Foot and Ankle Flashcards
Where is the hypovasc zone for PT tendon
2-6cm from insertion onto ***
What is the last failure for PTT
Spring lig
Why can people with PTT not preform single leg heel rise
PT not working - no locking of trans tarsal joints
Foot isn’t rigid - can’t push off
Use to det rigid vs flexible deformity
XR findings PTT
- Meary angle - goes NEGATIVE
(1st MT to talus) - Talar head uncoverage
- Valgus heel
- Valgus tilt on the AP (subfibular impingement) 2/2 deltoid insuff
Nonop PTT
MEDIAL post orthotic
Op stages PTT
St 1 - NO deformity (just pain), failed non-op 6mo - tenosynovectomy
St 2 - flexible, failed non-op - FDL to navic
2a: hindfoot valgus but forefoot fine (<40% uncoverage) - +med calc slide (increase FDL trsf power)
2b: valgus + forefoot abduction - +” “ AND lat col lengthening
2c: stable medial col (cotton, dorsal opening wedge)
unstable med col (1st TMT arthrodesis)
3 - rigid/OA - triple arthrodesis
4 - valgus tilt b/c deltoid insuff
Flexible - deltoid recon
Rigid - ankle fusion
What procedure do you add for most PTT procedures
GR - Silfverskiold
If tight only with knee extension, then gastrocnemius is tight = Strayer
If tight also with knee flexion, then soleus is also tight aka Achilles complex = triple cut
Deformity associated with peroneal tendon pathology
Cavovarus (stretch the lateral side)
If see this, need calc osteotomy at time of surg or orthotic for non op
Indications for op treatment of peroneal tendon pathology by surgery type
<50% - tenosynovectomy, repair longitudinal tears
>50% - tenodesis
What do you do for peroneal tendon pain if the tendons are absent (aka worn away)
FHL trf to 5th MT base
What is foot position for peroneal tendon sublux/dislocation
Forced eversion + DF
Rupture SPR
Remember to deepen the bony groove if needed during SPR repair vs recon
Dx: heel pain 1st out of bed in AM or rising from chair
Plantar fasciitis
= microtears at origin of PF = inflam
TTP at medial aspect tuberosity
Treat plantar fasciitis nonop vs op
Stretch, heel inserts
LIMITED cortisone
Op:
- Release medial 1/4 plantar fascia (dont cause flat foot by full release)
+/- Strayer for GR
What is Baxter’s nerve and what is the EMG finding
Medial heel pain
Entrapment of the 1st br of the lateral plantar nerve
EMG: abd dig quinti motor latency
Ddx heel pain (3)
Plantar fasciitis
Baxter’s nerve
Calc stress frx
Tarsal tunnel
Diagnose +trt calc stress frx
Pain w/ heel compression
Pain w/wo WB (aka all the time!)
Frx line on MRI perpendic to trabecular bone
NWB 6-8wks
Presentation tarsal tunnel
Plantar foot / medial heel pain (sensory > motor for EMG)
Flat foot can make worse
+Tinnel
Contents of tarsal tunnel
TDavnH
PTT, FDL, tib art/v/n, FHL
Tarsal tunnel syndrome entrapment of the tibial nerve
Causes tarsal tunnel
Engorged veins
PVNS
Space occupying lesion - ganglion, nerve sheath tumor - why get MRI!
Treat tarsal tunnel
SSRI
Medial posting (flat foot)
Op: release better if a mass
Prox 5cm to flexor retinac
Distal to deep fascia abd hall
What tendon trsf might you do during an insertional Achilles repair
If need remove >50% of the tendon, consider FHL repair
Treat non-insertional Achilles tendinopathy
Eccentric stretching!!
OR:
- Excise diseased tissue
- Tubularize
- >50% involvement FHL trs
Op vs non op Achilles rupture comparison points
Equiv PF strength
No diff re rupture
Less comp w/ non op
Options for Achilles rupture repair
<6wks (acute) - consider end to end
Chronic <3cm defect - V-Y recon
Chronic >3cm - FHL +/- V-Y (must have functional tibial n)
Biomech heel strike
AT contracts
Hindfoot unlocks (valgus)
Biomech during flat foot
Achilles eccentric contract
Hindfoot stays unlocked
Biomech toe off
Achilles concentric contract
Hindfoot locks
- PF tightens
- Windlass causes hindfoot supination
Lis Franc lig + mechanism injury
Med cuneiform to base 2nd MT
Indirect : axial load on PF foot
Direct : crush
Imaging LF inj
WB XR
Abd stress XR
MRI for non displaced inj
LF non op vs op
Non op only if lig only and no displacement on WB and stress XR
OR:
ORIF bony - LF screw (removed) or bridge plating (also removed)
Lig only - fusion
Deformity of missed LF
Midfoot arthritis
Flat foot -> hindfoot valgus
Zones for 5th MT base frx
1: avulsion = nonop WBAT
2: at joint = Jones = op for active, NWB others
3: distal to joint = pseudo Jones = fix most
Anyone fixing, check hindfoot varus that would overload the site
Describe pathophys HV
Prox phal goes lat
Medial capsule stretches
Lateral capsule scars short
EHL only thing that goes medial - pronation
Everything else moves lateral (seasmoids, adductor)
- Aka abd hal moves plantar
Normal HV measurements
IMA < 9
HVA < 15
DMMA < 10
Think IMA normal, HVA abnormal
Incongruent joint
Distal only - think Chevron, poss lat lig release
Think high IMA and HVA
Incongruent joint
No OA
Proximal MT osteotomy
Scarf, Ludloff, etc
HV w/ gen lig laxity or 1st MT OA
FUSE!
Lapidus
If DMMA high, what are you thinking of doing
Biplanar osteotomies
Biplanar Chevron
Complications HV surgery
AVN
Hallux varus - excessive lateral release, removing fib seasmoid
If flexible - do a salvage
If rigid - fuse
3 operative options for HR
If joint space preserved - cheilectomy (up to 30%), +/- Moberg DF osteotomy to change WB joint / improve ROM
No joint space - fuse
10DF, 5valgus, neutral rotation
Keller resection arthroplasty only in ELDERLY med compromised
What is a hammertoe / treat fixed vs flexible
MTP ext
PIP flex
DIP ext
Flexible: FDL to ext transfer
Fix: PIP fuse
What is a clawtoe / trt fixed vs flexible
MTP fixed ext
PIP flex
DIP flex
Flexible: EDL lengthening, FDL trs
Fix: PIP fusion
What is a mallet toe / trt
Isolated DIP flex
Trt: FDL tenotomy, DIP fusion
What is a crossover toe
Plantar plate disrupted
LCL stretches (now multiplanar unstable)
2nd toe migrates medial
3ary will get claw toe deformities
What is Freiberg infraction?
Trauma -> ischemia -> 2nd MT head AVN
Often to a long 2nd MT
See central resoprtion -> OA
Trt Freiberg infraction
Non-op like OA - carbon fiber
Op: move the OA out of articulating w/ DF osteotomy
Do NOT excise the MT head
3 types of bunionettes
T1: enlarged 5th MT head = hypertrophy
T2: shaft bowed = congenital
T3: wide angle bet 4/5th MT
Trt bunionettes
T1: distal chevron
T2: oblique shaft osteotomy
T3: unclear
Beware proximal osteotomy in the 5th MT shaft bc BS - high nonunion rate
What tendons are the seasmoids in? What is the function of the seasmoids?
In FHB tendon
Increased pulley/power of FHB
What is turf toe
Forced DF
Avulse plantar plate
Seasmoids migrate proximal
Trt turf toe
Strain - toe taping, stiff insole, OK for immediate return to play
Partial tear - no sports 2 wks
Complete tear - OR for repair if >3mm prox retraction
Treat a seasmoid nonunion
Resect
Complication of resection:
Hallux varus or valgus
If you take both out - cock up deformity of the toe (aka need an IP fusion)
Treat Morton’s neuroma
Cortisone inj can relieve all sx
Resect by incising the transverse MT lig
1ary = dorsal approach
Revision = plantar approach
How does an accessory navic form / best XR to see
From 2ary ossification center
XR = external oblique
Treat accessory navic
Immobilize first
Mod Kidner = excise, advance PTT
Traditional fracture pattern for navic stress fracture
Dorsolat to plantar med
Trt navic stress frx
Nondisplaced - NWB
Any displacement - ORIF screw
Embryonic cause of tarsal coalition
Failure of differentiation
What are the deformities of cavovarus foot
Cavus = high arch
Varus heel
Forefoot in equinus + pronation
1st MT PF
Associations for unilateral cavovarus - what should you check for
Spina bifida
Compartment syndrome
Polio
Association for bilateral cavovarus
CMT
How do you determine if cavovarus is flexible or not
Hindfoot block
Place lateral - does the 1sst ray come down and does the hindfoot correct to at least neural
If corrects, then the forefoot is driving the hindfoot and can leave alone
Trt cavovarus foot
Nonop: lat heel wedge
Op:
Forefoot driven - 1st MT DF osteotomy
Rigid hindfoot - calc osteotomy vs subtalar arthrodesis
Also consider
- Plantar fascia release
- PL to PB trsf to eliminate the deforming force on the 1st ray
Indications for ankle instability surgery
Instability despite 3mo of rehab
Surg treatment ankle instability
Anatomic repair = mod Brostrom w/ reinforcement from the inf peroneal retinac
- Lower risk nerve damage
Non-anatomic repair = sacrifice the tendons (think large athletes, revision surg, hypermobility)
Make sure check hindfoot varus (+/- calc osteotomy)
2 locations for ankle OCD
Post-med : congenital, avascular lesion
Ant-lat : post trauma
Treat ankle OCD
<1cm - microfrx
OATS - better w/o a mal osteotomy at the same time
What motor loss is most common in DM
Common peroneal n first
Then ant tib, intrinsitics (claw toe)
What is the minimum ABI and transcut O2 pressure predictive for healing
ABI min 0.45 (normal 1)
Transcut O2 >40 = predictive of healing
What test to order for diabetic foot patient if you suspect:
Abscess
Osteomyelitis
Abscess - MRI
Osteo - WBC labeled scan
If probe to bone, high likelihood for osteo
What tendon transfers do you need if doing a Lis Franc amp
PB to 5th met base
Extensors to dorsum of residual foot
Achilles lengthening
What is a Syme amp
Ankle disartic - take the talus off
Requires intact heel pad
MOST FUNCTIONAL!
What is a Chopart? A good or bad idea?
Take midfoot off - leave the calc/talus
What is the ideal length of a BKA? What is an Ertl?
@myotendinous jxn
15cm below knee joint - aka enough soft tissue to cover the stump
Ertl - bone bridging for better stability but must lean on bony union (time)
Increase in metabolic expenditure for each amp
1. Syme
2. Trauma vs vascular transtib
3. Trauma vs vascular transfem
Generally vascular amps (think diabetics) spend more energy with their amps (unhealthier at baseline)
- Syme - 15%
- Trauma transtib - 25%
Vasc transtib - 40% - Trauma transfem - 70%
Vasc transfem - 100%
