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

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