Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Transverse flatfoot – examination and therapy R. Zítka, M. Maršálek FN Brno ORTK 22. října 2014 Metatarsalgia •Metatarsalgias are forefoot pains localized distally from Lisfrank‘s joint •The clinical manifestation is the transverse extension of the forefoot – transversely flat foot •This static deformity is defined by divergence of marginal MTT, big toe valgosity, MTT varosity • •followed by I. MTT and V. MTT insufficiation and overload of II. -IV. MTT •"The leg is an work of art composed of 26 bones, 107 ligaments and 19 muscles" - once written by Leonardo da Vinci. The arch of the foot has three components on which it depends – the bone component consisting of the bones of the foot, their shape, the connective component formed by the ligmentous apparatus and the muscular component, the role of which is especially in the dynamic load of the foot • Výřez obrazovky Inervation of the foot Výřez obrazovky Výřez obrazovky Lake (1952) describes metatarses as a conical segment, slightly stretched by the ante-posterior direction, the individual heads touch the groung in the arc, with the convex shape forward Transverse Arch Výřez obrazovky Viladot 1975 Výřez obrazovky d e f 16% 28% 56% Metatarsalgia •Viladot - overload of the front of the leg • - Women with high heels, pes cavus, pes equinus • - Involvement of MTT itself, there is a change in pressure under load on the foot • - Short I.MTT, hypermobility of I.MTT, after osteotomies (first ray insuficiency syndrome) • - Long I.MTT (first ray overload syndrome) • - Neurological and congenital impairment (central ray overload syndrome • - Long metatarses (central ray overload syndrome) • § • 1) Výřez obrazovky 1995 Výřez obrazovky Kladívkové deformity prstů Výřez obrazovky Possible causes •Fractures from overload (no. II and III MTT) Congenital short/long MTT, MTT hypoplasia Freiberg - Köhler disease (Kölher II) Morton neuralgia, tarsal tunnel syndrome Plantar fibromatosa Post-stress state, scars, contractures (peroneal, m. triceps surae) Tumors Systemic diseases – RA, collagenosis, psoriasis, on. blood vessels, DM Spinal root afectation during intervertebral disc protrusion Nerve diseases – DMO, paresis, myopathy Diseases of the connective system - Marfan's sy, Ehlera-Danlos sy, Down sy. Iatrogeny – after surgery at I. MTT (shortening), • Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Útlak III. digitálního nervu předním okrajem plantární fascie Výřez obrazovky Examination •Clinical, medical history X-ray legs AP image in the load, oblique, lateral projection in the load Podoscopy, pedogram Výřez obrazovky Výřez obrazovky Výřez obrazovky •Podoscopy, pedogram • • Classification B1, B2, B3 Vliv senzomotorické stimulace na plochonoží u dětí - PDF Stažení zdarma Conservative therapy •- Wearing high-quality footwear with longitudinal vault support and heel guide (fixed heel) • - Load reduction, weight reduction • - Treatment of varicose veins, compensation of DM • - Stimulation and facilitation of the face in everyday life – walking barefoot in soft uneven terrain (grass, sand) • Conservative therapy • • -Passive support – orthopaedic inserts according to functional examination, individually manufactured shoes according to the podoscopy - retrocapital pelota (hearts), increase of the outer edge of the insert, which ensures proper conduction of the wall heel. - Corticosteroid injection - Active therapy – physiotherapy Rehabilitation / physiotherapy •The basis of physiotherapy is sensomotor exercises • • foot facilitation • • training of pressure distribution on the foot, training of support of three points, small legs in the centered position of the joints of the lower limb • •soft tissue techniques are used, mobilization of the joints of the foot is carried out • •relaxation and stretching in hypertone and in shortening • Rehabilitation / physiotherapy • •From physical therapy: • •antiedematous procedures – manual and instrumental lymphatic drainage • •water treatment – alternating and pedal baths, cold hot tubs are indicated • For muscle relaxation we can use ultrasound, electrotherapy (diadynamic DD currents, TENS – transcutaneous electrical neurostimulation) Surgical treatment •Shortening osteotomy of metatarses Combination with hallux valgus operations Preoperative, free movement in MTP joints must be Hoffman 1912 Mau 1940 Giannestras 1945 Wolf 1973 Helal 1975 •Weil surgery 1985 - in the treatment of metatarsalgia is preferred in patients with restriction of movement, in subluxation and luxation in MTP joints BRT osteotomy 1991 M. Vitek, V-TEK system 2009 Výřez obrazovky Výřez obrazovky (1912) Výřez obrazovky Výřez obrazovky Výřez obrazovky Du Vries (1953) Mann a Coughlin Výřez obrazovky Giannestras (1945), modified later by Coughlin Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Turan and Lindren - same type of fixation operation Screw Success rate 88% Pakloub 15% Výřez obrazovky Výřez obrazovky Lowel Scott Weil (Chicago, USA) 1985 Osteotomy length 2.5- 3cm "Z" sculpture of extensors Výřez obrazovky Výřez obrazovky Výřez obrazovky Postoperative care Výřez obrazovky •Limb to an elevated position 90% of the time in the first 10 poop. Days. Correction fixation in light plantar flexion Passive finger flexion exercises Removal of stitches in 14 days Verticalization in a special postoperative shoe 4-6 weeks X-ray feet AP under load and oblique scan 6 weeks after surgery Výřez obrazovky Výřez obrazovky Výřez obrazovky 1991, 2nd. 2005 Výřez obrazovky Výřez obrazovky Výřez obrazovky Výřez obrazovky Hammer toe surgery Výřez obrazovky Gocht (1925) - při rigidní extenzní kontraktuře MTP kl. Post (1882) Výřez obrazovky •http://www.uloz.to/xcM3dfo/4hd-weilova-osteotomie-mpg •http://www.foothyperbook.com/elective/metatarsalgia/metatarsalgiaSurg.html • Výřez obrazovky •In the reconstruction of the hip, knee, or any other joint, preoperative planning is necessary for avoiding mistakes during surgery. Since 1995, the authors have been doing this before forefoot surgery to increase the accuracy of the surgery. As much as possible, they try to correct only the lesion and to avoid preventive or extensive surgery on adjacent rays, except if the correction leads to a modified dysharmonious new morphotype with high risk of transfer lesion. The tolerance length seems to be 2 mm, particularly on the middle metatarsals (M2 and M3). This surgery should be performed only if the midfoot and backfoot are correct and if the gastrocnemius muscle has been checked on to eliminate a retraction needing stretching exercises before and generally after surgery.