Tuesday, December 30, 2014

Adult flat foot repair with implant

There are many ways to fix a flat foot.   This patient is an older patient and lives alone, a 12 wks nonweightbearing in a cast after a triple arthrodesis procedure is not a good option for this patient due to social conditions.   Discussed using the hyprocure implant as an option to allow for quicker recovery.   The results for this patient was amazing.   She is ready to do the opposite foot, the trick of this surgery is to make sure the ligaments in the subtalar joint are released properly and proper sizing of the implant itself. 

right foot after implant / stent notice the arch
Notice left foot flattening

Monday, December 1, 2014

Lump on back of the heel: Haglund's deformity, Achilles tendonitis, Tendonosis

Lump on back of the heel is the complaint most people put as the reason for their office visit. Diagnosis for this case is:  Haglund's deformity (aka pump bump), Achilles tendonitis / Tendonosis

Burning in the achilles, unable to run, jump or wear shoes due to the rubbing of the achilles. 
Tightness in the Achilles

Conservative treatments:
See 1) NSAIDS such as motrin, etc if tolerated
2) Physical therapy
4) Ice
5) Avoid shoes that rub on that area. 
7) Platelet Injections / Stem Cell therapy

Diagnostic tests:
  • MRI will likely show degeneration, partial tears or chronic inflammation, value of such is questionable. 
  • Xrays are great for seeing the bony deformity that is causing this condition and surgical planning. 

Surgical treatment:
  • Removing of the Bump 
  • Removing of any spurs as indicated. 
  • Removing inflammed or damaged achilles tendon
  • Repair of the Achilles back into the insertion.
Below is an actual FFLC patient preop Xrays and clinical photos. 

Notice the bump right above the achilles insertion
Another view of the swelling
Side view of the painful bump
What is looks like on Xray, Multiple issues to be addressed.
1) Haglund's Deformity (top Arrow)
2) Insertional spur growing into the achilles tendon (bottom arrow)
3) bone cyst / erosion from chronic inflammatory condition. 

Patient is an active runner, pain immediately subsided after surgery. 
"Bump" no longer visible or irritated. 
4 wks in a cast, then another 2 wks in a boot that he can remove to start range of motion excercises. 
Physical therapy and boot to be used for walking at 6 weeks. 
Tens unit can be used to help with the cast disease that develops from not using the limb for some time. 

Overall, this is a very simple surgery to correct the condition.  Technique chosen by your surgeon varies.    I personally prefers to keep the achilles attachment and remove the spurs from varying angles to avoid prolonged recovery.  This also allows for anatomical repair without a question as to where mother nature intended. 

FFLC taking new patients
239 430 3668 option 2 for scheduling or you can request online through our PATIENT PORTAL. 

Bump on bottom foot aka plantar fibroma

Plantar Fibroma treated with conservative care at first at our center without avail.   Initial treatment consists of topical gel of Verapamil 15% gel and other topical compounds to help relieve the pressure and pain in an attempt to reduce the size but was to no avail. Typical protocol is 3 x a day application up to  9 months even.   She was not able to continue conservative care due to pain with every step. 

How are they formed? 
No true answer to this. Theories have involved: microtrauma, genetic predisposition, that causes the body to form extra fibrous tissue. 

Where are the fibroma commonly located in the foot? 
Typically the medial to central band of the plantar fascia. 
Medial being the side towards your big toe and central being around the 2nd and 3rd to region.  The photos below is a classic example of the fibroma in the medial and central bands. 

What are the chance of regrowth and is surgery successful? 
Fibromas have a high recurrence rate, up to 80% in some papers.    
Recommendation is usually to only remove such only if symptomatic. 
Symptoms can occur with even very small fibromas, some patients with even huge fibromas do not hurt. From experience the patients that complain about pain are those that have the fibroma growing right over a nerve, often an inflammed nerve is found under this fibroma.   The best case scenario is no regrowth or recurrence but next best out come is that if the fibroma regrows it forms in a different area that does not compress on the nerve. 

What steps can my doctor take to improve success? 
Papers have stated up to a 1.5 cm margin of regular tissue to be taken out in addition to the fibroma itself to reduce the chances of recurrence. 

I have them on my hands and my feet is that normal? 
Some people do have it in both areas but not always.  A hand surgeon or plastic surgeon will help address the hand lesions.  You have the same band of tissue called the aponeurosis in the hand as well as the foot. 

If you or loved ones have this condition call us at 239 430 3668 option 2 to schedule an appt!

Preop from the side of the Fibroma
Bottom look at the fibroma, see the dark area
 due to rubbing of the fibroma in her shoes. 
z incision made for adequate exposure for removal
Note the lesion with viable margins also removed
 to help  prevent regrowth