Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
The podiatrist’s role in preventing falls in the elderly has recently got some attention at the international level. At the national meeting of the American Podiatric Medical Association, podiatrist Doug Richie Jr. presented information regarding the podiatrist’s role in preventing falls in the elderly. Some of the research that he presented was from a study by a podiatry group in Australia, who have contributed significantly to the understanding of the topic.
The Australian study led by by Dr. Martin J. Spink of La Trobe University looked at the effect of a multi-faceted podiatry intervention for older adults compared to routine podiatry care. Multi-faceted intervention was defined as the use of customized foot orthoses, advice on footwear and a subsidy for footwear, home-based foot and ankle exercises, a pamphlet of information regarding fall prevention, and routine podiatry care for a period of 12 months.
The study found that the group receiving the multi-faceted podiatry intervention suffered from 36% fewer falls than the patients randomized to the routine podiatry care group. Muscle strength, range of motion, and balance were all significantly and statistically improved in the intervention group when compared to the routine care group.
This study, in combination of what we already know about falls in the elderly, could be a very important piece of information in the way that health care is delivered. Fall prevention is a major priority in hospitals, with everyone involved in patient care also involved in the prevention of falls. Falls in the elderly can lead to disabling and even life-threatening injuries such as fractures and head injuries. It has been reported that over half of people over the age of 65 years will experience a fall each year, and that a third of these falls will lead to significant injury. The amounts to a health care cost exceeding $20 billion in the management of these injuries, which is projected to double in the next 15 years due to the aging population in the United States. Clearly, the cost associated with these serious injuries is a potential source of savings when discussing Medicare/Medicaid funding.
The role of the podiatrist in preventing falls is likely to increase with more knowledge and awareness of the subject. This prevention hinges on early detection of potential risk factors, including existing foot and ankle pathology, diabetic neuropathy, impaired vision, and impaired mobility just to name a few. Conservative measures such as muscle strength testing, range of motion testing, gait analysis, and the use of customized orthotics and bracing can have a great impact on the health and well-being of the elderly patient, and prevent a potential fall.
A newly emerging trend in foot and ankle surgery is the use of the Tightrope end-button device made by Arthrex. The device is a special type of suture material called fiberwire, attached to two small buttons at either end. A small needle is used to pass the suture through two bones, and then the suture material can be tightened to bring the bones together.
One of the uses of the device is in injuries to the tibiofibular syndesmosis. The syndesmosis is composed of several ligaments, including the anterior tibiofibular ligament, posterior tibiofibular ligament, and the interosseous tibiofibular ligament. Together this structure helps keep the fibular and tibia together, adding stability to the ankle joint.
In ankle fractures, the tibiofibular syndesmosis is often disrupted. If left unaddressed, the diastasis, or separation, between the tibia and fibula can lead to dysfunction and arthritis. A syndesmosis injury can often occur as an isolated event, sometimes referred to as a high ankle sprain.
The standard method of addressing this injury is to place a screw across the syndesmosis, sometimes referred to as a trans-syndesmotic screw. These are often placed through the bones until the ligaments can heal, and is then removed. However, complications such as broken screws and failed healing of the syndesmosis lead to research into alternatives.
The Tightrope design allows for some motion to occur at the tibiofibular syndesmosis. This allows for a more natural motion at the joint. The manufacturers state that the device never needs to be removed, so long as there aren’t any complications with the fixation, due to its allowance of micro-motion. This is in contrast to screw fixation, which necessitates another surgery.
Studies have shown good short-term results using the Tightrope for repair of syndesmotic injuries. It has been shown to be as effective as screw fixation in allowing for healing. While there are no long-term results available yet, nor are there any published studies comparing Tightrope fixation to screw fixation, the results thus far have been promising. Several studies are in development to more rigorously study this new form of fixation.
At least one study, however, has shown some complications from the use of the Tightrope device. Wilmott et al (Injury 2009) showed several soft tissue complications resulting from the use of the Tightrope. There study was small, however, and the patients involved in the study did show healing of the syndesmosis with use of the fixation device.
While it may be a new trend emerging in foot and ankle surgery, there is certainly more evidence necessary before Tightrope fixation for syndesmosis injuries can become the standard of practice. Larger, long-term studies will be necessary, comparing the device to fixation with screws.
The first metatarsophalangeal joint (MPJ, MTP Joint, or MTPJ) is highly susceptible to arthritis. This is the joint in your foot that attaches the big toe to the first metatarsal. It is a very important joint, and allows for propulsion during gait. There is a great amount of force that is put through the joint when walking, which is quickly absorbed through a number of joints in the foot. Because of this great amount of force place through the joint, it is also highly susceptible to arthritis.
Arthritis of the great toe joint, much like arthritis of any other joint, can be very difficult to treat. It is a painful condition that doesn’t always respond well to medications. There is no real cure for arthritis, and some people are affected by it at a much earlier age than others. Arthritis of the first MPJ is complicated by the fact that it is a weight-bearing joint.
Conservative treatment of first MTPJ arthritis is generally focused on preventing the advancement of arthritis by accommodating any foot deformities that may be present with orthotic devices. A foot deformity that increases pressure or force at the first MTPJ will speed up the progression of arthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used, such as naproxen or ibuprofen. Icing, protective measures, heat, and a number of other non-surgical therapies are often used with varied results.
Surgical options for the treatment of first MTPJ arthritis include a number of procedures, including fusion of the joint, osteotomies (bone cuts), resection of some of the bone, and joint implants, to name a few. Joint implants come in a variety of designs.
One of the types of implants commonly used is the Swanson-type implant. This is an implant that is made of a silicone, and has two stems. One stem is placed into the metatarsal, and the other into the proximal phalanx. Some of the bone must be removed for each stem to fit into its respective end, and a small hole is reamed out to place the stem. Once the implant is placed, it creates a false joint. The first MTPJ, therefore, would have a more functional and painless range of motion. This is the goal of the surgery.
The implants have a lifespan of around 30 years, and are generally well tolerated. Occasionally the implants can breakdown at a faster rate, and cause a condition known as detritic synovitis. This is a condition caused by small particles of the silicone being sheared off within the joint, which leads to inflammation.
These double stem silicone implants are not for everyone, and are generally not used in younger patients, due to the lifespan of the implant. There are a number of different surgical methods for treating first MTPJ arthritis; this type of implant is only one.
Ankle fractures are one of the most common injuries to the lower extremity. The injuries are almost always due to a twisting injury, where the foot is planted flat on the ground and the leg is forced in a twisting or sliding pattern. Ankle fractures are a frequent occurrence in high impact sports, as well as from everyday-type injuries. The anatomy of the ankle helps to define this injury, and a number of structures are at risk.
The ankle joint is composed of the tibia and fibula, which are the bones of the lower leg, as well as the talus, which is a bone of the foot. The tibia and fibula join at the syndesmosis, a structure that is key in holding the ankle in place. The tibia and fibula form a groove for the talus to move through, ensuring stability through range of motion at the ankle. A number of ligaments hold these structures together, mainly the lateral ankle ligaments and the medial ankle ligaments. The medial ankle ligaments are commonly referred to as the deltoid ligament.
A series of tendons run across the joint from the leg into the foot. These tendons belong to muscles that control the movement of the foot, including plantarflexion (pointing the foot in a downward position), dorsiflexion (bringing the foot upwards), inversion, and eversion. There are also a number of arteries, veins, and nerves that run across the ankle joint that provide blood and sensation to the foot.
Injuries to the ankle, as common as they are, can be described by several different classification systems. The two most commonly used are the Lauge-Hansen and Danis-Weber systems.
The Lauge-Hansen system classifies ankle fractures based on the mechanism of injury, taking into account both the position of the foot at the time of injury as well as the movement of the leg. For example, one of the categories for the classification is supination-external rotation. The first term denotes that the foot was in a supinated position at the time of injury. The second term indicates that the leg was externally rotated in relation to the foot, causing the injury. The four categories originally described by Lauge-Hansen included supination-external rotation (the most common mechanism of ankle fracture), pronation-external rotation, supination-adduction, and pronation-abduction. Another category was later added, pronation-dorsiflexion, indicating that the force causing the injury was an axial force through the bottom of the foot that would drive the talus bone up through the tibia. This, however, is more appropriately addressed as a pilon fracture.
Within each category of Lauge-Hansen mechanism, there are different stages indicating how extensive the damage is to the ankle joint. These stages correlate with the ankle structures effected by the injury. Shown in the diagram above, starting from top left and moving clockwise, are the supination-adduction, pronation-abduction, pronation-external rotation, and supination-external rotation injuries. The stages indicate the structures involved.
Another commonly used classification system for ankle fractures is the Danis-Weber classification. This is based on the anatomy involved in the injury, particularly the tibia-fibula syndesmosis, which is the joint between the two bones. The classification is based on the level of the fibular fracture associated with the injury. If the fracture is below the level of the syndesmosis, it is considered a type A injury. Type B would be at the level of the syndesmosis, and type B would be above the level. Danis-Weber classification helps to indicate the amount of damage to the tib-fib syndesmosis. Levels B and C are associated with damage to the joint, which may lead to instability of the ankle if not addressed during the treatment of the fracture.
The classification of ankle fractures is a very academic topic, and is used primarily to communicate between physicians treating the injured patient. Other descriptors may be beneficial in describing the injury, but the classification systems are a quick and easy way to relate what is going on with the injury between doctors and those involved. Because of the reliable patterns of ankle fractures, these classification systems are fairly universal, and have a good inter- and intra-observer reliability.
The navicular bone, located on the medial (inside) foot, is sometimes associated with an accessory bone. This accessory bone is most commonly referred to as an accessory navicular or os tibiale externum, but may also be called navicular secundum, prehallux, bifurcate navicular, accessory tarsal scaphoid, extra scaphoid, or a divided navicular. The accessory bone may be fused (attached) to the navicular, or it may be located within the tendon of the posterior tibial muscle, which attaches to the navicualr at this point.
Accessory navicular is present from birth, and results from a secondary ossification center of the bone. This means that there is an additional area of bony growth in the growing foot, which may eventually attach to the main portion of the navicular by either a bony attachment or with cartilage.
Symptoms of an accessory navicular include pain associated with shoes rubbing against the bony prominence, or pain developing from an eversion-type twisting injury. In the event of a twisting injury, the accessory bone may become detached from the main body of the navicular, essentially acting as a fracture of the bone.
Identification of the os tibiale externum, or the accessory navicular, begins with a thorough hirtory and physical examination. Frequently the accessory bone can be felt through the skin, or even seen on gross examination. X-rays are typically required to differentiate the accessory bone from an enlarged navicular or any other type of fracture of the bone. An MRI is not always necessary, but may be ordered if the diagnosis is not definite.
Once the condition is recognized, treatment may begin with conservative therapy, often involving padding the area and preventing it from rubbing against a shoe. In the event of a fracture through the bone, or a detachment of the bone from the main body of the navicular, it may be immobilized in a hard or soft cast. A number of factors play a role in this clinical decision-making.
Eventually, surgical removal of the accessory bone may be required to alleviate the symptoms. Depending on the particular type of accessory navicular, a number of different surgical techniques may be used. This is at the discretion of the treating foot and ankle surgeon. Typically, the offending bone will be removed in order to relieve the symptoms.
Post-operative care generally consists of protection with a cast, or a soft bandage and a surgical boot. Keeping off of the foot is usually indicated in allowing the foot to heal. Some pain and swelling should be expected. Analgesics may be used to alleviate some post-op pain, and elevation, ice, and rest are typically used to remove some of the swelling associated with the surgery. Details of the surgery may be discussed with your foot and ankle surgeon, including post-operative planning and the risks associated with surgery.