What would you do?

[347932]

I'd like to start a new thread to talk about some interesting cases I've come across. I'm hoping it will be more a precursor to those of you about to take your ABPS Written Exam and to the Attendings out there to share experiences.

I'll start:

62 yo white male patient presents with pain sub met one right foot. He also c/o painful bump on the top of his foot. He likes to golf and can't walk the course anymore due to the sub met 1st pain. Relates that the pain in his 1st MPJ approahces 8/10 after ambulating. He is wearing good sneakers for his visit toady and says that this is what he wears, even on the golf course. He visited several local foot and ankle surgeons who suggested a 1st Met Cuneiform fusion and comes in for a second opinion.
His PMH, PSH, FH, SH, Meds, All are all rather unremarkable.

Vasc: Palp Pulses, all WNL
Ortho: Plantarflexed 1st Ray with slight Ant Cavus foot type. Hallux Malleus. Pain on ROM of 1st MPJ but no crepitus noted. Extensor Hallucis Tendon is very tight. Dorsal Exostosis at the 1st Met/Cuneiform joint. No motion noted there with no pain on attempted ROM to the area and +ve Tinel's sign at the exostosis. No pain noted at Sesamoid apparatus in the chair and no pain on barefoot ambulation today. PAtient has moderate Cavus foot type on ambulation. All noted Right>>>Left
Derm: Unremarkable other than mild redness at area of dorsal exostosis.
Neuro: Unremarkable other than Tinel's.

So I'd like some questions, diagnosis, conservative and potential surgical options. Go...

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[krabmas]

I'd like to start a new thread to talk about some interesting cases I've come across. I'm hoping it will be more a precursor to those of you about to take your ABPS Written Exam and to the Attendings out there to share experiences.

I'll start:

62 yo white male patient presents with pain sub met one right foot. He also c/o painful bump on the top of his foot. He likes to golf and can't walk the course anymore due to the sub met 1st pain. Relates that the pain in his 1st MPJ approahces 8/10 after ambulating. He is wearing good sneakers for his visit toady and says that this is what he wears, even on the golf course. He visited several local foot and ankle surgeons who suggested a 1st Met Cuneiform fusion and comes in for a second opinion.
His PMH, PSH, FH, SH, Meds, All are all rather unremarkable.

Vasc: Palp Pulses, all WNL
Ortho: Plantarflexed 1st Ray with slight Ant Cavus foot type. Hallux Malleus. Pain on ROM of 1st MPJ but no crepitus noted. Extensor Hallucis Tendon is very tight. Dorsal Exostosis at the 1st Met/Cuneiform joint. No motion noted there with no pain on attempted ROM to the area and +ve Tinel's sign at the exostosis. No pain noted at Sesamoid apparatus in the chair and no pain on barefoot ambulation today. PAtient has moderate Cavus foot type on ambulation. All noted Right>>>Left
Derm: Unremarkable other than mild redness at area of dorsal exostosis.
Neuro: Unremarkable other than Tinel's.

So I'd like some questions, diagnosis, conservative and potential surgical options. Go...

What does his coleman's block test show? Is this truely all a forefoot deformity?

 

[347932]

What does his coleman's block test show? Is this truely all a forefoot deformity?

Plantarflexed 1st Ray. Yes forefoot only.

 

[jonwill]

Plantarflexed 1st Ray. Yes forefoot only.

Is the deformity rigid or flexible?

 

[347932]

Is the deformity rigid or flexible?

Flexible and reducible.

Sorry its my first time trying this in a long time. I should have put all that in the initial post. I'll do better next time and thanks for the patience!

 

[sinustarsi]

Seems like a he got forefoot valgus and local anterior cavus. You have to figure out where the apex of his cavus deformity is located. Non sx tx, will try inserts with cut-out or forefoot valgus posting to accommodate sub met pain. Before proceeding with sx, I will obtain a Neuro consult and also obtain a spine xray also due to his pes-cavus. As far a procedure, I will try fusing the IPJ with transfer to EHL(Jones procedure). You may also want to transfer the Peroneal longus to brevis. Consent him for possible dorsiflexion osteotomy at the base of 1st metatarsal if you think your dorsiflexion is not sufficient intra-op. I will let him know possible lapidus fusion at a future date if he is having pain at 1st met-cunieform. Also warn him about possible transfer lesion 2nd or 3rd met as possible complication.

 

[347932]

Seems like a he got forefoot valgus and local anterior cavus. You have to figure out where the apex of his cavus deformity is located. Non sx tx, will try inserts with cut-out or forefoot valgus posting to accommodate sub met pain. Before proceeding with sx, I will obtain a Neuro consult and also obtain a spine xray also due to his pes-cavus. As far a procedure, I will try fusing the IPJ with transfer to EHL(Jones procedure). You may also want to transfer the Peroneal longus to brevis. Consent him for possible dorsiflexion osteotomy at the base of 1st metatarsal if you think your dorsiflexion is not sufficient intra-op. I will let him know possible lapidus fusion at a future date if he is having pain at 1st met-cunieform. Also warn him about possible transfer lesion 2nd or 3rd met as possible complication.

Didn't get spinal films. Neuro consult negative for pathology. Conservative management as described attempted and failed. Consent as such minus the peroneal anastomosis. Transfer lesions discussed. Procedure done as described. No dorsiflexory osteotomy required. Patient educated about future necessity for fusion.

Well Done! Any other possibilities?

 

[Feli]

...As far a procedure, I will try fusing the IPJ with transfer to EHL(Jones procedure)...

...Consent him for possible dorsiflexion osteotomy at the base of 1st metatarsal if you think your dorsiflexion is not sufficient intra-op...

I would agree with this^

If he's a good surgical candidate (compliant and good vasc status), then probably he needs MPJ1 exostectomy (cheilectomy), exostectomy of 1MC, IPJ desis, Jones EHL transfer, and probably oblique DFWO. Lapidus is a good idea on paper due to arthritic changes, but most of his pain was MPJ... most of all, he's 62, and trying a dorsiflexory lapidus when you're already transferring an additional DF tendon into the 1st met miiiight not be the best idea.

...Good discussion.

 

[sinustarsi]

what about removing the sesamoid bone in addition to the procedure mentioned above based on the location of pain sub-met 1?

 

[347932]

what about removing the sesamoid bone in addition to the procedure mentioned above based on the location of pain sub-met 1?

No pain on palpation/manipulation of the sesamoids as per the physical examination. Why remove them?