Foot and ankle issues in collagen vascular disorders

Foot and ankle issues in collagen vascular disordersPatrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, VADirector, Eastern Virginia Medical School PMS 24Past President ACFAPediatricsCaptain, (SCWO), MSC, USNR-R

Previous researchCommon foot problems identified by survey, Seattle, WA Xrays taken at Detroit Childrens Hospital evaluatedFootmax scans collected, Philadelphia, PACollagen vascular disorders

Ehlers-Danlos SyndromeMarfans SyndromeOsteogenesis imperfectaEtc.

Special considerationsSoft tissue handlingVascular fragility?Bone fragility?Over pronation or saggingAnkle may still be tight!

Common foot problemsHypermobilityFlat feet with or without over pronation

Common foot problemsUncommon manifistationsBunions with joint fluid leak (ganglion cyst)

Principles of podiatric interventionAlign and maintain functional anatomyAvoid skin injuryDont rely on ligamentsSelect and time invasive intervention carefullyAlign and maintain functional anatomyFoot orthoses-> controversialArthrodesis -> anecdotally mediocre resultsOsteotomies -> more reliable, much experienceArthroresis -> controversial but promisingLigament replacement -> new devicesSub talar arthroresis

Subtalar ArthroresisHistory/variationsgoalsDisadvantagesAdvantages

HISTORYbone proceduresChambers 1946: bone blockSubotnick 1974 silastic carved plugCurrent:Metal implantsAbsorbable implantsHISTORYPolymersMetalsabsorbable

Goals of STARelief of painImproved joint alignment and functionInterruption of patho-mechanical progressioncorrection of deformity???

STATE OF THE ART

State of the art

Size matters!CT measurements of sinus tarsus Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable sub talar arthroeresis, JFAS, 2007

Metatarsus Adductus

DiagnosisInfancyToddler hoodChildhoodAdultery ;)

Multiplanar deformities

PrognosisNo reliable methodUncompensated: styloid process, HAV?, ankle injuries, lateral knee?, claw toesCompensated: complex over pronation, HAV?, hammertoesManagementObservation(?)stretching(?)CastingSplintingShoes(?)Surgery

Good solutions for bad ligaments

Strong: absorbable vs non absorbableMinimally invasive (small incisions)May obviate some bone surgeriesMay permit weight bearing immediately

External fixationMini railsMay obviate second surgeries, may result in less bone surgeries

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