foot drop foot drop chairpersons : dr. rupakumar.c.s. dr. ravikiran presented by : dr. syed imran
TRANSCRIPT
![Page 1: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/1.jpg)
Foot Drop
Chairpersons : Dr. Rupakumar .C.S. Dr. Ravikiran
Presented by : Dr. Syed Imran
![Page 2: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/2.jpg)
Definition : Inability to actively dorsiflex and evert the foot.
Introduction : Foot drop is a condition where the propulsion is partially impaired due to changes in gait.
![Page 3: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/3.jpg)
Anatomy of leg :Two muscular septa divide leg
into three compartmentsAnterior ( Extensor) compartmentLateral ( Peroneal ) compartmentPosterior ( Flexor ) compartment
![Page 4: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/4.jpg)
![Page 5: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/5.jpg)
Extensor compartment
![Page 6: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/6.jpg)
Lateral Compartment :
![Page 7: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/7.jpg)
Posterior Compartment :
![Page 8: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/8.jpg)
![Page 9: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/9.jpg)
Common Peroneal NerveHalf size of tibial nerveL4,5,S1,2Enters leg antero- laterally• Branches
![Page 10: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/10.jpg)
Sup Peroneal NerveSuperficial fibular NDeep to peroneus Longus then passes Anteroinf b/w peroneus longus and EDL
![Page 11: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/11.jpg)
Deep peroneal NerveOblique forward deep to EDL to
front of interosseus membrane and reaches Ant.Tibial artery in proximal 1/3
Branches
![Page 12: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/12.jpg)
![Page 13: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/13.jpg)
Etiology :Neuromuscular diseasePeroneal NerveSciatic NerveLumbosacral plexusL5 Nerve rootSpinal cord ( poliomyelitis, tumour )Brain ( Stroke, TIA )Genetic ( CMT )Non-organic
![Page 14: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/14.jpg)
Traumatic : Extensor and peroneal tendon injuries
Neurogenic 1. At level of common peroneal N• Direct injuries • Fractures and dislocations1. # / dislocation head / neck of fibula2. Dislocation of Sup. Tibiofibular jt3. Dislocation of knee4. Compound # upper 1/3 tibia
![Page 15: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/15.jpg)
Pathogenic1. High skeletal tibial traction2. Tight plaster around knee joint3. High tibial osteotomy4. Total knee replacementOthersLat meniscal
cysts,Exostosis,Tumour of head of fibula
![Page 16: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/16.jpg)
Above level of Common Peroneal N
At the thigh : # shaft femur, penetrating injuries
At the hip : Post dislocation of hip,# hip
At the gluteal region : Deep im injAt the spine : IVDP,Spina bifida,
tumours
![Page 17: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/17.jpg)
Infective : Leprosy,poliomyelitis, GBS, Syphillis
Metabolic : DM,Beri beri, Alcoholic neuritis
Exogenous toxin : Lead, arsenic, mercury.
![Page 18: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/18.jpg)
Classification :Seddon :1. Neurapraxia2. Axontemesis3. Neurotemesis
![Page 19: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/19.jpg)
Sunderland
![Page 20: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/20.jpg)
Signs and Symptoms :Weakness of dorsiflexion and
eversion of footHigh stepping gait : Foot slap
followed by heel strike, toe drag during swing phase,increased hip and knee flexion
Sensory loss
![Page 21: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/21.jpg)
Autonomous Zone of Common peroneal N
![Page 22: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/22.jpg)
Clinical ExaminationSigns of motor denervation :
Paralysis, loss of tone, areflexia, Insensibility to compression, atrophy
Signs of Autonomic denervation 1. Loss of sweating2. Vasomotor 3. Loss of hair4. Trophic ulceration
![Page 23: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/23.jpg)
Diagnostic tests :Nerve conduction velocity
![Page 24: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/24.jpg)
Electromyography
![Page 25: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/25.jpg)
Autonomic testsSweat test : Presence of sweat
within autonomous zone indicates that complete denervation has not occurred.
Wrinkle testSkin resistance test : Increased
resistance to passage of electric current
![Page 26: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/26.jpg)
Assessment of recovery :Tinels signMotor recoveryM0- No contractionM1- Return of contraction in proximal
gpM2 – Proximal gp + Distal gpM3- Muscles can act against resistanceM4 – All synergistic independent movts
possibleM5- Complete recovery
![Page 27: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/27.jpg)
Sensory recoveryS0- Absence of sensibility in
autonomous areaS1- Recovery of deep cutaneous painS2- Superficial cutaneous pain +
Tactile sensibility ( some degree )S3- Throughout autonomous areaS3+ - Recovery of 2-point
discriminationS4- Complete recovery
![Page 28: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/28.jpg)
ManagementConservativeAim : Prevention of deformity and
improvement of gait.1. Proper positioning of foot splints2. Passive movements of joints3. Electrical stimulation of muscles4. Ankle foot orthosis
![Page 29: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/29.jpg)
AFOFunctions :1. Provide toe dorsiflexion during
swing phase2. Medial and lateral stability at
ankle during stance3. Push off stimulation during late
stance• Dynamic or static
![Page 30: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/30.jpg)
Surgical managementNeurorrhaphyTendon transfersBony operations Choice of surgical correction depends on1. Mobility of joints2. Soft tissue and muscle contractures3. Availability of muscles and tendons for
transfer4. Bony changes5. Age
![Page 31: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/31.jpg)
NeurorrhaphyIndications1. Clean and sharply incised nerve
injury2. Contaminated and nerve
transection with ragged ends3. Nerve injury following blunt
trauma or closed fractures4. Following closed reduction or
manipulation of fracture
![Page 32: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/32.jpg)
TechniquesEpineural neurorrhaphyPerineural neurorrhaphyEpiperineural neurorrhaphyInterfascicular nervegrafting
![Page 33: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/33.jpg)
Epineural NeurorrhaphyGap can be closed end to end Without excessive tension
![Page 34: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/34.jpg)
Perineural Neurorrhaphy
![Page 35: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/35.jpg)
Tendon transfersWhen joints are mobile and
muscles and tendons are available for transfer
Objectives1. To provide active motor power
to replace function of paralysed muscle
2. To eliminate deforming force when antagonist is paralysed
3. To improve stability by improving muscle balance
![Page 36: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/36.jpg)
Principles of tendon transfer1. The muscle to be transferred
should be healthy2. Muscle strength should be grade 4-
53. Free range of movement in joint4. Any bony deformity should be
corrected5. It is desirable to use synergistic
muscle as it is easier to rehabilitate
![Page 37: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/37.jpg)
6. Joints proximal to parts to be moved should be stabilised by tendon action
7. Tendon must be attached under moderate tension
8. If tendon is split, tension must be equal at all points
9. Nerve and blood supply must not be impaired
![Page 38: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/38.jpg)
OBER’S TECHNIQUE
![Page 39: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/39.jpg)
Barr techniqueMake a skin incision on medial
side of ankle from insertion of tibialis posterior and post to malleolus proximally along medial border of tibia.
Split the sheath in a proximal direction until distal 5cm of muscle is mobilised.
![Page 40: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/40.jpg)
Make second incision anteriorly beginning distally at level of ankle joint extending laterally to tibialis ant tendon .
The dissection should be between tendons of tibialis anterior and EHL preserving dorsalis pedis artery.
![Page 41: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/41.jpg)
Make a generous window in interosseus membrane pass tibialis posterior tendon through window between bones.
Expose third cuneiform or base of third metatarsal,incise periosteum drill a hole large enough to receive tendon and anchor in bone with a wire
![Page 42: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/42.jpg)
Two-tailed trasferTwo tailed transfer of tibialis posteriorThe tendon of tibialis posterior is
identified through a small incision over the tuberosity of the navicular bone.
The tendon is then detached from its insertion and its synovial attachments are divided.
.
![Page 43: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/43.jpg)
five-centimetre longitudinal incision is made in the lower part of the leg close to the medial border of the tibia, about ten centimetres above the medial malleolus. The tendon of tibialis posterior is identified and pulled out.
![Page 44: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/44.jpg)
The tendon is then split longitudinally into two “ tails “ up to the point where it will cross the tibia proximally.
Two transverse incisions are made on the dorsum of the foot, one over the extensor hallucis longus tendon and the other more laterally, over the tendons ofthe extensor digitorum longus.
![Page 45: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/45.jpg)
A tendon tunneller (Andersen’s tunneller) is passed from the wounds in the dorsum to the wound in the leg. The tunnels are made subcutaneously.
Two separate tunnels are made for the two “ tails “ of the motor tendon.
![Page 46: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/46.jpg)
The motor slips are pulled through. One is implanted in the tendon ofextensor hallucis longus and the other in the tendons of extensor digitorum longus.
During this stage the knee is held in flexion of about 30 degrees and the ankle in dorsiflexion of at least 10 degrees.
![Page 47: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/47.jpg)
After operation a below-knee plaster is applied, with the foot further dorsiflexed to release any tension on the tendon sutures during healing.
Six weeks after operation the patient is started on walking training. On the average the patient needs another two weeks to learn to walk normally.
![Page 48: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/48.jpg)
Lengthening of tendoachillesWhite techniqueUse a posteromedial incision to expose the
Achilles tendon from its insertion to approximately 10 cm proximally, preserving the sheath
Divide the posteromedial two thirds of the tendon near its insertion.
Apply a moderate dorsiflexion force to the foot, and divide the medial two thirds of the tendon approximately 5 to 8 cm proximal to the site of the distal division.
![Page 49: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/49.jpg)
Dorsiflex the foot so that the tendon lengthens to the desired length
Carefully close the tendon sheath and subcutaneous tissues to prevent adherence of the tendon to the overlying skin.
Apply a short leg cast with the ankle in maximal dorsiflexion.
![Page 50: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/50.jpg)
White technique
![Page 51: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/51.jpg)
Z-Plasty
![Page 52: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/52.jpg)
Percutaneous lengthening
![Page 53: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/53.jpg)
Percutaneous lengthening
1. Medial cut at the insertion of the tendon onto the calcaneus, through one half of the width of the tendon.
2. Make the second tenotomy proximally and medially, just below the musculotendinous junction.
3. Make the third laterally through half the width of the tendon midway between the two medial cuts.
![Page 54: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/54.jpg)
Bony operationsWhen joints are stiff with muscle
and soft tissue contractures and bony changes ( fixed deformities)
Lambrinudi arthrodesisTriple arthrodesis
![Page 55: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/55.jpg)
Lambrinudi arthrodesis
![Page 56: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/56.jpg)
Lambrinudi arthrodesisRecommended for correction of
isolated fixed equinus deformity in patients older than 10 years.
Retained activity in the gastrocnemius-soleus, combined with inactive dorsiflexors and peroneals, causes the footdrop deformity.
![Page 57: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/57.jpg)
The posterior talus abuts the undersurface of the tibia, and the posterior ankle joint capsule contracts to create a fixed equinus deformity
In the Lambrinudi procedure, a wedge of bone is removed from the plantar distal part of the talus so that the talus remains in complete equinus at the ankle joint, while the remainder of the foot is repositioned to the desired degree of plantar flexion
![Page 58: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/58.jpg)
The Lambrinudi arthrodesis is not recommended for a flail foot or when hip or knee instability requires a brace
A good result depends on the strength of the dorsal ankle ligaments
![Page 59: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/59.jpg)
TechniqueWith the foot and ankle in extreme
plantar flexion, make a lateral radiograph, and trace the film.
Cut the tracing into three pieces along the outlines of the subtalar and midtarsal joints; from these pieces, the exact amount of bone to be removed from the talus can be determined with accuracy before surgery.
![Page 60: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/60.jpg)
Expose the sinus tarsi through a long lateral curved incision.
Section the peroneal tendons by a Z-shaped cut, open the talonavicular and calcaneocuboid joints, and divide the interosseous and fibular collateral ligaments of the ankle to permit complete medial dislocation of the tarsus at the subtalar joint.
![Page 61: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/61.jpg)
With a small power saw (more accurate than a chisel or osteotome), remove the predetermined wedge of bone from the plantar and distal parts of the neck and body of the talus. Remove the cartilage and bone from the superior surface of the calcaneus to form a plane parallel with the longitudinal axis of the foot.
![Page 62: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/62.jpg)
Make a V-shaped trough transversely in the inferior part of the proximal navicular and denude the calcaneocuboid joint of enough bone to correct any lateral deformity.
Firmly wedge the sharp distal margin of the remaining part of the talus into the prepared trough in the navicular, and appose the calcaneus and talus.
![Page 63: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/63.jpg)
Insert smooth Kirschner wires for fixation of the talonavicular and calcaneocuboid joints.
Suture the peroneal tendons, close the wound in the routine manner, and apply a cast with the ankle in neutral or slight dorsiflexion.
![Page 64: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/64.jpg)
ComplicationsAnkle instability Residual varus or valgus
deformities caused by muscle imbalance
Pseudarthrosis of the talonavicular joint.
![Page 65: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/65.jpg)
Triple arthrodesisThe most effective stabilizing
procedure in the foot is triple arthrodesis fusion of the subtalar, calcaneocuboid, and talonavicular joints
Triple arthrodesis limits motion of the foot and ankle to plantar flexion and dorsiflexion.
![Page 66: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/66.jpg)
Indications1. To obtain stable and static realignment of the
foot 2. To remove deforming forces3. To arrest progression of deformity 4. To eliminate pain 5. To eliminate the use of a short leg brace or to
provide sufficient correction to allow fitting of a long leg brace to control the knee joint
6. To obtain a more normal-appearing foot. Generally, triple arthrodesis is reserved for severe deformity in children 12 years old and older; occasionally, it may be required in children 8 to 12 years old with progressive, uncontrollable deformity.
![Page 67: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/67.jpg)
Make an oblique incision centered over the sinus tarsi in line with the skin creases on the lateral side of the foot, beginning dorsolaterally at the lateral border of the tendons of the long toe extensors at the level of the talonavicular joint
![Page 68: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/68.jpg)
Continue the incision posteriorly, angling plantarward and ending at the level of the peroneal tendons. Carefully protect the extensor and peroneal tendons, and carry the incision sharply down through the sinus tarsi to the extensor digitorum brevis muscle
![Page 69: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/69.jpg)
Incise the capsules of the talonavicular, calcaneocuboid, and subtalar joints circumferentially to obtain as much mobility as possible. If this release allows the foot to be placed in a normal position, removal of large bony wedges is not required. If correction is impossible after soft-tissue release, appropriate bony wedges are removed
![Page 70: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/70.jpg)
![Page 71: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/71.jpg)
![Page 72: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/72.jpg)
![Page 73: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/73.jpg)
Cut the removed bone into small pieces to be used for bone grafting. Place most of the bone graft around the talonavicular joint and in the depth of the sinus tarsi.
Correction is maintained with internal fixation, usually smooth Steinmann pins or Kirschner wires.
![Page 74: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/74.jpg)
Close the muscle pedicle of the extensor digitorum brevis over the sinus tarsi to reduce the dead space.
Close the wound over a suction drain, and apply a well-padded, short leg cast.
![Page 75: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/75.jpg)
![Page 76: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/76.jpg)
AftertreatmentWalking with crutches or a
walker, with touch-down weight bearing on the operated foot, is allowed as tolerated. The cast and pins or wires are removed at 6 to 8 weeks, and a short leg walking cast is applied and worn until union is complete, usually 4 weeks more.
![Page 77: Foot Drop Foot Drop Chairpersons : Dr. Rupakumar.C.S. Dr. Ravikiran Presented by : Dr. Syed Imran](https://reader037.vdocuments.site/reader037/viewer/2022103004/56649cd75503460f9499ea36/html5/thumbnails/77.jpg)
Thank You