Foot and Ankle cases 19

A 65-year-old female with a history of osteopenia presents complaining of hindfoot pain for the past 2 years. She denies any traumatic inciting event, but notices the pain primarily while ambulating. She has had to wear orthotics for many years but recently developed new ankle pain during the past 6 months. She reports particular difficulty when on uneven surfaces and that her ankle brace and orthotics do not seem to be working. Radiographs are obtained (Figs. 5–39 and 5–40).

 

 

Figure 5–39 Initial radiographs of the ankle.

 

 

Figure 5–40 A, B: Initial radiographs of the foot.

 

The most likely underlying etiology of the patient’s deformity is:

1. Talonavicular arthritis

2. Posterior tibial tendon deficiency

3. Charcot arthropathy

4. Spastic peroneal flatfoot disorder

5. Subtalar arthritis

 

Discussion

The correct answer is (B). The patient has stage 4 PTTD, which is characterized by tibiotalar joint involvement in addition to an adult-acquired planovalgus hindfoot deformity. The patient does have a dorsal talonavicular joint osteophyte indicating that there is some talonavicular arthritis, although this does not underlie the patient’s deformity. Spastic peroneal flatfoot disorder is primarily seen in children. Charcot arthropathy often present with deformity and reactive bone changes, which are not present.

Physical examination of the patient reveals a prominent callus underlying the talar head, with swelling and tenderness to palpation along the course of the posterior tibial tendon, as well as tibiotalar joint line. Hindfoot motion is rigid, while ankle motion is full with correctable alignment.

In addition to the patient’s foot deformity, the ligamentous deficiency most responsible for her ankle pain is:

1. The anterior talofibular ligament

2. The calcaneofibular ligament

3. The anterior-inferior tibiofibular ligament

4. The deltoid ligament

5. The transverse tibiofibular ligament

 

Discussion

The correct answer is (D). Longstanding planovalgus deformity due to PTTD may progress to medial ligamentous involvement of the ankle. The specific anatomy of the deltoid ligament is complex and controversial. The ligament is composed of a superficial and deep component. The superficial ligament attaches to the anterior colliculus, while the deep portion attaches to the posterior colliculus and intercollicular groove. The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) are components of the lateral ligamentous complex, while the anterior-inferior tibiofibular ligament and transverse tibiofibular ligaments are components of the syndesmosis complex.

The patient elects to proceed with conservative management for her foot and ankle pain utilizing a customized ankle-foot orthosis. She returns to the office 10 months later reporting new lateral ankle pain and swelling which began approximately 8 weeks ago. New radiographs are obtained (Fig. 5–41). Her ankle motion remains full with a completely flexible deformity through the ankle. Hindfoot motion remains rigid. The patient would like to consider surgical

intervention at this time.

 

 

 

Figure 5–41 A, B: Follow-up radiographs of the ankle.

 

Recommended surgery would include which of the following?

1. Ankle arthrodesis with distal fibulectomy

2. Triple arthrodesis

3. Triple arthrodesis with deltoid ligament reconstruction

4. Posterior tibial tendon debridement, flexor digitorum longus transfer, calcaneal osteotomy

5. Open reduction internal fixation of the fibula

6. Medial closing wedge osteotomy of the distal tibia

 

Discussion

The correct answer is (C). As the patient has a rigid planovalgus foot deformity, triple arthrodesis would be required to correct this deformity. The valgus ankle malalignment, which contributed to the fibular stress fracture seen in Figure 5–41A and B, should also be addressed with deltoid reconstruction. Both ankle arthrodesis and tibial osteotomies would not address the underlying foot deformity.

 

Objectives: Did you learn...?

 

Describe the stages of PTTD?

 

 

Describe the anatomy and pathophysiology of the deltoid ligament failure? Treat PTTD?