Foot and Ankle Flashcards

Question

What measurements should be evaluated on a WB AP view in the assessment of hallux valgus? [AAOS comprehensive review 2, 2014]

Answer 1

1. HVA (hallux valgus angle) normal = ≤15° 2. HVI (hallux valgus interphalangeus angle) normal = \<10° 3. IMA (intermetatarsal angle) normal = ≤9° 4. DMAA (distal metatarsal articular angle) normal = ≤10° 5. PPAA (proximal phalanx articular angle) normal = ≤10°

Answer 2

1. Joint congruency * Congruent joint * No subluxation * Articular surfaces are parallel * The medial and lateral extents of both surfaces are opposite one another * Incongruent joint * Lateral subluxation of the proximal phalanx * Articular surfaces are not parallel * The medial and lateral extents of the proximal phalanx migrates lateral to the same points on the metatarsal articular surface 2. Presence of joint arthrosis at MTP and TMT joint 3. Degree of hallux pronation

Answer 3

1. Correction of the hallux valgus and 1–2 IM angles 2. Creation of a congruent MTP joint with sesamoid realignment 3. Removal of the medial eminence 4. Retention of functional range of motion of the MTP joint 5. Maintenance of normal weight-bearing mechanics of the foot

Answer 4

1. IMA ≤13° AND HVA ≤40° = distal metatarsal osteotomy 2. IMA \>13° OR HVA \>40° = proximal metatarsal osteotomy 3. Instability of the first TMT = Lapidus procedure 4. Arthritis or spasticity of MTP joint = first MTP fusion 5. Increased DMAA = distal metatarsal redirectional osteotomy in addition to metatarsal osteotomy 6. Increased HVI angle = Akin osteotomy

Answer 5

1. Release of lateral structures (lateral MTP joint capsule, adductor hallucis tendon, transverse metatarsal ligament) * Fibular sesamoid is no longer excised due to risk of hallux varus (modified McBride) 2. Medial eminence excision (1-2mm medial to the medial sagittal sulcus) 3. Medial capsule plication

Answer 6

1. Medial closing wedge phalangeal osteotomy 2. Medial eminence excision 3. Medial capsulorrhaphy

Answer 7

1. Distal metatarsal osteotomy * Drill hole is placed in the centre of the metatarsal head * V-shaped osteotomy made at an angle of 60° * The plantar cut exits proximal to the sesamoids * The capital fragment is shifted laterally * The capital fragment can be safely shifted laterally 6.0mm in men and 5.0 mm in women and still maintain greater than 50% bony apposition of the fragments 2. Medial eminence excision 3. Medial capsulorrhaphy

Answer 8

1. Distal metatarsal osteotomy * Double step-cut osteotomy through the neck of the metatarsal * The width of the lateral spike on the distal fragment determines the amount correction (the wider the greater the lateral displacement) * The capital fragment displaces laterally and tilted plantar * Tiliting the distal fragment plantar prevents transfer metatarsalgia * The metatarsal is shortened 2. Medial eminence excision 3. Medial capsulorrhaphy

Answer 9

1. Longitudinal Z-type ostetomy * The 1st MT is translated laterally decreasing the IM angle * Modifications can lengthen/shorten the MT, correct DMAA and elevate or depress the head * DMAA can be corrected by rotating the distal fragment medially * Elevating or depressing the head is achieved by angling the longitudinal cut 2. Medial eminence resection 3. Medial capsule repair

Answer 10

1. Proximal osteotomies include: * Crescentic ostetomy * Proximal chevron * Wedge osteotomy * Medial opening * .Lateral closing * Long oblique (Ludloff)

Answer 11

Juvenile patient with an open proximal first metatarsal epiphysis and a hallux valgus deformity characterized by an abnormally widened 1–2 IM angle

Answer 12

Congruent hallux valgus deformity with an increased DMAA

Answer 13

1. Hypermobility of the first ray 2. Metatarsal cuneiform degenerative arthritis 3. Severe hallux valgus deformity 4. Recurrent hallux valgus

Answer 14

1. Distal soft tissue procedure (modified McBride) 2. Medial eminence resection 3. First metatarsal cuneiform fusion

Answer 15

1. Severe hallux valgus deformity 2. MTP degenerative arthritis 3. Rheumatoid arthritis + hallux valgus 4. Neurological disorder + hallux valgus (CP, CVA, head injury) 5. Failed hallux valgus surgery/recurrent hallux valgus

Answer 16

Elderly, low demand patients with mild to moderate hallux valgus and/or arthritic changes

Answer 17

1. Medial eminence resection 2. Partial proximal phalangectomy (proximal 1/3) 3. Medial capsulorrhaphy

Answer 18

1. Soft tissue complications * Infection * Wound breakdown/skin sloughing * Delayed wound healing * Adherent scar * Cutaneous nerve injury * i.Most common = dorsomedial cutaneous nerve to the great toe 2. Metatarsal osteotomy complications * Shortening * Consequence = transfer metatarsalgia to the 2nd MT head * Dorsiflexion * Consequence = transfer metatarsalgia to the 2nd MT head * Plantarflexion * Consequence = increased WB on 1st MT head leading to callus * Overcorrection of IM angle * By excessive valgus/lateral deviation of the first MT * Nonunion 3. Metatarsal head complications * Excessive medial eminence resection * Displacement * AVN 4. Hallux varus * Caused by: * Excessive medial eminence resection * Excessive tightening of the medial capsule * Excessive lateral release * Overcorrection of the IMA * Excision of the fibular sesamoid * Overcorrection with the postoperative dressing 5. Recurrent hallux valgus 6. Cockup deformity * Caused by: * Dual sesamoid excision * Keller procedure * FHL injury

Answer 19

Coughlin and Shurnas Clinical and Radiographic Classification of Hallux Rigidus

Answer 20

1. Subjective * Pain at end ROM * Pain just before toe off * Pain aggravated by shoes with heels * Dorsal and medial osteophytes create prominences that limit certain shoewear * Numbness along medial border of great toe 2. Objective * Tender dorsally * Pain at extreme dorsi and plantarflexion with PROM, * Overall PROM reduced * Pain during midrange of motion indicates more diffuse level of arthritis

Answer 21

1. Nonoperative * NSAIDs * Corticosteroid injections * Shoe modifications * eg. Morton extension to limit dorsiflexion, rockerbottom sole, wide or high toebox * Activity modification 2. Operative * Joint preserving * Cheilectomy * Indication – grade 1 or 2 without midrange pain * Technique – removal of 30% of dorsal metatarsal head articular surface * Cheilectomy + proximal phalanx dorsal wedge osteotomy (Moberg osteotomy) * Indication – grade 1 or 2 without midrange pain * Addition of Moberg osteotomy indicated if cheilectomy alone does not provide at least 30-40°of dorsiflexion * Technique – dorsal closing wedge osteotomy at base of proximal phalanx * Joint destroying * Arthrodesis * Indication – grade 3 or 4 (current standard) * Technique: * Flat or conical surface preparation * Fixation can be with K-wires, staples, dorsal plates, or screws * The most biomechanically stable construct is a dorsal plate and lag screw * What is the position of fusion? * 10-15° dorsiflexion relative to the floor and 10-15° of valgus * What are the most common complications? * Nonunion and metatarsalgia * Joint altering excisional procedures * Keller resection arthroplasty * Indications – patients \>70 or less active patients in whom surgical and recovery complications should be minimized * Technique – removal of the base of the proximal phalanx (decompresses joint and increases dorsiflexion) * Complications * Hallux cockup deformity * Toe off weakness * Transfer metatarsalgia * Interpositional arthroplasty * Indications - ?patients \<60 with late-stage hallux rigidus * Technique * Cheilectomy * Resection of the phalangeal base and placement of a biological spacer * eg. tendon, capsule, autograft, allograft * Arthroplasty/Hemiarthroplasty * Indications – none (arthrodesis has better and more reliable results)

Answer 22

Coughlin Classification * Type 1 – enlargement of the 5th metatarsal head or lateral exostosis (\>13mm) * Type 2 – abnormal lateral bend (congenital bow) to the distal fifth metatarsal (normal 4-5 IM angle) * Type 3 – abnormally wide 4-5 IM angle (\>8°) * Most common

Answer 23

Nonoperative (first line) * Widened toe box * Padding * Callus trimming * Orthotics when associated with pes planus Operative * Type 1 – lateral condyle resection * Type 2 – distal 5th MT ostetomy * Distal chevron - medializes the MT head * Type 3 – oblique diaphyseal rotational osteotomy * Oblique osteotomy with medial rotation of distal fragment

Answer 24

1. Medial tarsal branch of the dorsalis pedis (dorsal surface) 2. Superficial and deep plantar arteries (plantar surface)

Answer 25

Sangeorzan classification * Tuberosity * Capsular avulsion * Stress fracture * Body * Type I * Coronal plane fracture * Transverse fracture of dorsal fragment involving \<50% of bone * No forefoot malalignment * Type II * Oblique fracture extending dorsolateral to plantarmedial * Often with adduction forefoot deformity (most common) * Type III * Comminuted fracture * Often with abduction forefoot deformity

Answer 26

* Long second metatarsal * Metatarsal adduction * Equinus contracture

Answer 27

Dorsal navicular prominence (‘N spot’)

Answer 28

1. Dorsal – dorsal capsule and/or superficial deltoid ligament 2. Medial – posterior tibialis tendon 3. Plantar – plantar capsule and spring ligament

Answer 29

1. Low-energy, minimal soft tissue swelling = short leg WB cast or boot for 4-6 weeks 2. Substantial soft tissue swelling = nonWB cast or boot for 6-8 weeks

Answer 30

1. Tuberosity avulsion fractures * Untreated can lead to traumatic insufficiency of the posterior tibialis tendon and progressive flat foot deformity 2. Large intra-articular fragments

Answer 31

1. Joint incongruity \>2mm 2. Medial column shortening \>3mm 3. Inability to attain or maintain a joint reduction 4. Open fracture 5. Concomitant compartment syndrome 6. Skin tenting/at risk

Answer 32

1. Extrinsic muscles (originate proximal to the midfoot) * EDL, EDB, FDL * Extend MTP and flex the PIP and DIP 2. Intrinsic muscles (originate distal to the midfoot) * FDB, lumbricals, interosseos * Flex the MTP and extend the PIP and DIP

Answer 33

Flexible = present on standing but corrects with manipulation or ankle plantarflexion [JAAOS 2011;19: 505-514] Push up test * Flexible deformity is reducible with dorsal directed pressure on the plantar aspect of the involved metatarsal

Answer 34

1. Deformity is DIP flexion and netural PIP and MTP * Caused by pressure of the toe at end of the shoe (causes DIP flexion and tightness of FDL) or laceration/rupture of the EDL at the DIP joint 2. Nonoperative management * Cushioned toe sleeves * Padding * Roomy toe box with low heel 3. Surgical management * Flexible Mallet Toe * FDL release at level of the proximal phalanx * Consider transfer of FDL to dorsum of proximal phalanx to preven cockup deformity * Fixed Mallet Toe * DIP fusion or resection arthroplasty

Answer 35

1. Deformity is PIP flexion, DIP extension, MTP extension or neutral 2. Nonoperative management * High and wide toe box * Soft uppers * Padding or sleeves to protect dorsum of PIP joint 3. Surgical management * Flexible Hammer Toe * FDL tendon transfer * FDL is harvested, split into medial and lateral limbs * Passed to the dorsum of the proximal phalanx and sutured to each other and the extensor tendon with the MTP in 20° of plantarflexion and ankle in neutral dorsiflexion * Percutaneous flexor tenotomy * Release through incision just proximal to MTP joint [Int Orthop.2009 Oct; 33(5): 1279–1282.] * Fixed Hammer Toe * PIP resection arthroplasty or fusion

Answer 36

1. Deformity is PIP and DIP flexion, MTP extension 2. Nonoperative management * Same as hammer toe * High and wide toe box * Soft uppers * Padding or sleeves to protect dorsum of PIP joint 3. Surgical management * Same as hammertoe * Flexible Claw Toe * FDL tendon transfer * FDL is harvested, split into medial and lateral limbs * Passed to the dorsum of the proximal phalanx and sutured to each other and the extensor tendon with the MTP in 20° of plantarflexion and ankle in neutral dorsiflexion * Percutaneous flexor tenotomy * Release through incision just proximal to MTP joint [Int Orthop.2009 Oct; 33(5): 1279–1282.] * Fixed Claw Toe * PIP resection arthroplasty or fusion

Answer 37

Deformity is PIP and DIP flexion, MTP flexion or neutral

Answer 38

1. Plantar plate and capsule insufficiency due to trauma, inflammatory arthritis, synovitis (can be due to excessively long metatarsal) 2. Nonsurgical management * Metatarsal pad proximal to MT head * Budin splint 3. Surgical management * Mild deformity * Extensor tendon Z-lengthening or tenotomy * Moderate to severe deformity * Dorsal capsule release and extensor tendon Z-lengthening * Consider flexor tendon transfer * Irreducible with soft tissue procedures * Weil osteotomy * MT shortening osteotomy

Answer 39

1. Hallux valgus 2. Lesser toe MTP subluxation and dislocation * dorsal and lateral 3. Claw toes 4. Plantar fat pad displaces distal to MT head 5. Loss of medial longitudinal arch 6. Broadening of the forefoot

Answer 40

1. Resection of the lesser MT heads * 2 dorsal incisions (2nd and 4th webspace) * Alternative is a plantar transverse incision (severe dislocation, nonreducible deformity) * EDB transection and EDL lengthening * MT head resected at level of neck with lateral sloping cascade * Resect dorsal distal to plantar proximal * Stabilize the lesser toes with a retrograde K-wire from tip of toe to base of MT 2. First MTP fusion * Medial incision, standard fusion * Perform after lesser MT resection to prevent excessively long 1st ray 3. Correction of the claw toe * Rigid claw toe = resection of proximal phalanx heads * Dorsal elliptical or transverse incision * Flexible caw toe = closed manipulation * Claw toe correction is maintained by antegrade K-wire insertion from base of proximal phalanx to tip of toes after MT head resection, followed by retrograde advancement down MT shaft

Answer 41

1. Take down dressing 2. Compress the toe down the K-wire if overlengthened 3. Remove K-wire

Answer 42

PTTD (Posterior tibial tendon dysfunction)

Answer 43

1. Sustentaculum tali 2. Navicular 3. Medial/intermediate/lateral cuneiforms 4. Cuboid 5. Bases of 2,3,4 metatarsals

Answer 44

1. Heel strike * Decelerates subtalar joint pronation via eccentric contraction 2. Midstance * Stabilizes the midtarsal joints 3. Propulsive phase * Locks the transverse tarsal joint and shifts the Achilles line of pull more medially allowing it to be the primary invertor of the subtalar joint – both leading to a rigid lever for push off

Answer 45

1. Medial longitudinal arch collapse 2. Hindfoot valgus 3. Forefoot abduction and varus (‘too many toes’ sign) 4. Achilles contracture 5. Unable to perform single leg stance 6. Inversion lag or weakness of the PTT assessed in max plantarflexion and inversion [Instr. Course Lect 2015; 64:441]

Answer 46

1. AP foot WB * Talocalcaneal angle * Normal = 15-30 (abnormal \>30) * Talometatarsal angle (Simmon angle) * Normal = +4 to -4 (abnormal * Talonavicular coverage angle * Normal = upper limit ~20 (abnormal \>20) 2. Lateral foot WB * Calcaneal pitch * Normal = 10-30 (abnormal \<10) * Lateral talocalcaneal angle * Lateral talometatarsal angle (Meary angle) * Normal = +4 to -4 * Medial cuneiform height

Answer 47

Johnson and Strom Classification * STAGE I * No deformity (tenosynovitis with pain and swelling) * Able to perform a single-stance heel raise * May produce pain or weakness with repetition * STAGE II * Flexible deformity * STAGE IIa * Medial joint pain * Able to perform single-stance heel raise [Mann’s Surgery of the Foot and Ankle 2014] * Less than 40% talonavicular uncoverage [Instr. Course Lect 2015; 64:441] * Hindfoot valgus without significant forefoot abduction [Miller’s, 6th ed.] * STAGE IIb * Subfibular impingement * Unable to perform single-stance heel raise [Mann’s Surgery of the Foot and Ankle 2014] * 40-50% talonavicular uncoverage [Instr. Course Lect 2015; 64:441] * Hindfoot valgus and forefoot abduction [Miller’s, 6th ed.] * STAGE IIc * \>50% talonavicular uncoverage [Instr. Course Lect 2015; 64:441] * Hindfoot valgus and fixed forefoot supination/varus [Miller’s, 6th ed.] * STAGE III * Fixed/Rigid planovalgus deformity * STAGE IV * Lateral ankle arthritis and attenuation of the deltoid ligament with lateral talar tilt

Answer 48

Nonoperative * Immobilization in walking cast/boot ~6 weeks * Orthotic with medial heel wedge and medial column post after symptoms resolve or mild symptoms [Mann’s Surgery of the Foot and Ankle 2014] * Physiotherapy once asymptomatic Operative * Synovectomy

Answer 49

Nonoperative * Total-contact rigid orthosis (UCBL brace) * AFO * Physical therapy Operative * FDL transfer to navicular for all STAGE II * Isolate FDL from FHL at knot of Henry * Insert FDL into navicular near PTT insertion * FDL synergistic with PTT * Additional procedures based on findings: * Gastrocnemius contracture * Gastrocnemius recession (assess with Silfveskiold test) * Hindfoot valgus * Medial displacement calcaneal osteotomy (MDCO) * Forefoot abduction * Lateral column lengthening * Fixed forefoot varus (supination) * Stable medial column * Dorsal opening wedge osteotomy of the medial cuneiform (Cotton osteotomy) * Unstable medial column (plantar sag) * Medial column fusion * STAGE IIa * FDL transfer + MDCO * STAGE IIb * FDL tansfer + lateral column lengthening +/- MDCO * STAGE IIc * Stable medial column – Cotton osteotomy * Unstable medial column – medial column fusion (navicular, TMT or both)

Answer 50

Nonoperative * AFO Operative * Triple arthrodesis (talonavicular, subtalar, calcaneocuboid) * May include MDCO, Cotton osteotomy, 1st MT-tarsal fusion, gastrocnemius recession

Answer 51

Operative * If ankle valgus passively correctible – consider deltoid ligament reconstruction and triple arthrodesis * Fixed ankle valgus, arthritis – tibiotalocalcaneal arthrodesis

Answer 52

1. Origin is adjacent to the tibailis posterior and the PTT is adjacent to the FDL tendon posterior to the medial malleolus 2. Same line of pull 3. In-phase muscles (function primarily during midstance) 4. FDL strength matches peroneus brevis strength 5. FDL is expendable (FHL attachment with FDL tendon maintains lesser toe flexion)

Answer 53

1. Adequate subtalar motion (~15° of subtalar inversion) 2. Supple transverse tarsal motion (at least 10° of adduction)

Answer 54

1. Inadequate subtalar and transverse tarsal motion 2. Fixed forefoot varus deformity \>10° 3. Symptomatic arthritis (subtalar, talonavicular, calcaneocuboid) 4. Obesity

Answer 55

1. Shifts the line of pull of the Achilles medially which increases inversion power 2. Shifts the WB axis of the heel closer to the long axis of the tibia

Answer 56

1. Reduction of talonavicular and subtalar joints 2. Even plantar tripod (heel, first MT head and 5th MT head)

Answer 57

1. Lateral oblique incision parallel and slightly posterior to the peroneal tendons 2. Avoid the sural nerve 3. Oblique osteotomy is made parallel to the peroneals and exiting anterior to the plantar fascia insertion 4. Medial release can be achieved with a laminar spreader for stress relaxation and a cobb 5. Displace the calcaneus ~1cm medially 6. Fix with two percutaneous partially threaded lag screws from the nonWB portion of the posterior tuberosity

Answer 58

1. Incision extends from just behind the medial malleolus extending distally to the base of the first metatarsal 2. Open the tibialis posterior sheath and excise nonviable tendon 3. Open the FDL sheath and trace it distal to the navicular to the knot of Henry (just deep to abductor hallucis) 4. Release the FDL at the knot of Henry (optional to tenodese the distal FDL to the FHL to preserve small toe function) 5. 4-5mm drill hole made in navicular tuberosity * FDL is passed plantar to dorsal and sutured back onto itself and periosteum while the ankle is in plantarflexion and inversion 6. Consider imbrication of the spring ligament if necessary

Answer 59

1. Separate dorsal incision over the medial cuneiform 2. Dorsal opening wedge is created in the middle of the bone leaving the plantar cortex intact 3. Dorsal wedge allograft (fixation is optional – if needed a small dorsal plate is used)

Answer 60

1. Post-traumatic (70%) 2. Others * Chronic ankle instability * Malalignment * Primary osteoarthritis * Inflammatory arthritis (12%) * Peripheral neuropathy (Charcot arthropathy) * Talus osteonecrosis * Hemophilia * Gout * Septic arthritis 3. Incidence * Cadaver studies = 2-5% end-stage arthritis * Difficult to predict due to low prevalence and lack of correlation between xray and clinical findings

Answer 61

Diffuse ankle pain * Global disease Actvity-specific compaint * Focal disease Pain with max PF activities * Eg. Descending stairs, downhill walking * Posterior ankle pathology Anterior discomfort with DF activities * Anterior joint disease Subfibular pain * Either subtalar or ankle pathology Posteromedial pain * Often has a soft-tissue origin

Answer 62

Type 1 = isolated ankle arthritis Type 2 = ankle arthritis with intra-articular varus or valgus deformity or a tight heel cord, or both Type 3 = ankle arthritis with hindfoot deformity, tibial malunion, midfoot abductus or adductus, supinated midfoot, plantarflexed first ray, etc. Type 4 = Types 1-3 plus subtalar, calcaneocuboid or talonavicular arthritis

Answer 63

1. Ankle arthroscopy 2. Autologous chondrocyte implantation 3. Supramalleolar osteotomy 4. Distraction arthroplasty 5. Arthrodesis 6. Arthroplasty

Answer 64

Anterior impingement in the absence of global disease

Answer 65

1. Center the talus under the tibia in the coronal and sagital planes 2. Realign the hindfoot 3. Improve the force vector of the triceps surae

Answer 66

1. Asymmetric varus or valgus ankle OA with ≥50% preserved tibiotalar joint surface 2. Optimization of alignment in total ankle arthroplasty and ankle arthrodesis

Answer 67

1. Hindfoot instability not amenable to ligament reconstruction 2. Severe vascular deficiency 3. Severe neurologic deficit 4. Inflammatory disease 5. Charcot arthropathy 6. Poor bone quality 7. Acute or chronic infection 8. Age \>70 (relative)

Answer 68

The closer the CORA of the deformity is to the ankle the greater the effect on ankle malrotation and on medial distal tibial angle (increases)

Answer 69

1. Congruent deformity = ≤4° of tibiotalar tilt 2. Incongruent deformity = \>4°of tibiotalar tilt * Tibiotalar tilt is the difference between the medial distal tibia joint surface angle and the medial tibiotalar angle

Answer 70

1. Medial opening wedge osteotomy with plate fixation and allograft bone 2. Goal is to achieve 2-4°of valgus 3. Fibular osteotomy indicated if correction \>10° 4. Dome osteotomy with fibular osteotomy indicated if correction \>15°

Answer 71

1. Medial closing wedge osteotomy 2. Goal is to achieve 2-4°of varus 3. Dome osteotomy with fibular osteotomy indicated if correction \>15°

Answer 72

1. Delayed or nonunion 2. Overcorrection or undercorrection 3. Nerve injuries 4. Acute tarsal tunnel syndrome (varus to valgus correction)

Answer 73

1. Pros * More reliable pain relief * Revision surgery rare (occasional hardware removal) 2. Cons * Nonunion * 7% (up to 43% in high risk groups) * Functional limitations * Even in "succesful" fusions in long term * Adjacent joint arthritis accelerated * Incidence as high as 90% * Subtalar [most common] * Talonavicular

Answer 74

1. 5° of hindfoot valgus 2. Neutral plantar/dorsiflexion 3. 5-10° of external rotation

Answer 75

1. Arthroscopic-assisted * Indications: * End-stage ankle OA * Minimal deformity * Compromised soft tissue * Contraindication: * \>15° of varus or valgus in the coronal plane * Pros * Decreased soft tissue disruption and elimination of wound problems 2. Mini-arthrotomy (1.5cm anteromedial and anterolateral incisions) * Indication – same as arthroscopic * Contraindications – same as arthroscopic and anteriorly subluxated talus * Pros: * Better blood supply to fusion site than open (in cadaver studies) * No wound problems 3. Open fibular-sparing technique * Pros: * Intact fibula serves as a guide for proper rotation and positioning * Additional surface area for fusion * Acts as a block to valgus drift in cases of delayed union * Allows conversion to total ankle arthroplasty 4. Open anterior plating * Indication * Include patients with posttraumatic bone loss and/or poor bone quality * Pros: * Anterior approach allows enhanced visualization and conversion to total ankle arthroplasty * Limited bone resection * Rigid multiplanar screw fixation * Preservation of bony anatomy 5. Circular external fixator * Indications: * Previously failed arthrodesis * Talar osteonecrosis * Soft-tissue compromise * Severe deformity

Answer 76

1. Partially threaded screws * Various options exist – JAAOS described: * Homerun screw – posterolateral (lateral to Achilles) extending from posterior tibia down neck of talus * Medial tibia to head neck junction of talus * Plantarlateral talar neck to tibia 2. Anterior plating

Answer 77

1. Acute or chronic joint infections 2. Insensate foot 3. Severe multiplanar deformity 4. Charcot arthropathy 5. Talus osteonecrosis 6. Compromised soft tissues 7. Neuromuscular disease 8. Osteopenia

Answer 78

1. CBC, ESR, CRP 2. WB radiographs of foot and ankle 3. Ankle aspiration 4. Bone scan (in cases of normal BW and negative aspirate) 5. CT to monitor ballooning osteolysis

Answer 79

Wide range reported * 2% short term * 55% long term COFAS/Daniels Studies [JBJS 2014 Jan 15;96(2):135-42] * TAA Revision rate * 17% at 5.5y (7% for fusion) * Mobile bearing TAA Revision rate * Metal component revision 12% at 4.3y * Poly bearing revision 18% at 5.2y

Answer 80

1. Aseptic loosening and subsidence * Main indication of revision surgery * Suspected when \>5° or 5mm of component movement is seen on serial radiograph * Due to: * Failure to correct coronal plane deformity * Failure to correct ankle instability * Malrotation of the talar component to the tibial component 2. Osteolysis and cyst formation * Small, nonprogressive cysts are due to stress shielding * Large progressive cysts are due to implant wear debris and increased hydrostatic pressures * \<2mm lucent line around implant = lucency * \>2mm lucent line around implant = ballooning osteolysis 3. Ankle stiffness * Due to: * Significant lack of preop ROM * Oversized components (overstuffing) * Inadequate tibial resection * Component malposition * Soft tissue or bony impingement * Arthrofibrosis 4. Infection * Risk factors: * Previous ankle surgery * Prolonged surgical time * Low preop AOFAS ankle-hindfoot scores * Anterior approach associated with infection in 7% of TAA

Answer 81

1. Asymptomatic cysts * Serial examinations and CTs * Surgical intervention if becomes symptomatic or high risk cysts * Eg. directly inferior to talar component or high risk of fracture 2. Symptomatic cysts * Curettage of cysts and bone grafting +/-poly exchange or metal component revision

Answer 82

1. Acute (\<4 weeks) * I&D + poly exchange + parenteral Abx (6-8 weeks) 2. Chronic (\>4 weeks) * Two-stage revision with antibiotic cement spacer + parenteral Abx (6 weeks) * Followed by revision TAA, arthrodesis, retention of antibiotic cement spacer, or BKA

Answer 83

Open arthrolysis and TAL or gastroc recession

Answer 84

* Severe osteolysis * Component subsidence * Severe talar bone loss

Answer 85

Bone loss \>2cm (often use femoral head)

Answer 86

1. Severe subtalar arthritis and pain 2. Large talar bone loss 3. Nonreconstructable subsidence of talar component into subtalar joint

Answer 87

1. Position patient lateral (or supine) 2. Sinus tarsi approach – inline with tip of fibula and base of 4th metatarsal * Avoid sural nerve and peroneal tendons * Elevate EDB and retract distal * Remove all fat and tissue from sinus tarsi * Laminar spreader is inserted into the sinus tarsi 3. Articular surface is prepared by removing all cartilage (curettes, osteotomes) and scaled with an osteotome * Typically bone graft is not needed: * Local bone graft is available from calcaneus if needed * Distraction bone block may be needed in cases of posttraumatic calcaneus fractures * Tricortical iliac crest 4. Subtalar joint is positioned in 5 degrees of valgus * Provisional fixation is held with K-wires and alignment confirmed on fluoro 5. Fixation with 7.0 partially threaded cannulated screws * Usually two screws * Either two from the nonWB portion of the calcaneal tuberosity to the talar neck crossing the posterior facet * OR, one from the calcaneus to the talus and the other from the dorsomedial talar neck (just medial to tibialis anterior) to the calcaneus

Answer 88

1. Position patient supine 2. Sinus tarsi approach * Elevate EDB distally and visualize the subtalar joint, calcaneocuboid joint and lateral talonavicular joint * Prepare the articular surface by removing cartilage and scaling 3. Medial incision – 2cm distal and lateral to medial malleolus extending distally to the level of the medial cuneiform * Talonavicular joint is opened and articular surface is prepared 4. Joint fusion positions are obtained and provisionally held with K-wires * Subtalar joint in 5 degrees of valgus * Transverse tarsal joint is positioned with neutral forefoot supination/pronation and 0-5 degrees of abduction 5. Fixation usually proceeds with subtalar, then TN, then CC * Subtalar fixation with calcaneus to talus partially threaded cannulated screws * TN fixation with navicular to talus partially threaded cannulated screws (+/- Richard staples) * CC fixation with calcaneus to cuboid partially threaded cannulated screws (+/- Richard staples)

Answer 89

1. Weakness of tibialis anterior and peroneus brevis 2. Unopposed activity of peroneus longus and tibialis posterior 3. Equinus (ankle plantarflexion) 4. Cavovarus (hindfoot varus and increased medial longitudinal arch) 5. Claw toe deformity (due to intrinsic weakness and EDL and EHL recruitment to assist with dorsiflexion)

Answer 90

1. Dorsiflexion closing wedge 1st MT osteotomy 2. Lateralizing calcaneal osteotomy 3. PTT tendon transfer 4. +/-peroneus longus-to-brevis transfer (improves eversion and limits 1st MT plantarflexion) 5. +/-EDL or EHL tendon transfer to MT (improves dorsiflexion and assists in toe deformity correction)

Answer 91

Foot ulceration

Answer 92

1. Sensory neuropathy * Stocking distribution * Lacks protective sensation * Result = unnoticed repetitive trauma 2. Autonomic neuropathy * Dry skin and decreased integrity * Result = cracks and fissures in skin 3. Ischemia secondary to PVD * Result = ulcer and gangrene 4. Deformity * Cavus, ‘rocker bottom’, claw toes * Result = improper loading and increased plantar pressures

Answer 93

1. ABI \<0.45 2. Transcutaneous oxygen pressure \<30mmHg 3. Albumin \<3.0g/dL 4. Total lymphocyte count \<1,500/mm3

Answer 94

Wagner Classification

Answer 95

First branch of the lateral plantar nerve

Answer 96

1. Periosteum of the medial process of the calcaneal tuberosity 2. Flexor digitorum brevis 3. Abductor digiti minimi

Answer 97

Between deep fascia of abductor hallucis and medial caudal margin of quadratus plantae

Answer 98

Common synovial sheath starting 4cm above distal fibula and bifurcates at level of peroneal tubercle (on lateral aspect of calcaneus just distal to tip of distal fibula)

Answer 99

Peroneus brevis is anterior and medial to the peroneus longus

Answer 100

The peroneus brevis is superior and the the peroneus longus is inferior to the peroneal tubercle

Answer 101

1. Superior peroneal retinaculum (SPR) – primary restraint * Extends from posterior ridge of the distal fibula to the lateral wall of the calcaneus 2. Inferior peroneal retinaculum (IPR) * Continuous with the inferior extensor retinaculum * Extends over the tendons at the level of the lateral calcaneus and attaches to the peroneal tubercle creating a septum 3. Peroneal groove * Sulcus on posterior aspect of the distal fibula 4. Fibrocartilaginous rim * Laterally deepens groove by 2-4mm

Answer 102

1. Avulsion of base of 5th MT (peroneus brevis) 2. Fracture of os peroneum (peroneus longus) 3. Fleck avulsion of the distal fibula (SPR) 4. Peroneal tubercle hypertrophy (tendinosis/itis)

Answer 103

Circumferential fluid within the common synovial sheath wider than 3mm

Answer 104

Distal 3cm of the fibula where the tendon is compressed over the edge of the fibula

Answer 105

1. Single longitudinal tear (\<50% CSA) * Debridement, repair and tubularization 2. Multiple longitudinal tears or significant tendinosis (\>50% CSA) * Excision of degenerated portion and tenodesis of proximal and distal ends to the adjacent intact tendon (longus or brevis) 3. Single tendon complete tear * Tenodesis to adjacent tendon

Answer 106

1. FHL tendon transfer or allograft repair * If there is no proximal muscle excursion = FHL transfer * If there is adequate proximal muscle excursion: * Presence of tissue bed scarring = 2-stage silicone rod placement to establish synovial sheath followed by FHL transfer or allograft * Absence of tissue bed scarring = one-stage FHL transfer or allograft

Answer 107

Forceful dorsiflexion and eversion injury

Answer 108

1. Grade I – SPR elevated off lateral malleolus 2. Grade II – fibrocartilaginous rim elevated off lateral malleolus 3. Grade III – SPR bony avulsion off lateral malleolus 4. Grade IV – SPR torn from calcaneus and deep investing fascia of Achilles tendon

Answer 109

1. Nonoperative * Acute SPR injury – 6 weeks below knee cast (plantarflexed and inverted – ensure tendons are reduced) 2. Operative * Acute SPR injury – direct SPR repair * Chronic SPR injury * Tissue transfer – SPR reinforced with a split Achilles, plantaris, peroneus brevis, or tendon rerouting deep to the calcaneofibular ligament * Bone block – distal fibula osteotomy to create a bony lip * Groove deepening – peroneal groove is deepened * Note – hindfoot varus must be corrected (Dwyer calcaneal osteotomy)

Answer 110

1. Achilles tendon * Medially: * Posterior tibial artery supplies the tendon proximally (\>7cm from insertion) and distally (\<4cm from insertion) – Main Blood Supply * Laterally: * Peroneal artery supplies the midsection (4-7cm from insertion) * Blood vessels enter anterior/deep surface predominately 2. Skin [JAAOS 2017;25:23-31] * Posterior tibial artery medially and peroneal artery laterally * Watershed area is directly posteriorly 3. Best approach for open surgery * Posteromedially

Answer 111

1. Male 2. Fluoroquinolone 3. Corticosteroids 4. Tendinopathy 5. Haglund’s deformity 6. Contralateral Achilles repair

Answer 112

1. Historical * Cast immobilization 6-8 weeks * Outcomes: * Higher re-rupture compared to surgical 2. Functional rehabilitation * General protocol: * Week 0-2 * Backslab * nonWB immediately post injury * Week 3-4 * 2cm heel lift in walking boot * Protected WB * Active plantarflexion * Dorsiflex to neutral * Week 5-6 * WBAT * Week 7-8 * Remove heel lift * Slow dorsiflexion * Graduated strengthening * Proprioception * Gait train * Week 9-12 * Wean out of boot * Week \>12 * Progress strength, ROM, proprioception * Sport-specific training * Outcomes: * Re-rupture comparable to surgical and lower than cast immobilization * No clinically important differences in ROM, strength, calf circumference, functional outcome scores compared to surgery * Only differences compared to surgery: * Earlier return to work with surgery (19 days) * Increased plantarflexion strength with surgery (14% difference – may be important for athlete) * Lower risk of complications * Including superficial and deep infection, hypertrophic scar, tendon tethering to skin, and wound dehiscence

Answer 113

1. Open 2. Percutaneous – risk of sural nerve injury 3. Mini-open NOTE - less invasive techniques have decreased the risk of complications without increasing rerupture rates

Answer 114

1. 2 weeks nonWB (allow wound to heal) 2. TTWB in controlled ankle motion (CAM) boot 3. Full WB at 3 weeks 4. Begin unloaded ankle ROM exercises after 2 weeks 5. Return to sports at 9 months if able to perform single heel rise

Answer 115

* Thompson test * Palpable gap * Decreased plantarflexion strength * Limp * Relative dorsiflexion resting position

Answer 116

Patient is prone and both knees are flexed to 90 degrees, the ankle with the chronic achilles rupture will assume a more dorsiflexed position NOTE – when reconstructing a chronic achilles tear this can be used to match the resting tension of the unaffected side (need to prep out both legs)

Answer 117

1. Chronicity, residual gap size, remaining tissue quality and vascularity, location of rupture, and patient-specific factors 2. Tendon defect size * Most accurately measured after debridement to healthy tendon

Answer 118

1. Gap \<2cm * End-to-end repair\* 2. Gap 2-5cm * V-Y advancement +/- FHL transfer\* * Inverted V fascia cut with the limbs of the V being 1.5x the length of the defect * The limbs are repaired side-to-side and the stumps are repaired end-to-end * Alternative to VY – gastroc recession * Achilles turndown flap 3. Gap \>5cm * Autograft (gracilis, semitendinosus, fascia lata, quads with bone block)\* * Allograft (achilles) * FHL Tendon transfer +/- VY advancement or Turndown

Answer 119

1. Stronger than the PB or FDL tendons 2. The axis of pull of the FHL tendon most closely replicates that of the Achilles tendon 3. In phase with the Achilles tendon 4. Anatomic proximity to the Achilles tendon 5. The FHL distal muscle belly may impart some vascularity

Answer 120

1. Short (proximal) harvest * Released at the level of the fibro-osseous tunnel * Fixed to calcaneus with interference screw (or drill hole tying back onto self) 2. Long (distal) harvest * Released at the level of the knot of Henry or base of distal phalanx * Fixed to calcaneus via drill hole * Provides a double limb, U-shaped construct

Answer 121

1. Minimal gap (\<2-3cm) * Primary repair\* 2. Intermediate-gap (2/3-5/6cm) * V-Y advancement +/- FHL transfer\* * Achilles turndown flap +/- synthetic graft augmentation * FHL tendon transfer +/- VY advancement or gastroc recession * Peroneus brevis transfer (FDL transfer if gap to large for peroneus brevis) 3. Large-gap (\>5-6cm) * FHL transfer +/- V-Y advancement * Gastroc recession +/- free tendon graft or synthetic graft * FHL transfer and achilles turndown flap\* * Free hamstring autograft 4. Very large (\>10cm) * FHL transfer and Achilles allograft

Answer 122

1. Anatomic repair – repair of torn ligaments * Brostrom = midsubstance imbrication and suture of torn ligaments (ATFL and CFL) * Gould modification = augmented Brostrom repair with mobilized lateral portion of the extensor retinaculum which is attached to the fibula * Karlsson = ATFL and CFL are shortened and reattached to the distal fibula through drill holes with the proximal ends of the ligaments oversewn to the distal ends 2. Tenodesis stabilization – local graft harvest and tendodesis to restrict motion but no repair of injured ligaments * Watson-Jones procedure = peroneus brevis tenodesis from fibula to talus (recreates ATFL) * Evans procedure = perneous brevis tenodesis to fibula (recreates neither ATFL or CFL rather is between) * Chrisman-Snook procedure = split peroneus brevis tenodesis to fibula and calcaneus (recreates ATFL and CFL)

Answer 123

Hindfoot varus * Fixed hindfoot varus (does not correct with the Coleman block test) = Dwyer or lateralizing calcaneal osteotomy * Flexible hindfoot varus (does correct with the Coleman block test) = dorsal closing wedge first MT osteotomy

Answer 124

1. Peroneal tenosynovitis/tears 2. Attenuated superior peroneal retinaculum 3. Anterolateral impingement 4. Ankle synovitis 5. Loose bodies 6. OCL of talus

Answer 125

1. Curvilinear incision starting just anterior to the fibula starting proximal to ATFL insertion and extending distally 2. Dissect through subcutaneous tissue 3. Identify the inferior extensor retinaculum and retract distally exposing the ATFL 4. Open the capsular interval between AITFL and ATFL exposing the lateral shoulder of the talus 5. Pass a curved hemostat under the capsule and ATFL to pierce the capsule between ATFL and the peroneal sheath 6. Divide the ATFL midsubstance 7. Place the ankle in a dorsiflexed and everted position and a bump under the tibia to allow the talus to reduce posterior 8. Using No. 0 nonabsorbable suture imbricate the two ends of the ATFL in pants-over-vest fashion * Alternative – divide the ATFL close to the fibula and place one suture anchor at the origin of the ATFL and repair the ATFL to its origin in a purse-string manner

Answer 126

1. Anatomic direct repair 2. Reconstruction * Anatomic * Nonanatomic 3. Arthroscopic repair

Answer 127

Most common types: 1. Brostrom 2. Gould modification 3. Karlsson modification Advantages: * Low cost * Minimal invasiveness * Procedural simplicity * Low complication rates Contraindications: * Insufficient ligamentous tissue * Prior unsuccessful stabilization procedures * High BMI * Generalized ligamentous laxity

Answer 128

Types: 1. Autograft 2. Allograft Indications: * Poor-quality ligament remnants * Previously unsuccessful lateral ankle repair * High BMI * Generalized ligamentous laxity * Patients for whom direct repair may not be an option

Answer 129

Types: 1. Watson-Jones 2. Chrisman-Snook 3. (Evans) Cons: * Impairment in ankle and subtalar joint function * Unsatisfactory long term outcomes * Higher wound complication rates Indications: * Nonanatomic reconstruction use is controversial and use has declined * Possible indications: * Ligament reconstruction in the setting of TAA, cavovarus reconstruction and hindfoot realignment

Answer 130

1. Causes: * Inadequate anatomic reconstruction * Functional instability * Reinjury * Predisposing factors 2. Predisposing factors: * Ligamentous laxity * Long-standing instability * High functional demand * Cavovarus deformity

Answer 131

1. Surgery may not prevent posttraumatic ankle arthritis 2. Cavovarus is correlated with chronic lateral ankle instability

Answer 132

1. Medial * More common * Nontraumatic * Larger and deeper * More posterior 2. Lateral * Traumatic * Smaller and shallower * More anterior

Answer 133

1. Berndt and Harty (Radiograph) * Stage I - subchondral compression * Stage II - partially detached osteochondral fragment * Stage III - completely detached fragment without displacement * Stage IV - detached and displaced fragment 2. Ferkel (CT) * Stage I - intact roof/cartilage with underlying cystic lesion * Stage IIa - cystic lesion with communication to the surface * Stage IIb - open surface lesion with overlying fragment * Stage III - nondisplaced fragment with lucency beneath * Stage IV - displaced fragment 3. Hepple (MRI) * Stage I - articular cartilage only * Stage IIa - acute cartilage injury with bony fracture * Stage IIb - chronic cartilage injury with bony fracture * Stage III - detached, nondisplaced bony fragment * Stage IV - displaced fragment, uncovered subchondral bone * Stage V - subchondral cyst present 4. Ferkel and Cheng (Arthroscopic) * Grade A - Smooth, intact, but soft or ballotable * Grade B - Rough surface * Grade C - Fibrillations/fissures * Grade D - Flap present or bone exposed * Grade E - Loose, undisplaced fragment * Grade F - Displaced fragment

Answer 134

1. Acute OCL displacement 2. Chronic OCL failing 3-6 months of nonoperative management

Answer 135

1. Cartilage repair * Microfracture * Retrograde drilling 2. Cartilage regeneration * Autologous chondrocyte implantation (ACI) * Matrix-induced autologous chondrocyte implantation * Autologous matrix induced chondrogenesis 3. Cartilage replacement * Osteochondral autograft transfer (OAT) * Osteochondral allograft * Particulated juvenile cartilage allograft transplantation

Answer 136

Microfracture

Answer 137

1. Lesion \<1.5cm² = Microfracture 2. Lesion \>1.5cm² or revision treatment: * Does not extend to shoulder and no subchondral cyst = cartilage regeneration * Does not extend to shoulder and subchondral cyst present = OAT or ACI * Shoulder lesion = OAT or allograft * Large cystic lesion = allograft 3. Intact cartilage cap = Retrograde drilling \*\*\*Note -Medial lesions approached through sinus tarsi and lateral lesions through anteromedial incision (??)

Answer 138

1. Anteromedial * Medial to tibialis anterior * Risk = saphenous vein and nerve 2. Anterolateral * Lateral to peroneus tertius * Risk = superficial peroneal nerve (intermediate dorsal cutaneous branch) 3. Posterolateral * At the level of the tip of the fibula just lateral to the Achilles tendon * Risk = sural nerve and small saphenous vein 4. Posteromedial * At the level of the tip of the fibula just medial to the Achilles tendon

Answer 139

Strayer * Posteromedial incision (start 2cm from the gastroc indentation, length ~7cm) * Direct posterior incision risks injury to sural nerve * Deep fascia incised inline with the skin incision revealing the gastroc tendon * Sural nerve and short saphenous vein are identified deep to fascia and protected * Interval between gastroc and soleus developed bluntly * Gastroc tendon is cut under direct visualization