F&A Flashcards
Etiologies of Cavovarus Foot
<div>-Hereditary motor/sens neuropathy: CMT, SMA, CP, Polio, Friedreich Ataxia</div>
<div>-CNS lesions: MS, TBI, SCI, Stroke, Tumour</div>
<div>-PNS lesions: Tumour, polio, congenital (myelomeningocele, diastematomyelia, spinal dysraphism)</div>
<div>-trauma: talus malunion, compartment syndrome</div>
<div>-residual congenital cavovarus</div>
etiology of claw toes (in clubfoot)
EHL/EDC overdrive (to help with ankle DF from Weak tib ant) overpowers weak intrinsics
Hindfoot varus compensates for what deformity in cavovarus foot?
“Forefoot pronation (driven by a planterflex 1st ray)<div><img></img><br></br></div>”
Coleman Block test: (1) use (2) method
“(1) determine hindfoot flexibility - ie is cavovarus forefoot driven<div>(2) place block laterally under foot - ie leaving D1 ray free</div><div><img></img><br></br></div>”
Radiographic Findings in Cavovarus foot
Alignment parameters<div>-Meary angle (talus X 1st MT) >0 deg</div><div>-Hibs angle (calc X 1st MT) < 130 deg</div><div>-Calc Pitch >30 deg</div><div>Double talar dome</div><div>Open sinus tarsi</div><div>Bell shaped cuboid</div><div><br></br></div><div>AP: TN overcoverage</div>
Surgical Procedures for Cavovarus foot?
Soft-tissue<div>-Transfers: PL to PB, Tib post to dorsal lat cuneiform, EHL to TA, FHL to PB</div><div>-PF release</div><div>-Gastroc recession/TAL</div><div>-Lat lig recon</div><div><br></br></div><div>Osteotomies</div><div>-hindfoot: lateral calcaneal wedge/slide</div><div>-midfoot: 1st ray dorsal closing wedge</div><div>-forefoot: lateral column shortening</div><div>-supramalleolar: if ankle involved</div><div><br></br></div>
Classifcation of Adult Flat Foot? (Myerson modification)
1- no deformity, just tenosynovitis<div>2- Flexible deformity</div><div>3- fixed deformity</div><div>4 - foot and ankle deformity</div>
Treatment options for Flat Foot?
Non-op<div>-orthosis: arch support, medial heel wedge, forefoot support</div><div><br></br></div><div><u>Operative</u></div><div>Stage 2</div><div>Soft-tissue (<b>never do in isolation</b>)</div><div>-FDL transfer to navicular/PTT stump</div><div>-spring ligament reconstruction</div><div>Boney</div><div>-Calc osteotomy: calcaneal lengthening vs MDCO</div><div>-Cotton osteotomy: dorsal closing wedge of 1st ray or 1st TMT arthrodesis</div><div><br></br></div><div>Stage 3: Triple arthrodesis</div><div><br></br></div><div>Stage 4: TTC fusion</div><div><br></br></div><div>Dont forget to address ankle equinus<br></br><div><br></br></div><div><br></br></div></div>
Complications of Achilles tendon repair
-Incision: hypertrophic scar, wound dehiscence, infection<div>-Sural nerve injury</div><div>-Tethering of Achilles to skin</div><div><br></br></div><div>Surgery has 15% risk for complications other than re-rupture</div>
Chronic Achilles treatment?
Gap 3-5cm: augmentation (V-Y lengthening, local turndown), FHL Transfer<div>Gap >5cm: FHL (or FDL transfer) +/- dermal matrix synthetic</div>
Rheumatoid Foot Deformity and Tx?
Forefoot: hallux valgus and claw toes<div>-Tx: 1st MTP fusion and D2-D5 MTP joint resection +/- PIP resection and re-alignment/pinning</div><div><br></br></div><div>Midfoot collapse/pes planus: often from TMT</div>
Tx Algorithm for Hallux Valgus?
IMA<13, HVA<30 -> Distal Chevron<div><br></br></div><div>IMA>13, HVA>30 -> Proximal Osteotomy + DSTP, or MTP fusion</div><div><br></br></div><div>OA/spasticity –> Fuse</div><div>Hypermobile 1st TMT -> Fuse (Lapidus)</div><div><br></br></div><div>Congruent Joint: Akin, exostectomy, Chevron</div><div><br></br></div>
Severity Classification for Hallux Valgus
Mild: IMA <13 HVA<20<div>Mod: IMA 13-20 HVA 20-40</div><div>Sev: IMA >20 HVA>40</div>
Characteristics of Juvenile Hallux Valgus?
Hx: bilateral, cosmetic def, +FHX<div>Pes planus or metatarsus adductus deformity</div><div><b>increased DMMA</b></div><div>1st MT is in varus leading to increased IMA</div><div>high recurrence rate</div><div>tx: cuneiform osteotomy</div>
Fusion Position for 1st MTP
Neutral rotation<div>5 deg valgus</div><div>10-15 deg dorsi</div>
Causes for Hallux varus post-hallux valgus correction?
IMA over-correction through osteotomy<div>Excessive medial eminence resection<br></br>Excessive medial capsular tightening</div><div>Excessive lateral release</div><div>Excision fibular sesamoid</div>
Ankle arthroplasty vs arthrodesis
-both weaker gait cf controls<div>-equivalent patient satisfaction<div>-ankle arthroplasty ROM similar to control, <b>weaker PF strength</b></div></div>
Indications for fusion over ankle arthroplasty
insensate foot<div>acute/chronic infx</div><div>severe multiplanar deformity</div><div>charcot neuroarthropathy</div><div>talus osteonecrosis</div><div>poor soft tissue</div>
Ankle Fusion position
Neutral Flex<div>ER 10 deg (overall foot should be 25 deg ER relative to tibia)</div><div>5 deg Valgus</div>
Orthotic for ankle fusion?
Heel to toe rocker
OCD Talus Tx options?
“<div>-<1cm –> microfracture (if no cart cap), retrograde drilling (if cap intact)</div><div>->1cm –> OATS</div><div><img></img><br></br></div>”
Gastrocs Contracture results in?
knee flexion<div>ankle flexion (PF)</div><div>subtalar inversion/supination</div>
Conditions assx with gastrocs contracture
<b>neuropathic ulcers</b><div><b>charcot midfoot collapse</b></div><div><b>plantar fasciitis</b></div><div><br></br></div><div><div>Lesser degree PTTD, Achilles tendinopathy, ankle sprain and fracture, MTP synovitis, hallux valgus, claw toes and toe walking</div></div>
Methods to Decrease risk of equinus contracture post-Charcot amputation
Increase DF of foot with Transfer to Dorsum of talus (Tib Ant, PL, PB, EDL)<div><br></br></div><div>Gastrocs/TAL recession</div><div><br></br></div><div>Boney: TTC fusion</div>
Causes of charcot neuroarthropathy?
Common: DM (1-2.5%), EtOH<div>CNS: TBI, SCI, myelo, syringomyelia, MS</div><div>PNS: Leprosy, CMT</div><div>Congenital insensitivity to pain</div>
Symes amp: (1) technical goal (2) surgical techinque
(1) rigid socket to prevent fat pad migration<div>(2) fat pad to anterior tibia to prevent fat pad migration</div>
Stages of Charcot?
0: Inflamm –> frequent F/U<div>1: fragmentation –> TCC with NWB</div><div>2: coalescence –> TCC with PWB</div><div>3: reconstruction –> surgery if needed to achieve plantigrade foot</div>
Predictors of NON-healing of diabetic Ulcers
TcO2 <30mmHg<div>ABI <0.5</div><div>Serum Albumin <2.5g/dl</div><div>Absolute Lymph count <1,500</div>
Sesamoid Bones in Foot?
<b>-receive 50% of BW during normal gait</b><div>-Tibial (med head FHB)>fibular (lat head FHB)</div><div>->1 artery</div>
Assx injuries with ankle instability?
Peroneal tendonitis<div>Talar OCD</div><div>Talar lateral process #</div><div><br></br></div><div><b>NOT Post tibialis sublux/dislocation</b></div>
Causes of ankle impingement post-inversion injury?
Talar osteophyte<div>Scar tissue in lateral gutter</div><div>Hypertrophy Bassett ligament (distal AITFL)</div><div><br></br></div><div><b>NOT CN coalition</b></div>
Inverters of subtalar joint?
Tib ant, Tib post<div>EHL, FHL</div><div>Achilles</div>
Post-RA reconstruction with dusty toes - plan?
Release dressing<div>Remove tourniquet</div><div>Dangle Foot</div><div>Warm foot</div><div>Skewer toe onto K-wire and rotate</div><div>Remove Pin<br></br></div>
Treatment of MCP in Z-shaped thumb deformity
MCP: hyperextension deformity!<div><br></br></div><div><10 deg - nothing</div><div>10-20 - percutaneous pinning of MCP in 25-35° flexion x 4wk ± EPB tendon transfer</div><div>20-40 - volar capsulodesis vs sesamoidesis</div><div>>40 - MCP arthrodesis</div>
Watson Shift Test?
Apply dorsal-ward pressure to scaphdoi while bringing wrist from ulnar to radial<div>If unstable the scaphoid will dorsally sublux</div><div>Release of pressure will lead to clunk</div><div><br></br></div><div>FP in 33% due to lig lax</div>
Dorsal Ligament Sparing Approach
“1-Midpoint b/t listers and DRUJ<div>2-Dorsal tubercle of Triquetrum</div><div>3-Sulcus b/t scaphoid and trapezoid<br></br></div><div><br></br></div><div><img></img><br></br></div>”
RFs for foot ulceration in diabetics?
“<img></img>”
Dx criteria for RA?
“<img></img>”
Tx for mallet, hammer and claw toes?
“<div><ul> <li>Mallet Toe –> flexion contracture of the DIP (normal PIP/MTP). Tx: FDL tenotomy</li> <li>Hammer Toe –> PIP flexion deformity (normal DIP and MTP). Tx: FDL transfer to extensor</li> <li>Claw Toe –> Hyperextension at MTP with secondary flexion at PIP (and sometimes DIP). Tx: FDL transfer to extensor surface</li></ul></div><img></img><br></br><div><br></br></div>”
Algorithm for talar OCD treatment?
“-nonop, NWB<div>-subchondral drilling (if cartilage cap intact)</div><div>-<b>microfracture (if cartilage cap gone) - RC EXAM</b></div><div>-fixation/debridement if unstable</div><div>-OATS: osteochondral autograft transfer system (ie from knee), can do one large piece or mosaicplasty</div><div>-structural osteochondral allograft</div><div>-ACI: autologous chondrocyte implantation (harvest chondrocytes from knee, culture, implant)</div><div><div><br></br></div></div><div><div> <div> <div><img></img></div> </div></div></div>”
algorithm for hallux valgus
“<img></img>”
Non-op protocol for achilles rupture?
<ul> <li>0-2 wks: Initial immobilization + NWB</li> <li>2-4 wks: CAM (control ankle motion) + 2 cm heel lift + Protected weight bearing + ROM to neutral</li> <li>4-6 wks: WBAT</li> <li>6-8 wks: remove heel lift + Dorsiflexion stretching + Propioception</li> <li>8-12 wks: Wean off boot</li></ul>
Navicular stress fractures: location, tx
“<img></img><br></br><div>96% success for immobilization x 6 weeks for undisplaced fractures</div><div>Average time to return to sport = 5 months<br></br></div>”
In the treatment of hallux rigidus, what is the advantage of interposition arthroplasty with a synthetic cartilage implant when compared with arthrodesis?<div><br></br></div><div>A. Decreased surgical time</div><div>B. Improved ability to correct deformity</div><div>C. Restoration of normal ROM</div><div>D. Shorter time to maximum pain reduction</div>
<div>A.</div>
<div><br></br></div>
Interposition arthroplasty with a synthetic cartilage implant has been shown to be a viable alternative to arthrodesis in the treatment of hallux rigidus. The advantages of interposition arthroplasty include pain reduction equivalent to that observed after arthrodesis, fewer postoperative weight-bearing restrictions, and the maintenance of range of motion. Interposition arthroplasty is not recommended in patients with substantial deformity (hallux varus or hallux valgus more than 20°). Compared with arthrodesis, the time to maximum pain reduction is more prolonged with interposition arthroplasty.
