Foot drop

foot drop

1. FOOT DROP Dr.HARSHA NANDINI TALASILA M.S ORTHO

2. Foot remains in plantar flexion due to the weakness of the dorsiflexors and evertors of the foot. Due to common peroneal nerve palsy

3. COMMON PERONEAL NERVE Division of the sciatic nerve Composed of L4 L5 S1 and S2 It deviates laterally in the popliteal fossa Arches around the posterior aspect of the fibular head Encircles the fibular neck Divides into the superficial and deep peroneal nerves

4. SUPERFICIAL PERONEAL NERVE Passes between peroneus longus and extensor digitorum longus muscles MOTOR BRANCHES: PERONEUS LONGUS PERONEUS BREVIS SENSORY BRANCHES skin on the anterior and lateral aspects of the lower leg dorsum of the foot.

5. DEEP PERONEAL NERVE It passes obliquely beneath the extensor digitorum longus. MOTOR BRANCHES : TIBIALIS ANTERIOR EXTENSOR DIGITORUM LONGUS EXTENSOR HALLUCIS LONGUS PERONEUS TERTIUS EXTENSOR DIGITORUM BREVIS FIRST DORSAL INTEROSSEI SENSORY SUPPLY : 1 st WEB SPACE

6. CAUSES OF FOOT DROP

7. CAUSES OF FOOT DROP TRAUMATIC Tendon injuries to the dorsiflexors of the foot NEUROGENIC : At or below the level of common peroneal nerve DIRECT INJURIES : incised and penetrating injuries. FRACTURES AND DISLOCATIONS: Lateral condyle of tibia Head or neck of the fibula Knee dislocation Compound fracture of upper 1/3 rd of tibia

8. 3. IATROGENIC: High tibial skeletal traction Tight plaster around knee High tibial osteotomy Total knee replacement

9. Above the level of common peroneal nerve Fracture shaft of femur Posterior dislocation of the hip PIVD Spina bifida

10. INFECTIVE Leprosy Poliomyelitis Guillian barre syndrome Syphilis METABOLIC Diabetes mellitus Alcoholic neuritis TOXINS Lead Arsenic Mercury

11. CLINICAL FEATURES Loss of dorsiflexion of foot HIGH STEPPING GAIT Loss of sensation over the lateral aspect of the leg and dorsum of the foot.

12. HIGH STEPPING GAIT Ankle dorsiflexors act during the swing phase of the gait cycle During walking the foot slap in the ground on heel strike and then drops in the swing phase. To prevent this the patient flexes the hip and knee excessively in order to clear the ground.

13. DIAGNOSIS Nerve conduction studies Electromyography MRI Strength duration curve Tinel sign

14. Wait for recovery or regeneration

15. MANAGEMENT OF FOOT DROP CONSERVATIVE MANAGEMENT:Aim is prevention of the deformity and improvement of gait. Proper positioning of foot splints Passive movements of the joints Electrical stimulation of the muscles

16. ANKLE FOOT ORTHOSIS Function Provide toe dorsiflexion during the swing phase Medial and lateral stability at the ankle during stance Push off stimulation during the late stance phase Substitute for wide plantar flexion during stance.

17. SURGICAL CORRECTION OF FOOT DROP Mobility of the joints Soft tissue and muscle contractures Availability of the muscles and tendons for transfer Bony changes

18. SURGICAL MANAGEMENT TENDON TRANSFERS: anterior transfer of tibialis posterior. TENDOACHILLES LENGTHENING

19. TENDON TRANSFERS OBER’S TECHNIQUE KAUFER’S TECHNIQUE SRINIVASAN’S TECHNIQUE

20. OBER’S TECHNIQUE 1 st incision: medial longitudinal 7.5cms long tibialis posterior tendon is released from its attachment to the navicular . 2 nd incision: longitudinal medial incision 10cm long centered over the musculotendinous junction of tibialis posterior. Withdraw the tendon from the proximal wound. 3 rd incision: over the base of the 3 rd metatarsal. Tibialis posterior tendon is drawn from the second incision into the third incision. Its distal end is anchored to the base of the third metatarsal.

21. KAUFER’S TECHNIQUE Dissect the plantar portion of tibialis posterior tendon from its insertion. Half tendon is freed distally. Another incision is made 2cm proximal to the lateral malleolus and extending it upto base of 5 th metatarsal. The T.posterior tendon is passed through a tunnel made under the tibia and is sutured to the P.brevis tendon.

22. SRINIVASAN’S TECHNIQUE Patient in supine position,knee in extension,passive dorsiflexion of the ankle is done. Tendon of tibialis posterior is exposed by a short transverse incision at the navicular tuberosity . The tendon is divided close to its insertion site. A curved incision is made on the medial aspect of the lower third of leg. Tibialis posterior muscle and tendon are identified and it is withdrawn through this incision.

23. The tendon is split longitudinally to give two slips. Two small curvilinear incisions are made over the dorsum of the foot proximal to the summit of the tarsal bones. Through the medial incision EDL is identified and isolated Through the lateral incision EHL is identified and isolated Each slip of the tibialis posterior tendon are pulled through each of the curvilinear incision. With the foot in dorsiflexion the two tails of the T.posterior tendon are laced and fixed to the EHL and EDL tendons with non absorbable sutures.

24. Post operative Immobilize the limb in below knee POP cast with ankle in dorsiflexion of 70 degrees for 3 weeks.

25. TENDO ACHILLES LENGTHENING Open method Percutaneous method

26. WHITE TECHNIQUE Tendon achilles is released from its insertion on the calcaneum . Divide the posteromedial 2/3 rd of the tendon near the insertion. Divide the medial 2/3 rd of the tendon 5 to 8cm proximal to the distal division. Forceful dorsiflexion is done to lengthen the tendon.

27. PERCUTANEOUS LENGTHENING Patient in prone position,knee in extension,dorsiflex the ankle to tense the tendocalcaneus . 3 partial tenotomies are done. At the insertion of the tendon through one half of the tendon Proximal and medially just below the musculotendinous junction. Laterally half of the width of the tendon midway between the 2 medial cuts. Dorsiflex the ankle to desired angle.

28. POSTOPERATIVE LONG LEG CAST applied for 3 weeks followed by SHORT LEG CAST for 3 weeks. Later AFO is given with ankle in neutral dorsiflexion .

29. REFERENCES CHAURASIA NETTER’S ATLAS OF HUMAN ANATOMY CAMPBELL’S OPERATIVE ORTHOPAEDICS

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