Elective Lower Limb Surgery Flashcards
Outline the anterior (Smith-Peterson) approach to the hip
- Via inter-nervous interval between sartorius and TFL
- Rectus femoris is detached to arrive at anterior joint capsule
What structures are at risk during anterior approach to the hip
- Lateral femoral cutaneous nerve
- Femoral nerve
- Ascending branch of lateral femoral cutaneous artery
When is an anterior approach to the hip used
- Open reduction in DDH
- Biopsy
Outline the anterolateral (Watson-Jones) approach to the hip
- Approaches joint between TFL and gluteus medius
- Anterior portion of gluteus medius is detached to improve access to the femur
What structures are at risk during an anterolateral approach to the hip
Femoral nerve
Outline the posterior (Moore/Southern) approach to the hip
- Patient in lateral decubitus position
- Lateral incision made over GT and extended one hand above and below
- Fascial lata is split in line of its fibres
- Middle of gluteus medius is split in line of its fibres
- Short external rotators are exposed
- A stay suture is placed in the short external rotators
- They are reflected back to protect the sciatic nerve
What structures are at risk during posterior approach to the hip
Sciatic nerve
What muscle does the Trendelenburg test test
Gluteus medius
What second-line investigation can be used to confirm OA if the hip joint appears relatively well preserved on x-ray
Diagnostic local anaesthetic injection into the joint
What type of THR materials may be used in younger patients requiring hip replacement
Ceramic-on-polyethylene (as opposed to metal-on-polyethylene)
What causes the snapping hip (coxa saltans)
A) Snapping IT band over the GT
B) Iliopsoas snaps over the iliopectineal eminence
How are acetabular labral tears diagnosed
MRI
What are the attachments of the medial meniscus
- Anterior and posterior intercondylar areas
- Capsule
- MCL
What muscle ‘unlocks’ the knee
Popliteus
Outline the medial parapatellar approach to the knee
- Longitudinal incision skirting the medial border of the patella
- Joint is opened from medial border of quadriceps tendon
Outline the procedure for knee aspiration
- Knee in full extension
- Clean anterior aspect of knee
- Enter suprapatellar pouch on either medial or lateral side
What deformity is typically present in knee OA
Varus
What surgical intervention can be applied to young people with unicompartmental knee OA
High tibial (or distal femoral) osteotomy can be used to realign the weight-bearing surface of the limb
Describe the limits of subtalar joint movement
- Inversion 10 degrees
- Eversion 20 degrees
Describe the limits of forefoot movement
- Inversion 15 degrees
- Eversion 10 degrees
What causes claw toes
Weakness of the interosseous and lumbrical muscles (which normally extend the PIP and DIPs of the toes and flex MTPs)
Associations of hammer toes
- Hallux valgus
- Overcrowding of toes in pointed/small shoes
What is hammer toe
- Hyperextension of MTP and DIP
- Flexion of PIP
- Affects 2nd/3rd/4th toes
List the neurological causes of Pes Cavus
- Poliomyelitis
- Spinocerebellar degenerative diseases (e.g. Friedreich’s ataxia)
- Spastic diplegia
How may Pes Cavus be surgically corrected
- Lengthening of Achilles tendon
- Calcaneal osteotomy
- Flexor-to-extensor tendon transfer
Describe a bunion
Inflamed adventitious bursa produced over the prominent head of the first metatarsal by pressure and friction
Outline the surgical procedures for Hallux valgus correction
- Mild-moderate = distal osteotomy of the 1st metatarsal and bunionectomy
- Severe = shaft or proximal osteotomy
How does hallux rigidus develop in young people
- Injury e.g. kicking a football
- Causes osteochondritis dissecans of 1st metatarsal head
How may hallux rigidus be treated
- Stiff-soled shoes
- MUA +/- steroid
- Fusion of MTP joint
What is the most common cause of forefoot pain
Metatarsalgia
Describe Morton’s neuroma
Plantar of digital neuroma commonly affecting the plantar nerve running between the 3rd and 4th metatarsal heads of the 3rd webspace
What muscle provides the main support for the longitudinal arch of the foot
Tibialis posterior
What is the main cause of adult ‘flat feet’
Tibialis posterior insufficiency
