Brostrom repair

[sinustarsi]

How many of you guys correct forefoot valgus flexible for lateral ankle instability while doing brostrom? Brostrom have high success rate but what happens if you dont address the hindfoot varus dependent on the forefoot? What's the literature guide line? Also, what about plantar fasciitis and tarsal tunnel syndrome together. Pain in plantar medial calc/arch with early am pain and also with tarsal tunnel syndrome(no soft tissue mass or hindfoot abnormalities/equinus). Beside inserts/therapy and nsaids/shots, do you recommend sx? How often do these symptoms exist together and often misdiagnosed? Thanks

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[347932]

How many of you guys correct forefoot valgus flexible for lateral ankle instability while doing brostrom? Brostrom have high success rate but what happens if you dont address the hindfoot varus dependent on the forefoot? What's the literature guide line?

Lateral Ankle Instability can occur for more reasons than just Forefoot Valgus. I see it mostly from trauma that results in an instance of a damaged ATFL, which then causes the chronicity of the problem. I'm not one of those guys that "sells" complex procedures to "correct" these types of things. I attempt to correct what the patient's primary complaint is and then manage the foot type with custom orthotics, and this has served me very well. Especially with a flexible foot type, why not try something a little more conservative with the foot type, rather than "marry" your patient by performing a complex procedure.
Also, I haven't done the Brostrom procedure in years unless it's a full on blow out, stage 3 sprain which is rare in my experience. I fix the ATFL arthroscopically with thermocapsular shrinkage, and my patients are back on their feet in 2 weeks and seem to do wonderfully well.

Also, what about plantar fasciitis and tarsal tunnel syndrome together. Pain in plantar medial calc/arch with early am pain and also with tarsal tunnel syndrome(no soft tissue mass or hindfoot abnormalities/equinus). Beside inserts/therapy and nsaids/shots, do you recommend sx? How often do these symptoms exist together and often misdiagnosed? Thanks

I don't see these two pathologies together. Generally if there is a plantar fascial problem, there might be a nerve impingement, but not at the level of the Tarsal Tunnel, more at the level of Baxter's Nerve. I believe the literature says that if you are treating a plantar fascial problem for more than 6 months with no resolution you should explore the possibility of Tarsal Tunnel Syndrome. I don't wait that long. I'll usually get an NCV test (which isn't terribly accurate but MIGHT give you some information) within one month if the patient says none of the usual treatments are working at all. Tarsal Tunnel vs. Plantar Fasciitis can be a tricky affair and sometimes it can be an "intuition" type of situation.

In my experience, plantar fasciitis rarely needs surgery. I think that it is probably the most common pathology I see in the office and if I've done more than 6 partial plantar fasciotomies in the ten years I've been out I'd be surprised. IF the patient is compliant and they come to you in a reasonable amount of time from when the problem starts, we have so many conservative tools at our disposal that it's rare patients will end up in the OR (unless they really are very non-compliant and then do you really want to be doing surgery on them?). Conversely, with Tarsal Tunnel Syndrome, my experience has been that if they don't respond to injections they almost always end up in the OR for a decompression, which is not a fun recovery for them (again one of those "marry" your patient situations).

 

[PADPM]

I'm not sure my clinical experience has paralleled Kidsfeet's. I treat a very large number of patients with heel pain on a weekly (and daily) basis. I would agree that many patients are often misdiagnosed as having plantar fasciitis when in fact the patient has an entrapment neuropathy. I have also treated many patients who have been misdiagnosed with PF who have posterior tibial tendon dysfunction.

However, I have seen many patients who have a combination of plantar fasciitis with classic post static dyskinesia, etc., etc., and symptoms of nerve entrapment with burning/shooting pains and pain with percussion and palpation of the tarsal tunnel.

Plantar fasciitis will rarely cause burning or shooting pain, and nerve entrapments will usually not cause post static dyskinesia. But I HAVE seen these two together many times and I believe when they exist together it's most often caused by biomechanical faults.

I agree with Kidsfeet that I believe that surgical intervention is VERY rarely indicated for plantar fasciitis. There are so many excellent conservative options available, if one of my patients fails conservative care I investigate other causes such as nerve entrapment, metabolic issues (thyroid), rheumatologic causes (Reiters, ankylosing spondylitis, etc.) or back/spine pathology/radiculopathy, partial tear of the fascia and/or calcaneal stress fracture.

My feeling about tarsal tunnel syndrome is that once again, I attempt ALL conservative care and make every attempt to avoid surgical intervention. I don't put a lot of weight in EMG/NCV's, since they will often be negative even if a TTS exists. These tests will often be negative unless there is actual Wallerian degeneration of the nerve. So although it is great if the results are positive, if the results are negative, you have to make a clinical judgement.

The reason I make EVERY attempt to avoid surgery is simple. Although I have fortunately have had success performing this surgery, I have been very select with my patient population. But I have treated many failed cases and in my experience treating a lot of patients who have had this procedure performed, the results usually turn out one of two way;

1) The patient gets complete relief or almost complete relief

2) The patient has horrible recurrent pain forever

There is rarely a patient who does "a little better" or "moderately better". They usually do great or horrible. And re-doing TTS surgery is another nightmare.......

So, plantar fascia surgery is one I avoid because I simply believe conservative care works the vast majority of the time, and TTS surgery is one I avoid if possible because the potential outcome can be a nightmare, though I've been lucky........so far.

 

[Feli]

I don't have the exp of the two posters above, but I read a bit on the path/surg/evidence, do a lot of OR cases, etc... so, fwiw, I guess what makes sense to me is:

-Brostrom +/- reverse Kouts calc osteotomy = money for hindfoot valgus with recurrent invert sprains/instability.

-Posterior lengthening, realign STJ desis (or MBA if flexible... rare in adults) +/- some medial column work (PT repair, FDL xfer, Lapidus or NC or TN desis, etc) is a decent option for valgus + fasciitis.

 

[347932]

I don't have the exp of the two posters above, but I read a bit on the path/surg/evidence, do a lot of OR cases, etc... so, fwiw, I guess what makes sense to me is:

-Brostrom +/- reverse Kouts calc osteotomy = money for hindfoot valgus with recurrent invert sprains/instability.

-Posterior lengthening, realign STJ desis (or MBA if flexible... rare in adults) +/- some medial column work (PT repair, FDL xfer, Lapidus or NC or TN desis, etc) is a decent option for valgus + fasciitis.

This is what I mean about "selling" complex procedures. I realize this was more of an academic exercise, but in my residency I saw this much to often.

A patient came in with what I would consider a relatively simple issue, like a new, very recent onset of Plantar Fasciitis and next thing you know, they're booked in the OR for a "slam" as we used to call it. I guess I function with the KISS mentality, and so far, I haven't really hit too many roadblocks. Turning the simple into the complex is not my style. I would even venture to say that doing what you proposed for a valgus foot type who presents with ONLY plantar fasciitis is a sure to way to end up "marrying" your patient. If they have other foot complaints that are directly related to the foot type...I'm all for it, but especially with a somewhat flexible foot and ONLY Plantar Fasciitis, why the complex case?

Some of the literature points to the issue of mechanoreceptor break down once a single ankle sprain occurs, which then leads to recurrence. I've would say that it is VERY rare to see an isolated RF varus foot type causing recalcitrant ankle sprains. I think I've seen that twice in my career so far and they did respond very well to the reverse Kouts. Otherwise, as I've said, the arthroscopic soft tissue repair does wonders if done correctly and if the patient is compliant. Then deal with the foot type conservatively with custom orthotics. This has achieved the desired result in even the most elite college athletes. That being said, if there are issues with a rigid foot type that causes the recalcitrant sprain AND the mechanoreceptor issue, then, once again, I'm all for the complex recon, but so far in my career, this presentation is exceedingly rare. I've done with good success, but it is a long recovery for the patient, both immediately post operatively and also rehabilitation wise.

 

[Feli]

This is what I mean about "selling" complex procedures. I realize this was more of an academic exercise, but in my residency I saw this much to often.

...Turning the simple into the complex is not my style. I would even venture to say that doing what you proposed for a valgus foot type who presents with ONLY plantar fasciitis is a sure to way to end up "marrying" your patient....

...as I've said, the arthroscopic soft tissue repair does wonders if done correctly and if the patient is compliant. Then deal with the foot type conservatively with custom orthotics. This has achieved the desired result in even the most elite college athletes. That being said, if there are issues with a rigid foot type that causes the recalcitrant sprain AND the mechanoreceptor issue, then, once again, I'm all for the complex recon, but so far in my career, this presentation is exceedingly rare. I've done with good success, but it is a long recovery for the patient, both immediately post operatively and also rehabilitation wise.

You make good points. I think the key is really presenting the options well, and then understanding what the patient wants and needs (and what kind of mental/physical surg compliance candidate they are)?

Sure, an orthotic will help to prevent sprains if worn during basketball games, but aside from the fact that deformities are usually progressive, what about going down hotel stairs in flip flops during spring break or dancing at a wedding in dress shoes? They'd still be at risk for ankle sprains. It's a tough issue... surg cost + convalescence/risks versus a ton of out-of-pocket cost for multiple orthoses? There's no easy answer.

Additionally, just because you never see or hear from the patient again (after offering surg, doing surg + follow up, or after providing conservative treatment), that sure doesn't mean everything turned out roses... there are other area F&A providers they may have gone to if they didn't get the answers or result they were seeking. You never know. All you can do is offer the best options and treat them well. It's ultimately their body, their choice.