F&A - RC Qs Flashcards
<div>RC 2016 - When doing a subtalar arthrodesis from the lateral side, what is the structure you see once you have debrided the medial aspect of the joint? </div>
<ol> <li>FDL </li> <li>EDM </li> <li>FHL </li> <li>Tib post</li></ol>
C.<div><ul> <li>Discussed with LaMothe:</li> <ul> <li>If POSTERIOR to middle facet then FHL</li> <li>If ANTERIOR to middle facet the FDL as FHL under sustentaculum</li> </ul></ul></div>
<div>RC 2015 - Contraction of the gastroc results in:</div>
<ul> <li>A. Plantarflexion</li> <li>B. Flexion of the knee and ankle</li> <li>C. Flexion of the knee and ankle and subtalar supination</li> <li>D. Flexion of the knee and ankle and subtalar pronation</li></ul>
C.<div><div>The Achilles tendon is part of a musculotendinous unit that spans three joints, producing knee flexion, tibiotalar flexion, and subtalar inversion</div></div>
RC 2008 - A fisherman sustained an open medial malleolus fracture and sharp laceration to tib post tendon. How should you manage the Tib-post tendon injury? <ul> <li>A. Repair primarily</li> <li>B. UCBL orthosis</li> <li>C. Tenodesis the distal part to FHL</li> <li>D. Reconstruct the deficit with FDL to navicular</li></ul>
A.<div>Acute repair of a tibialis posterior tendon laceration can lead to a good result.</div><div>Small case series of these<br></br></div>
<div>RC 2008 - Question on lesser toes, which is true</div>
<ol> <li>on ground 75% during stance phase</li> <li>max peak pressure of MT head is significantly larger</li> <li>equal distribution across lesser toes</li> <li>don’t provide stability in stance phase</li></ol>
<div>answer: b</div>
<ul> <li>They concluded that the toes are in contact for about 3/4 of the walking cycle and exert pressures similar to those from the metatarsal heads</li> <li>The great toe takes the highest pressures (30% of total toe pressure), with the second taking 25%, the third 20%, the fourth 15% and the fifth 10% = C is false</li> <li>While the extremes of the foot (heel and hallux) are in contact with the ground for only 54% to 64% of stance phase the forefoot, specifically the middle forefoot, contacts the ground for 86% of stance phase.</li></ul>
RC 2014 - List 4 inverters of the subtalar joint
<ul> <li>Tib post</li> <li>Tib Ant</li> <li>FDL</li> <li>FHL</li> <li>Achilles</li></ul>
<div>RC 2015 - In a Chopart amputation, what 2 things can you do to prevent equinus contracture?</div>
<div><div><ul> <li>Soft Tissue</li> <ul> <li>Transfer for MORE DF (to dorsum of talus)</li> <ul> <li>Tibialis anterior</li> <li>Peroneus longus</li> <li>Peroneus brevis</li> <li>EDL</li> </ul> <li>Less PF strength = Recession of gastrocs/Achilles</li> </ul> </ul> <ul> <li>Boney procedures:</li> <ul> <li>TTC fusion</li> </ul></ul></div></div>
RC 2013 - Symes amputation due to diabetic toes. Which is an important part of the operation: <ol> <li>Attach fat pad to posterior tibia</li> <li>Attach fat pad to anterior tibia</li> <li>Resect fat pad</li> <li>Attach Tibialis Posterior to anterior tibia</li></ol>
“B.<ul> <li>"”Several techniques have been used to prevent migration of the heel pad on the end of the stump, such as taping the heel flap, skewering the heel flap to the bone with a kirchner wire, or leaving a small sliver of calcaneus attached the heel flap””</li> <li>Drill several holes through the anterior edge of the tibia and fibula, and suture the deep fascial lining the heel flap to the bones””</li></ul>”
<div>RC 2018, 2014, 2012 - Patient has a Symes. All of the following except</div>
<ol> <li>Rigid socket not needed for success</li> <li>Lift often needed on contralateral side</li> <li>Heel pad migration may preclude weight bearing</li> <li>The long lever arm is an advantage</li></ol>
“B.<ul><li>A: SYMES amp has a bulbous end - so the prosthetics have cutouts that make them ‘nonrigid’</li><li>Carroll K - Prosthetics and Patient Management: A Comprehensive Clinical Approach</li><ul><li>Amputation limb is appreciably shorter than contralateral limb (so no contra-lateral lift needed)</li><li>Connection between socket and foot must be rigid</li></ul></ul><div><ul> <li>A: Rigid SOCKET is necessary to prevent fat pad migration; rigid prosthesis (aka. foot) is NOT necessary (can use carbon fiber energy storing foot)</li> <li>(rigid socket bears weight up the whole lower leg instead of being an end loading stump)</li> <li><br></br></li><ul> </ul></ul></div>”
<div>RC 2018, 2016, 2014 - A 47yo male insulin-dependent diabetic presents with a callus on the plantar aspect of the 5th metatarsal head. This was managed with trimming of the callus and local skin care, but is worsening. On exam he has mild cavus alignment bilaterally. What is the best treatment?</div>
<ol> <li>Gastrocsoleus stretching exercises and referral for specialized diabetic footwear</li> <li>Medial calcaneal slide osteotomy</li> <li>Dorsiflexion osteotomy of the 5th metatarsal</li> <li>Percutaneous lengthening of the Achilles tendon</li></ol>
A.<div><ul> <li>Variations in 2016 question (poorly remembered) included improved glycemic control and ulcer debridement</li> </ul> <div>JAAOS 1995 The Diabetic Foot</div> <ul> <li>This patient is presenting with a Wagner Grade 0 ulcer ie. No open lesions</li> <li>Management should involve shoe modification and molded inserts</li> <li>For grade 1 or 2 (superficial & deep ulcers), total contact casting is the treatment modality of choice (90% healed at 5.5 weeks)</li><li>grade 3 = deep ulcer with exposed tendon + infection = debride, abx</li> <li>Nothing in this reference about perc TAL</li> </ul> <div></div> <div>JBJS 2003 Effect of Achilles lengthening on neuropathic plantar ulcers</div> <ul> <li>RCT of Achilles lengthening + total contact casting in patents w/ grade II ulcers and <5 degrees dorsiflexion (NOT THIS PATIENT)</li> <li>100% HEALING in the TAL group (vs 88% in the cast only)</li> <li>75% less recurrence at 7 months and 50% less recurrence at 2 years in TAL group</li></ul></div>
<div>RC 2013, 2011 - Regarding diabetic healing, what is predictive of good healing?</div>
<ol> <li>Transcutaneous oxygen pressure > 30mmHg</li> <li>ABI of 1.5</li> <li>Toe pressure of 20 mmHg </li> <li>Your patient ate Lisa’s cooking</li></ol>
“A.<div><br></br></div><div><img></img></div><div><br></br></div><div>ie predictors of non healing</div><div><ul> <ul> <li>ABI < 0.45</li> <li>Transcutaneous pressure < 30mmHg</li> <li>Serum albumin < 2.5g/dl</li> <li>Absolute lymphocyte count < 1,500</li> </ul></ul><div><br></br></div></div>”
<div>RC 2012 - What Transcutaneous O2 is needed for wound healing in diabetics?</div>
<ol> <li>15 mm</li> <li>30 mm</li> <li>50 mm</li> <li>70 mm</li></ol>
“2.<div><img></img><br></br></div>”
RC 2015, 2012 - What is the most important predictor of healing in a diabetic ulcer? <ol> <li>severity of DM</li> <li>blood supply</li> <li>peripheral neuropathy</li> <li>chronicity of the ulcer</li></ol>
<div>ANSWER: B ***</div>
<ul> <li>Peripheral neuropathy is NUMBER 1 risk factor for development of ulceration but blood supply is predictive of healing potential</li> <li>Predictors of non-healing:</li> <ul> <li>ABI < 0.45</li> <li>Transcutaneous pressure < 30mmHg</li> <li>Serum albumin < 2.5g/dl</li> <li>Absolute lymphocyte count < 1,500</li> </ul></ul>
<div>RC 2011 - DM is a common cause of Charcot arthropathy of the foot and ankle. List 3 other causes.</div>
<div><ul> <li>JAAOS 2009 Charcot Neuroarthropathy of the Foot and Ankle</li> <ul> <li>CNS: SCI, TBI, syphilis, myelo, syringomyelia, MS</li> <li>PNS: Alcoholism, Leprosy, CMT</li> <li>Congenital: insensitivity to pain</li> </ul></ul></div>
<div>RC 2012 - Diabetic guy, with what sounds like a Charcot foot in the stem with medial arch collapse. What would you find on exam? </div>
<ol> <li>Pain doing a single heel rise</li> <li>Warm dry foot with prominence along medial talar head, increase callosities</li> <li>Decreased eversion and normal inversion</li></ol>
B.<div><br></br></div><div><div>Hard to rule out any option as could be painful for heel raise and could have change in ROM but I think best answer is B as it describes Charcot foot pathology</div></div>
<div>RC 2014, 2009 - What is the cause of osteopenia in a neuropathic (Charcot) joint?</div>
<ol> <li>Increased blood flow</li> <li>Non-weight-bearing due to treatment</li> <li>Neuropathy</li> <li>Cannot remember the last option</li></ol>
A.<div><ul> <li>Autonomic Dysfunction:</li> <ul> <li><b><i><u>AV shunting / increased blood flow--> increased cytokines --> upregulation of osteoclasts --> bony resorption</u></i></b></li> </ul> <li>Neurotraumatic Destruction:</li> <ul> <li>Repetitive microtrauma –> sensory anomaly prevents recognition and activity modification</li> </ul> <li>Motor Neuropathy:</li> <ul> <li>Extrinsics > intrinsics –> equinus –> altered ground reaction forces –> fracture/deformity</li> </ul> <li>Inflammatory:</li> <ul> <li>TNFa, IL1 release –> NTKB –> osteoclast stimulation</li> </ul></ul></div>
“<div>RC 2018, 2013 - Patient arrives in your clinic walking with a red and swollen foot. No fever. History of DM. XR looks like this (Dislocated midfoot). No skin breakdown. No pain. Treatment?</div> <div></div> <div><img></img></div> <ol> <li>Total contact cast</li> <li>ORIF</li> <li>Midfoot fusion</li> <li>Amputation</li> </ol> <div></div>”
<div>A.</div>
<div><br></br></div>
<div><ul> <li>Eichenholtz Classification:</li> <ul> <li>Inflammatory --> treatment total contact casting</li> <li>Fragmentation ---> total contact casting</li> <li>Coalescence --> total contact casting --> crow</li> <li>Reconstruction</li> <ul> <li>Indications for surgery:</li> <ul> <li>Ulceration from exostoses/dislocations</li> <li>Fusions in reconstructive phase</li> <li>Amputation for recurrent ulcerations/OM</li> </ul> </ul> </ul></ul></div>
<div>RC 2018, 2016, 2013 - What is true regarding the sesamoid bones in the foot? </div>
<ol> <li>They are supplied by a single artery</li> <li>Together they receive 50% of weight during normal gait</li> <li>The fibular sesamoid is larger than the tibial</li> <li>Both sesamoids lie within the 2 muscle bellies of the flexor hallucis brevis</li></ol>
b.<div><ul> <li>Sesamoid complex transmits as much as 50% of body weight</li> <li>The larger tibial sesamoid lies within the medial head of the flexor halluces brevis, the smaller fibular sesamoid lies within the lateral head</li> <li>Usually a single artery per sesamoid, but up to 2-3 per sesamoid have been described</li></ul></div>
RC 2017, 2014, 2012 - List 5 causes of adult cavovarus foot
<ul> <li>JAAOS - Adult Cavovarus Foot</li> <ul> <li>Congenital</li> <ul> <li>Myelomeningocele</li> <li>Syrinx</li> <li>Diastematomyelia </li> <li>SMA</li> <li>Hereditary motor and sensory neuropathy (CMT)</li> </ul> <li>Acquired/adult</li> <ul> <li>Neuro</li> <ul> <li>CNS: Stroke, SCI, TBI, tumour, MS</li> <li>PNS: tumor, polio</li> </ul> <li>Trauma</li> <ul> <li>Compartment syndrome</li> <li>Talus malunion</li> </ul> </ul> <ul> <li>Residual congenital cavovarus</li> </ul> </ul></ul>
<div>RC 2016 - List 6 clinical / pathoanatomic findings in the flexible adult flatfoot</div>
“<ul> <li>Alignment</li> <ul> <li>Forefoot: ““too many toes”” sign</li> <li>Midfoot: pes planus, Loss of longitudinal arch</li> <li>Hindfoot: Excessive hindfoot valgus</li> </ul> </ul> <ul> <li>Equinus contracture</li> </ul> <ul> <li>Pain and tenderness along medial border of foot, posteromedial ankle</li> <li>Inability to perform single heel raise</li> <ul> <li>Weak Tib post</li> </ul></ul>”
<div>RC 2013 - Flexible Pes Planovalgus with no abduction. She is unable to do a single stance heel raise. What operation</div>
<ol> <li>TN fusion</li> <li>Triple fusion</li> <li>FDL transfer with medializing calcaneal osteotomy</li> <li>TP advancement</li></ol>
C. NEVER DO TENDON TRANSFER IN ISOLATION - NEEDS MDCO
RC 2012 - Middle age female with severe flat foot deformity acquired over last 2 years. What is the cause? <ol> <li>Tarsal coalition</li> <li>Posterior tibial tendon dysfunction</li> <li>Charcot foot</li> <li>Ryan operated on it 2 years ago</li> </ol> <div></div>
2.<div><div>Charcot foot is possible with the right history, but two years is a long time course for this and PTTD is much more likely</div></div><div><br></br></div><div>PEDS DDX:</div><div><ul> <li>Tarsal coalition</li> <li>Tarsal coalition</li> <li>Tarsal coalition</li> <li>Poorly corrected club foot with midfoot break</li> <li>Congenital vertical talus</li> <li>Congenital oblique talus</li> <li>Spastic diplegia (hemiplegia is spared for some reason)</li></ul></div>
RC 2016, 2014 - A patient with flexible flat feet undergoes lateral column lengthening through the anterior calcaneus. Which of the following is a complication of lateral column lengthening? <ol> <li>Calcaneocuboid arthritis</li> <li>Subtalar instability</li> <li>Increased pressures and stress fracture of the sesamoids</li> <li>Pronation of the forefoot</li></ol>
A.<div><ul> <li>JAAOS - Adult Acquired Flatfoot</li> <ul> <li>Lateral column lengthening provides correction to the abducted talonavicular joint and raises the arch</li> <li>It also decreases eversion and increases the pressure along the plantar lateral border of the foot</li> <li>Lengthening may result in lateral foot overload, fifth metatarsal stress fracture and significant stiffness</li></ul></ul> <ul> <li>Roche and Calder. Foot Ankle Clin N Am. 2012.</li> <ul> <li>Evans suggested preserving the joint through his osteotomy; however, studies have shown that the contact pressure generated across the calcaneocuboid joint after lengthening may actually rise, raising concerns that this may predispose to early degenerative change…They found that joint contact pressures were increased from baseline levels after Evans procedures by 111%. The addition of a medializing calcaneal osteotomy reduced this pressure increase to 93%. </li> <ul> <li>Lots of biomechanical evidence for CC arthritis, little clinical evidence</li> </ul> </ul> <li>Neufeld SK (Foot and Ankle Clin 2001)</li> <ul> <li>Calcaneal lengthening osteotomies can result in over correction and result in excessive and fixed SUPINATION, thought to be a cause of lateral foot pain</li> <li>Overlengthening can cause metatarsocuboid arthritis or instability</li></ul></ul> <ul> <li>Moseir-LaClair S, Pomeroy G, Manoli II A. Intermediate follow-up on the double osteotomy and tendon transfer for stage II posterior tibial tendon insufficiency. Foot Ankle Int 22:283-291, 2001</li> <ul> <li>14% CC arthritis (but 50% of cases had pre-existing arthritis) </li> </ul></ul></div>
<div>RC 2011 - Advantage of lateral column lengthening over medial calc osteotomy for stage 2 PTTD? </div>
<ol> <li>better forefoot abduction</li> <li>improved restoration of hindfoot alignment</li> <li>better fusion</li> <li>Less non-union</li></ol>
A.<div><ul> <li>Jer: I’m guessing ‘A’ should say ‘better forefoot abduction correction’?</li><li>Bolt PM (FAI 2007) A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot</li> <ul> <li>Lateral column lengthening had greater initial and final re-alignment</li> <li>Lateral column lengthening had higher non-union</li> <ul> <li>High radiographic prevalence of OA</li> </ul> <li>Rate of repeat surgery was 2x higher with osteotomy than lengthening</li> </ul><ul> </ul></ul></div>
RC 2015 - 55yo lady presents 6mos following a minor ankle inversion injury with progressive pain and swelling posterior to the medial malleolus. What would you expect to find on exam? <div> a. Positive anterior drawer test</div> <div> b. Rigid subtalar motion</div> <div> c. Positive Coleman block test</div> <div> d. Unable to do single limb heel raise</div>
D.<div><ul> <li>I think they’re getting at PTTD possibly…</li> <li>Anterior drawer should have corresponding pain at anterolateral ankle</li> <li>Rigid subtalar motion indicates subtalar coalition or end stage disease, unlikely with this presentation and age group</li> <li>Possible to do Coleman block</li></ul></div>
- The Evans procedure is better at correcting talar head coverage or talonavicular coverage
- Triple C has is associated with higher complications than Evans
- A complication of Triple C is CC joint subluxation
- 'Severe' Deformity requires proximal osteotomy and DSTP
- Lateral release of adductor hallucis tendon and intermetatarsal ligament
- Medial tightening = medial capsule plication
- OA
- Inflamm arthropathy
- Neuromusc disease
- Severe OP
- Revision surgery
- Multiple lesser toe deformites
- Buncionectomy and chevron osteotomy
- Distal soft tissue release and Akin osteotomy
- Fusion of the 1st MTP
- Fusion of the first metatarsal-medial cuneiform joint
- #4 - Lapidus (first TMT fusion + distal soft tissue procedure) would likely be the best option, however, a TMT fusion alone is not ideal. A first MTP fusion is an appropriate treatment option for a severe bunion – especially in an elderly patient. ie would require a soft tissue procedure distally to address the INCONGRUENCE of the joint
- Incongruent deformities are classified as mild (hallux valgus angle less than 30 degrees and IM angle less than 13 degrees), moderate (hallux valgus angle less than 40 degrees and IM angle greater than 13 degrees), and severe (hallux valgus angle greater than 40 degrees and IM angle greater than 20 degrees).
- For advanced moderate and severe deformities, a distal soft-tissue procedure with a proximal osteotomy will give a reproducible satisfactory result in most cases, although it is technically demanding. The MTP arthrodesis is an excellent procedure for treating a severe hallux valgus deformity, particularly in older patients and those with rheumatoid arthritis, spasticity, or arthrosis. arthrodesis is used along with the complete distal soft-tissue procedure.
- Proximal osteotomy
- Distal osteotomy
- Proximal phalanx osteotomy
- MTP fusion
- Group discussion - argument that since it is incongruent, would need a distal soft tissue procedure with your proximal osteotomy, controversial
- Decreased HV angle
- increased DMAA
- increased incongruity
- decreased IM angle
- A – Early onset have increased HV (1st mt is in VARUS)
- B – 48% - The defining characteristic of a juvenile bunion
- C – Can have subluxation or not
- D – No they can have a variety of IM a
- Often is bilateral with a family history
- Usually presents with cosmetic concern, not pain
- The deformity often is associated with flexible flatfoot or metatarsus adductus
- The 1st metatarsal is in varus with a resultant increased intermetatarsal angle between the 1st and 2nd metatarsal
- There is an increased distal metatarsal articular angle with a congruent joint
- Much higher recurrence rate (up to 50%)
- Coughlin MJ (FAI 1995) Juvenile Hallux Valgus: etiology and treatment
- Retrospective study of 45 patients with 60 feet
- Early onset was characterized by increased deformity and an increased DMAA
- 72% had maternal transmission
- ""an increased DMAA may be the defining characteristics of juvenile hallux valgus""
- Over-correction of IMA through osteotomy
- Excessive medial eminence resection
- Excessive medial capsular tightening
- Excessive lateral release
- Excision fibular sesamoid
- If Bony procedure required, need osteotomy
- Polydactyly is frequently noted
- 30% recover non-op
- medial column defect
- Belthur MV (JPO 2011) The Spectrum of Preaxial polydactyly of the Foot
- 20/28 feet with polydactyly had hallux varus
- Lovell and Winter's Pediatric Orthopedics:
- Often associated with short first metatarsal, bracket epiphysis of the first MT, pre and post-axial polydactyly and fibrous band that acts as a tether along medial side of great toe
- ""mild forms of hallux varus with a flexible deformity generally resolve spontaneously, but that condition should be differentiated from congenital hallux varus""
- Treatment:
- There is no role for conservative management
- McElvenny --> soft tissue release and resection
- Resection and grafting of physeal bridge = bracket epiphysis
- Opening wedge osteotomy
- Amputation
- A. Fuse 1st MTP at 30o dorsiflexion to MT
- B. Release all lesser toe extensors and capsule
- C. Perform less toe MT osteotomies from proximal-dorsal to distal-plantar
- D. Do not recreate the lesser MTP cascade
- A. Triple arthrodesis
- B. Subtalar and talonavicular arthrodesis
- C. Talonavicular arthrodesis
- D. Talonavicular resection
- I think you could argue for B quite strongly.
- JAAOS 1994 - Rheumatoid foot and ankle
- ""Occasionally, isolated involvement of the talonavicular joint will occur without deformity. Formation of cysts and joint destruction can sometimes be extensive. In these circumstances, isolated TN arthrodesis has been recommended. However, progression of arthritis destruction in adjacent joint is possible. We have found SPECT useful before proceeding with TN arthrodesis….some authors advocate double arthrodesis or TN and CC joints for younger more active patients""
- A. AFO
- B. Triple
- C. Subtalar
- D. TN
- Release dressing
- Remove tourniquet
- Dangle Foot
- Warm foot
- Skewer toe onto K-wire and rotate
- Remove Pin
- Increased plantar pressures
- Intraoperatively, 10 degrees of dorsiflexion is all that is needed for normal gait
- The instantaneous center of rotation remains the same
- Dorsal osteophyte limits plantarflexion
- Kinematic analysis of the first metatarsophalangeal joint in patients who have hallux rigidus reveals a decrease in the total arc of motion, with relatively normal plantar flexion but markedly restricted dorsiflexion.
- Motion analysis reveals instant centers of rotation that are displaced and located eccentrically about the metatarsal head.
- Patients who have symptomatic hallux rigidus have been found to have higher-than-normal dynamic plantar pressures of the first ray.
- Decreased plantar pressures of the first ray have been reported after resection arthroplasty and implant arthroplasty.
- The minimum physiological dorsiflexion of the first metatarsophalangeal joint that is necessary for a normal gait is unknown; however, the values that have been reported in the literature have ranged from 15 to approximately 90 degrees
- Custom orthotic
- 1st MTP fusion
- Keller’s resection
- Proximal phalanx osteotomy
- Shoe modifications, such as a Morton extension orthosis
- Often poorly tolerated
- Cheilectomy and Proximal Phalanx Osteotomy
- Arthrodesis
- Favorable and time-tested procedure for managing late and end stage hallux rigidus
- Keller Resection Arthroplasty
- Better choice for patients > 70 years, less active
- JAAOS 2007 - Bunionette Deformity
- Metatarsal head translated dorso-medial (relieve callosities)
- Lateral eminence resection
- Medial soft-tissue release of 5th MTP
- 4-5 IM angle:
- Normal < 6.5-8o
- Average symptomatic bunionette 9.6o
- Lateral deviation angle:
- Average is 2.6o (0-7o)
- Average of 8o with symptomatic bunionette
- 5th MTP angle:
- Usually <14o
- Normal width of metatarsal head is <13mm
- Cuboid
- Medial cuneiform
- Navicular
- Base of 5th phalanx
- Tip of fibula
- Posterior talus
- FHL insertion
- Insertion of peroneus brevis
- Chart review of 637 patients (664 ankles) who received a TAA between May 2007 and January 2014 and had a minimum follow-up of 3 months.
- Chemoprophylaxis was prescribed only in the setting of a history of VTE or active coagulopathy. Patients were continued on chemoprophylactic agents if they were taking these medications preoperatively
- Our results suggest that clinically detectable VTE after TAA is uncommon. Patients without identifiable risk factors do not appear to require chemoprophylaxis following TAA. We recommend continuation of antiplatelet or anticoagulation therapy in patients who are taking these medications preoperatively and the initiation of chemoprophylaxis postoperatively in patients with known risk factors for VTE.
- The incidence of symptomatic DVT after total ankle replacement and use of low-molecular-weight heparin is comparable with that in patients undergoing total knee or hip replacement
- we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT
- Our results indicate that we do not have the evidence to advocate the routine use of LMWH in this patient group
- arthroplasty has a closer gait pattern to controls
- Arthroplasty and arthrodesis have equivalent patient satisfaction
- plantarflexion with arthroplasty is equal to control
- Gait power is greater with arthrodesis vs arthroplasty (?)
- Ankle arthroplasty group has same plantar flexion strength as the control group
- Both Ankle arthroplasty and ankle arthrodesis demonstrate a weaker gait than the control group
- Arthrodesis and ankle arthroplasty patients report similar patient reported outcomes
- Ankle athroplasty gives a range of motion that is similar to that of the control group
- Plantar flexion motion was not equivalent to normal in either group
- Improvements in patient-reported Ankle Osteoarthritis Scale and Short Form-36 scores were similar for both treatment groups
- The gait patterns of patients following three-component, mobile-bearing total ankle arthroplasty more closely resembled normal gait when compared with the gait patterns of patients following arthrodesis
- Infection
- Loosening and osteolysis
- Medial malleolus fracture
- Ipsilateral hindfoot/subtalar arthritis
- Haddad (JBJS 2007) Component loosening and/or subsidence (28%) were the primary reasons for revision
- Reported rates of infection after TAA range from 1-3.5%
- A. double rocker bottom
- B. heel to toe rocker bottom
- C. Forefoot rocker
- D. negative rocker bottom
- Heel to toe orthoses reduce need for ankle motion
- Other Options:
- Double Rocks accommodate for midfoot pathology
- Toe only rocker --> increase weightbearing proximal to MT heads (forefoot problems)
- Negative Rocker --> foot in fixed dorsiflexion
- A. Knee OA
- B. Ipsilateral hindfoot OA
- C. Back OA
- D. Contra-lateral ankle OA
- Hemoglobin A1C
- Discuss fusion
- Discuss total ankle arthroplasty
- Order patient supportive orthosis
- Neurology consult
- Discuss TAA
- Discuss fusion
- orthotics
- Slight overcorrection is necessary to balance the ankle. In general, the distal tibial surface angle is overcorrected to 2 to 4 degrees of valgus to compensate for the loss of cartilage in the medial tibiotalar joint.
- In our experience, deformity >10 degrees generally necessitates fibular correction.
- 10 degrees dorsiflexion, neutral rotation, 5 degrees valgus
- neutral flexion, neutral rotation, 5 degrees varus
- neutral flexion, 5 degrees external rotation, 5 degree varus
- neutral flexion, 10 degrees ER, 5 degrees valgus
- JAAOS 2000- Ankle Arthrodesis
- The foot should be externally rotated 20-30o relative to the tibia
- The ankle joint in neutral flexion, 5-10o external rotation and slight valgus (5o)
- 15 ER, 5 valgus, neutral dorsiflexion
- 5 IR, 5 valgus, neutral dorsiflexion
- 5 plantarlexion, neural varus-valgus, no rotation
- no rotation, 5 dorsiflexion, 5 varus
- AAI is distinguished from early ankle OA in that the tibiotalar joint space is maintained
- Nothing in article about size of osteophytes and severity of symptoms
- Obviously decreased joint space = OA and therefore would have poor outcomes if treated with cheilectomy alone…
- Results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs. The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports
- A. Loose body
- B. asymmetric joint space narrowing
- C. osteochondral lesion less than 1cm
- D. anterior lipping of distal tibia
- CN coalition
- Medial talar osteophyte
- Scarring and fibrosis of tissue in lateral gutter of ankle
- Hypertrophy of terminal aspect if AITFL
- Anterior bony impingement of the ankle is the osteophytic impingement of the anterior rim of the tibia and the sulcus of the talus
- The recurrent inversion ankle sprain creates chronic inflammation and hypertrophic changes of the synovial tissue between the talus and the anterior tibia. An accumulation of synovitis and scar tissue is entrapped in the anterolateral gutter of the ankle usually following inversion injuries. The patient will have swelling after activity and limited ankle dorsiflexion and supination as well
- Bassett’s ligament, a thickened distal fascicle of the anterior inferior tibiofibular ligament (AITFL) that extends distally on the lateral malleolus, is believed to be an independent accessory ligament and the cause of anterolateral soft tissue impingement when the ankle is plantar flexed
- Lateral ankle instability
- Anterolateral OCD
- Posteromedial OCD
- Full thickness chondral defect of the talus
- Achilles tendon is tight
- Tibialis posterior is tight
- Gastrocnemius is tight
- Subtalar joint is stiff
- The Silverskiold test differentiates an isolated gastrocnemius contracture from combine gastrocnemius and soleus contractures by assessing passive ankle dorsiflexion with the knee both flexed and extended
- A. Plantarflexion
- B. Flexion of the knee and ankle
- C. Flexion of the knee and ankle and subtalar supination
- D. Flexion of the knee and ankle and subtalar pronation
- Uquilas CA (JBJS 2015) Everything Achilles
- The Achilles tendon is part of a msculotendinous unit that spans three joints, producing knee flexion, tibiotalar flexion, and subtalar inversion
- A. Plantar fasciitis, hallux rigidus, neuropathic foot ulcers
- B. Hallux rigidus, neuropathic foot ulcer, plantar fasciitis
- C. Plantar fasciitis, Morton’s neuroma, neuropathic foot ulcers
- D. Plantar fasciitis, neuropathic foot ulcers, charcot midfoot collapse
- “Strong association with metatarsalgia, neuropathic ulceration, plantar fasciitis, Charcot midfoot breakdown”
- “Lesser degree PTTD, Achilles tendinopathy, ankle sprain and fracture, MTP synovitis, hallux valgus, claw toes and toe walking”
- Incision issues: Hypertrophic Scar, Wound breakdown, Infection
- Sural nerve injury
- Tethering of Achilles to skin
- Diabetes
- Obese (BMI > 30)
- smoker
- Neuropathy
- Immunocompromised states
- Age > 65
- Sedentary life
- Peripheral vascular disease
- FHL
- FDL
- Tibial Posterior
- Plantaris
- FHL tendon transfer --> FHL is stronger than FDL and peroneals
- Similar axis of force to Achilles
- In phase transfer
- He will get more passive ROM with non-surgical treatment
- He will have larger diameter calf with surgery
- If treated non-op, this includes early weight-bearing
- Re-rupture rate at 2 years is significantly less in operative group
- 10 studies
- Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included
- Surgery had 15.8% increased risk for complications other than re-rupture
- Mohtadi Study
- 144 patients randomized to operative vs non-operative
- Both groups had early WB and ROM
- No difference in re-rupture rates, higher soft tissue complications in operative group
- Wound complications: 14.6% vs 0.5%
- Re-rupture: 10.7% casting, 1.4% open, 1.5% functional brace
- Overall complication rates:
- 6.7% in open repair with early mobilization
- 15.6% perc repair and early mobilization
- 12 studies with 800 patients
- Once again higher rate of re-rupture with non-op and higher rate of complications with OR
- Functional brace had re-rupture rate of 2.4% vs 12.6% in casting group
- FHL
- V-Y
- Synthetic graft
- Cast/bulky splint in plantarflexion
- Non-WBing with crutches
- Transition to aircast boot with 2cm heel lift
- Protected WBing with crutches
- Allowed to do active plantarflexion, eversion/inversion out of aircast below neutral
- Advance to WBAT in aircast boot with 2cm heel lift
- May continue exercises as above
- Start removing heel lift, 1 lift/week
- Continue WBAT in boot, no crutches
- May continue exercises as above
- Wean out of boot, using crutches initially for wean
- Progress ankle ROM, strength (including calf raises), proprioception
- Continue rehab including sport-specific retraining
- Eccentric heel drop program
- Soroceanu A (JBJS 2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials
- 10 studies
- Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included
- Surgery had 15.8% increased risk for complications other than re-rupture
- Surgical patients returned to work 19.16 days sooner (p = 0.0014).
- There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).
- MRI
- Anterior drawer test in plantarflexion
- CT of the syndesmosis
- Arthrogram showing dye extending to peroneal tendon sheath
- Peroneal tendonitis
- Posterior tibialis subluxation/dislocation
- Occult fracture of anterior process of talus (is this actually supposed to be lateral process?)
- OCD of the talus
- JAAOS 2009 - Commonly missed peri-talar injuries
- Osteochondral injuries of the talar dome often accompany the ankle sprain/fracture
- Lateral talar process fractures
- ""Commonly misdiagnosed as an ankle sprain because the the location of maximal tenderness 1cm inferior to tip of lateral malleolus""
- JAAOS 2009 - Peroneal Tendon Injuries
- Peroneal subluxation and dislocation associated with ligamentous ankle injuries
- JAAOS 2005 - Process and Tubercle Fractures of the Hindfoot
- Lateral talar process fractures mimic ankle sprains
- Fractures of the anterior calcaneal process also occur after inversion of the plantarflexed ankle
- Stress radiographs
- Arthrogram
- MRI
- CT
- Stress radiographs may be useful in establishing a tear of the lateral ligamentous complex….. but the present lack of clinical usefulness of this information…do not recommend the routine use of stress radiographs
- MRI imaging evaluation can be useful, particularly in demonstrating associated causes of ankle pain, such as chondral injury, bone bruising, radiographically occult fractures, sinus tarsi injury, periarticular tendon tears, degeneration, and impingement syndrome
- Surgical options
- Non anatomic repair- falling out of favour due to wound complications and recurrent instability
- Anatomic direct repair of ATFL and CFL
- Anatomic reconstruction with graft (allo = auto)
- Indications: obese, poor tissue quality, failed repair
- Autograft options
- Local (P. longus, EDB)
- Free (Achilles, hamstrings, bone patellar tendon bone)
- Allograft options
- Toe flexors/extensors, fascia lata, hamstrings, p. longus described
- Open vs arthroscopic -> 2 RCTs show equivalent outcomes at 1 year
- Arthroscopic risks SPN and sural nerve
- Complications higher for non-anatomic repair
- Instability
- Wound complications
- Risk factors for recurrence
- Patient factors:
- Pre-disposing: ligamentous laxity, long-standing instability, high functional demand, and cavovarus deformity
- Re-injury
- Functional instabliity
- Surgical Factors: inadequate anatomic reconstruction (ie anatomic reconstruction have less instability)
- Arthroscopic complications
- “relatively high” complication rate (no numbers mentioned)
- most often nerve damage
- Communicating branch b/t SPN and sural (avg distance 4.7 cm from lateral malleolus) à”Safe Zone” of 1.5cm from lateral malleolus
- Custom, full length, semi-rigid orthotic
- Recessed first ray
- Lateral hindfoot wedge or post
- Lowered medial arch
- Heel cushion
- A. Micro # with MM osteotomy
- B. Microfracture with arthroscopy
- C. Retrograde drilling
- D. Transplant ipsilateral knee
- JAAOS 2010 - Osteochondral Lesions of the Talus
- Retrograde drilling if cartilage cap is intact
- MM osteotomy not needed for microfracture, only needed if placing grafts/need appropriate angle for plugs
- OATS generally only if > 1-1.5cm
- Anteromedial
- Posteromedial
- Posterolateral
- Anterolateral
- A. Partial release of the plantar fascia
- B. Skin incision and inspection of the plantar fascia
- C. Release of the tarsal tunnel
- D. Full release of the plantar fascia
- Plantar fasciotomy, either partial or complete, is the common surgical procedure chosen for treating recalcitrant cases
- Biomechanical and finite-elements studies have shown that release of >40% of the plantar fascia has detrimental effects on other ligamentous and bony structures in the foot; therefore, releases should be limited
- Release of tarsal tunnel only indicated if tarsal tunnel symptoms present
- Anterior inferior tibfib ligament
- Posterior inferior tibfib ligament
- Interosseous Ligament
- Inferior Transverse Ligament
- Tibial Nerve
- Superficial Peroneal Nerve
- Deep Peroneal Nerve
- Sural Nerve
- Saphenous Nerve
- Dalteparin is provided to prevent DVT and recommended as prophylaxis
- No evidence for DVT and prophylaxis is not recommended
- Venous doppler showed 10-40% DVT below knee following TAA and prophylaix is recommended
- DVT prevalence is 20-40% in ankle fracture surgery
- No difference in rates of DVT with prophylaxis or not
- Recommend against use of prophylaxis, uness 3+ RFs
- obesity
- history of VTE
- history of trauma
- use of hormonal replacement or oral contraception therapy
- anatomic location of surgery
- procedure duration 60 minutes or more
- general anesthesia
- postoperative nonweightbearing immobilization greater than 2 weeks
- Maximal vertical displacement at mid stance
- Maximal vertical displacement occurs at the same time as maximal horizontal displacement
- 50% kinetic energy becomes ….
- Stance phase takes up 70% of gait cycle
- in standing position is 5cm anterior to S2 vertebral body
- vertical displacement
- during gait cycle COG displaces vertically in a rhythmic pattern
- the highest point is during midstance phase
- lowest point occurs at the time of double limb support
- horizontal displacement
- COG displaces 5cm horizontally during adult male step
- only tib-ant
- psoas and tib-ant
- psoas, hamstrings, tib-ant
- psoas, quads, tib-ant
- Jer: based on table below - would suggest C - psoas and tib ant are concentric and hamstring eccentric
- Loss of osseous support
- Excessive resection of the medial eminence
- Excision of lateral sesamoid
- Formerly done in the classical description of the McBride
- Overrelease of lateral capsular structures
- Release or transfer of the adductor hallucis alone is not sufficient to produce dynamic hallux varus
- Overplication of medial capsule
- Overtranslation of intermetatarsal angle or hallux valgus interphalangeus
- The static type results from osseous disruption at the MTP joint following overcorrection (aggressive medial eminence resection or overcorrection of the IMA) during osteotomy procedures.
- The dynamic type is a result of disruption of muscle balance at the base of the proximal phalanx.
- Although hallux varus can occur due to a combination of intraoperative procedures, it is most commonly reported, and perhaps best explained, after a McBride procedure with fibular sesamoid excision.