practice case(s)

[heybrother]

The 1st MPJ and the Strayer

This patient is a 40ish year old woman. She is Spanish speaking only. She had surgery essentially a year ago and she is not very happy. She has 2 problems.

Problem #1 - She's very unhappy about her fusion. X-rays provided. How would you interpret her X-rays? Is she fused? She's in pain - where do you think that pain would be? Is there a surgery that can correct this problem? The tissue over the incision site is questionable - is there a non-surgical offloading strategy that could be employed?

Problem #2 - She had an endoscopic gastrocnemius recession. She hurts at both portals and has radiating posterior nerve pain in the distribution of the sural nerve. Ankle dorsiflexion ROM is adequate. No posterior "divet" (Not sure if this is something other people have experienced - I've personally seen a few endoscopic gastrocnemius recessions which are essentially Strayers in which the patient has an enormous divet/canyon/drop off on their posterior leg).

Tell me things.

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[heybrother]

The Bunion King of the Northeast

You are a young, brash podiatrist trying to make a name for yourself in the northeast, probably in NY. This patient presents to you and hangs on your every word. They love your framed Podiatry News article in which you were cited for your expertise in recognizing the dangers of flips flops in the summer. After perusing your shoe carousel, promotions on Balance Braces, and pharmacopia of nail antifungals and CBD creams they relate that they need their bunion fixed. Their former podiatrist was sure he could get it right the 3rd time around, but he left to practice at a VA to avoid the terrible malpractice environment that is destroying medicine in this country. After explaining to her that most young podiatrists have no understanding of biomechanics you assure her that you will fix this problem easily with a custom orthotic and a small surgical procedure. After all you explain, you are certified by numerous prestigious podiatry surgical boards.

What surgery do you offer the patient::

(a) 1st MPJ fusion, but you warn her its a really bad procedure and she may have difficulty walking afterwards. She probably won't even be able to ever jog or run again. She'll need to be NWB for weeks and they non-union a lot. You have a specific vitamin prescription from a pharmacy you work with that isn't in town that she'll need to ensure a good outcome. Its kind of expensive though, but don't worry - your insurance will pay most of it.
(b) Plain old McBride baby. Just loosen that joint up and get the toe back where it needs to be. You caution the patient to make sure all the tapings and bracings and strapping stay in place (and they'll need to be reapplied regularly) because if anything goes wrong or your resident puts the dressing on wrong the bunion could recur.
(c) Reverse Austin, Reverse Akin. This is no different than how we treat a valgus deformity. As a trained podiatrist you recognize that most bunions have an osseous component and once we rebalance the bone back under the toe appropriately the toe will return to its intended position.
(d) Reverse lapidus with frontal plane correction to get the sesamoids back under the 1st ray.
(e) One of the above + Hardware removal. We need to get those old screws out because obviously they could cause metal poisoning.

Ok - that was all for fun above. If you don't get it - wait a few years.
What surgery would you do? What are reasonable outcomes of the procedure you select?)

 

[heybrother]

I had Clubfoot Surgery as a Kid

The patient is young - between 18 and 30. He had clubfoot surgery as a child. I have no access to his prior records. He has a great blue collar job and he was promoted to a roll with a lot more activity, walking, lifting - unfortunately, this has made his pain much more difficult to manage. Obese, no other significant comorbidities. Pain is essentially - the medial foot - posterior tibial tendon, soft tissue/ligaments/capsule of TN joint, spring ligament, medial arch. No sinus tarsi pain or lateral pain. No ankle pain. TN joint is non-reducible but there's still some rearfoot motion/eversion. Pretty significant equinus. They believe he did have a TAL as a child. No dorsiflexion at the 1st MPJ.

(a) Surgical recommendations?
(b) Conservative therapy?
(c) What are the implications of surgery in a young patient?
(d) What sort of time table are we looking at - does this patient require a procedure urgently or at their discretion?
(e) Is he causing arthritis and injury to his foot by continuing to walk?
(f) What is the likelihood this patient will continue to have more surgery in the future?

 

[ldsrmdude]

I am disappointed in our students/residents. These are some great cases that @heybrother wrote up and no one comments or tries answering the questions? These are the kind of cases you'll probably like during rotations/residency because they're not just straight-forward typical cases, and this is how they'll present. Any takers?

 

[heybrother]

They just need more cowbell... err cases!

He's having some trouble on the court

This patient is between 10 and 15 years old. He's a perfectly nice young man who presents in the company of his father. No comorbidities. Plays sports. Active. Over the last few months his father has become concerned that he's having difficulty keeping up in sports. Also has concerns about the shape of his feet. Patient denies pain, but he has trouble finishing a basketball game. That's the past few months though. Something new is up. Over the last week he's begun experiencing swelling to the right foot. Side by side the right is more swollen. He denies pain unless he's running or jumping. No history of injury, fall, twist. No erythema or warmth.

Some mild tenderness over the 1-3rd tarsometatarsal joints - in the sense that this is where the pain would be. No obvious clinical instability. Mild discomfort with stress/"piano keying" of joints. Foot is freely mobile. As for the rest, seems like me describing the foot would just take the fun out of it! It looks like the X-ray. Stands like the X-ray.

Stepping back from our young man
-What is the expected alignment of the tarsometatarsal joints
-You are examining a patient in your office who has midfoot pain, swelling, some sort of injury and the radiographs are not conclusive - what are 2 additional films you can capture that can provide valuable information?

Focusing more on our chronic problem
-What are surgical and non-surgical considerations for the patient?
-When does such a patient warrant non-surgical treatment? Surgical treatment?
-What if we he came in and said it didn't hurt at all and he just wondered - how is my kid's foot going to turn out?
-I've given a spectrum of ages for the patient - is there an ideal time frame? Does the age of the patient change your considerations?

More basic
-Just read the X-ray.
-Describe the foot

 

[Podstar]

The Bunion King of the Northeast

You are a young, brash podiatrist trying to make a name for yourself in the northeast, probably in NY. This patient presents to you and hangs on your every word. They love your framed Podiatry News article in which you were cited for your expertise in recognizing the dangers of flips flops in the summer. After perusing your shoe carousel, promotions on Balance Braces, and pharmacopia of nail antifungals and CBD creams they relate that they need their bunion fixed. Their former podiatrist was sure he could get it right the 3rd time around, but he left to practice at a VA to avoid the terrible malpractice environment that is destroying medicine in this country. After explaining to her that most young podiatrists have no understanding of biomechanics you assure her that you will fix this problem easily with a custom orthotic and a small surgical procedure. After all you explain, you are certified by numerous prestigious podiatry surgical boards.

What surgery do you offer the patient::

(a) 1st MPJ fusion, but you warn her its a really bad procedure and she may have difficulty walking afterwards. She probably won't even be able to ever jog or run again. She'll need to be NWB for weeks and they non-union a lot. You have a specific vitamin prescription from a pharmacy you work with that isn't in town that she'll need to ensure a good outcome. Its kind of expensive though, but don't worry - your insurance will pay most of it.
(b) Plain old McBride baby. Just loosen that joint up and get the toe back where it needs to be. You caution the patient to make sure all the tapings and bracings and strapping stay in place (and they'll need to be reapplied regularly) because if anything goes wrong or your resident puts the dressing on wrong the bunion could recur.
(c) Reverse Austin, Reverse Akin. This is no different than how we treat a valgus deformity. As a trained podiatrist you recognize that most bunions have an osseous component and once we rebalance the bone back under the toe appropriately the toe will return to its intended position.
(d) Reverse lapidus with frontal plane correction to get the sesamoids back under the 1st ray.
(e) One of the above + Hardware removal. We need to get those old screws out because obviously they could cause metal poisoning.

Ok - that was all for fun above. If you don't get it - wait a few years.
What surgery would you do? What are reasonable outcomes of the procedure you select?)

That is a hell of a hallux varus. After two failed surgeries, 1st MPJ arthrodesis is the best option here. The bone stock is probably shot after two failed procedures so any other bone or length compromising procedure would be incredibly risky. I would go with 1st MPJ fusion and would be ready to use a calcaneal autograft if necessary.

 

[Podstar]

They just need more cowbell... err cases!

He's having some trouble on the court

This patient is between 10 and 15 years old. He's a perfectly nice young man who presents in the company of his father. No comorbidities. Plays sports. Active. Over the last few months his father has become concerned that he's having difficulty keeping up in sports. Also has concerns about the shape of his feet. Patient denies pain, but he has trouble finishing a basketball game. That's the past few months though. Something new is up. Over the last week he's begun experiencing swelling to the right foot. Side by side the right is more swollen. He denies pain unless he's running or jumping. No history of injury, fall, twist. No erythema or warmth.

Some mild tenderness over the 1-3rd tarsometatarsal joints - in the sense that this is where the pain would be. No obvious clinical instability. Mild discomfort with stress/"piano keying" of joints. Foot is freely mobile. As for the rest, seems like me describing the foot would just take the fun out of it! It looks like the X-ray. Stands like the X-ray.

Stepping back from our young man
-What is the expected alignment of the tarsometatarsal joints
-You are examining a patient in your office who has midfoot pain, swelling, some sort of injury and the radiographs are not conclusive - what are 2 additional films you can capture that can provide valuable information?

Focusing more on our chronic problem
-What are surgical and non-surgical considerations for the patient?
-When does such a patient warrant non-surgical treatment? Surgical treatment?
-What if we he came in and said it didn't hurt at all and he just wondered - how is my kid's foot going to turn out?
-I've given a spectrum of ages for the patient - is there an ideal time frame? Does the age of the patient change your considerations?

More basic
-Just read the X-ray.
-Describe the foot

The x-rays indicate pes planus which would account for him not being able to keep up with his peers and in sports. If the patient is not having pain with his pes planus I would stick with conservative treatment, if any at all, through orthotics, bracing, and shoe modifications. If he is having chronic pain that is bothering him then I would consider surgery such as a medial displacement calcaneal osteotomy, lateral calcaneal lengthening osteotomy, or maybe an arthroereisis (however there is a high complication rate reported up to 18%). I would stay away from fusion in this young of a patient as they would end up with proximal and distal arthritis and you could always fuse them later on if necessary. Ideally you would want the growth plates to be closed before doing surgery.

Pain with stress/piano keying indicates a TMTJ injury.

I'll leave it at this because my experience with mid and hindfoot is for the most part nonexistent at this point.

 

[Podstar]

The 1st MPJ and the Strayer

This patient is a 40ish year old woman. She is Spanish speaking only. She had surgery essentially a year ago and she is not very happy. She has 2 problems.

Problem #1 - She's very unhappy about her fusion. X-rays provided. How would you interpret her X-rays? Is she fused? She's in pain - where do you think that pain would be? Is there a surgery that can correct this problem? The tissue over the incision site is questionable - is there a non-surgical offloading strategy that could be employed?

Problem #2 - She had an endoscopic gastrocnemius recession. She hurts at both portals and has radiating posterior nerve pain in the distribution of the sural nerve. Ankle dorsiflexion ROM is adequate. No posterior "divet" (Not sure if this is something other people have experienced - I've personally seen a few endoscopic gastrocnemius recessions which are essentially Strayers in which the patient has an enormous divet/canyon/drop off on their posterior leg).

Tell me things.

I can still see some joint space in the 1st MPJ, but I also see some bridging of bone and it does not look like the nonunions I have seen, so I am going to say she is fused. I can see that she has a floating first toe that does not purchase the ground when WB based off the x-ray. The pain could be at the fusion site or at the IPJ of the hallux due to jamming. Conservatively you could use a reverse Morton's extension to help get the toe to the ground. Maybe a plantarflexing osteotomy surgically?? I am not really sure about this.

Sural nerve injury or neuritis is a complication following gastroc recession. Depending on how far along postop she is, this may resolve on its own. If it is not resolving, conservatively you could Rx Gabapentin for nerve pain and surgically you could release the nerve if it is entrapped in scar tissue or use RFA.

 

[heybrother]

I'm a bit sick irl so my responses will be a bit limited.

MPJ/Strayer first. The toe clinically is way up. She has sub-1st metatarsal head pain. The toe is clinically fused. I would say its also radiographically fused. One of the questions you'll have to ask yourself - what are the radiographic findings you can use to determine if fractures and fusions are healing. The classics are things like (a) cortical continuity (b) fracture/fusion gap filling (c) callus formation (d) intact/stable hardware. There are also clinical findings but that's another time and place. Its convenient to have a serious of radiographs to track progression.The IPJ is shot - it has no motion either. She can't put the toe down when standing and she's adjusting her gait. How will you position a 1st MPJ fusion in the sagittal plane? (trying to keep the questions coming). The usual response is likely to be a "X number of degrees". From what? 1st MPJ Fusions that are malpositioned can be revised with osteotomy. How do you produce the cut to realign the fusion - I'm open to the idea there are a number of different answers to this question, but I'm specifically looking for a type of saw that can produce the realigning cut. Last of all, you'll note that the MPJ was plated. Most plates are marketed as anatomic, but they do not always fit the anatomy - especially at joints that have had arthritis. It is entirely possible to have anatomy that angulates the plate dorsally the toe will be pulled to the plate producing inappropriate dorsiflexion.

As for the gastroc - my first question was, has the patient already completed a course of physical therapy - and unfortunately she had done 3 months without improvement. A more specific question would potentially be - what physical therapy had she done. I would hope at least something resembling ASTYM was performed. I'm in a "foot" state which raises questions about whether a post-surgical nerve problem within the calf is within my scope of practice, but you want to at least think problems through. Presumably, they bagged / scarred / cut / entrapped the nerve. You could do gabapentin - the patient is 40s and non-diabetic. Gabapentin is not without complications and people who are working may not tolerated being snowed. I suppose you could image to try and see if you can capture the problem on MRI to guide therapy - I'm sort of skeptical you'll catch it. Perhaps a pain specialist could ablate the nerve. As far as releasing or needling or going after it - the endoscopic nature of it potentially makes it more complicated. Perhaps someone else will have some recommendations - I have personally seen sural nerve issues before after gastrocnemius recession (did we bag it OR did we irritate the nerve through traction by changing ankle ROM) but they usually resolved/improved with physical therapy.

 

[GreenHousePub]

The Bunion King of the Northeast

You are a young, brash podiatrist trying to make a name for yourself in the northeast, probably in NY. This patient presents to you and hangs on your every word. They love your framed Podiatry News article in which you were cited for your expertise in recognizing the dangers of flips flops in the summer. After perusing your shoe carousel, promotions on Balance Braces, and pharmacopia of nail antifungals and CBD creams they relate that they need their bunion fixed. Their former podiatrist was sure he could get it right the 3rd time around, but he left to practice at a VA to avoid the terrible malpractice environment that is destroying medicine in this country. After explaining to her that most young podiatrists have no understanding of biomechanics you assure her that you will fix this problem easily with a custom orthotic and a small surgical procedure. After all you explain, you are certified by numerous prestigious podiatry surgical boards.

What surgery do you offer the patient::

(a) 1st MPJ fusion, but you warn her its a really bad procedure and she may have difficulty walking afterwards. She probably won't even be able to ever jog or run again. She'll need to be NWB for weeks and they non-union a lot. You have a specific vitamin prescription from a pharmacy you work with that isn't in town that she'll need to ensure a good outcome. Its kind of expensive though, but don't worry - your insurance will pay most of it.
(b) Plain old McBride baby. Just loosen that joint up and get the toe back where it needs to be. You caution the patient to make sure all the tapings and bracings and strapping stay in place (and they'll need to be reapplied regularly) because if anything goes wrong or your resident puts the dressing on wrong the bunion could recur.
(c) Reverse Austin, Reverse Akin. This is no different than how we treat a valgus deformity. As a trained podiatrist you recognize that most bunions have an osseous component and once we rebalance the bone back under the toe appropriately the toe will return to its intended position.
(d) Reverse lapidus with frontal plane correction to get the sesamoids back under the 1st ray.
(e) One of the above + Hardware removal. We need to get those old screws out because obviously they could cause metal poisoning.

Ok - that was all for fun above. If you don't get it - wait a few years.
What surgery would you do? What are reasonable outcomes of the procedure you select?)

Thoroughly enjoyed the write up on that one. Forgot to mention the loud scoffing you do when the patient describes what the other guy did for her.

Maybe quote the extensive "training" I got in residency seeing my bosses patients for him.

In real life I'd fuse the 1st MPJ and leave the 2nd MPJ alone. Tell them that's how it's going to be unfortunately. Anything else outside of a 1st MPJ fusion is just going to be adding yourself onto the court docket to be sued along with the first guy.

 

[GreenHousePub]

I can still see some joint space in the 1st MPJ, but I also see some bridging of bone and it does not look like the nonunions I have seen, so I am going to say she is fused. I can see that she has a floating first toe that does not purchase the ground when WB based off the x-ray. The pain could be at the fusion site or at the IPJ of the hallux due to jamming. Conservatively you could use a reverse Morton's extension to help get the toe to the ground. Maybe a plantarflexing osteotomy surgically?? I am not really sure about this.

Sural nerve injury or neuritis is a complication following gastroc recession. Depending on how far along postop she is, this may resolve on its own. If it is not resolving, conservatively you could Rx Gabapentin for nerve pain and surgically you could release the nerve if it is entrapped in scar tissue or use RFA.

This would be an indication for a CT scan, a plain film xray is not going to tell you if it's fused. As an aside doing a plantarflexory osteotomy on a non-union would be malpractice.

You have a good train of thought though.

 

[Scrantonicity]

You could also do a complete take-down of the fusion, whether it's fused or not...remove the hardware, cut out a small wafer of bone at the fusion site, and then do a total joint replacement. I did this on a patient recently, and I used the Arthrosurface Toe Motion (NOT the silastic implant)--it worked wonders...basically gave them their joint back. Definitely want to make sure those sesamoids are free though--I had to be (carefully) aggressive with a McGlamry elevator to get them freed up again.

 

[josebiwasabi]

Anecdotally, I have done 6 revisions of arthrosurfaces which had to be converted to bone block arthrodesis. All of them had failed within 2-5 years of implanting them.

 

[Scrantonicity]

Anecdotally, I have done 6 revisions of arthrosurfaces which had to be converted to bone block arthrodesis. All of them had failed within 2-5 years of implanting them.

Yeah? That sucks. I've been doing it for about 6 years and haven't seen an issue with it. I have had patients come see me 3+ years after I did one side, asking me to do the other. Anyways, as with any device, there's many factors that could lead to failure (patient selection, surgeon skill, etc)...I definitely don't blame you for having a bias after removing 6 of em though. I have a few devices/implants in mind that are in my mental "crap" pile only because I've had to remove or revise them more than a few times...

 

[josebiwasabi]

Yeah? That sucks. I've been doing it for about 6 years and haven't seen an issue with it. I have had patients come see me 3+ years after I did one side, asking me to do the other. Anyways, as with any device, there's many factors that could lead to failure (patient selection, surgeon skill, etc)...I definitely don't blame you for having a bias after removing 6 of em though. I have a few devices/implants in mind that are in my mental "crap" pile only because I've had to remove or revise them more than a few times...

Yeah I am just anti 1st mtp implant in general haha. For me it's cheilectomy, keller (obviously has limited indications) or arthrodesis.

Glad to see it works well in your hands though!