Foot and Ankle Flashcards
1
Q
Where is the watershed area of the PTT?
A
2-6 cm proximal to the navicular
2
Q
Obese patient comes in with feet that look like this? How can you stage this?
A
-
Stage I - Tenosynovitis
- No deformity
- (+) single-leg toe raise
-
Stage IIA - Flatfoot deformity
- Exam
- Flexible hindfoot
- (-) single-leg heel raise
- Mild sinus tarsi pain
-
Imaging
- Arch collapse deformity on imaging
- Exam
-
Stage IIB - Flatfoot deformity
- Exam
- Flexible hindfoot
- Forefoot abduction (“too many toes”)
- Imaging
- >40% talonavicular uncoverage
- Exam
-
Stage III
- Exam
- Flatfoot deformity
- Rigid forefoot abduction
- Rigid hindfoot valgus
- Imaging
- Arch collapse deformity
- Subtalar arthritis
- Exam
-
Stage IV
- Exam
- Flatfoot deformity
- Rigid forefoot abduction
- Rigid hindfoot valgus
- Deltoid ligament compromise
- Ankle pain
- Imaging
- Arch collapse deformity
- Subtalar arthritis
- Talar tilt in ankle mortise
- Exam
3
Q
Difference between adult and juvinile hallux valgus
A
- often bilateral and familial
- pain usually not primary complaint
- varus of first MT with widened IMA usually present
- DMAA usually increased
- often associated with flexible flatfoot
- complications
- recurrence is most common complication (>50%)
- overcorrection
- hallux varus
4
Q
Risk factors for hallux valgus
A
-
intrinsic
- genetic predisposition
- ligamentous laxity
- convex metatarsal head
- pes planus
- rheumatoid arthritis
- cerebral palsy
-
extrinsic
- shoes with high heel and narrow toe box
5
Q
Pathoanatomy of hallux valgus
A
- valgus deviation promotes varus position of metatarsal
- sesamoid complex becomes lateral to the metatarsal head, which moves medially
- medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
- adductor tendon becomes deforming force
- inserts on fibular sesamoid
- lateral deviation of EHL
- plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx
- windlass mechanism becomes less effective
- leads to transfer metatarsalgia
6
Q
Radiographs for hallux valgus
A
-
views
- weight bearing AP and Lat
-
sesamoid view can be useful
- displacement of sesamoids
- often displaced laterally
- joint congruency and degenerative changes can be evaluated
-
radiographic parameters (see below) guide treatment
-
Hallux valgus (HVA)
- Long axis of 1st MT and prox. phal.
- Identifies MTP deformity
- Normal = < 15°
-
Intermetatarsal angle (IMA)
- Between long axis of 1st and 2nd MT
- Normal = < 9°
-
Distal metatarsal articular (DMAA)
- Between 1st MT long. axis and line through base of of distal articular cap
- Identifies MTP joint incongruity
- Normal = < 15°
-
Hallux valgus interphalangeus (HVI)
- Between long. axis of distal phalanx and proximal phalanx
- Normal = < 10 °
-
Hallux valgus (HVA)
7
Q
Approach to adolescent bunions
A
- best to wait until skeletal maturity to operate
- can not perform metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
- surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
- severe deformity with a DMAA > 20 perform a double MT osteotomy
- technique
- soft tissue procedure alone not successful
- similar to adults if physis is closed (except in severe deformity)
8
Q
Options for treatment of hallux valgus
A
-
Nonoperative
- shoe modification/ pads/ orthoses
- silastic spacer
- orthoses more helpful in patients with pes planus or metatarsalgia
-
Soft Tissue Procedure - modified McBride
- never appropriate in isolation
- in conjunction with medial eminence resection osteotomy
- release medial capsule of 2nd MTP; can be sutured to lateral capsule of 1st
-
adductor hallucis is released and interposed
- Can be left to scar down
- Transverse intertarsal ligament is releases which attaches to the fibular sesamoid
- Don’t resect the fibular sesamoid as was done with the original McBride or you will get hallux varus
-
distal metatarsal osteotomy
- mild disease (HVA 20-40, IMA 10-13)
- distal metatarsal osteotomies include
- Chevron
- biplanar Chevron
- Mitchell
- may be combined with proximal phalanx osteotomy
-
proximal metatarsal osteotomy
- moderate disease (HVA >40°, IMA >13°)
- proximal metatarsal osteotomies include
- crescentric osteotomy
- Broomstick osteotomy
- Ludloff
- Scarf
-
double (proximal and distal) osteotomy
- severe disease (HVA 41-50°, IMA 16-20°)
- DMAA > 15
- Scarf + chevron
- Lapidus + Akin
-
first cuneiform osteotomy
- severe deformity in young patient with open physis
-
Lapidus procedure (1st metatarsocuneiform arthrodesis)
- severe deformity
- Metatarsus primus varus
- hypermobile 1st tarsometatarsal joint
-
MTP Arthrodesis
- Gout
- Rheumatoid arthritis
- Down’s syndrome
- cerebral palsy
- Severe DJD
- Ehler-Danlos
- Resection arthroplasty
-
proximal phalanx (Keller) resection arthroplasty
- largely abandoned
- still indicated in some elderly patient with reduced function demands
9
Q
Complications associated with HV
A
-
Recurrence
- most common cause of failure is insufficient preoperative assessment and failure to follow indications
-
Avascular necrosis
- medial capsulotomy is primary insult to blood flow to metatarsal head
-
Dorsal malunion with transfer metatarsalgia
- due to overload of lesser metatarsal heads
- Hallux Varus
-
Cock up toe deformity
- due to injury of FHL
-
2nd MT transfer metatarsalgia
- often seen concomitant with hallux valgus
- shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
-
Neuropraxia
- Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve.
10
Q
Iatrogenic causes of this deformity
A
- overcorrection of 1st IMA
- excessive lateral capsular release with overtightening of medial capsule
- overresection of medial first metatarsal head
- lateral sesamoidectomy
11
Q
Classification of Hallux Rigidus
A
Cougling and Shurnas
-
Grade 0
- Stiffness with normal XR
-
Grade 1
- mild pain at extremes of motion
- mild dorsal osteophyte, normal joint space
-
Grade 2
- moderate pain with range of motion increasingly more constant
- moderate dorsal osteophyte,
-
Grade 3
- significant stiffness, pain at extreme ROM, no pain at mid-range
- severe dorsal osteophyte, >50% joint space narrowing
-
Grade 4
- significant stiffness, pain at extreme ROM, pain at mid-range of motion
- same as grade III
12
Q
Options for treatment
A
Hallus Rigidus
-
NSAIDS, activity modification & orthotics
- grade 0 and 1 disease
- activity modifications
- avoid activities that lead to excessive great toe dorsiflexion
- Morton’s extension with stiff foot plate is the mainstay of treatment
- avoid activities that lead to excessive great toe dorsiflexion
- stiff sole shoe and shoe box stretching may also be used
-
Joint debridement and synovectomy
- patients with acute osteochondral or chondral defects
-
Dorsal cheilectomy - common first approach, high success rates
- grade 1 and 2 disease (with reports of treating even up to grade 4)
- pain with dorsiflexion is an indicator of good results with dorsal cheilectomy
- shoe wear irritation from dorsal prominence and pain (ideal candidate)
-
contraindication
- pain mid-range of the joint during passive motion (grade IV)
-
technique
- remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection
- the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively
-
Moberg procedure (dorsal closing wedge osteotomy of the proximal phalanx)
- Sometimes done in conjunction with cheilectomy
- runners with reduced dorsiflexion (60° is needed to run)
- Alternatively a proximal MT osteotomy can be used to improve dorsiflexion as a joint salvage procedure, however is not recommended and is associated with metatarsalgia
- failure of cheilectomy to provide at least 30 to 40 degrees of motion
-
technique
- increases dorsiflexion by decreasing the plantar flexion arc of motion
-
Keller Procedure (resection arthroplasty)
- elderly, low demand patients with significant joint degeneration and loss of motion (>70)
- MTP arthroplasty
-
MTP joint arthrodesis - best definative option for failed chilectomy, in some patients with more severe disease can go straight to this
- grade 3 and 4 disease (significant joint arthritis)
13
Q
Strongest construct for first MTP arthrodesis
A
Dorsal plate with compression screw is biomechanically strongest construct
14
Q
4 Risk factors for Achilles rupture
A
Age
Steroids
Cipro
Eccentric muscle contraction
15
Q
Treatment options for acute achilles rupture
A
-
Epidemiology
- men
- 30-40
- 4-6 cm above calcaneal insertion
-
Nonoperative
- functional bracing/casting in resting equinus (20 deg plantar flexion) with protected early functional rehab
-
indications
- sedentary patients
- elderly patients
- medically frail patients
- patient desires to avoid surgery
- increased risk of rerupture
-
outcomes
- patient will have decreased plantar flexion strength
- Increased risk of re-rupture
-
End-to-end Achilles tendon repair
- acute rupture (< 3 months)
-
technique
- Posteromedial incision
- Avoid or beware sural nerve
- Carefully incise periotenon
- Find each end, debride and perform and end to end repair using krochow technique and nonabsorbable suture
- Oversew the peritenon with 4-0 absorbable sutures
-
outcomes
- decreased re-rupture rate
- increase plantar flexion strength
-
disadvantages
- skin complications including infection, sloughing (5-10%)
- risk factors for wound complications included
- tobacco abuse
- steroid use
- diabetes mellitus
- female sex
- sural nerve injury
-
rehab
- initially immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair
- functional rehabilitation during treatment improves range of motion and outcome
-
percutaneous repair
- weaker and not recommended
- sural nerve at highest risk for injury
16
Q
Indications for non-operative treatment of achilles rupture
A
sedentary patients
elderly patients
medically frail patients
patient desires to avoid surgery
increased risk of rerupture
17
Q
Increased risk of wound complications of achilles repair
A
tobacco abuse
steroid use
diabetes mellitus
female sex
sural nerve injury
obesity
18
Q
Options for treatment of chronic achilles tear or re-rupture
A
-
Nonoperative
- physical therapy - toe strengthening, gait training
- AFO
- Primary repair < 3 cm
-
Reconstruction with VY advancement
- defect 3-5cm
-
FHL transfer
- defect 5-10cm
- transfer FHL through osseous tunnels in the calcaneus, weave FHL to native achilles tendon
- >10cm = Allograft
-
Gastroc turndown
- another option but a large procedure
19
Q
3 complications associated with treatment of achilles
A
- Dehisence/Infection
- Re-rupture
- Sural nerve palsy
20
Q
5 differential for Chronic Achilles inflammation
A
-
Paratenonitis
- Inflammation of the peritendinous structures, including the paratenon and septum
-
Tendinosis
- Asymptomatic degeneration of tendon without inflammation, with regional focal loss of tendon structure
-
Paratenonitis with tendinosis
- Inflammation of the peritendinous structures along with intratendinous degeneration
-
Retrocalcaneal bursitis
- Mechanical irritation of the retrocalcaneal bursa
- Younger patient, shoe wear
- haglund
-
Insertional tendinitis
- Inflammatory process within the tendinous insertion of the Achilles tendon
- middle age, boney enlargement
- tendon calcification
21
Q
Middle aged woman with chronic heel pain. Differential? Likely Diagnosis? Helpful imaging?
A
Insertional Tendonitis
-
Differential
- insertional tendonitis
- tendonosis
- retrocalcaneal bursitis
-
AP, lateral of the foot
- lateral foot shows bone spur and intratendinous calcification
-
MRI and ultrasound
- can demonstrate amount of degeneration
- Early - fluid around the tendon
- Late - intratendonous calcification, degeneration of the tendon
22
Q
Treatment of Insertional Achilles Tendonitis
A
- Conservative
- physical therapy with eccentric training
- Challenges muscle, to strengthen, promote repair and increase metabolic activity
- gastrocnemius-soleus stretching
- shoe wear
- heel sleeves and pads (mainstay of nonoperative treatment)
- small heel lift
- locked ankle AFO for 6-9 months (if other nonoperative modalities fail)
- physical therapy with eccentric training
-
retrocalcaneal bursa excision, debridement of diseased tendon, calcaneal bony prominence resection
- failure of nonoperative management
- < 50% of Achilles needs to be removed
-
tendon augmentation or transfer (FDL, FHL, or PB) vs. suture anchor repair
- when > 50% of Achilles tendon insertion must be removed
23
Q
Young patient with chronic heel pain. Differential? Likely diagnosis? Helpful imaging?
A
Retrocalcaneal bursitis
-
Differential
- insertional tendonitis
- tendinosis
-
Physical exam
- Palpate
- Two finger squeeze = pain localized to anterior and 2 to 3 cm proximal to the Achilles tendon insertion
- fullness and tenderness medial and lateral to tendon
- Pump bump = bony prominence at Achilles insertion
- Move
- pain with dorsiflexion (compresses the space)
- Palpate
-
AP, lateral, oblique of the foot
- lateral of foot demonstrates Haglund deformity
- Loss of kager triangle due to bursitis
- Swelling of tendon >9mm
- 2cm above the joint line
-
MRI
- rarely needed
24
Q
Treatment of retrocalcaneal bursitis
A
-
activity modification, shoe wear modification, therapy, NSAIDs
- ice
- shoewear - external padding of Achilles tendon
- PT
- no injections
-
Retrocalcaneal bursa excision and resection of Haglund deformity
- disease refractory to nonoperative management
25
Q
6 mechanism of Achilles Tendonosis
A
- overuse - common in soccer players
- imbalance of dorsiflexors and plantar flexors
- poor technique
- poor tendon blood supply - watershed area
- 2-6cm proximal to insertion
- genetic predisposition
- fluoroquinolone antibiotics
- inflammatory arthropathy
26
Q
Options for treatment of achilles tendonosis
A
-
activity modification, shoe wear modification, physiotherapy, NSAIDs
- first line of treatment
-
techniques
- Retraining
- physical therapy with eccentric training
- Gastroc stretching
- shoewear
- heel lifts or shock absorber
- cast or removable boot (severe disease)
- Orthoses to correct pronation (tendonitis)
-
outcomes
- nonoperative management is 65% to 90% successful
-
glyceryl trinitrate patches, prolotherapy, and aprotinin injections
- Theory is injections to break down fibrous tissue - NOT appropriate for tenodonitis, only paratenonitis
-
indications
- evolving indications due to lack of evidence at this time
-
**Risks for failing non-op
- Age
- Duration of symptoms
- Degree of degeneration
-
Percutaneous tenotomies
- longitudinal tenotomy made in the degenerative area
- strip the anterior Achilles tendon with a large suture to free any adhesions
-
open excision of degenerative tendon with tubularization
- moderate to severe disease that is refractory to non-op treatment
-
Technique
- Posterior incision with development of full thickness flaps
- Incise paratenon and debride posterior, medial and lateral portion of the tendon
-
outcomes
- 70% to 100% successful
-
tendon transfer (FHL, FDL, or PB)
- This is not used for paratenonosis, only for tendonitis
-
indications
- degeneration of >50% of the Achilles tendon
- >55 years of age
- MRI evidence of diffuse tendon thickening without a focal area of disease
27
Q
Risk of failing non-operative treatment for achilles tendonosis
A
Age
Duration of symptoms
Degree of degeneration
28
Q
3 Iindications for FDL transfer in achilles tendonosis
A
- degeneration of >50% of the Achilles tendon
- >55 years of age
- MRI evidence of diffuse tendon thickening without a focal area of disease
29
Q
Name as many ossicles of the feet as you can
A
- Up to 40 accessory ossicles and multiple sesamoids have been described in the foot and ankle
-
Definition
- accessory ossicles - are secondary ossification centers that remain separated from the normal bone
- sesamoids - are bones that are incorporated into tendons and move with normal and abnormal tendon motion
-
Most common ossicles
- os trigonum
- accessory navicular (os tibiale externum)
- os intermetatarseum
-
Most common sesamoids
-
os peroneum
- located in the peroneus longus tendon
-
hallux sesamoids
- located in the flexor hallucis brevis tendon at the base of the 1st metatarsal head
-
os peroneum
-
Os trigonum
- 10-25%
- Posterior ankle impingement, FHL entrapment
- DDx - Shepherd’s fracture
-
Type II accessory navicular
- 2-12%
- Posterior tibial tendon dysfunction
- DDx - Navicular tuberosity avulsion frx, type I accessory navicular
-
Os subfibulare
- 2%
- Painful os subfibulare
- DDx - Lateral malleolus avulsion frx
-
Os peroneum
- 9-20%
- Painful os peroneum, fracture, diastasis
- DDx - Painful os vesalianum, bipartite os peroneum
-
Os vesalianum
- 2%
- Painful os vesalianum
- Ddx - Avulsion frx of the 5th metatarsal base
-
Hallux sesamoids
- ~100%
- Fracture, stress fracture
- DDx - Bipartite tibial sesamoid
30
Q
5 factors for decreased healing potential in DFU
A
-
5 factors associated with decreased healing potential
- uncontrolled hyperglycemia
- inability to offload the affected area
- poor circulation
- infection
- poor nutrition
31
Q
Wagner classification diabetic foot ulcer
A
-
Grade 0
- Skin intact but bony deformities lead to “foot at risk”
- Shoe modifications with serial exams
-
Grade 1
- Superficial ulcer
- Office debridement and contact casting
-
Grade 2
- Deeper, full thickness extension
- Operative formal debridement and contact casting
-
Grade 3
- Deep abscess formation or osteomyelitis
- Operative formal debridement and contact casting
-
Grade 4
- Partial Gangrene of forefoot
- Local vs. larger amputation
-
Grade 5
- Extensive Gangrene
- Amputation
32
Q
Brodsky classification diabetic foot ulcer
A
-
Depth
- 0
- At risk foot, no ulceration
- Patient education, accommodative footwear, regular clinical examination
- 1
- Superficial ulceration, not infected
- Off-loading with total contact cast, walking brace or special footwear
- 2
- Deep ulceration, exposing tendons or joints
- Surgical debridement, wound care, off-loading, culture-specific antibiotics
- 3
- Extensive ulceration or abscess
- Debridement or partial amputation, off-loading, culture-specific antibiotics
- 0
-
Ischemia
- A
- Not ischemic
- B
- Ischemia without gangrene
- Non-invasive vascular testing and vascular reconstruction with angioplasty/bypass
- C
- Partial forefoot gangrene
- Vascular reconstruction and partial foot amputation
- A
33
Q
Work-up for this patient
A
Diabetic Ulcer
-
History
- often painless
- time, first noticed, treatment
- hx of neuropathy or associated diabetic symptoms
- sugar control history
- PMHx
-
Physical exam
-
depth of ulcer
- probe from bone
- presence of infection
- look for cellulities, pus
- check for gangrene
- Silfverskiöld test
-
Semmes-Winstein
- __go from smaller to larger
- 5.07 = diabetes
-
Circulation
- assess dorsalis pedis and posterior tibialis pulses
- ABI’s > 0.45
- toe pressure >40mm Hg
-
Transcutaneous oxygen pressures (TcpO2)
- considered gold standard to assess wound healing potential
- > 30 mm Hg is a good sign of healing potential
-
depth of ulcer
-
Labs
- WBC > 1000
- ESR, CRP
- albumin > 3.0
- HgA1C
-
Radiographs
- AP, lateral, and oblique of foot and ankle
- evidence of flatfoot, boney prominence, charcot joint
- OM
-
MRI
- useful to determine presence of osteomyelitis
-
Bone scan
- obtain with technetium Tc99m, gallium (Ga)67, or indium (In) 111
- useful to differentiate between
- soft tissue infection
- osteomyelitis
- Charcot arthropathy
- Bone biopsy
- If grade 3 or you suspect infection
34
Q
What are 5 important factors for wound healing
A
- albumin > 30 g/L
- lymphocyte > 1000 mm3
- transcutaneous oxygen > 30mmHg
- gold standard
- ABI > 0.45
- toe pressure > 40mmHg
35
Q
Treatment plan for diabetic foot
A
-
Nonoperative
-
wound care
- goals of wound care and dressings
- provide moist environment
- absorb exudate
- act as a barrier
- off-load pressure at ulcer
- goals of wound care and dressings
-
shoe modifications
- includes deep or wide shoes, custom insoles, rocker bottom soles, etc.
- of the available shoe only modifications, rocker sole shoes best reduce the plantar pressure on the forefoot
-
wound care
-
total contact casting (TCC)
- gold standard for mechanical relief plantar ulcerations
-
technique
- weekly change with wound care
- often necessary for up to 4 months
- TCC followed by Charcot restraint walker then custom shoe
-
pneumatic walking brace
- alternative to TCC, same principal
- allows better wound surveillance
-
surgical debridement, antibiotics, local wound care, contact casting
- grade 3 or greater ulcers should undergo I&D with antibiotic treatment before casting
-
ostectomy +/- TAL (tendon-achilles lengthening)
- bony prominence causing internal pressure
-
technique
- TAL indicated if tight achilles
- several studies have shown TAL to be effective to help heal and prevent recurrence of plantar forefoot ulcers
-
syme amputation
- forefoot gangrene and a palpable posterior tibial artery pulse
36
Q
Causes of charcot joint
A
6S and 1C
- Sugar (Diabetes)
- syrnix/syringomelia (UE)
- spinal bifida
- spirit (EtOH)
- syphilis
- scaly disease (leprosy)
- congential insensitivity to pain
37
Q
Pathophysiology
A
-
Pathophysiology
-
neuropathy
- severe sequelae result from presence of both sensory and autonomic involvment
- sensory dysfunction leads to lack of protective sensation.
- autonomic dysfunction leads to drying of skin due to lack of normal glandular function.
-
angiopathy
- < 33% of patients with diabetic ulcers have decreased arterial flow
-
neuropathy
-
Theories
-
neuroanatomic
- insensate joints subjected to repetitive microtrauma
-
neurovascular
- autonomic dysfunction increases blood flow through AV shunting, resulting in bone resorption and weakening
-
neuroanatomic
-
Ulcer location
-
forefoot
- skin breakdown secondary to increased pressure, exacerbated by tight Achilles tendon or gastrocnemius
- treatment is total contact casting
-
midfoot
- increased pressure from architectural collapse
- treatment is resection of offending bone (cuboid or cuneiform) through a separate incision from the ulcer
-
hindfoot
- vascular etiology
-
forefoot
-
Molecular biology
- RANK/RANKL/OPG triad pathway thought to be involved
- involves IL-1 and TNFa
- markers
- bone turnover markers increased (increased osteoclastic activity)
- bone formation markers unchanged
38
Q
Brodsky classification charcot foot
A
-
Type 1: involves tarsometatarsal and naviculocuneiform joints
- most common location (60% of cases)
- collapse leads to fixed rocker-bottom foot with valgus angulation
-
Type 2: involves subtalar, talonavicular or calcaneocuboid joints
- 10% of cases
- unstable, requires long periods of immobilization (up to 2 years)
-
Type 3A: involves tibiotalar joint
- 20% of cases
- late varus or valgus deformity produces ulceration and osteomyelitis of malleoli
-
Type 3B: follows fracture of calcaneal tuberosity
- late deformity results in distal foot changes or proximal migration of the tuberosity
- Type 4: involves a combination of areas
- Type 5: occurs solely within forefoot
39
Q
Eichenholtz classification charcot foot
A
-
Stage 0
- Joint edema
- Radiographs are negative
- Bone scan may be positive in all stages
-
Stage 1 - fragmentation
- Joint edema
- Radiographs show osseous fragmentation with joint dislocation
-
Stage 2 - coalescence
- Decreased local edema
- Radiographs show coalescence of fragments and absorption of fine bone debris
-
Stage 3 - reconstruction
- No local edema
- Radiographs show consolidation and remodeling of fracture fragments
40
Q
Diabetic patient comes in with painful foot. Work-up?
A
Charcot Foot
-
History
- Take a complete and AMPLE history
- Characterize the event - trauma?
- swollen foot and ankle
- pain in 50%, painless in 50%
- loss of function
- PMHx - diabetes (1 vs 2), length of time, PVD
-
Physical exam
-
Look
- swollen, warm, erythematous joint
- mimics infection
- skin temperature 3.3degC higher than unaffected side
- Put foot up on chair, if erythema resolves it’s charcot
- Look for any evidence of prominences or ulcerations
-
Feel
- joint may be mechanically unstable
- Silfverskiöld test
- Neuro
- Semmes-Winstein
- go from smaller to larger
- 5.07 = diabetes
- Semmes-Winstein
-
Circulation
- assess dorsalis pedis and posterior tibialis pulses
- ABI’s > 0.45
- toe pressure >40mm Hg
-
Transcutaneous oxygen pressures (TcpO2)
- considered gold standard to assess wound healing potential
- > 30 mm Hg is a good sign of healing potential
-
Look
-
Laboratory
- HgA1C
- ESR and WBC can be elevated making it difficult to differentiate from osteomyelitis
-
Wound healing levels
- absolute lymphocyte count >1500/mm3
- serum albumin >3.0g/dL
- ABI >0.45
- toe pressure >40mmHg
-
Wound culture
- obtain biopsy, ulcer curettage, or aspiration (not wound swab) to rule out osteomyelitis before starting antibiotics
-
Histology
- synovial hypertrophy
- detritic synovitis (cartilage and bone distributed in synovium)
-
Radiographs
- obtain standard AP and lateral of foot, complete ankle series
-
findings
- early changes
- degenerative changes may mimic osteoarthritis
- late changes
- obliteration of joint space
- fragmentation of both articular surfaces of a joint leading to subluxation or dislocation
- scattered “chunks” of bone in fibrous tissue
- surrounding soft tissue edema
- joint distension by fluid
- heterotopic ossification
- early changes
-
Bone scan
-
technetium bone scan
- may be misleading
- positive for neuropathic joint and osteomyelitis
-
indium WBC scan
- will be negative (cold) for neuropathic joints and positive (hot) for osteomyelitis
- this is a valuable study to differentiate from osteomyelitis
-
technetium bone scan
-
MRI
- best for differentiating abscess from soft-tissue swelling
- difficult to differentiate infection from Charcot arthropathy on MRI
- Angiography may be considered if there is though of PVD
41
Q
Treatment approach?
A
Charcot Joint
- diabetic team consult for blood glucose management
-
contact casting, medications
-
technique
- use for 2-4 months, change every 2-4 weeks
- Hindfoot and ankle (Type 3) will require a longer immobilization
- Charcot restraint orthotic walker (CROW) boot can be used after contact casting
- later, can be fitted with custom shoe with orthotics
-
medications
- bisphosphonates - promising
- calcitonin
- neuropathic pain medications
- gabapentin
- antidepressants
- topical anesthetics
-
outcomes
- 75% healing rate
-
technique
-
resection of bony prominences (exostectomy) and TAL
-
indications
- suitable for patient with viable healing potential and stable deformity creating skin at risk of continued ulceration
-
technique
- goal is to acheive plantigrade foot that allows ambulation without skin compromise
-
indications
-
arthrodesis
-
indications
- for severe deformity
-
outcomes
- average time to fusion is 3 to 5 months
-
indications
-
amputations
-
indications
- severe deformity not ammenable to arthrodesis
- goal is for a partial or limited amputation if vascularity allows it
-
indications
42
Q
Options for fixation for arthrodesis of charcot joint
A
-
internal fixation
- screw, pin, plate, tibiocalcaneal nail
- high complication rate
-
external fixation
-
indications
- morbid obesity
- poor bone quality
- poor soft-tissue envelope
- ulcers with underlying osteomyelitis
-
high complication rate (up to 70%)
- infection (superficial and deep)
- hardware malposition
- recurrent ulceration
- fracture
- commonest complication is pin track infection
-
indications
43
Q
Acceptable amputation for charcot joint
A
acceptable limited amputation that lead to a functionable and braceable foot include (forefoot stability is preserved if not more than 2 rays are resected)
lateral three ray amputation
medial two ray amputation
two central ray amputation
Lisfranc (with TAL) amputation
Chopart amputation
Syme amputation
only perform in younger patient with good pulses at ankle)
44
Q
Options for achilles tendon lengthening
A
45
Q
What are the phases of gait?
A
-
Overview
- one gait cycle is measured from heel-strike to heel-strike
-
consists of
-
stance phase
- period of time that the foot is on the ground
- ~60% of one gait cycle is spent in stance
-
swing phase
- period of time that the foot is off the ground moving forward
- ~40% of one gait cycle is spent in swing
-
stance phase
-
Stance phase (“I Like My Tea Presweetened”)
-
initial contact
- occurs when foot contacts the ground
- FIRST ROCKER METATARSALGIA- heel - occurs only in the context of congenital deformity or tight heelcord
- muscular contractions
- hip extensors contract
-
loading response (initial double limb support)
- occurs after initial contact until elevation of opposite limb
- SECOND ROCKER - stiff ankle, plantarflexed MT will cause increase pressure threw the foot
- muscular contractions
- ankle dorsiflexors (tibialis anterior) contract eccentrically to control plantar flexion moment
- quads contracts to stabilize knee and counteract the flexion moment (about the knee)
-
mid-stance (single limb support)
- from elevation of opposite limb until both ankles are aligned in coronal plane
- muscular contractions
- hip extensors and quads undergo concentric contraction
-
terminal stance (single limb support)
- from when ankles are aligned to until the opposite to when heel strikes in contralateral limb
- muscular contractions
- toe flexors contract
- The post tib will invert the subtalar joint to lock the hindfoot and provide a solid lever arm for toe-off
- THIRD ROCKER - forefoot on ground - progressive MTP deformities
-
Pre-swing phase
- from initial contact of opposite limb to just prior to elevation of ipsilateral limb
- muscular contractions
- hip flexors contract to propel advancing limb
-
initial contact
-
swing phase (“In My Teapot”)
-
initial swing (toe off)
- from elevation of limb to point of maximal knee flexion
- muscular contractions
- hip flexors contract
-
mid-swing (foot clearance)
- following knee flexion to point where tibia is vertical
- muscular contractions
- ankle dorsiflexors contract to ensure foot clearance - mostly tib ant
- Anything comprimising tib ant will cause the extensors to fire to help recruit
- Tight gastrocs will increase subtalar extension with the knee in extension, plantar fascia and achilles are overloaded
-
terminal swing (tibia vertical)
- from point where tibia is vertical to just prior to initial contact
- muscular contractions
- hamstring muscles decelerate forward motion of thigh
-
initial swing (toe off)
46
Q
Where is the center of gravity in the body
A
- 5cm anterior to S2 vertebral body
- displaced 5cm horizontally and 5cm vertically during adult male step
47
Q
What are the determinants of gait?
A
-
pelvic rotation
- pelvis rotates 4 degrees medially (anteriorly) on swing side
- lengthens the limb as it prepares to accept weight
-
pelvic tilt
- pelvis drops 4 degrees on swing side
- lowers COG at midstance
-
knee flexion in stance
- early knee flexion (15 degrees) at heel strike
- lowers COG, decreasing energy expenditure
- also absorbs shock of heel strike
- early knee flexion (15 degrees) at heel strike
-
foot mechanisms
- ankle plantar flexion at heel strike and first part of stance
-
knee mechanisms
- at midstance, the knee extends as the ankle plantar flexes and foot supinates
- restores leg to original length
- reduces fall of pelvis at opposite heel strike
-
lateral displacement of pelvis
- pelvis shifts over stance limb
- COG must lie over base of support (stance limb)
48
Q
Etiology and pathoanatomy
A
-
Etiology
-
Neuromuscular
- __CMT/HMSN
- CP
- stroke
- anterior horn cell
-
Traumatic
- __compartment syndrome
- crush
- talus nonunion
- peroneal nerve
- Idiopathic
- Residual clubfoot
-
Neuromuscular
-
Deformity caused by
- spasticity - contracted plantar fascia
- Peroneus longous is stronger than tibialis anterior - plantarflexes first ray
- Strong tibialis posterior, weak peroneus brevis
- Weak flexor intrinsics overpowered by strong extensor extrinsics
-
Pain
- Overloading of metatarsal heads - metatarsaliga
- Prone to ankle sprains, peroneal injury, IT syndrome, medial knee arthrosis
- Lateral stress fractures, claw toes, ankle impingement
49
Q
Work-up for cavus foot
A
-
History
- Pain on the lateral side of the foot
- Stress fracture of the base of the fifth MT
- Lateral ankle instability (from varus)
- Metatarsaligia (distal migration of the fat pads)
- Early degeneration of the medial side of the ankle
- history for trauma, stroke, family history for HNMD
- Goals of the patient
- Pain on the lateral side of the foot
-
Physical exam
- Assess for Calluses along metatarsal heads and lateral foot
- Gait
- High stepping gait due to equinus contracture or foot drop
- Feel
- Assess for pain along any tendons
- Assess for pain along the ATFL or base 5th
- Assess the tripod of the foot
- Move
- Map the strength of each tendon, look for deficiency
- Feel stability of the ankle
-
Neuro exam
- Assess for bilateral pathology suggestive of CMT or polio
- Assess for UMN or LMN pathology
- Look at peroneal distribution
-
Peak-a-Boo
- Can see the heel from the front due to varus
-
Coleman block test
- flexible hindfoot will correct to neutral when block placed under lateral aspect of foot
-
Silverskiold
- Test for tight achilles/gastroc
- always remove shirt and look for spinal dysraphism
- Consider referal to neurologist
-
EMGs
- If you suspect a neuromuscular condition
-
Plain Radiographs
- AP
- Talo-1st metatarsal angle (0-3 deg)
- Measures the forefoot position
- Lateral
- Meary’s angle
- Calcaneal pitch
- Subtalar arthritis
- AP ankle
- Varus of talus under mortise - hindfoot
- Canale
- Can look for any varus malunion or evidence of previous fracture
- AP
- Bone scan or sequence of lidocaine injections might help to find the pathology
-
CT
- Can be done if there is presence of boney deformity
-
MRI
- To assess vascularity of talus or other bones
50
Q
Approach to conservative treatment
A
-
Conservative - non-rigid deformity
-
Accomodative orthotics
- custom, full length
- __high shoe box for claw toes
- Recessed first ray
- Low arch support
- Heel cushion
- MT pad if metatarsalgia present
- Ankle brace for instability
- AFO for any foot drop or substantial weakness
- Baclofen, diazepam, Botulinum toxin
- PT - Gastrocnemius stretching, proprioceptive retraining
-
Address any associated injuries
- Stress fractures, ankle instability, peroneal tendon
-
Accomodative orthotics
-
general surgical indications
- Surgery should be delayed until progression of the deformity begins to cause symptoms and/or weakness of the muscular units resulting in contractures of the antagonistic muscle units
- Some will say you should do it right away because it is often a progressive deformity
51
Q
Surgical treatment options for cavus foot
A
-
plantar fascia release, posterior tibial tendon transfer, tendoachilles lengthening (TAL), and +/- 1st metatarsal dorsiflexion osteotomy
-
indications
- flexible hindfoot cavus deformities (normal Coleman block test)
- Plantar fascia release through a medial incision
- +/- transfer posterior tibialis to dorsum of foot to improve foot drop (augment weak tibialis anterior)
- +/- transfer of peronues longus to brevis (to help offset pull threw arch and improve eversion)
- In stroke patients you can use an ‘out of phase’ muscle - FDL or FHL
-
Hallux Clawing
- 1st metatarsal osteotomy and transfer of EHL to neck of 1st MT when hallux clawing combined with cavus foot
-
Other options
- TAL - depending on results of silverskiold (gastroc recession vs achilles lengthening)
- Split anterior tibialis transfer
- For a neurologic deformity
- FDL/FHL release if the toes are clawed in a neutral position
- Often done for stroke patients
- Posteromedial release
- Free the NV bundle
- Subtalar and ankle capsule, deltoid ligament
- Medial TN release
- Following trauma or compartment syndrome may need to release or lengthen tendons
- TSF
- For a very severe deformity can use a frame for correction to prevent stretch of the NV structures
-
indications
-
calcaneal valgus producing osteotomy
-
indications
- rigid hindfoot cavus deformities (abnormal Coleman block test)
-
technique
- combine with soft tissue procedure discussed above, and dorsiflexion 1st metatarsal osteotomy
-
indications
-
Supramalleolar osteotomy +/- derotation
- For a more severe deformity about the hindfoot
-
Midfoot osteotomy
- For a more severely deformed foot
-
Lateral ray lengthening
- Out of favour but an option for a severe deformity
- Cuboid or calcaneous
-
Dorsiflexion osteotomy first ray
- If the forefoot is pronated following hindfoot correction
- Closing wedge dorsal osteotomy
- Dorsal wedge 5mm = 12 deg change
- Secure with dorsal plate and screws
-
concomitant weil for second ray
- shortening > 5mm
-
triple arthrodesis
- severe rigid deformities
- may be helpful in select cases but is falling out of favor
- A calcaneal osteotomy may still be required if you can’t get enough varus correction via the subtalar joint
- Should be done in conjunction with tendon rebalancing or will see stress threw other joints
52
Q
Common reasons to have pain following ankle instability
A
- up to 50% continue to experience symptoms following an acute ankle sprain
- most common cause of chronic pain is a missed injury, including
- injury to the anterior process of calcaneus
- injury to the lateral or posterior process of the talus
- injury to the base of the 5th metatarsal
- osteochondral lesion
- injuries to the peroneal tendons
- injury to the syndosmosis
- tarsal coalition
- impingement syndromes
53
Q
Factors that contribute to chronic ankle instability
A
-
Mechanical
- Pathologic laxity
- Arthrokinetic restriction
- Synovial changes
- Degenerative changes
-
Functional
- Impaired proprioception
- Impaired neuromuscular control
- Impaired postural control
- Strength deficits
58
Q
Approach to chronic ankle instability
A
-
Suggested approach for chronic instability
- Ankle arthroscopy to assess concurrent pathology
- Anatomic bronstum repair of the ligaments
- Subsidize with reconstruction with ispilateral free gracilis if ligaments are elongated
- Other options include hamstring or allograft
- Long term data lacking supporting anatomic repair vs reconstruction
-
arthroscopy
-
indications
- recurrent ankle sprains and chronic pain caused by impingement lesions
- anteriorinferior tibiofibular ligament impingement
- posteromedial impingement lesion of ankle
-
procedure
- debride impinging tissue
-
indications
-
Gould modification of Brostrom anatomic reconstruction
-
procedure
- an anatomic shortening and reinsertion of the ATFL and CFL
- reinforced with inferior extensor retinaculum (gould modification) and distal fibular periosteum
-
results
- good to excellent results in 90%
-
procedure
-
Tendon transfer and tenodesis (Watson-Jones, Chrisman-Snook, Colville, Evans)
-
procedure
- a nonanatomic reconstruction using a tendon transfer
-
technique
- Uses peroneal tendon to reconstruct the ligament
- any malalignment must be corrected to acheive success during a lateral ligament reconstruction
- Coleman block testing used to distinguish between fixed and flexible hindfoot varus
-
results
- subtalar stiffness is a common complication
- Not recommended due to loss of function of peroneals
-
procedure
60
Q
Management
A
Midfoot arthritis
-
NSAIDS, activity modification, orthotic/bracing
-
modalities
- steroid injections under xray guidance; can be diagnostic/therapeutic
- should include _longitudinal arch support_s, a stiff sole & possibly a rocker bottom
- AFO can also be used with a rocker bottom
-
modalities
-
Midfoot arthrodesis with bonegraft and internal fixation
- Bone graft is not commonly used and there is really no evidence to support it (unless the foot is flat and you want to plantarflex it)
- then use a tricortical iliac crest graft
-
Medial Column
- Considerations
- failure of non operative management
- Which joints to fuse
- Selective cortisone injection
- Usually the first 2 rays, then the 3rd is often not necessary, but this varies
- If there is sag at nav-cun joint, might need to extend fusion proximally
-
outcomes
- midfoot joints are non essential joints with fusion typically resulting in near normal foot function
- **Anatomic realignment is the most important predictor of good outcomes in post-traumatic OA
- Considerations
-
Lateral Column
- More mobile, at risk of nonunion and stress fractures
- Options are limited and difficult
- Peroneus brevis or tertius interposition arthroplasty
- Spherical arthroplasty implants
-
Post-op
- 3 months NWB
- Start walker at 12 weeks, with PT
- Full recovery in one year
- Bone graft is not commonly used and there is really no evidence to support it (unless the foot is flat and you want to plantarflex it)
-
Achilles tendon lengthening/hindfoot realignment
- may need to be done concomitantly
61
Q
Approach to midfoot arthrodesis
A
-
Approach
- Incision between 1/2 and over 4th, make sure you have an adequate skin bridge
- Be careful, the NV bundle is over the base of the second
- The perforator of dorsalis pedis is in between the first and second
- Be careful, the NV bundle is over the base of the second
- Dissect with scissors, once down to bone can make flaps
- Incision between 1/2 and over 4th, make sure you have an adequate skin bridge
-
Clean the joint
- Laminar spreader
- Clean the joint with curette
- K-wires to trephanate the bone to promote healing
- First fuse 1/2, then once they are stable to can fuse the talocuneiform joint if you need to
- realign & fuse the 1st ray through the TMT & 2nd/3rd ray via the naviculocuneiform and intercuneiform joints
- There are some small studies to suggest plates are better than lag screws alone
- tarsometatarsal joints are 2-3 cm deep and warrant appropriate preparation prior to fusion
- may use screws, staples, plates designed for midfoot fusions
- Close with Nylon
-
Postoperative management
- Bulky dressing and cast
- Should remain NWB for 3 months
-
Complications
- Fusion Nonunion
- Neuroma
- Stress fracture
- Adjacent joint OA
63
Q
Options for treatment
A
-
activity modification, bracing to immobilize the ankle, and NSAIDS
- indicated as first line of treatment in mild disease
- single rocker sole shoe modification can improve gait and pain symptoms
- AFO
- medications to manage arthropathy
-
Operative
- indicated upon failure of conservative treatment in a patient with radiographic evidence of ankle arthritis
- Address proximal deformity and foot deformity
- Supramalleolar osteotomy
- otherwise fusion will fail
- Address any soft tissue deficit if there is only early OA
- IE - cavus with bronstrum
-
Ankle debridement with anterior tibial/dorsal talar exostectomy
- mild disease with pain during push off
-
Distraction arthroplasty
- controversial but may be beneficial for mild disease
- Releives the pressure off the joint
-
Supramalleolar osteotomy
- mild to moderate disease with malalignment of ankle, with near-normal ROM
- Dome osteotomy with plate fixation
- Wedge ostetomy
- mild to moderate disease with malalignment of ankle, with near-normal ROM
-
Arthrodesis
-
Options
- External fixation - good for septic or osteopenic bone
- Arthroscopic
- older, less active
- less deformity (<15deg)
- quicker recovery/DC from hosptial
- Open
- better debridement for more severe deformity
- Important - adequate debridement, alignment, compression, ? Need for augmentation (graft)
-
Options
-
Arthroplasty
-
indications
- posttraumatic or inflammatory arthritis
- elderly patient
-
contraindications
- uncorrectable deformity
- severe osteoporosis
- talus osteonecrosis
- charcot joint
- ankle instability
- obesity, and young laborers increase the risk of failure and revision
-
indications
- Some studies show arthrodesis is equivalent to arthoplasty, but there are no good long term data
- Arthroscopic arthrodesis has shorter time to DC from hospital, but similar outcomes
- Arthoplasty may be better with more severe adjacent joint disease - unclear in the lit, but more complications and revision surgery in the long term
64
Q
You are planning an ankle arthroplasty for this patient. Indications? Contraindications? Outcomes?
A
- patient selection is crucial
-
indications
- posttraumatic or inflammatory arthritis
- elderly patient
-
contraindications
- uncorrectable deformity
- severe osteoporosis
- talus osteonecrosis
- charcot joint
- ankle instability
- obesity, and young laborers increase the risk of failure and revision
-
techniques
- new generation arthroplasty minimizes bony resection, retains soft tissue stabilizers, and relies on anatomic balancing
- must balance the ankle at the time of arthroplasty
-
outcomes
- recent 5-10 year outcome studies demonstrate up to 90% good to excellent clinical results
- long-term studies are still pending on the newest generation of ankle arthroplasty
-
complications
- syndesmosis nonunion
- include wound infection, deep infection, and osteolysis
- syndesmosis nonunion
65
Q
Indications for ankle arthrodesis
A
-
Indications - painful arthritis following
- infection
- trauma (most common cause)
- chronic instability
- AVN of the talus
- inflammatory arthropathy
- primary OA
- neuropathic arthropathy
- tumor resection
- salvage for failed ORIF
- salvage for failed TAA
- assess hindfoot joint and consider TTC or arthoplasty if there is invovlement
67
Q
Technique for ankle arthrodesis
A
-
Optimal Position
- neutral dorsiflexion
- 5-10° of external rotation
- 5° of hindfoot valgus
-
Talocalcaneal, calcanealcuboid and cubonavicular should be in good condition
- Otherwise consider replacement or multiple fusion
-
If ankle malalignment present may need to stage the fusion
- Assess all soft tissues, previous scars, NV status
- Neuropathy may require TTC
- Alignment of the foot
- Hindfoot ROM
- All tendons
- Still need function of plantarflexion and dorsiflexion
- Assess all soft tissues, previous scars, NV status
-
Imaging
- Full foot and ankle views
- Get full length standing views
- Consider CT or MRI for AVN talus
-
Arthroscopic arthrodesis
- only indicated if minimal deformity present(<15 degrees)
- Outcomes shown to be similar to open
- poor soft tissue envelope, multiple medical co-morbidities
- Establish Portals
- Burr down subchondral bone
- Percutaneous 6.5mm or 7mm screws using flouro - both medial
- Can also use acutwist screws
- 3 screws is ok - use the rule of thirds
- Mini-open - minimal soft tissue stripping, but also doesn’t allow for deformity correction
-
Open arthrodesis
-
Anterior approach is easiest
- Between Tib Ant/EHL or EHL/EDL
- Preserves ability to do conversion to TAA if there is degerative joint disease later
- 10 cm anterior to the joint
- Carefully identify EHL and incise the sheath, take it laterally to protect the NV bundle
- Incisie the capsule
- Try to debride the bone without flat cuts, this will preserve length; want to also be able to make slight adjustments for positioning
- Bone graft deficiet, otherwise unecessary
-
Lateral approach with fibular osteotomy - with greater deformity and you need to correct the valgus, need to ostetomize the fibula to correct this
- Incision between sural and superficial peroneal 10-12 cm
- Osteotomize the fibula 6cm above the joint
- Can make flat cuts or decorticate the joint
-
Medial approach - can ostetomize the med mal
- Two incisions
-
Anterior approach is easiest
-
Fixation
-
screw fixation - 2-4 screw - better than plates due to less soft tissue stripping and can be difficult to get compression threw a plate
- From lateral process to medial cortex
- Lateral tibia to medial talus
- posterior tibia to talar neck
- plate and screw construct
- external fixation - lower fusion rates
-
screw fixation - 2-4 screw - better than plates due to less soft tissue stripping and can be difficult to get compression threw a plate
68
Q
Indications for TTC
A
- diabetic neuropathy
- osteoarthritis
- posttraumatic injury
- talar AVN
- RA involving the ankle and subtalar joints
- failed TAR or TAA with insufficient talus for ankle fusion
You will maintain the same dorsi/plant with TTC or ankle fusion, but will loose 40% subtalar motion with TTC
69
Q
Approach to work-up and treatment
A
TTC
-
History
- Pain, function, baseline function
- Previous trauma, surgery
- PMHx - diabetc control, PVD
- Physical
- Previous scars, obvious deformity
- Ankle ROM, subtalar ROM
- Function of tendons
- NV status
- Complete insensate foot is contraindication
-
Imaging
- WB AP/lateral, oblique of both foot and ankle
- consider full length standing
- CT to assess boney antomy
- MRI as needed
-
Indications for TTC
- diabetic neuropathy
- osteoarthritis
- posttraumatic injury
- talar AVN
- RA involving the ankle and subtalar joints
- failed TAR or TAA with insufficient talus for ankle fusion
-
Contraindictions
- Insensate foot
- Active infection
-
Technique
-
Approach
- Medial Mall, anterior, posterior
- Lateral fibular osteotomy
- Useful if there is severe deformity to get access to both the ankle and subtalar joints
- Don’t use if there is any consideration that you might convert to TAR later
- Can be used for bone graft for significant bone loss
- Decorticate your cartilage to bleeding bone, try to presever bone
- Bone graft as necessary
-
Alignment
- Valgus if possible
- 10 deg ER
- Neutral plantarflexion, no dorsiflexion
- Heel incision- between malleoli and 1 cm behind the chopart joint
- Guide wire into the medullary canal of the tibia with flouroscopic guidance
- Assess position
- Drill 1mm over your nail to prevent fracture
- Insert nail
-
Approach
- Post-op
- NWB 6 weeks
- WBAT in air cast 6 weeks
- fit for brace at 10-12 weeks with rocker bottom sole for transition
70
Q
subtalar/triple arthrodesis
A
- Assess and realease achilles PRN
-
Approach - 7-8 cm
-
lateral
- tip of the fibula to base 4th
- between peroneals and EDC
- elevate EDB
- release calcaneocubiod ligament and capsule
-
medial
- tip of medial mall to base of 1st
- protect tib ant, cauterize the saphenous
- release the spring ligament, incise TN capsule
-
lateral
- Prepare the joints
- chisel or osteotome to remove the cartilage, preserve the subchondral architecture
- bone graft deficit only as necessary
- Stabilize with k-wires
- Cannulated 6.3mm screws
- Calcanal-talar - compression
- 2 in TN joint - retrograde
- first compression
- second postitional
- Then antegrade anterioprocess into cuboid
- Layered closure
- Post-op
- Assess wounds at 2 weeks
- NWB 10 weeks
- If healing then can start WB in an air cast for several weeks, then progress out of cast
-
Complications
- nonunion
- maluion
- persistent pain
- hardware irritaiton
- infection
- sural neuralgia
73
Q
Ferkel grading system for talus OCD
A
CT
Stage 1: Cystic lesion within dome of talus with an intact roof on all view
Stage 2a: Cystic lesion communication to talar dome surface
Stage 2b: Open articualr surface lesion with overlying nondisplaced fragement
Stage 3: Nondisplaced lesion with lucency
Stege 4: Displaced fragment
used for grading and determining treatment
75
Q
Diagnosis? Work-up?
A
Lesion of the Talus
-
Take a complete and AMPLE history
- Characterize the pain, previous trauma, surgeries, treatment
- instability
- pain, swelling, and mechanical symptoms such as catching or locking
- Previous treatment, injections
- PMHx
-
Physical exam
- Effusion, alignment, gait
- Cavus, planus can predisposed to trauma
- Swelling, tender points
- Rule out instability - anterior drawer
- Assess tendon strenth, NV status
- Effusion, alignment, gait
-
Radiographs
- may be normal
- may see subtle luceny or bone fragmentation
- Make sure to rule out evidence of arthritis
- Assess alignment
-
CT
- The best way to observe and address bone loss
- Used for staging and treatment planning
-
MRI
- indicated in ankle sprains that do not heal with time
- Can identify other pathology and qualify any cartilage damage
- Often overestimates the boney loss and should not be used for staging
-
Diagnostic Injection
- No relief should seek alternative treatment
78
Q
What value of compartment pressure do you worry about compartment syndrome
A
- indicated in patients with altered mental status
- absolute value of 30 to 45 mm Hg or
-
within 30 mm Hg of diastolic BP (delta p)
- if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic pressure and follow postoperatively as intraoperative pressures may be low and misleading
79
Q
Approach to foot compartment syndrome
A
Emergent Fasciotomy
-
9 major compartments of foot
- medial
- lateral
- interosseous (x4)
- central (x3: superfical, middle, and deep)
- posterior tibial neurovascular bundle and quadratus plantae are in the deep central compartment
- Can be done through 1-3 incisions, a dual incision approach is the gold standar
-
dorsal medial incision
- in between the 1/2 ray
- allows decompression of 1st and 2nd interosseous (lateral), medial, and deep central compartments
-
dorsal lateral incision
- in line with 4th ray
- allows decompression of 3rd and 4th interosseous (lateral), superfical central, middle and central)
- some add an additional medial incision
-
Treatment of sequale
- try to treat non-opearatively
- can try posterior tibial nerve neurolysis
- treat claw toes with IP fusion and MTP capsulectomy
- treat cavus as deformity requires
86
Q
Ogden classification of peroneal subluxation
A
Grade 1
The SPR is partially elevated off of the fibula allowing for subluxation of both tendons
Grade 2
The SPR is separated from the cartilofibrous ridge of the lateral malleolus, allowing the tendons to sublux between the SPR and the cartilofibrous ridge
Grade 3
There is a cortical avulsion of the SPR off of the fibula, allowing the subluxed tendons to move underneath the cortical fragment
Grade 4
The SPR is torn from the calcaneous, not the fibula
87
Q
Work-up for peroneal tendon subluxation
A
-
History
- Take a complete and AMPLE history
- Usually young patient,
- patients often report they felt a pop with a dorsiflexion ankle injury
- clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
-
Physical exam
-
Examine (Look)
- swelling posterior to the lateral malleolus - for grade1 and 2 when there is only a partial tear
- Look for hindfoot varus with associated cavus foot - block test
-
Palpate (feel)
- tenderness over the tendons
- ‘pseudotumor’ over the peroneal tendons
- Anterior drawer for CFL and ATFL
-
ROM (move)
- voluntary subluxation of the tendons +/- a popping sound
-
apprehension tests
- the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance cause subluxation/dislocation and apprehension
-
compression test
- pain with passive dorsiflexion and eversion of the ankle
-
Examine (Look)
-
Radiographs - AP, lateral, mortise weight bearing views
- recommended views - best recognized on an internal rotation view
- Get foot XR - needed to evaluate for varus hindfoot or evidence of cavus, other boney injuries
- may see a cortical avulsion off the distal tip of the lateral malleolus (rim fracture)
- Hypertrophy of peroneal tubercle
- Rule out os peroneum fracture
-
US
- Can assess for fluid around the tendons
- Can do a dynamic test to assess for subluxation of the tendons
-
MRI
- best evaluated with axial views of a slightly flexed ankle
- Look for fluid in the tendon sheath, abnormalities to tendons
- can demonstrate anatomic anomalies leading to pathology
- peroneus quartus muscle
- low-lying peroneus brevis muscle belly
- Hypertrophied peroneal tubcerle
88
Q
Treatment of peroneal subluxation
A
-
Rest, ice, NSAIDS, orthoes, PT
- PT for stretching and eccentric training
- short leg cast immobilization and protected weight bearing for 6 weeks
- all acute injuries in nonprofessional athletes
-
technique
- tendons must be reduced at the time of casting
-
outcomes
- success rates for nonsurgical management are only marginally better than 50%.
-
Approach to operative treatment
- Consider damage to tendons
- Consider predisposition to subluxation
- repair of superior peroneal retinaculum and deepening of the fibular groove
- Debride peroneus quartus
- Debride peroneal tubercle
- Address any foot deformities
- Make sure if they have hindfoot varus that you do a corrective osteotomy to take the tension off your repair
-
Excise longitudinal tears indications
- acute tendon dislocations in serious athletes who desire a quick return to a sport or active lifestyle
- presence of a longitudinal tears
-
groove-deepening with soft tissue transfer and/or osteotomy
-
indications
- chronic/recurrent dislocation refractor to non-operative treatment
-
technique
- Supine, lateral approach
- Address tendons
- Debride and tubularize brevis
- Debride brevis and tenodes brevis to longus
- less able to reconstruct SPR so treatment focuses on other aspects of peroneal stability
- typically involves groove-deepening in addition to soft tissue transfers or bone block techniques (osteotomies to further contain the tendons within the sulcus)
- plantaris grafts can act to reinforce the SPR, can reconstruct with CFL
- hindfoot varus must be corrected prior to any SPR reconstructive procedure
-
indications
-
Post-op care
- SLC, NWB for 6 weeks
- WBAT in air cast with start ROM at 8 weeks
- Resume strength and return to activity at 3 months
89
Q
Approach and managment for painful os peroneum
A
- Usually associated with less healthy - DM, RA, HTN
- Chronic pain over the lateral foot
- Pain distal to the fibula with weakened eversion and platarflexion of the first ray
- Painful os peroneum will have pain over the latearl side of the foot
-
Imaging
- Harris views to assess enlargement of the peroneal tubercle
- Foot views to look at where and if there is an os peroneum, assess for any fracture
-
Treatment
- Conservative
- Operative
- Debridement with tubularization
- Debridement of os with tubularization
- End-to-end repair
- Debridement with tenodesis to brevis
90
Q
Differential diagnosis of heel pain
A
- Plantar Fascitis
-
Heel Pad atrophy
- Difficult to diagnose and treat
-
Baxter’s nerve entrapments
- Distal to heel pad but can often occur in conjunction with plantar fascitis
- Will see atrophy of abductor digiti quinti
- Always try conservative measures first
- Then if > 3 months with refractory cases
- Can release abductor hallucis
-
Calcaneal Stress Fracture
- Gradual increasing pain in calcaneus
- XR - interuption in trabecular lines with sclerosis at cal tub
- MRI and bone scan can be diagnostic
- Tx
- Period of immobilization with gradual return to activities
-
Tarsal Tunnel Syndrome
- Overdiagnosed
- Pain in posteromedial ankle
- MRI for space occupying lesion
- Sx for very refractory cases or space occupying lesion
- Release behind posterior mall and abductor hallucis sheath
92
Q
Muscles that share insertion onto the calcaneous with the plantar fascia? What nerve is usually affected?
A
- abductor hallucis
- flexor digitorum brevis
- quadratus plantae
- Irritation of the first branch of the lateral planter nerve (baxter’s nerve) found between first and second layers
94
Q
Diagnosis? Epidemiology?
A
Freiberg’s Infraction
- Osteonecrosis most often seen in 2nd second metatarsal (MT) head
- term is a combination of infarction and fracture
-
demographics
- most commonly seen in patients 13-18 years
- more common in female adolescent athletes
-
Risk factors
- more common in patients with long 2nd metatarsals
-
Pathophysiology
- thought to be related to a disruption in the blood supply due to microtrauma and stress overloading
- leads to eventual collapse of 2nd MT head
95
Q
Smille Classification of Freiberg infraction
A
- Stage 1
- Subchondral fracture visible only on MRI
- Stage 2
- Dorsal collapse of articular surface on plain radiographs (best seen on oblique)
- Stage 3
- Collapse of dorsal MT head, with plantar articular portion intact
- Stage 4
- Collapse of entire MT head, joint space narrowing
- Stage 5
- Severe arthritic changes and joint space obliteration
97
Q
Classficiation of bunionette deformity
A
-
Type I
- Enlarged 5th MT head or lateral exostosis
- Treatment - Condylectomy (excision of lateral bony eminence)
-
Type II
- Congenital bow of 5th MT, normal 4-5 IMA
- Chevron (distal) osteotomy +/- lateral eminence resection
-
Type III
- Increased 4-5 IMA (most common)
- Oblique mid-diaphyseal metatarsal osteotomy
- shave plantal aspect 5th MT head if plantar callosity present (never excise 5th MT head)
102
Q
Work-up and Treatment of sesamoid injury
A
-
Radiographs
- Views
- AP and lateral of foot
- medial oblique (sesamoid view)
- axial sesamoid view
- findings
- proximal migration of sesamoids - be suspicious of intrinsic minus hallux
- Views
-
Bone scan
- helps distinguish a bipartite sesamoid from a fracture
- use caution with interpretation as 25%-30% of asymptomatic patients can have increased uptake
- increased uptake compared to uninjured side helps diagnosis
-
NSAIDs, reduced weightbearing, activity modification, orthoses
- indicated as first line of treatment
-
short leg cast with toe extension
- acute fracture (controversial)
-
Shaving keratotic lesion
- keratotic lesion present increasing pressure on sesamoids
- *Acute fractures can be fixed with 2.0mm screws
-
partial or complete sesamoidectomy
- nonoperative management fails after 3-12 months
- Historically was the most common form of treatment
- Bilateral excision leads to cock-up deformity and unilateral can lead to valgus/varus
- Theoretically will put FHL at risk of rupture
- Should be kept available only as a salvage procedure
- technique (see below)
-
autologous bone grafting
- nonunion or fracture
- Good outcomes reported
-
dorsiflexion osteotomy
- plantar-flexed first ray with sesamoid injury
105
Q
Mechanism and injuries associated with turf toe
A
-
Mechanism & pathophysiology
- hyperextension of the great toe MTP joint
- hyperextension compounded by axial loading of the posterior hindfoot
- occurs in collision and contact sports when athlete pushes off to accelerate
-
Associated injuries
- sesamoid fracture
- stress fracture of proximal phalanx
- hallux rigidus (late sequelae)
-
Prognosis
- can be a devastating injury to the professional athlete
111
Q
What is an Evans osteotomy?
A
calcaneus lateral opening wedge osteotomy
For lateral column lengthening
112
Q
What is a Dwyer osteotomy?
A
Medial calcaneal closing wedge
for correction of varus hindfoot
(Not lengthening)
116
Q
This is best for what disease?
A
AFO
best for posterior tibial tendon insufficiecy
Classic indication for AFO
130
Q
In addition to standard views, what 2 additional x-rays may be helpful in diagnosing ankle instability
A
ER stress test
>4mm medial clear space
>6mm tibiofibular clear space
133
Q
Name the foot deformity associated the myelomeningocoele at:
L1
L2
L3
L4
L5
S1
A
Think about what is knocked out by level:
L1: equniovarus
L2: equinovarus
L3: equinovarus
L4: cavovarus
L5: calcaneovalgus
S1: Foot deformity (no ankle)
