FANKLE Flashcards
pathophys of charcot bone destruction
hypervascularity of bone
best tendon to augment for PTTI correction
FDL - plantaris is inferior
what can prohibt a talar head dislocation from reduction
Post tib tendon
spring ligament components and tears
2 bands -supmedial/inf medial - generally sup medial is torn
which nerve is NOT covered by popliteal block
saphenous
pes planovalgus leads to what on lateral ankle
subfibular impingement
what ligament tears are seen with adult flat foot
spring lig damaged; (Sup/Med band)
what is lateral impaction syndrome
when calc and talus sublux in flat foot and impinge to fibula on eversion
what is down side of k-wire for listfranc
recurrence after pin removal
what is subtalar arthroeresis
implant in subfibular space to limit eversion - often a/w persistent pain
anatomic risk factors for 2nd mt stress frx
hallux rigidus, long second MT; hallux valgus
what is the Chopart joint
talonavicular and calccuboid
long term tx for sequelae of chopart joint dislocation
usually develo OA and a rigid rocker bottom or carbon fiber insert can help
most accurate way to measure syndesmotic disruption on XR
TIB FIB Clear space > 6mm
tx of sx of talar OCD
if CYSTIC - OCD graft ; if non-cystic < 1.5cm - debride + drilling if cartilage disrupted; NON-cystic <1.5cm AND cartilage is good – retrograde drilling and grafting
what percent of lisfranc are missed
20% missed on original xray;
what causes hammertoe deformity
contracted Flexor digitorum LONGUS from EDL OVERPULL
hammertoe vs mallet toe
Hammer is PIP FLEXION; DIP hyperextension; MTP is also extended
etiology of plantar ulcers in diabetes
NOT vascularity but rather neuropathy
after removal of border digit for osteo what must happen
custom molded shoe insert to prevent shift of weight
m/c location for mortons neuroma
second and third webspace
r.f for plantar fascitis
bMI > 30
what exericses are best for Plantar fasciitis
PF specific stretching not just achilles
risk factor for mortons neuroma
female gender
tx of longitudinal peroneus brevis tears
can suture repair to prevent tear propagation and to avoid tenodesiis to longus
risk factor for poor outcome of coaltion resectio
adult age and > 50% facet invovlement
m/c sequelae after calc frx
Subtalar OA
which muscles affected first in CMT
intrinsics bc longest axons; then p brevis and tib ant
what can cause peroneal retinaculum injury
sudden dorsiflexion
complication after steroid for morton neuroma
hammertoe
after calc fracture what causes ant ankle pain
impingement due to lost calc height, need to restore talar declination
causes of turf toe
usualy hyperdorsiflexion with axial load;less common is same with a valgus force (beach volleyball players)
best clamp postion for syndesmostic reduction
inline with ankle axis
FDL transfer to extensor hood is for
flexible hammer toe
tx for flexible mallet toe
FDL tenotomy
what radiographic sign indicates hallux will recurr
medial sesamoid position. It should be well centered otherwise recurrence
when evaluating surgery for flat foot consider
TMT fusions if mid foot collapse; don_t jump straight to medializing calc osteotomy
diabetic foot infection on IV abx what next
debridement; no immediate amputation unless unstable
diabetic nec fasciitis organism
usually polymicrobial; if single isolate then Group A strep
chopart amputation is through
HINDFOOT - between Talonavic and Calccuboid
does steroid help with mortons’ neuroma
not for long term
why do you need two incision for talar neck
bc need to restore medial comminution to avoid varus collapse and then use better bone on lateral side for fixation
dorsomedial cutaneous nn over great toe is branch of which nn
Sup peroneal nn
does timing of talar neck oRIF impact osteonec
NO
tx of kohlers
self limting so no cast; but generally just supportive arches and activity modification
cut offs for wound healing (ABI, TcO2, Toe pressure)
ABI> 0.45; TcO2 > 30; or toe pressure > 40 (can be skewed by calicified vessels)
where does sup peroneal nn exit
10-12cm above tip of lateral malleolus; intermediate branch is for dorsal lateral foot
p brevis tendon repairs vs debridement
if > 30% debride tendon and tubulerize; tenodsesis after 50-60%
ankle fracture in poor controlled DM consider what surgery
perc fixation and NWB
tx of chronic lateral process talus fractures
fragment excision - look for sinus tarsi pain
tx of bunnionette
type 1 - cut head; type 2 chevron; type 3 is with wide IMA and do dipahyseal oseotomy
best IMAGING study for syndesmosis injury
MRI
what is the goal of the gravity stress
to assess deltoid ligament injury in setting of lateral malleolar injury
when to use bulk talar allograft
shoulder talus lesions that are too big for OCD transplat - in younger patients to avoid fusion
what is the approach for talocalc coalition
between FDL and FHL
what is the approach for calcaneonavicular coaliton
latearl over sinus tarsi
most effective non op for PTTD
AFO
anterior ankle impingment first step tx
consider steroid injection before scope bc uusally not a bony impingement but rather a fat pad
anke OA with adjacent degen whats best option
TAA if possible bc fusion will exacerbate adjacent OA
nerve at risk during retro TTC nail
lateral plantar nn
achilles gap options
<2cm primary repair; 2-5cm - V-Y; > 5cm or chronic do turn down and FHL augment
which coalitions are hard to see on plain film
Talocal - need ct or MRI
what exercises are a.w achilles ruptures
PLYometric; isometric and isotonic are NOT effect for tendinosis
transverse tarsal amputaiton is same as
chopart - b/w Talonavic and calccuboid - needs achilles lenghten and tib ant transfer to talar neck
patient with recalcitrant plantar foot pain with several injections - consider_
heel pad atrophy and tx is more heeling padding
INITIAL bracing for PTTD
AFO; then can consider a custom orthosis with medial support
non healing plantar hallux IP ulcer
if tissue conditions are good then consider Keller resection; any fusion would worsen then problem.
when does post tib function during gait
during terminal stance to iniate elevation and inversion of hindfoot
TAA vs Fusion in function
increased stride length, cadence, and velocity in ankle arthroplasty.
failed ankle replacement due to PJI what next
staged fusion
flatfoot recon options don_t forget to evaluate
MIDFOOT collapse - must fix this
indications for supramalleolar ankle osteotomy
near normal ROM; minimal talar tilt or varus heel; MEDIALLY ankle OA no worse than A or 3A on Tanaka Scale
Tanaka Ankel OA classification
1 -early sclerosis, osteophytes NO joint space narrowing; 2 is meial joint space narrowing; 3 is subchondral bone contact with lost MEDIAL joint space; 3b is whole dome is involved, 4 is complete bone contact
medial vs lateral OCD
medial - no trauma; more posterior; and larger/deeper; Lateral - trauma; superifical/shallow; central or anterior; less likely to heal spontaneously and more symptomatic
tx of plantar fascia ruptures
cast immobilization
diagnosis of charcot vs infection via imaging
MRI and Indium 111 bone scan
posterior tarsal tunnel defined by
flexor retinaculum (lacinate lig); calcaneous is medial; talus is medial; abductor hallicus is inferior - includes tibial nn, post tib artery, FHL, FDL, PT
tibial nerve branchign in foot
medial and lateral plantar (each has their own sheath and bifurcation is distal to tarsal tunnel) medial calcaneal nerve
Anterior tarsal tunnel space defined by
inf ext. retinaculum; fascia over talus and navicular - contents include DP nn, EHL, EDL, and dorsalis pedis
role of the subtalar joint in gait
during early stance it convets internal tibial rotation to foot pronation and calc eversion
medial subtalar dislocation features
more common; inversion, plantar flexion mxn; foot locked in supination; sus tali acts as a fulcrum for neck of talus; a/w post proces talus, navicular frx, reduction is usually blocked by peroneal EDB talonavic joint capsule
lateral subtalar dislocaitons features
open; eversion/plantar flexion; ant process of calc is the fulcrum; foot locked in pronation; a/w lat process talus frx, ant calc; cuboid; fibula - reduction blocked by PT, FHL, FDL
after subtalar dislocation is reduced - whats next step
CT - look for associated fractures
optimal position of ankle fusion
neutral DF; 5-10 ext rot; 5 hindfoot valgus; 5mm post talar translation
risk factors for ankle fusion NONunion
previous substalar fusion and VARUS
scope vs ankle fusion
shorter hospital stays with scope with SIMILAR outcomes and fusion rates
dorsal vs lateral plates for fibula frx
dosral is stronger but peroneal irritation
muller weiss disease
adult onset navicular AVN - typiall talus goes lateral - requires medial column fusion
when to perform Lapidus for Hvalgus
in addition to OA, or severe IMA deformity; also look at second MT for transfer stress reaction caused by hypermobile 1st TMT joint
ideal tx of transfer metatarsalgia
pad directly proximal to MT head to offload area
main imbalance in CMT
P longus overpowers the Tib Ant forcing first ray in PF leading to varus
TMT amputation requires
Achilles lengthening; transfers wont heal and arent strong enough to balance out achilles
upposed pull of post tib can result in
HINDfoot valgus as midfoot gets pulled into supination
when is distal MT osteotomy enough for Hvalgus
if IMA < 13-15 and HVA < 25
indications for distal and prox MT osteootomy for H valgus
HVA 40-50 AND IMA > 16
when to MTP fuse for h valgus
CP, Downs; RhA, Gout, Ehlers Danlos
when to lapidus
MT primus varus; concomittent pes planus; very large IMA; 1st TMA OA; or hypermobile TMT (look for stress frx at MT 2)
tx of heel pad atrophy is
more padding
what is displaced inferiorly in calc frx
lateral aspect of posterior facet. Medial aspect is the constant fragment
p brevis vs p longus at peroneal tubercle
p tubercle is on calc, Brevis is DORSAL
tx algorithm for peroneal tendon tears
if small tears - debride, repair/tubulerize, if type 2 (one is unsuable and one is good -then tenodesis to each other); if type 3 - both are useless, then allograft transfer if muscle excrusion is present, otherwise FHL transfer
FHL transfer to achilles vs debride and repair - whats the diff
FHL transfer has increased ankle PF without compromising Hallux PF
eval of turf toe requires
MRI; stress dorsiflexion view is not usually possible in acute setting
high IMA noted by
lateral sublux of the sesamoids; needs a proximal osteotomy
lateral placement of saw in h valgus correction can lead to
hallux varus
best approach for TTC fusion
lateral; allows acces and prep of TT and Talocalc surfaces
first line tx of freibergs
metatarsal pads
what is first portal in ankle scope and structure at risk
Tib Ant bc first make medial portal and use visualization to make anterolateral inorder to avoid SPN
where does DPN and dorsalis pedis live
b/w TA EHL
medial and lateral plantar nerves sit on what layer
plantar aspect of layer 2 - QP; lumbricals and FHL, FDL tendons
achilles myotendinous junction turns which way at insertion
90 deg medial so superficial fibers insert laterally
third layer of foot contains
Adductor Hallucis (oblique, transverse heads), FHB, FDMB
talar body main blood supply
retrograde via arter of tarsal canal; more recent studies show blood supply comes from post tib.
where are navicular stress fractures
dorsal third
Deep peroneal innervates
Tib Ant, EHL, EDL, and innervates EDB and EHB in foot
transverse tarsal joints during heel strike
subtalar everts making these joints PARALLEL and UNLOCKED for uneven ground
ATFL is under greatest strain in what postion
PF, inversion, int rot.
CFL is under greatest strain when
DF and inversion
tibia rotation and DF vs PF
DF is coupled with tibia internal rotation; PF is coupled with tibia EXT rotation
what percentage of H valgus is familial
70% have a familial history
normal IMA
<9-10.
HVA normal
< 15deg
PPAA
is prox phalanx base angle vs diaphysis ; should be < 15
what is AKIN osteootmy and when
prox phalanx medial closing wedge - done for > 10 deg difference
When to usse Chevron
IMA < 13; HVA < 30; if DMAA >10 need a biplanar
when to perform MTP fusion for h valgus and how much
if HVA > 40; fuse with 10-15 of valgus and 10-15 DF - done in CP, RhA
what is presentation of a severe turf toe
MTP hyperextesion with IP flexion (intrinisc minus)
what happens if you see sesamoid migrated PROXIMALLY
plantar plate rupture
problem with bone scan and sesamoid injury
25-30% increased uptake on asympomatic patients
juvenile H valgus features
up to 50% can have congruent high DMAA; higher recurrence, can be a/w metatarsus adductus
surgery for freiberg
dorsal closing wedge to bring unaffacted plantar cartilage up and also causes shortening which helps
Mallet Toe joint positions
MTP is neutral; PIP neutral; DIP flexed
Hammertoe joint positions
MTP extended; PIP flexed; DIP extended
Claw
MTP extended; PIP flexan DIP Flex
tx of mallet toei
if flexible - perc FDL tenotomy
Hammer toe surg
resection arthroplasty with FDL tenotomy
pathophys of claw toe
tight flexors pull IP joints in flexion while MTP extends and MT head is depressed pulling plantar plate distally
normal 4-5 IMA
< 9; tx with diaphyseal rotation if > 12
dwyer calc osteotomy moves which direction
LATERAL
what is mod Bronstrom
using Inf peroneal retinaculum to make anatomic augment of lateral ATFL and CFL
what is normal tib fib clear space
MORE THAN 6mm on AP; 1mm on mortise
main downside to NON-anatomic lateral lig recone
subtalar stiffness
where is antero medial portal in ankle
MEDIAL to Tib ANT at level of tip of malleolus - if placed too medial (m/c error) then malleolus blocks view
Anterolateral ankle impingment 2 locations
seen with lateral ankle instability; m/c location is sup border of ATFL; and then distal aspect of AITFL
best way to diagnosie ankle impingement
exam - PF and direct pressure; better than MRI
what is basset ligament
inferior aspect of AITFL invoveld in syndesmotic antero lateral impingment
supramalleolar ostoetomy for varus deformity_
medial opening wedge; if > 10deg need a fibular osteotomy too
supramalleolar ostoetomy for valgus deformity_
medial closing wedge with oblique fibular osteotomy for lengthening
limitations of scope fusion
cant correct deformity
what is consequence of fusion in ankle PF
knee goes into recurvatum to accommodate
main downside of TAA vs fusion
MUCH higher revision surgery rate
hindfoot OA m/c caused by
trauma
isolated TN OA caused by
inflammatory conditions (RhA)
which joint OA limits hindfoot motion most
Talonavicular - 90% of motion is limted if TN is fused - therefore if TN is bad - do a triple fusion anyways
which joint fails to fuse in Triple fusion
Talonavicular
pain with extreme PF in hallux rigidus is caused by
draping of dorsal capsule and EHL over a osteophyte
best fixation for MTP fusion for h rigidus
compression screw and plate - goal is 15 deg valgus; and 25 deg DF
does achilles invert or evert hindfoot
INVERT - even though hindfoot is valgus - achilles inserts on medial aspect of axis of rotation
when to add tendon transfer to achilles injury
if > 50% is inflammed or older patients > 55 (FHL, FDL or even P brevis)
diff in wound size for achilles repair
perc and mini open do have lower wound issues but higher sural nerve issues with perc vs regular open
inssertions of Post tib
anterior limb to navic and first cuneiform; middle limb to 2-3cuneiform, cuboid and 2-5MT: and final limb is to sus.tali
post tib during stance phase
eccentric contracture to take load off spring ligament
main antagonnist of post tib
p brevis
what is evans osteotomy
lateral column opening via ant proces of calc
if you need to perform triple fusion but tissue is bad
consider medial incision only talonavic and subtalar fusion; CC can be ignored
Pb tears vs p longus tears
P brevis tears are more common at level of FIBULAR groove
tib ant insertion
1st cuneiform and medial 1st met base
when to repair hallucis flexor laceration
if both FHL and FHB are out. Isolated FHL is controversial
FHL vs FDL at knot of henry
FHL crosses dorsal to FDL
posteromedial ankle pain with toe motion
consider FHL pathology - tenosynovitis
how to acute P brevis/longus tears occur
acute inversion to a dorsiflexed ankle
tx of calc stress frx
do not need NWB - but walking cast or boot 4-6 weeks is enough
common deformity in lesser toes with CMT
claw toe - due to strong intrinsics
order of muscle involvement in CMT
intrinsics; P brevis then tib ant
TAR vs fusion in adjacent OA
TAR has less progression of degen on XR
pain that dreases with traction across toe and motion
phys exam test for synovitis
what does RhA do to lesser MTP joints
valgus deviation and clawing
how does mortons extension work
limits MTP dorsiflexion to minimize pain
if both peroneals are damaged and no excursion
FHL transfer
if recalcitrant plantar fascitis and sx of nerve sx what is surgery
distal tarsal tunnel release AND partal PF release
what is best stretching protocol for plantar fascitis
NWB Achilles stretches is better than WB stretches
what does baxters nn innervates
sensation and motor to FDB and abductor quinti minimi - often compressed with people who spend time on toes (ballet, sprinters)
how long should non -op for baxters last
at least 6 months
pain with fat pat atrophy of heel vs PF pain
Fad pat atrophy pain is more proximal and more lateral
patho of neuroma
not a true neuroma - has perineural fibrosis and endoneural thickening
local analgesic vs steroid for neuroma
equal effectiveness at 3 and 6 months
what position worsesns tarsal tunnel
DF and eversion
pathoanatomy of CMT foot
first week intrinsics lead to high arch and clawing; then weak tib ant gets over powered by P longus in 1st ray; then p brevisis weak and overpowered by PT
what soft tissue procedures for CMT
transfer p longus to brevis; release TN joint and medial tissue and post tib lengthening to counter the varus forces; can also transfer Post tib to front
what is ABI cutoff for POOR healing in feet
if ABI <0.45 poor wound healing
