋄ Proximal deformity » Gait evaluation 10 Clinical Presentation Midfoot arthritis may lead to rigid flatfoot » Forefoot abduction » Collapse of longitudinal arch of foot » Osteophyte formation ⋄ Difficulty with shoes ⋄ Ulceration 11 Imaging » 3 view foot ⋄ Weightbearing » 3 view ankle ⋄ Weightbearing 12 Imaging Findings: » Joint space narrowing due to loss of articular cartilage » Subchondral sclerosis » Periarticular osteophyte formation » Deformity 2. Nonsurgical Treatment Options 14 Nonsurgical Management Nonsurgical management of some variety should always be attempted » Analgesics » Orthotics/Bracing » Injections 15 Nonsurgical Management » Analgesics » Anti-inflammatories ⋄ Topical ⋄ Diclofenac gel (Voltaren) ⋄ Oral ⋄ OTC vs Rx 16 Nonsurgical Management » Anti-inflammatories ⋄ Diagnostic injection ⋄ Localize joint of concern ⋄ Therapeutic injection ⋄ Improved pain – duration unknown 17 Nonsurgical Management Orthoses » Functional foot orthotic » Ankle Foot Orthoses (AFO) ⋄ Can be particularly useful with multiple joint involvement 3. Surgical Treatment Options 19 Surgical Management Decision driven by » Severity of symptoms » Functional limitations » Overall medical condition » Patient goals 20 Surgical Management Considerations » Degree of arthritis of nearby joints » Presence of knee deformity » Limb length discrepancy 21 Surgical Management » Complications ⋄ Wound healing issues ⋄ Infection ⋄ Peripheral nerve injury ⋄ Malunion/Nonunion ⋄ Neuroma formation ⋄ Hardware failure » Contraindications ⋄ Infection ⋄ Poorly-controlled comorbid conditions 22 Surgical Management Procedure selection » Arthroplasty » Arthrodesis » Arthroscopy 23 Surgical Management Procedure selection » Arthroplasty ⋄ Cheilectomy ⋄ Interpositional arthroplasty ⋄ Anchovy procedure ⋄ Implant » Used in limited scenarios 24 Surgical Management Arthrodesis » Most utilized procedure » Which joints to fuse? » Is deformity correction needed? » In situ 25 Surgical Management Arthrodesis: Midfoot & Midtarsal Joints » Address CORA (Center of Rotation of Angulation) ⋄ Most often the medial column ⋄ The talus-first MT axis needs to be reestablished in both the sagittal and transverse planes 26 27 28 Surgical Management Arthrodesis: Subtalar Joint » Is deformity correction needed? ⋄ Addition of osteotomy » In situ » Anterior, middle and posterior facets 29 Surgical Management » Proximal to distal ⋄ Often begins with addressing equinus deformity ⋄ Gastrocnemius recession or TAL » Consider approach ⋄ Soft tissue ⋄ Fixation construct 30 Surgical Management Incision: Midfoot & Midtarsal Joints » Longitudinal ⋄ 1, 2 or 3 based on number of joints involved ⋄ Consider skin bridges 31 Surgical Management Incision: Subtalar joint » Sinus tarsi approach ⋄ Most commonly used in isolated procedure ⋄ Distal tip of fibula, across sinus tarsi and extending towards the 4th metatarsal base 32 Surgical Management Incision: Subtalar joint » Sinus tarsi approach ⋄ Deep fascia incised along inferior border of EDB muscle belly 33 Surgical Management Incision: Subtalar joint » Sinus tarsi approach ⋄ Joint preparation access ⋄ Maintain normal joint contours 34 Surgical Management Incision: Subtalar joint » Medial approach ⋄ May be used to avoid additional lateral incision if other medial procedures (i.e., talonavicular arthrodesis) are also being performed. 35 Glissan’s Principles of Arthrodesis 1. 2. Complete removal of all cartilage that will prevent contact of the raw bone surfaces Accurate and close fitting of the fusion sites 3. 4. Optimal positioning Maintenance of position until fusion is complete 36 Surgical Management » As with any arthrodesis, joint preparation is key: ⋄ Curettes ⋄ Osteotomes ⋄ Drill 37 Surgical Management Fixation » Midfoot & Midtarsal ⋄ Screws (3.5, 4.0) ⋄ Plates ⋄ Anatomic ⋄ Staples 38 Surgical Management Fixation » Subtalar ⋄ Almost exclusively fixated with screws (6.0, 6.5, 7.0) ⋄ Neutral or slight valgus position ⋄ Varus not well-tolerated 39 Surgical Management Triple arthrodesis » Utilized for variety of foot deformities » Includes fusion of: 1. Talonavicular joint 2. Subtalar joint 3. Calcaneocuboid joint 40 Surgical Management Triple arthrodesis » First popularized by Edwin Ryerson in 1923 » Astion et al. ⋄ 3-D tracking system ⋄ Talonavicular joint has the greatest ROM, and isolated fusion essentially eliminates all motion at remaining two joints 41 Surgical Management Triple arthrodesis » Traditional approach is via two incisions – medial and lateral ⋄ Allows adequate access for joint preparation and reduction » Joint reduction ⋄ Subtalar à Talonavicular à Calcaneocuboid 42 Surgical Management Double arthrodesis » Recent data suggests benefit of double arthrodesis (TN + STJ) ⋄ CC not included unless painful, arthritic or required for deformity correction ⋄ Spares another potential site for complication 43 Surgical Management Double arthrodesis » Can be performed through a single medial incision if needed ⋄ Particularly useful in chronic deformity in which the lateral soft tissue is contracted and wound complication is of concern » Must be cautious with deltoid ligament Surgical Management: Special Considerations 4th and 5th TMT » Treatment of the symptomatic lateral TMT joint » arthritis is challenging ⋄ Mobile joints ⋄ Arthrodesis could lead to non-union, chronic pain and stress fracture ⋄ Several reports of motion sparing procedures like soft tissue interposition and ceramic interposition arthroplasty Utilized more frequently in neuropathic population 44 Surgical Management: Special Considerations Neglected calcaneal fracture » Posterolateral approach » Goal is to regain lost height ⋄ Distraction arthrodesis with graft is typically needed 45 Surgical Management: Special Considerations Neglected calcaneal fracture » Posterolateral approach » Goal is to regain lost height 46 47 Surgical Management » Arthroscopy ⋄ Role of arthroscopy covered in future lecture ⋄ Limited use of arthroscopy in midfoot and forefoot, though some examples exist in literature 48 Surgical Management Postoperative care » Surgeon dependent » For arthrodesis procedures: ⋄ 6-8 weeks NWB in a posterior splint/cast/CAMboot » Additional 4-6 weeks WBAT in CAMboot 49 Summary » History – often recalls trauma » X-rays needed to help confirm diagnosis » Consider nonsurgical options first » Surgical intervention most commonly includes arthrodesis 50 REFERENCES H Kurup & N Vasukutty. Midfoot arthritis- current concepts review. J of Clin Orthop Trauma 11 (2020) 399-405. A Zonno & M Myerson. Surgical Correction of Midfoot Arthritis With and Without Deformity. Foot Ankle Clin N Am 16 (2011) 35–47. Mcglamry's comprehensive textbook of foot and ankle surgery (2020). Shawen et al. Spherical Ceramic Interpositional Arthroplasty for Basal Fourth and Fifth Metatarsal Arthritis. Foot Ankl Int (2007) 896901. D. J. Glissan. The Indications for Inducing Fusion at the Ankle Joint by Operation, with Description of Two Successful Techniques. Australian and New Zealand Journal of Surgery (1949). Grice et al. Efficacy of Foot and Ankle Corticosteroid Injections Foot Ankl Int (2016). 51 THANKS! Any questions? Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. 52 CREDITS Special thanks to all the people who made and released these awesome resources for free: » Presentation template by SlidesCarnival » Photographs by Unsplash