Today we will present a patient who came to the London Foot and Ankle Centre for a second opinion.
Mr LS was born with a clubfoot which was operated on at a very young age.
The operation was successful and he was able to live an active life and took part in all sports activities. At the age of 53 years, he started to experience increasing discomfort mainly over the lateral aspect of his hindfoot and he had the impression that his foot was collapsing under him.
When he came to the clinic, he could hardly walk a mile and when trying to be more active he had increasing pain. In the morning he felt very stiff but with gentle walking he felt a bit better but any prolonged weight-bearing activity caused considerable discomfort.
Because of persistent/increasing pain Mr. LS saw a foot surgeon who arranged some x rays and an MRI scan and offered him an operation to fuse the ankle joint (arthrodesis of the tibiotalar joint). He also had an injection into the subtalar joint (joint between talus and calcaneum) which took away most of his pain but unfortunately the pain recurred after 6 weeks.
LFAC 1st Consultation
As Mr LS was not keen on an ankle fusion, he wondered if he would be a candidate for an ankle joint replacement and came to see me for a second opinion. At this stage Mr LS presented with a pronounced hindfoot valgus and a collapsing of the inside of his foot when weight-bearing and walking.
The ankle joint still had a decent good range of movement but dorsiflexion was mildly reduced and forced dorsiflexion also caused mild discomfort. There was some tenderness over the medial aspect of the ankle but not so much over the anterolateral aspect of the ankle joint.
Pain on palpation was mainly over the sinus tarsi and the subfibular area where there was an impingement. This means that the fibular was abutting the calcaneus as the calcaneus was subluxed laterally.
Arranged a Standing CT Scan
The midfoot joints did not cause him any pain. Sensation and circulation were normal. Because of the massive hindfoot valgus we arranged a standing CT scan to get further information about the alignment and to assess the joints properly.
The standing CT scan confirmed pronounced arthritic changes in the subtalar joint, a collapse of the hindfoot associated with a massive valgus of the calcaneum in relation to the talus and the impingement of the calcaneus against the tip of the fibula.
The ankle joint on the other hand looked still fairly good, there was only some minor wear and tear at the front of the ankle and moderate impingement of the anterior aspect of the ankle joint. The transverse tarsal joint looked fairly good as well.
3D Images Results Clearly Displayed the Source of Pain
When Mr LS saw the images of the standing CT scan especially the 3D reconstruction it was very obvious that the main source of pain was not the ankle joint but the subtalar joint.
He therefore agreed to have an operation to realign the hindfoot and subsequently had an operation to fuse the subtalar joint in a more normal position and additionally had a medial sliding calcaneal osteotomy to improve the hindfoot alignment. Finally, we also removed the prominent bone from the front of the ankle joint.
First 5 Weeks
Mr LS was immobilised for two weeks in a cast and then a boot and non-weight-bearing for a total of 5 weeks after which he started partial weight-bearing in the boot.
After 10 weeks
He was fully weight-bearing in the boot and was allowed to walk without the boot. He took it easy and had physiotherapy to help him regain a normal gait pattern as his hindfoot alignment had changed considerably and he had to get used to the new position of his foot. Mr LS made good progress and gradually increased his activities as comfort allowed.
After 11 Months
He came to see me recently for a check-up and after 11 months Mr LS is able to walk more than 10 000 steps daily without any problems. He lives in the countryside and enjoys going for regular walks.
After a long day on his feet, he might still get some very mild swelling but he does not get any pain and he is very much aware of the excellent stability of the ankle and foot.
The ankle joint itself does not cause pain and he is delighted that he did not have any major operation on the ankle joint as it was originally recommended to him by the previous surgeon.
What One Can Learn from This Case
That a good physical examination combined with up-to-date imaging (ultrasound-guided injection and standing CT scan) will provide the necessary information to make the right decision and perform the correct operation.
It would have been a real shame had he undergone a fusion of the ankle joint as initially recommended as he still would have the pain from the arthritic subluxed subtalar joint and the hindfoot would still have collapsed under his leg.
Mr LS is now very happy with the outcome of the operation as he is able to do everything he wants not experiencing any pain.
