Managing Severe Foot and Ankle Deformities in Global Humanitarian Programs
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Hallux Rigidus & Arthritis of the Big
Hallux Rigidus & Arthritis of the Big Toe Osteoarthritis of the Big Toe ▪ Hallux rigidus often leads to osteoarthritis of the big toe ▪ “Hallux” means big toe ▪ “Rigidus” means rigid ▪ Big toe “jams” when walking ▪ This breaks down the joint ▪ Causes pain and eventually arthritis Hallux Rigidus: Can Be Disabling ▪ We use the big toe when we ▪ Walk ▪ Stoop ▪ Climb ▪ Stand ▪ Not the same as a bunion Can Be a Slow & Progressive Process ▪ May first appear as swelling & redness ▪ May first occur with ▪ Certain activities ▪ Certain shoes From Hallux Limitus to Hallux Rigidus ▪ Hallux limitus ▪ Motion is somewhat limited ▪ Hallux rigidus ▪ Range of motion decreases ▪ Becomes stiffer & loses motion ▪ More pain & destruction, resulting in arthritis What Causes Hallux Rigidus? ▪ Structural problems related to the shape of the foot ▪ Affects the way the foot functions ▪ Overuse (stooping, squatting, bending the toe) ▪ Contributors: ▪ Previous injury ▪ Certain shoe wear ▪ Other disorders Symptoms: The Early Stages ▪ Pain & stiffness in the big toe during use ▪ Walking, bending, standing, etc. ▪ Difficulty with certain activities ▪ Squatting, running, etc. ▪ Cold, damp weather can aggravate symptoms ▪ Swelling & inflammation may occur Symptoms: The Later Stages ▪ Range of motion progressively decreases ▪ Pain even during rest ▪ Bone spurs & joint enlargement ▪ Difficulty with certain shoes & activities What To Do ▪ Earlier treatment means better chances of slowing the progression ▪ See a foot & ankle surgeon when you notice symptoms ▪ The sooner it -
Hallux Valgus
MedicalContinuing Education Building Your FOOTWEAR PRACTICE Objectives 1) To be able to identify and evaluate the hallux abductovalgus deformity and associated pedal conditions 2) To know the current theory of etiology and pathomechanics of hallux valgus. 3) To know the results of recent Hallux Valgus empirical studies of the manage- ment of hallux valgus. Assessment and 4) To be aware of the role of conservative management, faulty footwear in the develop- ment of hallux valgus deformity. and the role of faulty footwear. 5) To know the pedorthic man- agement of hallux valgus and to be cognizant of the 10 rules for proper shoe fit. 6) To be familiar with all aspects of non-surgical management of hallux valgus and associated de- formities. Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Continu- ing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $15 per topic) or 2) per year, for the special introductory rate of $99 (you save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. -
Spondyloarthritis Diseases
Spondyloarthritis Diseases Spondyloarthritis Diseases A group of individually distinctive diseases with common, unifying clinical, genetic and pathophysiological features Ankylosing spondylitis (ASp) Psoriatic arthritis (PsA) Reiter’s syndrome (RS) / reactive arthritis (ReA) Undifferentiated spondyloarthritis (USpA) Enteropathic arthritis (ulcerative colitis, regional enteritis) Psoriasis, a related condition Spondyloarthritis Diseases Enthesitis (enthesopathy): the central inflammatory Unifying features unit of spondyloarthritis Classic example: Calcaneal spurs at plantar fascia and Achilles Clinical: tendon (Lover’s heel) Each distinguished by three main target sites of inflammation Enthesitis: fibrocartilage insertions of ligaments, tendons & fascia Spondyloarthritis: spine and sacroiliac joints Features of inflammation: •Infiltration of entheses by activated T cells Synovitis: peripheral joints •Granulation tissue forms (activated macrophages and fibroblasts) •Bone erosions and heterotopic new bone formation Spondylitis: syndesmophytes and ankylosis Sacroiliitis ASp • Subchondral regions of • Erosion of cartilage on iliac side synarthrotic SI joints invaded by • Bone plate blurring, joint space Annulus fibers eroded, then Activated T cells and granulation “widening” and reactive sclerosis Activated T cells invade replaced by fibrocartilage: Inflammation resolves, but tissue • Fibrous ankylosis replaced by bone the junction of annulus •Subperiosteal new bone progressive cartilaginous obliterating SI joint fibrosis and vertebral body, formation -
Saethre-Chotzen Syndrome
Saethre-Chotzen syndrome Authors: Professor L. Clauser1 and Doctor M. Galié Creation Date: June 2002 Update: July 2004 Scientific Editor: Professor Raoul CM. Hennekam 1Department of craniomaxillofacial surgery, St. Anna Hospital and University, Corso Giovecca, 203, 44100 Ferrara, Italy. [email protected] Abstract Keywords Disease name and synonyms Excluded diseases Definition Prevalence Management including treatment Etiology Diagnostic methods Genetic counseling Antenatal diagnosis Unresolved questions References Abstract Saethre-Chotzen Syndrome (SCS) is an inherited craniosynostotic condition, with both premature fusion of cranial sutures (craniostenosis) and limb abnormalities. The most common clinical features, present in more than a third of patients, consist of coronal synostosis, brachycephaly, low frontal hairline, facial asymmetry, hypertelorism, broad halluces, and clinodactyly. The estimated birth incidence is 1/25,000 to 1/50,000 but because the phenotype can be very mild, the entity is likely to be underdiagnosed. SCS is inherited as an autosomal dominant trait with a high penetrance and variable expression. The TWIST gene located at chromosome 7p21-p22, is responsible for SCS and encodes a transcription factor regulating head mesenchyme cell development during cranial tube formation. Some patients with an overlapping SCS phenotype have mutations in the FGFR3 (fibroblast growth factor receptor 3) gene; especially the Pro250Arg mutation in FGFR3 (Muenke syndrome) can resemble SCS to a great extent. Significant intrafamilial -
Angular Limb Deformities in Foals: Treatment and Prognosis*
Article #4 CE Angular Limb Deformities in Foals: Treatment and Prognosis* Nicolai Jansson, DVM, PhD, DECVS Skara Equine Hospital Skara, Sweden Norm G. Ducharme, DVM, MSc, DACVS Cornell University ABSTRACT: This article presents an overview of the clinical management of foals with angular limb deformities. Both conservative and surgical treatment options exist; the choice of which to use should be based on the type, severity, and location of the deformity as well as the age of the foal. Conservative measures include controlled exercise, rigid external limb support, and corrective hoof trimming. Surgical treatment modalities comprise tech- niques for manipulating physeal growth and, after physeal closure, various corrective osteotomy or ostectomy methods. The prognosis is generally good if treatment is initi- ated well in advance of physeal closure. ngular limb deformities and their treat- Conservative Treatment ment in foals and young horses constitute In most foals born with mild to moderate a significant part of the orthopedic prob- angular deformities, spontaneous resolution A 2 lems that veterinarians must manage. This article occurs within the first 2 to 4 weeks of life. In discusses the clinical management and prognosis newborn foals, periarticular laxity is the most of these postural deformities. likely cause, and these foals require no special treatment other than a short period of con- TREATMENT trolled exercise. In our opinion, mildly and The absence of controlled studies has moderately affected foals should not be confined impaired the accumulation of scientific data to a stall because exercise is important for nor- guiding the management of angular limb defor- mal muscular development and resolution of the mities in foals (Table 1). -
Conformational Limb Abnormalities and Corrective Farriery for Foals
Conformational Limb Abnormalities and Corrective Farriery for Foals For the past couple of years the general public has questioned the horse industry, and one of the questions is “Are we breeding horses more prone to breakdown with injuries”? It seems that we hear more often now that there are more leg and foot problems than ever before. Is it that we are more aware of conformational deficits and limb deviations, or are there some underlying factors that make our horses prone to injury? To improve, or even just maintain the breed, racing should prove soundness as well as speed and stamina. 1 The male side is usually removed from the bloodline if unable to produce good results at the racetrack. However, the female may have such poor conformation that she never even gets into training, but yet she enters the broodmare band. The generational effect of this must surely lead to an increase in the number of conformational deficits in our foals and yearlings.1 Something that we hear quite often is “Whoever saw the perfect horse”? and “There are plenty of horses with poor conformation that win races”. That doesn’t mean we should not continue to attempt to produce horses with good conformation. There is an acceptable range of deviation from the ideal, and therefore these deformities have to be accepted if it does not jeopardize the overall athletic soundness of the horse. Although mild conformational deficits may not significantly impact soundness, more significant limb deformities cause abnormal limb loading, lameness, gait abnormalities, and interference issues. 2 Developmental deformities of the limb include angular, flexural, and rotational limb deformities. -
George E. Quill, Jr., M.D. Louisville Orthopaedic Clinic Louisville, KY
George E. Quill, Jr., M.D. Louisville Orthopaedic Clinic Louisville, KY Foot and Ankle Frequently Asked Questions What is a bunion? The term bunion refers to a fairly common foot deformity composed of prominence of the medial forefoot that is associated with lateral deviation and sometimes rotation of the great toe toward the lesser toes. The medical term for this condition is hallux valgus, which better describes the patient who has a broad forefoot compared to the heel, deviation of the forefoot bones in stance and rotation of the great toe outward toward the lesser toes. While hallux valgus is not always a painful condition, it is one of the most common reasons patients will have difficulty with shoewear and normal activities of daily living and present to the orthopaedic surgeon’s office. Not all bunion or hallux valgus deformities require surgery, but operative intervention can correct the deformity and improve comfort levels in a patient who has pain on a daily basis and/or progression of their deformity over time. Please visit our website at www.louisvilleorthopedic.com for patient education documents. Isn’t it common for bunions to come back after surgery? Recurrent hallux valgus can occur for a variety of reasons, but should be relatively infrequent if the right procedure is done correctly for the appropriate patient. Bunions often occur after surgery if the surgeon and the patient did not choose the right operation for the patient. It is imperative that the patient and the doctor appreciate the particularly unique pathoanatomy and address all of this at the first surgical procedure to get appropriate correction the first time around. -
Arthrogryposis Multiplex Congenita Part 1: Clinical and Electromyographic Aspects
J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.4.425 on 1 August 1972. Downloaded from Journal ofNeurology, Neurosurgery, anid Psychiatry, 1972, 35, 425-434 Arthrogryposis multiplex congenita Part 1: Clinical and electromyographic aspects E. P. BHARUCHA, S. S. PANDYA, AND DARAB K. DASTUR From the Children's Orthopaedic Hospital, and the Neuropathology Unit, J.J. Group of Hospitals, Bombay-8, India SUMMARY Sixteen cases with arthrogryposis multiplex congenita were examined clinically and electromyographically; three of them were re-examined later. Joint deformities were present in all extremities in 13 of the cases; in eight there was some degree of mental retardation. In two cases, there was clinical and electromyographic evidence of a myopathic disorder. In the majority, the appearances of the shoulder-neck region suggested a developmental defect. At the same time, selective weakness of muscles innervated by C5-C6 segments suggested a neuropathic disturbance. EMG revealed, in eight of 13 cases, clear evidence of denervation of muscles, but without any regenerative activity. The non-progressive nature of this disorder and capacity for improvement in muscle bulk and power suggest that denervation alone cannot explain the process. Re-examination of three patients after two to three years revealed persistence of the major deformities and muscle Protected by copyright. weakness noted earlier, with no appreciable deterioration. Otto (1841) appears to have been the first to ventricles, have been described (Adams, Denny- recognize this condition. Decades later, Magnus Brown, and Pearson, 1953; Fowler, 1959), in (1903) described it as multiple congenital con- addition to the spinal cord changes. -
Driscoll Health Plan Clinical Guideline
Driscoll Health Plan Clinical Guideline Clinical Guideline: Creation Effective Review Bunion and bunionette surgical treatments Date: Date: Date: 09/01/2007 09/01/2007 05/22/2021 PURPOSE: To define the conditions and requirements for surgical treatment of bunions and bunionettes. DEFINITIONS: Bunions and bunionettes - a broad category of conditions involving deformities of the metatarsals and metatarsophalangeal joints encompassing terms such as hallux valgus (bunion), bunionettes (tailor’s bunion), hallux limitus, and hallux rigidus. GUIDELINE: Indications and Documentation Requirements: 1. Surgical treatment of bunion or hallux valgus: Driscoll Health Plan considers bony correction surgery for bunion medically necessary for a member that meets the following criteria: Development of a neuroma secondary to the bunion; OR • Limited or painful range of motion and pain upon palpation at the first toe MTP joint; OR • Nonhealing ulceration caused by bunion; OR • Painful prominence of the dorsiflexed second toe due to pressure from the first toe AND all of the following: • Radiographic confirmation of an intermetatarsal (IM) angle greater than 9 degrees and/or hallux valgus (HV) angle greater than 20 degrees; AND • Documentation of persistent pain and difficulty walking despite at least six months conservative treatment under the direction of a healthcare professional, which includes, but may not be limited to: Alternative or modified footwear Corticosteroid injections Debridement of hyperkeratotic lesions Foot orthotics (shoe inserts) (generally contractually excluded) Oral analgesics or nonsteroidal anti-inflammatory drugs (NSAIDS) Protective cushions/pads; AND • Documentation of skeletal maturity Clinical Guideline: STAR, CHIP, STAR Kids Confidential: For use only by employees and authorized agents of Driscoll Health Plan. -
Osteotomy Around the Knee: Evolution, Principles and Results
Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-012-2206-0 KNEE Osteotomy around the knee: evolution, principles and results J. O. Smith • A. J. Wilson • N. P. Thomas Received: 8 June 2012 / Accepted: 3 September 2012 Ó Springer-Verlag 2012 Abstract to other complex joint surface and meniscal cartilage Purpose This article summarises the history and evolu- surgery. tion of osteotomy around the knee, examining the changes Level of evidence V. in principles, operative technique and results over three distinct periods: Historical (pre 1940), Modern Early Years Keywords Tibia Osteotomy Knee Evolution Á Á Á Á (1940–2000) and Modern Later Years (2000–Present). We History Results Principles Á Á aim to place the technique in historical context and to demonstrate its evolution into a validated procedure with beneficial outcomes whose use can be justified for specific Introduction indications. Materials and methods A thorough literature review was The concept of osteotomy for the treatment of limb defor- performed to identify the important steps in the develop- mity has been in existence for more than 2,000 years, and ment of osteotomy around the knee. more recently pain has become an additional indication. Results The indications and surgical technique for knee The basic principle of osteotomy (osteo = bone, tomy = osteotomy have never been standardised, and historically, cut) is to induce a surgical transection of a bone to allow the results were unpredictable and at times poor. These realignment and a consequent transfer of weight bearing factors, combined with the success of knee arthroplasty from a damaged area to an undamaged area of joint surface. -
Does the Patellofemoral Joint Need Articular Cartilage?—Clinical Relevance
Review Article Page 1 of 6 Does the patellofemoral joint need articular cartilage?—clinical relevance Lars Blønd1,2 1Department of Orthopaedic Surgery, Aleris-Hamlet Parken, Copenhagen, Denmark; 2Department of Orthopaedic Surgery, The Zealand University Hospital, Koege, Denmark Correspondence to: Lars Blønd, MD. Falkevej 6, 2670 Greve Strand, Denmark. Email: [email protected]. Abstract: The patellofemoral joint (PFJ) is enigmatic and we know the pathomorphology for anterior knee pain (AKP) is multifaceted. This paper review alignment and biomechanical factors associated with AKP both in the younger generation with or without cartilage changes and discusses the importance or obscurity of cartilage in the PFJ pathoanatomic changes such as trochlear dysplasia (TD), patella alta, increased femoral anteversion, lateralized tibial tubercle, external tibial torsion and valgus deformity affects the patellofemoral articulation. In order to achieve effective and durable results, it is of importance that any significant deviation in patellofemoral alignment should be corrected by realignment surgery, before considering cartilage procedures in the PFJ Patellofemoral alignment factors in both the frontal plane, the transverse plane and as well as the sagittal plan needs to evaluated thoroughly by not only clinical examination and X-ray, but also by MRI scans or CT scans. Keywords: Patellofemoral; malalignment; cartilage repair; anterior knee pain (AKP); trochlear dysplasia (TD); osteoarthritis Received: 01 January 2018; Accepted: 02 May 2018; Published: 24 May 2018. doi: 10.21037/aoj.2018.05.01 View this article at: http://dx.doi.org/10.21037/aoj.2018.05.01 The patellofemoral joint (PFJ) is enigmatic and we know not established the precise link between pain and cartilage the pathomorphology for anterior knee pain (AKP) is lesions (1). -
Expanded Indications for Guided Growth in Pediatric Extremities
Current Concept Review Expanded Indications for Guided Growth in Pediatric Extremities Teresa Cappello, MD Shriners Hospitals for Children, Chicago, IL Abstract: Guided growth for coronal plane knee deformity has successfully historically been utilized for knee val- gus and knee varus. More recent use of this technique has expanded its indications to correct other lower and upper extremity deformities such as hallux valgus, hindfoot calcaneus, ankle valgus and equinus, rotational abnormalities of the lower extremity, knee flexion, coxa valga, and distal radius deformity. Guiding the growth of the extremity can be successful and is a low morbidity method for correcting deformity and should be considered early in the treatment of these conditions when the child has a minimum of 2 years of growth remaining. Further expansion of the application of this concept in the treatment of pediatric limb deformities should be considered. Key Concepts: • Guiding the growth of pediatric physes can successfully correct a variety of angular and potentially rotational deformities of the extremities. • Guided growth can be performed using a variety of techniques, from permanent partial epiphysiodesis to tem- porary methods utilizing staples, screws, or plate and screw constructs. • Utilizing the potential of growth in the pediatric population, guided growth principals have even been success- fully applied to correct deformities such as knee flexion contractures, hip dysplasia, femoral anteversion, ankle deformities, hallux valgus, and distal radius deformity. Introduction Guiding the growth of pediatric orthopaedic deformities other indications and uses for guided growth that may is represented by the symbol of orthopaedics itself, as not have wide appreciation. the growth of a tree is guided as it is tethered to a post (Figure 1).