Foot and ankle issues in collagen
vascular disorders
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Patrick Agnew, DPM, FACFAS, FACFAP, Virginia Beach, VA
Director, Eastern Virginia Medical School PMS 24
Past President ACFAPediatrics
Captain, (SCWO), MSC, USNR-R
Previous research
• Common foot problems identified by survey,
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Seattle, WA
Xrays taken at Detroit Children’s Hospital evaluated
Footmax scans collected, Philadelphia, PA
Collagen vascular disorders
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Ehlers-Danlos Syndrome
Marfans Syndrome
Osteogenesis imperfecta
Etc….
Special considerations
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Soft tissue handling
Vascular fragility?
Bone fragility?
Over pronation or sagging
Ankle may still be tight!
Common foot problems
• Hypermobility
• “Flat feet” with or without over pronation
Common foot problems
• Uncommon
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manifistations
“Bunions” with joint
fluid leak (ganglion
cyst)
Principles of podiatric intervention
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Align and maintain functional anatomy
Avoid skin injury
Don’t rely on ligaments
Select and time invasive intervention carefully
Align and maintain functional anatomy
• Foot orthoses-> controversial
• Arthrodesis -> anecdotally mediocre results
• Osteotomies -> more reliable, much experience
• Arthroresis -> controversial but promising
• Ligament replacement -> new devices
Sub talar arthroresis
Subtalar Arthroresis
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History/variations
goals
Disadvantages
Advantages
HISTORY
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bone procedures
Chambers 1946: bone block
Subotnick 1974 silastic carved plug
Current:
Metal implants
Absorbable implants
HISTORY
• Polymers
• Metals
• absorbable
Goals of STA
• Relief of pain
• Improved joint
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alignment and
function
Interruption of pathomechanical
progression
“correction” 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
Diagnosis
• Infancy
• Toddler
hood
• Childhood
• Adultery ;)
Multiplanar deformities
Prognosis
• No reliable method
• Uncompensated:
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styloid process, HAV?,
ankle injuries, lateral
knee?, claw toes…
Compensated:
complex over
pronation, HAV?,
hammertoes
Management
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Observation(?)
“stretching”(?)
Casting
Splinting
Shoes(?)
Surgery
Good solutions for bad ligaments
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Strong: absorbable vs non absorbable
Minimally invasive (small incisions)
May obviate some bone surgeries
May permit weight bearing immediately
External fixation
• Mini rails
• May obviate
second
surgeries,
may result in
less bone
surgeries
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