Foot deformities in systemic diseases: causes, symptoms, diagnosis, treatment

Foot deformities are characteristic manifestations of systemic diseases of the musculoskeletal system (SDMS).

ICD-10 codes

• Q77.5 Dystrophic dysplasia.
• Q77.7 Spondyloepiphyseal dysplasia.
• Q77.8 Other osteochondrodysplasia with growth defects of tubular bones and vertebral column.
• Q77.9 Osteochondrodysplasia with growth defects of tubular bones and vertebral column, unspecified.
• Q79.6 Ehlers-Danlos syndrome.

In multiple epiphyseal dysplasia, pseudoachondroplasia, and late spondyloepiphyseal dysplasia, congenital functionally significant deformities are rare.

With age, contractures caused by deforming arthrosis of the ankle and foot joints increase, valgus or supination deformities are formed, and flattening of the epiphyses progresses. Conservative treatment includes massage, exercise therapy, physiotherapy, drug therapy for arthrosis, orthopedic positioning, use of orthoses, and orthopedic footwear. In case of persistent deformities causing functional disorders, surgical treatment is indicated.

In Ehlers-Danlos syndrome, Larsen syndrome, congenital spondyloepimetaphyseal dysplasia, congenital spondyloepiphyseal dysplasia, dystrophic dysplasia, congenital foot deformities are observed in most patients. They are usually rigid and more pronounced than in isolated orthopedic pathology. What they have in common is progressive bone deformities. High frequency of dislocations and subluxations in the joints of the foot, in epiphyseal dysplasia - flattening of the epiphyses. Severe osteoporosis, degenerative-dystrophic changes, rapidly increasing with immobilization, use of the Ilizarov apparatus are typical. Atypical attachment of the tendon of the anterior tibial muscle to the diaphysis of the first metatarsal bone, provoking the development of relapse of adduction of the anterior section, is noted in 30% or more patients. However, the phenotypic polymorphism of the spondylosis is extremely wide; there are children with minimal clinical manifestations and without foot deformities at all. Deformities in various spondylosis differ significantly not only from non-systemic ones, but also from each other and require a different approach to treatment. In this case, priority is given not to the restoration of disturbed anatomical relationships and functions, but to the restoration of the support of the foot.

Clubfoot in dystrophic dysplasia

Characteristic features.

• Underdevelopment of the ankle joint fork, discrepancy between its size and the size of the talus (Fig. 110-9).
• Anterior subluxation (dislocation) of the ankle joint.
• Accessory sphenoid bones, additional nuclei of their ossification; increase in size and deformation of the first sphenoid bone.
• Dislocation in the first cuneometatarsal joint (up to 30%).
• Varus foot, caused not only by subluxations in the Chopart and Lisfranc joints, but also by progressive varus deformation of the diaphyses of the metatarsal bones with their thinning.
• Deltoid deformity of the first metatarsal bone, thickening of the proximal phalanx of the first toe.
• Brachyphalangism, symphalangism, clinodactyly.
• With age, subluxations and dislocations in the metatarsophalangeal joints appear and progress.

Treatment

Conservative treatment of severe degrees of deformation is ineffective. It is impossible to hold the talus in the ankle joint fork or to reduce the dislocation in the first metatarsocuneiform joint. When using staged plaster casts, aseptic necrosis of the talus is common.

In case of relatively mild deformations, early tenoligamentocapsulotomy is indicated with mandatory reduction of the dislocation in the 1st metatarsophalangeal joint, modeling resection of the beveled articular surface of the 1st cuneiform bone, and displacement of the tendon of the anterior tibial muscle. In case of more severe deformations, tenoligamentocapsulotomy must be combined with the use of the Ilizarov apparatus, which delays the possibility of its implementation until the age of 2-2.5 years. Severe bone deformations force us to resort to early resections of the foot bones. Immobilization after surgery is performed in a hypercorrection position of 15-20°. In case of anterior dislocation in the ankle joint and deformation of the talus, the operation of choice is early astragalectomy. To prevent relapses, corrective lavsanoplasty of the ligaments along the outer surface of the foot is indicated in all cases. From the age of 9-10 years, it is advisable to use early arthrodesis of the subtalar joint and Chopart joint.

Clubfoot in Larsen syndrome

Characteristic features.

• Fusion of two nuclei from which the calcaneus is formed in the postnatal period, resulting in its moderate deformation.
• Accessory tarsal bones and their ossification points.
• Subluxations and dislocations in the scapho-cuneiform and intercuneiform joints, the Lisfranc joint, which are not typical for other SZOD. The formation of cavus deformity occurs due to dislocation in the Lisfranc joint.
• Spatulate deformity of the distal phalanx of the first finger.
• Dislocations in the metatarsophalangeal joints.

Treatment

Early conservative treatment is effective in mild forms, without dislocations in the joints of the midfoot, but there is an increased risk of developing secondary deformations and aseptic necrosis of its bones. In case of atypical attachment of the anterior tibialis muscle (detected by ultrasound) and dislocations, surgical treatment is indicated, in severe cases - using the Ilizarov apparatus. To prevent relapses of dislocations characteristic of Larsen syndrome after reduction, it is necessary to stabilize the joints with the formation of artificial ligaments.

Congenital spondyloepiphyseal dysplasia, congenital spondyloepimetaphyseal dysplasia

With VSED and VSEMD, severe and rigid clubfoot, congenital gross bone deformities that rapidly progress with age are possible. Changes in the metaphyses of the short tubular bones of the foot are characteristic. However, in general, the distal parts of the skeleton are affected to a lesser extent than the proximal ones in these diseases. In some forms (pseudo-Morquio syndrome), there is a very sharp shortening of the metatarsal bones and phalanges of the fingers, the feet acquire a square shape.

Treatment

Conservative treatment of gross deformations of the foot bones is not very effective. Surgical treatment combines TLCT, the Ilizarov apparatus, modeling bone resections and transplantation of the anterior tibial muscle. Stabilization of the achieved result by forming artificial ligaments is indicated; in case of deformations of the talus - astragalectomy. Milder functionally insignificant deformations of the feet do not require surgical correction.

Clubfoot in Ehlers-Danlos syndrome

A characteristic feature is a combination of rigid deformations in some joints of the foot and hypermobility in others. With multiple joint lesions, clubfoot resembles arthrogrypotic.

Treatment

Staged plaster casts should be used from the first weeks of life. However, there is a high risk of developing secondary rocker foot, which can develop without treatment against the background of static load with unresolved deformation. As a result, plastering according to the Ponseti method with surgical correction of the equinus component is indicated. The first signs of secondary deformations require discontinuation of conservative therapy and surgical treatment. In case of severe hypermobility, tendon elongation is approached in a dosed manner, in some cases capsulotomy is abandoned, and postoperative immobilization is performed strictly with the average position of the foot. Due to the inferiority of connective tissue, the risk of developing postgurnicket neuropathies and postoperative hematomas is increased.

Rocker foot in zlers-danlos syndrome

Rocker foot is almost not amenable to conservative therapy. Staged plaster casts (from the first month of life) allow partial correction of abduction and dorsiflexion of the forefoot, reduce tension of soft tissues and the risk of their necrosis during early surgical treatment. Either one-stage open reduction of the talus is indicated, or, in the most severe deformities, the use of the Ilizarov apparatus. There is an increased risk of secondary deformities with a pronounced heel component, which requires dispensary observation of the patient with an examination at least once every 3 months, correction of orthopedic footwear.

Adducted foot

Deformation is encountered mainly in the mildest subclinical variants of SZOD. Conservative treatment is indicated in the absence of dislocations in the tarsal joints, atypical muscle attachment and gross bone deformations. In other cases, early surgical treatment is indicated.

Considering the relative rarity of the reduced foot in SZODA, as well as its complexity and uniqueness, requiring surgical correction, treatment is carried out in specialized institutions that have experience in treating such patients. All patients are prescribed drug treatment of osteoporosis before and after surgery, the use of chondroprotectors, angioprotectors, drugs that improve tissue metabolism. After the end of plaster immobilization and until the foot is fully grown, the use of orthopedic shoes, regular massage courses, exercise therapy, physiotherapy and spa treatment are indicated.

Outpatient observation is carried out with frequent examinations - at least once every 6 months. This is especially important in hypermobility syndromes. When deciding on surgical treatment of relapses, the connection of the patient's functional insufficiency with deformations of other parts of the musculoskeletal system is primarily taken into account. Moderately expressed relapses that do not cause significant difficulties in movement, as a rule, are not subject to surgical correction. It is impossible to cure a patient with SZODA completely. However, adequate treatment allows to significantly correct existing deformations and improve the patient's quality of life.

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