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is there such a thing as insertional exostos on the lst cuneiform.if so,to remove the exostosis,is it necessary to sever the tendon of the tibialis anterior at its attachment to remove the exostosis.if you were to re-attach the tendon of the tibialis anterior,would you attach it in the same position or to the 2nd or 3rd cuneiform to maintain adequate dorsi-flexion of this tendon

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Hi EMIL1066

to Podiatry Arena.

Your question may receive more replies if posted in the foot surgery discussion area. That is the best area to raise a question RE: Issues, questions and research about foot surgery.

May I also ask you to provide a little information about yourself. It is always good for members to have a little background knowledge. This enhances discussions & encourages professional debate.

Many thanks,

Mandy

__________________
:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

“ Though the mills of God grind slowly;
Yet they grind exceeding small;
Though with patience he stands waiting,
With exactness grinds he all. ”

TO MANDY-HOW DO I POST THIS QUESTION TO FOOT SURGERY FOR A REPLY THANK YOU

Hi Emil:
Yes, you can get an exostosis here, whether or not it would be classified at an "insertional" is up for debate.
The exostosis is normally dorso-medial with evidence of arthritis at the met-cun joint (thus the debate as to osteophyte or not. The AT has a fairly wide attachment and you should be able to get the spur off without detaching the entire tendon. If you do, merely reattach with bone anchors and cast.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Hi Emil,

I see Steve has replied to your question so there's no need to move it unless Admin wishes to do so.

Future ref: If you wish to start a new discussion thread. Click on the desired forum eg. foot surgery discussion area. Then click on the 'start a new thread' icon at the top of the page.



Mandy

__________________
:)
twirly

Mandy Brooks
Brooks Podiatry
S64 0DE

Suffering a fondness for odd things.

“ Though the mills of God grind slowly;
Yet they grind exceeding small;
Though with patience he stands waiting,
With exactness grinds he all. ”

Steve,I appreciate your effort to answer my question.However,in due respect,I disagree with some of your comments.These are the reasons:First of all,you state '' yes,you can get an exostosis here(insertional) Then you contradict your statement by saying and implying thats its questionable,in your words,'' up for debate''whether it can be be insertional.Steve,can you back up your initial comment with any written articles in any journal,papers or textbooks in podiatry ? in regards,to evidence of arthritis in the lst meta-cuneiform joint,wouldn't it likely to be an osteophyte and not an exostosis.You can have an exostosis on the foot without having any form of arthritis. Steve,where would you re-attached a severed tendon of the tibialis anterior using a anchor-lock such as wright ?bear in mind,any significant decrease in the function of the tibialis anterior can lead to a possible drop-foot

Hi emil

I was under the assumption that you had a patient with an exostosis at the 1st met-cun. that you needed help with. I was TRYING to answer your query with my experience in having performed several of these.

If you'd like to research the semantics concerning exostosis vs osteophytes, then please do. I think you can handle it yourself.

If you need help with a procedure that perhaps you are not familiar or experienced in then I'd be glad to help.

The debate is whether or not an exostosis in this area is more an enthesopathy from the Tib Ant or an osteophyte from an arthritic process in the joint. There is no contradiction. You haven't shown me the radiograph.

As far as reattaching; the tendon is not "severed" and you normally do not need to detach the entire tendon to get to the offending exostosis. If you need an anchor, any choice of bone anchors will work, surgeons choice.

If you are unfamiliar with handling tendons then I would refer this patient out.

Good luck

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Hi Steve, jsut thought I would pop in a thank your expertise and assistance at pod arean.
I congratulate you on your efforts and thank you for your professionalism

Wishing you and your a Very safe and healthy festive season

Cheers

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Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557

steve-appreciate again your quick reply.I do not have a patient with this problem.Does insertional exostosis(enthesis) exist on the lst cuneiform? You say yes.my research failed to reveal anything on this subject.I have done meta-cuneiform exostosis on the dorsum of the mid-foot with saucerization and there are written articles on this.Since you have done these insertional exostosis,have you used any written references or guidelines in doing these procedures? If so,can you name a few? Since the tendon of the tibialis anterior attaches to the dorsal medial aspect of the cuneiform and,to a lesser extent,to the plantar base of the metatarsal,you would think it would be necessary to detach part of the tendon to remove the exostosis at the insertion of the cuneiform.Anyway,what is your success rate? Have you had any complications such that may result from damage to either or both nerves of the dorsal cutaneous or deep peroneal? Also,do you find it necessary to coagulate any bleeding vessels while doing this procedure

Hi Emil:
You're welcome.
Actually the procedure if fairly simple, merely underscore and use the instrumentation of choice to resect. As in any surgery, you can tie or coag bleeders. This depends on your training and the size and location of the vessels.
I have a patient I've seen within the past two months with one of these. I will try to upload her x-ray in the next day or two so you can examine it.
Sorry for the misunderstanding.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Steve I agree with you.If I were to perform a procedure like this.I would underscore the tendon,retract the tendon with a senn and remove the bump with either a bone rasp or a #44 shannon bone bur bit.I woudn't use a saggital saw bladeand would keep the tendon intact. Is there a insertional exostosis at the lst cuneiform? I don't think so.There is no validity as evidence by the lack of supporting documentation n the podiatry literature.I do believe it could confused with a saddle bone deformity in this area.Steve, would like your input on my next thread-thank you

Hi Emil:

You can remove these any way you'd like. I normally use a small osteotome / rongeur / hand rasp. The tendon is usually not an issue.

It's a rather simple procedure really. The main concern is establishing the origin of the patient's symptoms. If there is significant joint pain;pain on ROM;crepitus, then you may wish to do a fusion. If the pain is merely superficial and associated with a small spur then you can get by with the exostectomy.

Some of these patients return a few years post exostectomy and their joint has deteriorated to the point where a fusion is indicated. Obviously these spurs, in retrospect, were osteophytic.

Emil: if you don't mind, it would be helpful if you might inform me of your training, background and experience.

Thanks

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Hi Emil:
Here is an xray and reverse fluoro of a patinet I performed surgery on X 3 weeks ago; for your viewing pleasure.
Let me know what you think.
Steve
BTW: the surgery was for an accessory Navicular and tendon repair, he had no pain distally where this exostosis is.

Attached Images

	IMGP4623_2.jpg (38.1 KB, 29 views)
	IMGP4624_2.jpg (26.9 KB, 27 views)

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

hi steve-wow,what an extraordinary x-ray finding.It matches the possible Wisconsin state whitetail deer taken by bob decker last november in buffalo county.The x-ray AP view definitely gives the impression of a medial exostosis at the lst cuneiform.On the other hand,do we possible have a bone tumor,such as,a osteoma secondary to some type of prior trauma ? Steve,is this case an example of a insertional exostosis(enthesis) ? I don't think so,for the following reasons-the patient is asymptomatic in this area.If the extrinsic tendon was overlying this large exostosis,you normally expect some form of irritation on this tendon.Palpation should elict a pain response.I assume this was not the case and therefore the tendon is not involved.Probably the best way to resolve this issue is the gold standard for tendon pathology,the MRI.A high tech MRI such as G.E with better magnets would be great.This should tell us if there is increased signal intensity or normal intensity at the attachment and this may be the key answer along with review of the recording disk. On another question,did you do kinder type of procedure to remove the accessory navicular and what was you outcome especially regarding foot function-have a happy new year-emil

Hi Emil:

HAHAHAHAHA
I saw a photo of that deer! Quite impressive, a tad larger ten the one I got last year!
-------------------------------------
Again, this is not the "insertional exostosis" I was looking for - that one is somewhere filed away. If I come across it again I'll post it. Can't recall the patients name so I can't find it.

In any event, the patient here had a post tib, accessory nav problem that I performed surgery on. He did have pain with "deep" palpation the this cuneiform spur, but I didn't think it symptomatic enough to warrant excision.

I agree, it's a bit proximal and I would guess most likely secondary to an old direct trauma.

IF and when I remove it, do you think I should get it mounted?!

Steve