Hallux Varus

Hallux varus is a positional deformity of the great toe.  The toe is adducted, or directed towards the midline of the body.  This may cause difficulty wearing shoes, as the toe can rub against the inside of the shoe.  Additionally, it may cause a secondary contraction deformity at the hallux interphalangeal joint, which is the joint of the great toe.  Patients may also have cosmetic complaints. 

Hallux varus is most commonly seen as a complication of bunion correction.  When hallux valgus, the condition that causes a bunion, is over-corrected, the result is hallux varus.  Essentially, the great toe has been moved from one direction, past its normal position, and put into a different, unpleasant position.  Hallux varus may also be seen in inflammatory arthritic conditions such as rheumatoid arthritis or psoriatic arthritis, or in neurologic conditions such as Charcot-Marie-Tooth disease.  It can also be of a traumatic etiology.

When the deformity is painful, surgical intervention is indicated for correction.  When a foot and ankle surgeon evaluates a patient for hallux varus, it is important to consider the degree of deformity as well as any pathology that may be coming from the joint itself. 

Often times the first metatarsal-phalangeal (MTP) joint may be fused to correct for hallux varus.  This serves a number of purposes.  First, it holds the toe in a corrected position, so that it does not deviate from the optimal position.  Secondly, it addresses any arthritis that may have developed from the misaligned joint.  Misalignment of a joint is often the source of pain and arthritis.  This joint fusion, or arthrodesis, serves to address this problem.

However, fusion of a joint may not be necessary if there is no damage to the joint cartilage yet.  In cases like these, a tendon transfer around the great toe, or hallux, may be warranted. 

There are a number of different tendon transfers that have been described for the correction of hallux varus.  These techniques will typically involve the use of the extensor hallucis longus or the extensor halluics brevis.  These two muscles help to control the hallux, and the tendons of them may be used to correct a flexible deformity such as hallux varus. 

Depending on the surgeon’s preference, one or more tendon transfers may be used to correct hallux varus.  However, the most important thing for the surgeon to evaluate is the flexibility of the deformity.  If the toe can go back into it’s normal alignment easily, then a tendon transfer may be indicated.  If the toe can not be fully reduced, and there is evidence of arthritis on x-ray, then an arthrodesis may be a more appropriate procedure.

Central Florida Foot and Ankle Center 
101 6th St Nw Winter Haven, Fl 33881 
Phone: (863) 299-4551 
www.FLFootandAnkle.com

Post-Traumatic Arthritis

The term "arthritis" refers to inflammation of a joint.  There are a number of causes of this inflammation, but most commonly it is due to a degeneration of cartilage within the joint, known as osteoarthritis.  The diagnosis of post-traumatic arthritis is used when there is a history of acute trauma or damage to the joint.  The injury may have occurred during sports, a fall, a motor vehicle accident, or any other source of trauma.  In the foot and ankle, this is a common cause of chronic pain.

Post-traumatic arthritis of the ankle joint is extremely common following a bad sprain or fracture of the bones of the joint.  In fact, most studies indicate that upwards of 50% of ankle arthritis is due to a history of injury, and is not a primary arthritic condition.  Any joint of the foot or ankle may be affected if there is a history of injury.  The symptoms include pain and swelling in a joint, fluid accumulation within the joint, and difficulty with activities such as sports, exercise, walking up stairs, and other activities that put added stress on the affected joint. 

Following an injury to the foot or ankle, the joints may become misaligned through faulty healing, or may have damage to the cartilage from the injury itself.  This misalignment of a joint can cause major pain and disability, which will worsen over time. 

A diagnosis of post-traumatic arthritis is often made clinically.  There is generally a history of trauma to the joint, whether it is remembered or not.  Often the trauma can be subtle, such as repetitive ankle sprains.  X-rays may be used by the treating physician to confirm the diagnosis, and to evaluate the symptomatic area. 

Treatment of post-traumatic arthritis often focuses on removing the symptoms of pain and preventing further deformity.  Orthotics and other forms of bracing are often helpful for foot and ankle post-traumatic arthritis.  Icing, rest, and the use of oral anti-inflammatory medications may be helpful as well.  Injections into the joint with corticosteroids may also provide some relief.

Occasionally surgery may be warranted in severe cases.  Depending on which joint of the foot or ankle is affected, various procedures may be beneficial to the patient.  This may include procedures such as fusing joints so that they no longer move, rearranging tendons and ligaments to provide more support to the joint, and possibly cutting bones and moving them to realign the joint. 

Central Florida Foot and Ankle Center 
101 6th St Nw 
 Winter Haven, Fl 33881 
Phone: (863) 299-4551 
www.FLFootandAnkle.com

Common Pedal Coalitions

A coalition refers to the union of two parts that are not normally united.  In the foot, this refers to the union of two bones where there is usually either a joint or a space between the bones.  Coalitions can theoretically be seen between any two adjacent bones, but are more common in some areas of the foot than in others. 

There are three types of coalition that are described.  These include cartilaginous coalitions, fibrous coalitions, and true osseous coalitions.  Osseous coalitions will completely eliminate movement between the two bones, while fibrous and cartilaginous coalitions will limit the motions. 

Coalitions are thought to form from the failure of the mesenchyme, the tissue that dictates bone structure in the developing fetus, to differentiate.  The mesenchyme will normally differentiate into two distinct bones.  In the presence of coalition, this does not happen.

The most common pedal coalition is seen between the distal and intermediate phalanges of the toes, most frequently in the fifth toe.  This coalition is typically of little consequence, and is rarely symptomatic.  It is present in almost half of the population, with many suggesting that this is actually and anatomic variant rather than a pathological abnormality. 

Pathological coalitions are described as incorporating the bones of the rearfoot, or the major tarsal bones.  The rearfoot complex dictates movement of the entire foot, and a limitation of movement in these joints can cause significant pain and deformity.  The most common types of tarsal coalition are between the talus and calcaneus (talocalcaneal coaltion), between the calcaneus and the navicular (calcaneonavicular coalition), and between the talus and the navicular (talonavicular coalition).  Of these three, talocalcaneal and calcaneonavicular coalitions are by far the most common.

These tarsal coalitions often present with the triad of a rigid flatfoot deformity, spasm of the peroneal muscles, and pain.  The treatment of tarsal coalition centers around reducing the pain associated with the deformity, and begins with conservative treatment such as immobilization, orthotics, shoe modifications, and corticosteroid injections locally into the area of pain. 

Surgery is often indicated in theses cases, as conservative treatment can be very limited in its effectiveness and recurrence of pain is likely.  Depending on the extent of the coalition and which joint is involved, various procedures focus on either the resection of the coalition or complete fusion of the joints involved.  Resection serves to increase motion at the joint, which would restore function and eliminate pain.  A fusion of the joint limits the motion completely, which would eliminate pain but would not restore function of the joint. 

The diagnosis of tarsal coalition is often aided with the use of CT scanning or MRI.  These advanced imaging modalities aid the surgeon in planning the appropriate treatment, and can evaluate the extent of the coalition.  They can also be used to uncover a coalition that can not be seen on x-ray.

Central Florida Foot and Ankle Center 

101 6th St Nw Winter Haven, Fl 33881 

Phone: (863) 299-4551 

www.FLFootandAnkle.com

Joint Mobilization in the Foot and Ankle

Joint mobilization is a technique that is often used in the rehabilitation of foot and ankle injuries. It involves the passive movement of a joint by a trained professional, often a physical therapist or a doctor. Joint mobilization is generally categorized into five different types of mobilization. The five grades of joint mobilization are classified based on the mechanoreceptors being activated.

Grade I joint mobilization is directed towards cutaneous mechanoreceptors, and the motion involves a minimal amount of tension on the joint through oscillation. Grade II is similar to Grade I, but has a higher amount of tension placed through the joint and affects a greater amount of mechanoreceptors. Grade III selectively activates more of the joint and muscle mechanoreceptors and less of the cutaneous receptors. Grade IV has a sustained movement at the end range of motion at the joint, and is targeted more towards the slow adapting mechanoreceptors of the joints and tendons. Grade V joint mobilization is also referred to as a manipulation, and involves a more rapid movement of the joint at its end range of motion.

Often times there is a limitation in motion at the ankle joint as a result of injury or prolonged immobilization secondary to surgery or casting. Limited range of motion in the direction of dorsiflexion is referred to as equinus, and is often the cause of foot problems and pain. Research has shown that joint mobilization at the ankle joint can help improve range of motion. A study by Green et al. in 2002 showed that patients who sustained an acute inversion ankle sprain, when treated with certain types of mobilizations of the ankle showed improvement in pain levels and functional outcomes. Similarly, Landrum et al. showed an improvement in range of motion following prolonged immobilization of the ankle. Dorsiflexion following joint mobilization was improved.

Joint mobilization of the ankle joint is typically done in combination with the subtalar joint, as these two joints work closely together during movement of the ankle and rearfoot, and are commonly both injured in strains and sprains. It is generally combined with muscle strengthening and stretching exercises that will also help to improve range of motion and lead to a better functional outcome. A rehabilitation program is typically devised between the doctor and the patient following an injury to the foot and ankle, or in cases of surgical reconstruction following trauma or a chronic condition.

Central Florida Foot and Ankle Center

101 6th St Nw

Winter Haven, Fl 33881

Phone: (863) 299-4551
www.FLFootandAnkle.com

Subtalar Joint Arhtroereisis

Subtalar joint arthroereisis is a procedure performed for the correction of a flatfoot deformity. It is most commonly performed in children with a flatfoot deformity that is reducible (meaning that the corrected position can be achieved with manipulation) but may also be used in the adult population for correction of a flexible flatfoot. For very young children, it is frequently performed as an isolated procedure. For older pediatric patients and for adults, it is commonly performed along with adjunct procedures such as an Achilles tendon lengthening, gastrocnemius recession, tendon transfer procedures, arthrodesis of adjacent joints of the foot, or osteotomies that help realign the foot into a more functional position.

Arthroereisis (also known as arthrorisis and arthroerisis) is defined as the limitation or restraint of excessive or abnormal motion across a joint. For those with pes planovalgus, or a painful flatfoot deformity, this excessive motion is corrected at the subtalar joint. The subtalar joint in this foot type is deviated medially, creating a foot that functions with the subtalar joint in its maximally pronated position. This results in a dull, achy, or throbbing pain in the arch of the foot or in the leg, fatigue of the foot and leg, and pain in the lateral foot over the sinus tarsi. In the pediatric patient, who may not necessarily complain of pain, symptoms may include generalized clumsiness, easy fatigue, difficulty in sports and recreation, complaints of leg or foot tiredness or aches, excessive shoe wear, and a refusal to walk long distances or participate in physical activities.

Arthroereisis is a surgical procedure, and should only be attempted after conservative measures have failed to provide relief. Conservative measures may include the use of orthotics, other methods of padding and taping, and possibly the use of cortisone injections in older patients. When conservative therapy has failed, surgical intervention may become an option.

Arthroereisis is performed by placing an implant into the sinus tarsi, which limits the motion of the subtalar joint. Specifically, the motion that is blocked is the anterior displacement and adduction of the talus, which prevents excessive pronation at the joint. This effectively corrects the flatfoot deformity at the subtalar joint, creating a foot the functions closer to normal.

The implants used in arthroereisis procedures were described by Vogler based on his interpretation of how they functioned. These three categories were the stable self-locking wedge implants, the axis-altering implants, and the direct impact implants. This classification has more recently been criticized due to a perceived overlap in function of the various devices used.

The most popular type of implant used is the Maxwell-Brancheau (MBA) implant. The MBA implant is a small, bullet-shaped device that is placed into the sinus tarsi underneath the neck of the talus. It is composed of a titanium alloy, and functions to absorb much of the shock that is placed through the bones during weight-bearing activities. The device prevents the anterior displacement and adduction of the talus, thus reducing pronation at the subtalar joint. The devices are typically left in indefinitely, unless they cause pain or discomfort later. If that is the case, they can be taken out through a relatively simple hardware removal procedure. More recently, absorbable devices have hit the market that are completely resorbed by the body in one year.

Other implants come as alternatives to the MBA implant, such as the STA-peg device. This implant has a small stem that must be inserted into the floor of the sinus tarsi through a small drill hole. The top of the device creates a functional block for the talus, and prevents the anterior displacement and adduction by blocking the lateral process of the talus. Thus, these devices were referred to as the “axis-altering” devices in the past. However, because of the additional drilling of the calcaneus that is necessary for implantation of the device, as well as the necessity of bone cement to hold it in place, the STA-peg has become a less popular option for subtalar joint arthroereisis.

Central Florida Foot and Ankle Center

101 6th St Nw

Winter Haven, Fl 33881

(863) 299-4551

www.FLFootandAnkle.com

Common Benign Tumors of the Foot and Ankle

When looking at any new lesion on the body, the first thing to think about should be differentiating between benign and malignant lesions. New lumps and bumps on the body can be of great concern to a patient, as they may have the tendency to think of them as cancerous. While it’s true that a new lump or bump of the foot and ankle may be malignant, most soft tissue tumors of the foot and ankle tend to be benign.

Important things to consider when deciding whether a lesion looks malignant or not include it’s rate of growth, its resemblance to the surrounding tissue, any invasion into surrounding tissues, size, whether the lesion is fluid-filled, and whether or not the lesion is freely movable. A benign lesion will typically show a steady growth rate, will resemble the surrounding tissue that it is in, will be freely movable, will typically be small, will not invade surrounding tissues and/or bone, and will commonly be cystic or fluid-filled. This last piece can be evaluated with trans-illumination of the lesion.

Some of the most common benign tumors of the foot and ankle include ganglion cysts, plantar fibromas, lipomas, neurofibromas, and neurolemoma.

Ganglion Cyst – These are soft, well-circumscribed, cystic masses that are often seen on the dorsum, or top, of the foot. They result from a weakness in the tissues surrounding a tendon or a joint, and will cause an out-pocketing of the fluid within the tendon or joint. They can be very painful, particularly when they rub against a shoe or compress a close-be nerve. They can also be present in the wrist. Historically they have been referred to as “bible bumps” due to the primative treatment of popping them with a heavy book, such as a bible. Today, they are more appropriately treated by surgical excision.

Plantar Fibroma – These lesions represent a thickening of the plantar fascia, which is a thick band of soft tissue that runs along the bottom of the foot. Most commonly, plantar fibromas are found in the central or medial portion of the plantar fascia. Between 10-15% of people will have them on both feet, and they can cause a considerable amount of pain due to the pressure that they cause on the foot when walking or standing. These two can be treated with surgical excision, but have a high rate of recurrence.

Lipoma – This is the most common of the benign soft tissue tumors. It results from a localized overgrowth of the fat cells in a particular area of the body, commonly seen in the foot. They are a soft, freely movable mass that may compress neighboring nerves, or cause pain with walking or standing. They can be treated with surgical excision.

Neurofibroma – These are tumors of the spindle cells found within a nerve, causing expansion of the nerve. Neurofibromas may affect both superficial and/or deep nerve. The superificial neurofibromas are often romeved, while the deep ones are often left alone, as they can be difficult to remove and may result in complications. A disorder known as von Recklinghausens disease is associated with the formation of many neurofibromas, some of which may turn malignant.

Neurolemoma - This is a tumor of a peripheral nerve sheath, which covers all peripheral nerves. They result in small, tender nodules along the nerve, which can be exquisitely painful. They typically effect the major nerves of the foot and ankle, and may be removed by teasing them out of the nerve surgically.

Many other soft tissue masses may present in the foot and ankle – this list is only some of the more common findings to affect the region. A doctor should examine any new or painful lesion. Imaging tests such as x-ray or MRI can be used to further evaluate the lesion. For unknown lesions, biopsies may be taken either as diagnostic testing or as definitive treatment.

Central Florida Foot and Ankle Center

101 6th St Nw Winter Haven, Fl 33881

Phone: (863) 299-4551

www.FLFootandAnkle.com

Chemical Matrixectomy for Ingrown Toenails

Ingrown toenails are a common complaint of patients visiting a podiatrist. This involves the nail plate growing into the surrounding skin, most commonly at either the medial or lateral borders of the nail, with or without a localized infection. They can be very painful, and generally will worsen over time. In the presence of infection, a small abscess may form at the area of the ingrown nail, with a small amount of pus present. The infected skin will become red and swollen, and there will likely be some discharge from the area.

In the podiatrist’s office, these are typically dealt with by excising the offending border of the nail. This consists of making a small cut in the nail longitudinally, and rotating the ingrown border out of the skin. This procedure is done under local anesthesia to minimize the discomfort to the patient during the procedure.

Once the nail border is taken out, a common procedure is the chemical matrixectomy. This involves taking a strong chemical and essentially burning the nail matrix that produces the nail. By burning the matrix, the nail is prevented from growing back in that area, thus preventing recurrence of the ingrown toenail. The chemical matrixectomy has a very high success rate, with a reported recurrence of only 5-7%.

The process most commonly involves the use of phenol, a strong chemical used to burn the nail matrix. Phenol causes proteins to denature, which will not allow the nail to grow back where it is applied. The phenol is usually applied to the nail matrix several times. A piece of gauze may be used to protect the surrounding tissues, so that they are not damaged by the phenol. After the use of phenol, alcohol may be used to dilute the solution. The procedure is commonly referred to as a “P&A”, which stands for phenol and alcohol.

Some clinicians may prefer to use sodium hydroxide to remove the nail matrix, though phenol is much more commonly used. If sodium hydroxide is used, it is followed by an application of acetic acid to neutralize the reaction and stop the damage to the tissues.

Following the chemical matrixectomy, the surgical site is treated like a burn. Silver Sulfadiazine is often used as an antibiotic, and the wound is dressed with a bandage. The procedure will generally heal very well, with minimal time off of work and activity. Generally the doctor performing the procedure will want to follow up with the patient in a week’s time to ensure that the site is healing and there is no infection.

Central Florida Foot and Ankle Center

101 6th St Nw

Winter Haven, Fl 33881

(863) 299-4551

www.FLFootandAnkle.com

Surgical Correction of Brachymetatarsia

Brachymetatarsia is a term used for a shortened metatarsal. The metatarsal may be significantly shorter than normal, which can cause cosmetic displeasure, functional limitations, and secondary callus formation to any areas of skin that may be rubbing against each other or against a pair of shoes. Those with brachymetatarsia and subsequent digital deformities may have difficulty finding shoes that fit them comfortably.

Most commonly, brachymetatarsia affects only one metatarsal. The most common metatarsal affected is the fourth metatarsal. Causes of brachymetatarsia may include trauma, post-surgical brachymetatarsia, or associated with a specific disease process such as Down’s Syndrome, Apert’s Syndrome, osteodystrophy, sickle cell anemia, or poliomyelitis. However, it is most frequently a congenital deformity with no specific underlying cause.

Clinically, it is common to see the digit attaching to the affected metatarsal cocking upwards, and often with an under-riding digit next to it. This is frequently seen with fourth metatarsal disease, where the fourth digit rides up in the air, and the fifth digits lies underneath the fourth. A callus on the plantar surface of the foot (bottom) is frequently seen in the area underneath the head of the fourth metatarsal, due to increased pressure in the area.

There are three categories of surgical correction of brachymetatarsia. All three methods involve lengthening the bone, but go about it in different ways.

One method is to use a bone graft to lengthen the bone. This method requires a single surgical intervention. A cut is made into the bone and a bone graft is placed between the two cut ends to lengthen the metatarsal. The bone graft used may come from the patient’s own bone, commonly the iliac crest (hip bone), or it may be a synthetic bone graft that is used. Complications of this type of surgery include damage to the soft tissues of the digits, particularly the nerves and arteries than run into each digit. With a single incident of elongation, these neurovascular structures can become damaged.

Another method is with the use of callus distraction. In this method, A cut is made through the metatarsal. However, instead of filling in this space with the desired length, an external fixator device is attached to each end of the cut bone. This device allows for a more gradual lengthening of the bone, typically at a rat of about 0.5mm per day. The external fixator device uses pins to go through the bone and come out through the skin, and rings attach to these pins. The device can then be lengthened daily to distract the healing bone, thus lengthening it in the process. The downside to this particular method is that the device must be worn for a period of time until the desired lengthening is achieved. This can be particularly cumbersome in a child.

The last main category of surgical intervention for brachymetatarsia is a single operation involving a cut in the bone in such a way that it can slide to lengthen. This osteotomy is then fixed with screws and/or pins. This technique is not as popular of an option as the first two, as the surgeries have shown to be less successful.

With any of these surgical procedures, the goal is to re-establish a normal parabola for both the tips of the toes and the metatarsal heads (the portion of the metatarsal that attaches to the digits). The parabola to the toes addresses the cosmetic appearance, while the parabola to the metatarsal heads addresses the functional outcome. Functionally, the joints at the metatarsal and the digits (the metatarsophalangeal joints, or MTP’s) aid in propulsion while walking. The parabola is determined by looking at an x-ray, which will aid the foot surgeon in planning the operation.

Many times, other procedures are combined with the lengthening of the affected digit. This may include shortening of the adjacent metatarsals, as they are often elongated in cases of brachymetatarsia. In other words, if the fourth metatarsal is too short, the third metatarsal may be too long. Thus, lengthening the fourth and shortening the third would be required to establish a normal foot.

When brachymetatarsia occurs in several metatarsals, they will all be addressed at once. This way, the surgeon can establish a foot that is more functional, alleviates any pain or discomfort associated with the deformity, and is aesthetically pleasing to the patient.

If you have symptoms similar to those of brachymetatarsia, discuss them with your doctor or foot and ankle surgeon. A proper examination is essential, including x-rays to evaluate the bone structure of the foot.

Central Florida Foot and Ankle Center101 6th St Nw Winter Haven, Fl 33881Phone: (863) 299-4551www.FLFootandAnkle.com

Cold Injuries

With the winter months upon us, cold injuries are becoming more commonly seen in the community. This is particularly true in cold climates, but it doesn’t take freezing temperatures to cause cold injury. With the addition of a moist environment and prolonged exposure to the elements, cold injuries can be seen in moderate temperatures. Here are five different types of cold injuries, and some of the key aspects of each:

• Trench Foot – Trench foot was named after the injuries mostly seen during World War II. It occurs at temperatures above freezing, and has been reported to occur in temperatures up to 60 degrees Fahrenheit. When the feet are exposed to a cold, damp environment for an extended period of time, that is when Trench Foot may appear. The addition of a constrictive shoe causes blood to leave the feet, further adding to the problem. The affected foot, ankle, and leg will be swollen and cold, with blotchy skin. It is typically painful or numb, and will usually be red. There may or may not be bleeding blisters on the feet as well.
• Immersion Foot – This is a condition that occurs after exposure to a wet, warm environment, typically for a period of longer than 48 hours. The skin will appear blanched, and there may be macerations on the feet as well. This condition appears very similar to Trench Foot, but is usually associated with a longer period of time.
• Frostnip – Frostnip is a superficial cooling of the tissues without cellular destruction, even though there is formation of ice crystals within these tissues. The term frostnip is often used synonymously with a first degree frostbite. It most commonly effects areas exposed to freezing temperatures or areas of poor circulation, such as the cheeks, earlobes, nose, fingers, and toes. There is typically pain, numbness, or tingling to the effected area, and a paleness to the skin. Frostnip will usually resolve with re-warming, and will not typically leave any permanent tissue damage.
• Frostbite – Frostbite is perhaps the most commonly seen of the cold injuries, particularly in cold climates. It occurs when the body is exposed to freezing temperatures and can occur in minutes to body parts that are already cold, such as the fingers and toes, as well as the nose and earlobes. Additional contributory factors include wind chill, wet clothing, alcohol or tobacco use, poor circulation, diabetes, neuropathy, or in patients taking beta-blockers. Frostbite is often classified based on the extent of damage, ranging from superficial damage like frostnip, to serious, life-threatening damage including gangrene and loss of the part.
• Pernio (Chillblains) – Pernio, sometimes called Chillblains or erythrocycosis, refers to inflamed tissue of a of a purple or red hue that develops in response to repeated exposure to cold, damp conditions above freezing. It is most commonly seen in children, and typically appears as circular markings on the tips of the toes or fingers. It may be associated with a burning, tingling, or itchiness as well.

The most important piece of the treatment for any of these conditions is the recognition of risk factors and prevention. The elderly are at a particularly high risk, due to susceptible tissues and poor circulation. Also at risk are the homeless, and anyone who spends a lot of time outdoors for extended periods of time, such as outdoor enthusiasts and hunters. Diabetics are also at high-risk, often due to poor circulation as well as neuropathy.

Preventative measures include wearing proper shoes in inclement weather. Waterproof shoes and boots should be worn in any type of damp environment, particular if the exposure time will be for longer than an hour. Socks should be changed when they become damp, and wool or acrylic socks should be worn by those that plan on being outside for extended periods of time.

Re-warming the effected areas may be done by either passive or active re-warming. Passive re-warming involves using one’s own body heat to re-warm. This may include keeping the area, such as the hands, tucked underneath the armpits or within a blanket. Active re-warming uses outside heat to re-warm, such as warm liquids and drinks. A good drink should be warm, non-alcoholic, and without caffeine. The presence of alcohol or caffeine may actually decrease body temperature, further exacerbating the problem.

A patient should be re-warmed as quickly as possible, without burning the patient. Typically a patient should be re-warmed at a rate no faster than 1 degree Celsius per hour, to avoid pain and other complications. Re-warming areas with tissue damage can be painful, and pain medications are often given to combat this.

For most conditions, passive re-warming is adequate. It is important for someone with a cold injury not to try to warm themselves up by rubbing the area. The skin overlying the affected area is often quite macerated, and rubbing the area can cause a breakdown of the skin. When the body’s natural barrier is broken down, it can lead to infections and possible gangrene.

Central Florida Foot and Ankle Center

101 6th St Nw

Winter Haven, Fl 33881

Phone: (863) 299-4551

www.FLFootandAnkle.com

Charcot Foot

Also referred to as Charcot Arthropathy, Charcot Joint, or a neuropathic joint, Charcot Foot is a serious condition of the foot and ankle that is characterized by joint dislocation, fractures through weakened bone (pathologic fractures), and deformities of the foot and ankle. It is a progressive disorder that is associated with peripheral neuropathy. It was originally described as being caused by syphilis in the 1700’s, and was named for French neurologist Jean-Martin Charcot after he gave the first neurologic description of the disease in 1868. It has since evolved to be associated with a number of different causes of peripheral neuropathy, the most common of which is in association with diabetic peripheral neuropathy.

The incidence of Charcot Foot is relatively low, with ranges of 0.15-2.5% of diabetic patients developing the condition in their life. However, the incidence in specialized foot clinics has been reported as being as high as 13%.

The way that Charcot Foot develops is not completely understood. There are two theories for its development; the neurotraumatic theory and the neurovascular theory. The neurotraumatic theory describes Charcot Arthropathy developing due to repetitive trauma to the foot, that goes unrecognized by the insensate patient. The neurovascular theory describes the development of Charcot Arthropathy as being the result of an autonomic neuropathy that decreases blood flow to the lower extremity, thus decreasing bone synthesis and weakening the bones. The most universally accepted explanation for the pathogenesis of Charcot Foot is that it is a combination of these two events. That is, the neuropathic patient does not feel the damage that is being done to their already weakened musculoskeletal system.

Charcot Foot is classified using several different systems, most of which rely on which part of the foot is effected. Most commonly, the joints effected are the tarsometatarsal joints and the cuneonavicular, talonavicular, and calcaneocuboid joints. Charcot foot may also develop in the forefoot or in the ankle, those these scenarios are less common.

The signs and symptoms of Charcot Foot include a red, hot, swollen foot with intact skin. The affected foot is often several degrees warmer than the unaffected foot, and the patient is insensate. It is common for a patient with Charcot Arthropathy to also have an ulcer, which can complicate the diagnosis. In this case, the skin has been breached and infection is likely. Tests may be ordered to search for bone and/or systemic infection.

Treatment depends on the extent of the condition. Since there are a number of factors involved, including a patient’s general health, stage of the disease, and the presence/absence of infection, there are a number of considerations to plan for. The mainstay of treatment for the acute phase is to immobilize the foot and reduce the forces placed on the foot.

Immobilization is accomplished most frequently with a total contact cast. This is a cast that covers the entire foot, ankle, and leg. Casts are changed often, and serial x-rays are taken by the doctor to monitor the progression of the deformity. Infections are treated aggressively, and forces through the foot are addressed by having the patient in a non-weight bearing status.

After the acute phase, treatment is centered on prevention of recurrence. This includes measures such as treatment of the underlying condition (such as diabetes) as well as an emphasis on foot health. Proper fitting shoes are essential, and special shoes may be ordered or custom-made to reduce forces through the foot that can contribute to the development of Charcot Foot and ulcerations.

Surgery is warranted in some cases, where the deformity can be reduced and the progression of the disease can be prevented. An acutely inflamed foot is never operated on; the resolution of the initial symptoms is required before surgery can be planned.

While it may not be an extremely common condition, Charcot Foot is something that is always considered in the diabetic patient. It can be an extremely debilitating disease, and the progression can be unrelenting in some cases. Early detection is the key to a better prognosis, which is one of the many reasons why there is such an emphasis on foot health in the diabetic patient.

Central Florida Foot and Ankle Center

101 6th St Nw

Winter Haven, Fl 33881

Phone: (863) 299-4551

www.FLFootandAnkle.com