ARCH PPT.

A SEMINAR ON ARCHES OF FOOT AND ITS RELATED

DISORDERS

PRESENTED BY

DR. BHARAT DURGIA

PG, ORTHOPAEDICS

GMCH

MODERATOR

DR. K. C. SAIKIA

PROFESSOR, ORTHOPAEDICS

GMCH

DATE: 23RD DECEMBER’09.

ANATOMY OF FOOT

• 28 bones including 2 sesamoids.

• 14 phalanges• 5 metatarsals• 7 tarsals

JOINTS OF THE FOOT anatomy contd…

THE FOOT• pliable platform to support the body

weight

• lever to propel the body forward

• The ligamentous bony arrangement of the foot allows considerable flexibility/deformation with weight bearing contact

ARCHES OF FOOT

ARCHES OF FOOT

• Distinctive feature in man

• Present since birth

• Segmented

• Provides concavity

CLASSIFICATION OF ARCHES

LONGITUDINAL ARCH

• formed between posterior end of calcaneus and head of the metatarsals

• highest on the medial side MEDIAL LONG. ARCH

• lowest on lateral side LATERAL LONG. ARCH

TRANSVERSE ARCH• highest in a coronal

plane that cuts through the head of the talus

• disappears near the heads of the metatarsals

FORMATION OF THE ARCHES

MEDIAL LONGITUDINAL ARCH Ends- anterior end is formed by the

heads of the 1st ,2nd & 3rd metatarsals. posterior end is formed by the medial tubercle of the calcaneum.

Summit- superior surface of body of the talus.

Pillars- The anterior pillar - formed by the talus, the navicular, the 3 cuneiform and the 1st three metatarsal bones. The posterior pillar- formed by the medial part of calcaneum.

Joint- talocalcaneonavicular joint.

LATERAL LONGITUDINAL ARCH• Ends- anterior by the head of 4th and

5th metatarsal bone & posterior by the lateral tubercle of the calcaneum

• Summit- at the level of the articular facets on the superior surface of the calcaneum

• Pillars- anterior by the cuboid and 4th and 5th metatarsals. The posterior pillar by the lateral half of the calcaneum.

• Joint- calcaneocuboid joint,

LATERAL LONGITUDINAL ARCH contd……

• characteristically low and has limited mobility

• built to transmit weight and thrust on the ground thereby helping in balancing act.

TRANSVERSE ARCHES

ANTERIOR TRANSVERSE ARCH

• formed by the head of the five metatarsal bones.

• complete arch

POSTERIOR TRANSVERSE ARCH

• formed by the greater part of the tarsus and metatarsus.

• incomplete

MAINTENANCE OF ARCHES

FACTORS RESPONSIBLEBony factors-• Important for the posterior

transverse arch

Intersegmental ties-(Ligaments /muscles)

• The spring ligament-for medial longitudinal arch.

• The long and short planter ligament-for the lateral longitudinal arch.

• Interosseous muscle-for transverse arch.

FACTORS RESPONSIBLE contd…….

Tie beams-(Bowstrings) • It connect the two end of

the arch.• Longitudinal arch- the

planter Aponeurosis.• The muscles of the first

layer of sole.• Transverse arch-

adductor hallucis muscle.

Slings-• They keep the summit of

the arch pulled up.•

THE LONGITUDINAL ARCH• The medial longitudinal arch is

pulled upward by the tendons of the posterior compartment of the leg to the sole.

• The lateral longitudinal arch by the peroneus longus and peroneus brevis.

• The tendon of tibialis anterior and peroneus longus together form a sling ( or stirrup) which keeps the middle of the foot upward.

The transverse arch• Maintained by Peroneus

longus tendon as it passes across the sole it pulls the medial and the lateral margin of the sole together.

• Tibialis posterior also supports the transverse arch which grips many of the bones of the sole through its slips.

FUNCTION OF THE ARCHES OF FOOT

distribute the body weight to mainly the heel and the toes.

act like a spring great help in walking and running.

act as shock absorbers in stepping and jumping.

protect the soft tissues of the sole.

MOVEMENTS OF THE FOOT

• Dorsiflexion-25*

• Planterflexion-35*

• Pronation (eversion plus abduction) -5*

• Supination (inversion plus adduction) -20*

BIOMECHANICS OF THE ARCHES

• mechanical stable six legged stool like structure

• 1/3rd of the subtalar joint range is available for pronation and 2/3rd for supination.

• For weight bearing no muscle activity to maintain the posture

• Functions as one link in a biomechanical kinetic chain

• stance phase of the gait cycle risk to musculoskeletal integrity

WINDLASS MECHANICS• Engineering concept

• Windlass mechanics are absolutely essential for correct foot function

• coordinated action of the layers of muscle, tendon, ligament and bony architecture, to maintain arch height and foot rigidity.

• 1st metatarsal must be allowed to planterflex

DISORDERS RELATED TO ARCHES OF FOOT

PES PLANUS• pes planovalgus, fallen arches,

flat feet or pronation of feet.

• loss of normal medial longitudinal arch

• flexible or rigid

• talonavicular subluxation throughout stance phase is a major biomechanical consequence

• higher incidence of low back pain

Pes planus contd……..

FLEXIBLE FLAT FOOT

the arch is normal when unloaded however with loading the arch is lost.

This is the most common type.

It is due to inadequate passive arch support (weak, loose ligaments).

Flexible Flat Foot Pes planus contd……..

Congenital conditions-

1. idiopathic calcaneovalgus deformity

2. Hyperpronation

3. accessory navicular

4. Marfan’s syndrome

5. fragile X syndrome

• Acquired conditions-

1. rheumatoid arthritis

2. plantar fascia rupture

3. tibialis posterior rupture

Pes planus contd……..

RIGID/FIXED/SPASTIC FLAT FOOT

• the arch is absent regardless of loading

• an acceptable medial longitudinal arch does not appear with weight bearing

• may be due to a congenital deformity

Pes planus contd…….

RIGID/FIXED/SPASTIC FLAT FOOT

Congenital causes

1. congenital vertical talus

2. tarsal coaliation

3. calcaneovalgus deformity

4. equinovalgus deformity

5. accessory navicular

Acquired causes

1. osteochondral fracture

2. juvenile rheumatoid arthritis

3. reactive peroneal spasm from fracture or chronic joint disease.

AFFECTS OF FLAT FOOT ON SUBTALAR JOINT

• with foot eversion, the calcaneus no longer supports the head of the talus, which deviates medially and plantar ward, dropping into the medial aspect of the foot arch becomes less pronounced

• axis of subtalar joint becomes more horizontal more inversion and eversion

• the longitudinal axis is moved more medially (than the normal 23 deg .) more dorsiflexion and plantar flexion

• this change in the sub-talar axis greater relative inversion-eversion and dorsiflexion and plantar flexion

pes planus contd…..

CLINICAL MANIFESTATIONSmust distinguish between flexible and rigid flat foot

hyper mobile foot forefoot varus heel cord contracture. Lateral deviation of Achilles

with weight bearing; severe Achilles contracture hyperpronation of hind foot. Supination of the forefoot everted heel with fails to invert

with toe raise; abducted forefoot;


X- RAYS• Standing lateral:

- normal straight line relationship between talus & first metatarsal; lost

- sag at either the talonavicular or naviculocuneiform joint;

(Talus- 1st metatarsal angle-

Normal-0*

Mild deformity-<15*

Moderate deformity-15-30*

Severe deformity->30*)

• Standing AP views: -degree of heel valgus

-degree of talo-navicular uncoverage / subluxation;

•


TREATMENTNON OPERATIVE:- rarely requires treatment

main emphasis of treatment heel cord stretching

SUPINATE the foot while stretching in order to "lock the midfoot“

in most cases orthotics are ineffective

in some cases, patients with a calcaneovalgus deformity medial heel wedge can be used

many feet improve as the child ages, at least until 5 to 6 yrs old, so orthotics are unnecessary in them.

OPERATIVE PROCEDURES1. Durham flatfoot plasty

(Caldwell; coleman)

• Indications are flexible pes planus, failure of prolonged conservative treatment to relieve foot pain, and abnormal shoe wear.

• Advancement of the tibialis posterior and osteoperiosteal flap with arthrodesis of the navicular first cuneiform joint.

2. Posterior calcaneal displacement osteotomy (koutsogiannis) –

• in symptomatic pes planus with excessive valgus deformity. Calcaneal osteotomy is done to displace the posterior part of the calcaneum medially to restore normal weight bearing alignment.

•

3. Anterior lengthening-distraction wedge osteotomy (dilwyn evans; mosca)-

Calcaneum is lengthen by inserting a corticocancellous bone graft just proximal to the calcaneocuboid joint.

4. Triple arthrodesis-

when the deformity becomes progressively more fixed and symptomatic

after 12 years of age

5.. Kinder procedure-

• excision of the accessory navicular and rerouting the tibialis posterior tendon into a more planter position.

CONGENITAL VERTICAL TALUS

• Most common cause of rigid flat foot

• Rigid, rocker-bottom type of planovalgus foot, with the hind foot in equinus and the forefoot abducted and dorsiflexed

• axis of talus passes below the first metatarsal-cuneiform axis, and the talocalcaneal angle is >40⁰.

• Associated with number of neuromuscular disorders

Cong. Vertical Talus contd…..

Pathology

detected at birth by the presence of a rounded prominence of the medial and plantar surface of the foot produced by the abnormal location of the head of the talus.

talus is distorted plantarward and medially vertical

the navicular lies on the dorsal aspect of the foot anterior and inferior to the lateral malleolus.

ADAPTIVE CHANGES IN TARSALS

• Talus assumes shape of an hour-glass; in marked equinus position; only the posterior third of its superior articular surface articulates with the tibia.

• Calcaneus goes in equinus position and get displaced posteriorly, with plantar surface becoming rounded

Callosities develop

• With full weight is bearing, the forefoot becomes severely abducted, and the heel does not touch the floor.

• Adaptive changes in soft tissue structures also

CONG. VERTICAL TALUS CONTD……

CLINICAL PRESENTATION

• talar head is prominent medially, convex sole, forefoot is abducted and dorsiflexed, & the hind foot is in equinovalgus;

• rigid flat foot deformity

• sole of foot has a rocker-bottom (convex) deformity

• patient demonstrate peg-leg gait (awkward gait with limited forefoot push off);

CONG. VERTICAL TALUS CONTD…..

RADIOGRAPHPLANTAR FLEXION VIEW:

(LATERAL)

In normal foot the long axis of the first metatarsal passes planter ward to the long axis of the talus.

In congenital vertical talus the axis of the first metatarsal remains dorsal to the long axis of the talus, indicating dorsal dislocation of the midfoot and forefoot.

TREATMENT

NON OPERATIVE

Conservative treatment controversial

Gentle manipulation and immobilization in cast will facilitate the surgery planned for later date

OPEARTIVE OPTIONS• Age and the severity of the deformity determines the type

of surgery.

• Child between 1-4 yrs Open reduction and realignment of the talonavicular and subtalar joint (Kumar, Cowell and Ramsay).

• Child with 4-8 years Open reduction and extra articular subtalar arthrodesis (Grice-green procedure)

• 12 years or more Triple arthrodesis

• Joystick method

Kumar, Cowell and Ramsay procedure

• Open reduction and realignment of the talonavicular and subtalar joint

Grice-green procedure

• Open reduction and extraarticular subtalar fusion

• Dennyson and Fulford modification with screw fixation

Kodros and Dias Joystick method

TARSAL COALITION• failure of segmentation of the

primitive mesenchyme

• Most common type is calcaneonavicular and talocalcaneal coalition.

• Calcaneonavicular coalition- ages 8-12yrs; may be bony, cartilaginous or fibrous

• Talocalcaneal coalition-12-16yrs of age; marked reduction or absent of subtalar motion

RADIOGRAPH

• for CN coalition oblique view

• lateral view may show talonavicular beaking

• talocalcaneal coalition C-sign

• CT-scan:• -best study, especially for

talocalcaneal coalition.

beaking of anterior aspect of neck of talus associated with middle facet tarsal coalition

Treatment• Initially conservative-a trial of reduced activity or cast

immobilization or both is done for 4-6 weeks.• Operative:-for persistent pain after conservative treatment.

For talonavicular coalition:• Excise coalition with wide bone block• Interpose extensor digitorum brevis, gel foam or bone wax

into the defect to prevent recurrence.

For talocalcaneal coalition:• In middle facet tarsal coalition, resection of the bar with

interposition of flexor hallucis longus or gel foam or bone wax into the defect.

Triple arthrodesis-in older patient with degenerative changes.•

PES CAVUS an abnormally high arch

• Hyperextension of the toes at the metatarsophalangeal joints.

• hyper flexion of the interphalangeal joints.• Pronation and adduction of the forefoot.• A “bony” dorsum of the midfoot with

wrinkled skin folds on the medial planter aspect.

• Lengthened lateral border and shortened medial border.

• Callus beneath the metatarsal head.• Varied stiffness of the subtalar joint.• Varus deformity of the heel.• Tightness of the tendoachillis with or

without equinus contracture.•

ETIOLOGY• associated with

neurologic disorders

• Exact cause can be determined by thorough history & investigations like EMG, MRI & NCV etc.

Causes are:-• Charcot Marie Tooth disease• Poliomyelitis• Spinal dysraphism• Cerebral palsy• Primary cerebellar disease• Arthogyropsis• Severe clubfoot • Friedreich ataxia• Post-traumatic• Idiopathic

EXAMINATION Lateral block test

(Coleman and Chesnut block test )

• Assesses hind foot flexibility of cavovarus foot (flexible feet correct to normal).

Muscle strength and flexibility

Scoliosis & thorough neurological

examination.

Plantar flexed first metatarsal is allowed to hang free from block; supple hind part of foot then corrects

RADIOGRAPHS• In 1940, Brockway stated that

“cavus feet should never be operated upon until radiographs with the patient standing have been taken.”

• Standing lateral view : assessment of ankle joint position, calcaneal pitch (measures the degree of Calcaneal deformity) & midfoot and forefoot position, (especially the degree of plantar flexion of the 1st ray)

• -x-ray of the entire spine

TREATMENT• correction of the separate components within the foot and the

ankle.

• CLAW FOOT 1. For fixed contracture of the MTP & IP joints• Lengthening of the EDL & EHL• Tenotomy of the EDB & EHB• Dorsal capsulotomy of the MTP joints• Resection of the head & neck of the proximal phalanges• Release of the planter fascia, if indicated.• Arthrodesis of the IP joints of the hallux with temporary fixation with k-

wires.

b) Modified Jones procedure for clawing of great toe-

• Tendon suspension of the first metatarsal-the EHL tendon is attached to the neck of 1st metatarsal.

• IP joint arthrodesis with k-wire.

FOREFOOT EQUINUS• a) Proximal metatarsal

osteotomy and planter fasciotomies (Gould)-

• Double planter fasciotomies.

• Closing wedge greenstick dorsal proximal metatarsal osteotomies.

• Jones procedure can be added.

• Equinus of the forefoot correction may also require the Hibbs procedure- which involves transfer of the EDL tendon to the 3rd cuneiform

Tarsometatarsal truncated wedge arthrodesis (Jahss)

• Arthrodesis of all the tarsometatarsal joints

• planter fascia release is not recommended.

• Not recommended for significant cavus deformity at the midtarsal level.

MIDFOOT CAVUS1. Anterior tarsal wedge

osteotomy (Cole)

• Midtarsal joints are preserved.

• Plantar fascial release may be required.

• Disadvantage: foot is shortened, widened

and thickened.

2. V-osteotomy of the tarsus (Japas)

• no bone is excised

• Proximal border of the distal fragment of the osteotomy is depressed planter ward

• Metatarsal head is elevated, thus correcting the deformity and lengthening the planter surface of the foot.

COMBINED CAVUS (Calcaneocavus deformity)

a) Calcaneal wedge osteotomy (Dwyer)

b) Cresenteric Calcaneal osteotomy (Samilson)

CALCANEOVARUS & CAVOVARUS

DEFORMITYa) Calcaneal triplanar osteotomy with lateral ligament

reconstruction

Peroneus brevis tenodesis (Myerson)

b) Triple arthrodesis

SUMMARY• Arches of the foot are important in distributing the weight of

the body and in the gait cycle, especially in stance phase.

• It acts as shock absorbers while walking and running and also protects the soft tissue of the sole.

• Disorders in the arches not only produce abnormality in the foot but also in the ankle, knee, hip, and spine

THANK YOU