Foot and Ankle Flashcards
Where is the watershed area of the PTT?
2-6 cm proximal to the navicular
Obese patient comes in with feet that look like this? How can you stage this?

-
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
Difference between adult and juvinile hallux valgus
- 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
Risk factors for hallux valgus
-
intrinsic
- genetic predisposition
- ligamentous laxity
- convex metatarsal head
- pes planus
- rheumatoid arthritis
- cerebral palsy
-
extrinsic
- shoes with high heel and narrow toe box
Pathoanatomy of hallux valgus
- 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

Radiographs for hallux valgus
-
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
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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)

Approach to adolescent bunions
- 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)
Options for treatment of hallux valgus
-
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
Complications associated with HV
-
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.
Iatrogenic causes of this deformity

- overcorrection of 1st IMA
- excessive lateral capsular release with overtightening of medial capsule
- overresection of medial first metatarsal head
- lateral sesamoidectomy
Classification of Hallux Rigidus
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

Options for treatment

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)

Strongest construct for first MTP arthrodesis
Dorsal plate with compression screw is biomechanically strongest construct
4 Risk factors for Achilles rupture
Age
Steroids
Cipro
Eccentric muscle contraction
Treatment options for acute achilles rupture
-
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
Indications for non-operative treatment of achilles rupture
sedentary patients
elderly patients
medically frail patients
patient desires to avoid surgery
increased risk of rerupture
Increased risk of wound complications of achilles repair
tobacco abuse
steroid use
diabetes mellitus
female sex
sural nerve injury
obesity
Options for treatment of chronic achilles tear or re-rupture
-
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

3 complications associated with treatment of achilles
- Dehisence/Infection
- Re-rupture
- Sural nerve palsy
5 differential for Chronic Achilles inflammation
-
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
Middle aged woman with chronic heel pain. Differential? Likely Diagnosis? Helpful imaging?

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
Treatment of Insertional Achilles Tendonitis
- 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

Young patient with chronic heel pain. Differential? Likely diagnosis? Helpful imaging?

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

Treatment of retrocalcaneal bursitis
-
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


















































