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Case - 1 |
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Patient profile |
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68 yrs old wellbuilt active retired armyman.
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C/o pain in left >rt ankle gradually increasing since 19 yrs -post injury.
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Deformity of left ankle >rt gradually increasing.
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Taking off-on analgesics |
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On examination |
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Varus deformity of lt >rt ankle
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Ankle & Subtalar movements painful & restricted
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Treatment |
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Ankle & subtalar arthrodesis using newer IM nail.
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Important steps |
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Entry- bisecting line from2nd toe to center of heel and junction ofanterior 1/3
posterior 2/3 of heel pad.
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Trans fibular approach, Joints prepared.
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Morcellaised fibula used as graft.
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Throughout the procedure joint held in corrected position and guide wire-nail inserted. |
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Extra locking screw is inserted freehand. |
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Nail is sunk in than tibial locking is done and than grafts packed and compression
is given by pulling the assembly. |
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Distal locking done. |
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Nail design |
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Properly placed hole for calcaneum and talus
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Extra locking facility in axial direction in calcaneum which increase stability
by 40 %
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All sizes and diameters are made
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Discussion |
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At present no such nail is available in india
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We got it made here by using technical specifications of Biomet company
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Can only be used in cases having ankle and subtalar arthritis
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Conventional method is using cross screws |
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All Advantage of IM nail plus following additional advantage |
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Rigid fixation,can allow early weight bearing |
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Compression can be given |
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Lateral to medial transfixation locking screws |
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A load sharing device that affords torsional rigidity and better calcaneal purchase
through the posterior to anterior transcalcaneal locking screw |
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Fully cannulated closed section design |
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Optimal patient sizing 10 ,11 ,12 mm diameter ,15 and 18 cm length |
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Precise reproducible instrumentation |
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Areas of improvement |
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Compression device
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Zig for post to ant screw
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Titanium alloy
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Comparative study to establish its superiority over conventional mathod |
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Case - 2 |
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Patient profile |
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Afrozabanu 48 years female
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c/o Deformity of big toe since long;probably childhood
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c/o pain in big toe since 1 year with difficulty in wearing routine slipper or chapple
andf pain on walking
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On examination painful and restricted movement of 1st MTP joint with hallux varus
deformity.all other joints supple |
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Investigation |
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X-ray-shows Hallux varus with degenerative changes in MTP joint
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Blood investigation Hb,TC,DC,ESR,RBS,RA Factor,S.Uric acid-Normal
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Treatment |
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Arthrodesis of MTP joint with plate fixation
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Offloading plaster and encouraging early weight bearing after 3 weeks |
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Presently walking comfortably without pain with routine slipper and chapple |
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Sharing the difficulties encountered |
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Convincing the patient about arthrodesis
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Approach-extensor tendon always comes in the way
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Requires small curettes and mini saw for cuts for correction of deformity
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Mini plate for fixation-require less energy to be put in for tightening the screws |
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Temptation to remove more bone for correction of deformity |
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Late suture removal |
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Osteoporotic and small bones gives only one chance to put in the screw-less room
for shifting the plate |
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Advantage on other methods of fixation |
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Routine K-wire fixation
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may needs to be kept outside the skin
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Loss of reduction
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can not retain for long periods-fear of infection and loosening |
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Do not allow early weight bearing |
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Areas of improvement |
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Better implants
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Learn to be gentle not only with the soft tissue but also with the bone
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Temptation to remove more bone
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Case - 3 |
A 22 yrs old woman presented with complaints of a short 4th toe on the left side
since birth. She was having brachymetatarsia . A one stage lengthening procedure
was done using the bone graft from the hip bone.A near normal toe was then achieved.
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&##39;A 15 Years old boy was suffering since long with pain and difficulty in walking
and moving foot. He was treted by various doctors with no success. He presented
to FACI Team and had restricted painful eversion and Inversion of subtalar joint
& x-ray showed congenital Calcaneonavicular Bar. He got enough conservative
trial with Orthosis, Rest and Nsaids. Ultimately he had advised Surgery. Through
an oblique Incision on to Sinus Tarsi Bar was Exposed & Excised Fully. Interpostion
of free fat graft was done. Postoperatively Patient has more than 50% Improved movement
arc and no Pain.
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Case - 4 |
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Patient profile |
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Male 22 yrs
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Twisting injury to the right ankle
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Tenderness and swelling over the antero lateral tibial plafond
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Financially compromised.
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Case - 5 |
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Patient profile |
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50 year Female
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R A since 25 years.
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Severe Rheumatoid dz
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DMARD&##39;s |
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Difficulty in walking |
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Problem |
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Footwear
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Painful Callosity
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No response with custom made orthosis
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on steroids and DMARDs
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Case - 6 |
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Patient profile |
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A 42 year old female
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Not responding to conservative treatment. since 3 years
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Shoe wear problems
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Tender 2nd MTPJ
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Procedure |
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Distal lateral release.
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Medial 1st tmt exposure.
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Preparation for arthrodesis.
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Medial eminence removal.
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Fusion with correction.
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Medial capsular plication.
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Case - 7 |
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Patient profile |
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A 20 year old female with
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Not responding to conservative treatment. since 3 years.
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painful callosity under the 4 th Mt head.
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Brachymetatarsia |
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Hypoplastic metatarsal.
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1st and 4th Mt most affected.
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Rare ,Incidence :0.022% to 0.05%.
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Female:Male= 25:1.
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Causes : Congenital,Endocrinal,Acquired
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When one MT is 5 mm or proximal to the parabolic arc of the MT heads.
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Cosmesis.
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Cause of pain |
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transfer metatarsalgia.
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cock up deformity.
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callus formation.
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Treatments |
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Orthotic supports.
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One stage lengthening.
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Gradual lengthening.
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Advantages of one stage lengthening |
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Shorter period to union.
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Less morbidity.
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Upto 15mm length.
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Disadvantages |
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lesser length.
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Risk of NV deficit.
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Brachymetatarsia .. |
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Many methods described for one stage Lengthening.
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Baeck & Chung JBJS Br. 1998 80(6) &##39;gradual one stage distraction&##39; to negate the
disadvantages.
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Baeck & Chung JBJS Br. 1998 80(6) &##39;gradual one stage distraction&##39; to negate the
disadvantages.
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Dorsal longitudinal incision.
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Retract the extensor tendon.
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Mid shaft osteotomy of MT.
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Proximal to distal k wire.
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Initial 7-8 mm distraction.
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Gradual lengthening with lamina spreader 1.5mm over 3 minutes for 20 mins
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Tricortical Iliac graft pre-drilled with K wire.
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Kwire passed upto MT base.
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Z lengthening of ext. tendon done.
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BK plaster slab applied.
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Case - 8 |
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Patient profile |
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43 year male.
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Painless deformity of ankle.
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Inability to bear weight.
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Case - 9 (Ankle arthrodesis with newer IM nail) |
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Patient profile |
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68 yrs old wellbuilt active retired armyman.
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c/o pain in left > rt ankle gradually increasing.
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since 19 yrs -post injury.
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Deformity of left ankle >rt gradually increasing.
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Taking off-on analgesics.
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On examination |
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Valgus deformity of lt > rt ankle.
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Ankle & Subtalar movements painful & restricted.
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since 19 yrs -post injury.
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Deformity of left ankle >rt gradually increasing.
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Taking off-on analgesics.
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treatment |
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Ankle arthrodesis using newer IM nail.
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At present no such nail is available in india.
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Multinationals do not market in india.
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presently we are using nails made for other purpose as ankle arthrodesis nail.
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Conventional method is using cross screws.
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Important steps |
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-
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Trans fibular approach.
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|
-
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Morcellaised fibula used as graft.
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|
-
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Joints prepared.
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throughout the procedure joint held in corrected position and guide wire-nail inserted.
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Extra locking screw is insetred freehand.
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Nail design |
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Properly placed hole for calcaneum and talus.
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Extra locking at 90 degrees in calcaneum which increase stability by 40 %.
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All sizes and diameter are made.
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Case - 10 (Bhavsar) |
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Patient profile |
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Mr,Bhavsar, male aged 34 years.
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Vehicular accident,1999.
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Case - 11 (Crush fracture body of talus1) |
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Patient profile |
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Male aged 11 years.
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H/O fall from height.
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Injury to ankle foot.
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Severe edema & pain.
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Treatement |
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Treated initially with rest, ice, crepe, elevation, slab.
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Taken for surgery after 3 days.
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Discussion |
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Bad injuries.
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Needs accurate repositioning & reduction.
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Long term results???
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Arthritis???
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AVN ???
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Case - 12 (harish chandwani) |
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Patient profile |
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Harish Chandvani.
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Male aged 43 years.
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IH/o road traffic accident on 21/5/2006.
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Compound injury RT ankle .
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Wounds healed with secondary procedures
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Pop removed & patient mobilized.
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Weight bearing advised after 14 weeks.
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Persistent posterior ankle pain with restriction of movements.
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Inability to do routine works.
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Discussion |
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Talonavicular joint was not reduced properly from beginning.
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Posterior comminution excision made joint more unstable.
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Fusion of talonavicular & subtalar joints.
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