Foot and Ankle (Complete) Flashcards
What joints comprise the Chopart joint?
[JAAOS 2016;24:379-389]
Calcaneocuboid and talonavicular
- aka. Transverse tarsal joint
What is the most common accessory bone in the foot?
[JAAOS 2016;24:379-389]
Accessory navicular
What is the differential for lateral ankle pain?
[AAOS comprehensive review 2, 2014]
- Acute or chronic lateral ankle instability
- Lateral talar process fracture
- Osteochondral lesion of the talus
- Anterior process of the calcaneus fracture
- Fifth metatarsal base fracture
- Peroneal tendon pathology
- Subtalar instability
- Soft tissue impingement
- Bone impingement lesion
- Tarsal coalition
What is the differential for heel pain?
[Mann’s Surgery of the Foot and Ankle 2014]
- Plantar fasciitis
- Calcaneal stress fracture
- Entrapment of Baxter’s nerve
- Subcalcaneal bursitis
What are the three components of the spring ligament?
[Mann’s Surgery of the Foot and Ankle 2014]
AKA Plantar calcaneonavicular ligament
- Superomedial (largest)
- Medial plantar oblique
- Plantar inferior
Describe the coleman block test?
- The heel, lateral border of the foot and the 4th and 5th rays are placed on a 2.5-4cm block with the 1st-3rd rays free
- If the hindfoot varus corrects = hindfoot is flexible, forefoot driven deformity
- If the hindfoot varus does not correct = hindfoot is rigid
***Used for varus/cavovarus foot
What is the most common compressive neuropathy of the lower limb?
[JAAOS 2016;24:1-10]
Common peroneal nerve palsy
What is the most common site of compression of the CPN?
[JAAOS 2016;24:1-10]
Fibular neck
What are potential causes of CPN palsy?
[JAAOS 2016;24:1-10]
- Compressive (most common)
- Others:
- Knee dislocation
- Severe ankle inversion injury
- Laceration
- Blunt trauma
- Iatrogenic
What is the classic gait associated with a CPN palsy?
[JAAOS 2016;24:1-10]
Steppage gait
- Ipsilateral knee is lifted higher than normal during the swing phase to avoid dragging the toes on the ground, followed by slapping the forefoot on the ground after heel strike
What resulting foot deformity occurs in untreated CPN palsy?
[JAAOS 2016;24:1-10]
Equinovarus deformity
Following a postoperative or traumatic CPN palsy when should an EMG/NCV study be performed?
[JAAOS 2016;24:1-10]
2-6 weeks
- Repeated every 3 months to monitor for improvement or deterioration
Why is the EMG/NCV study recommended to be delayed 2-6 weeks?
[HSS J. 2006 Feb; 2(1): 19–21.]
- The degree of muscle denervation can only be accurately determined once Wallerian degeneration is complete
- This is a length dependent process where longer distal segments take longer to degenerate
- Evident as fibrillations
- If the study is done too early it may underestimate the extent of injury
What is the management of a postoperative compression CPN palsy?
[JAAOS 2016;24:1-10]
- Initial nonsurgical management
- Activity modification (eg. cessation of leg crossing, padding of the fibular head, avoid squatting, night splints)
- Physiotherapy
- Stretch plantarflexors and invertors
- Strengthening dorsiflexors and evertors
- AFO (allows clearance of foot during ambulation)
- Surgical decompression
- Considered if no improvement after trial of nonoperative treatment (minimum 3 months) or if motor loss is rapidly progressive
- May also be considered over initial nonoperative treatment if EMG/NCV studies show severe conduction loss or disruption of motor innervation
- Tendon transfer
- Considered if no improvement with nonoperative and surgical decompression
- Tendon transfer = posterior tibial tendon (PTT) transfer to lateral cuneiform or cuboid
- Medial cuneiform can be used if only the anterior muscle compartment is affected
- 4-IncisionTechnique
- Incision distal to medial malleolus (extends 5cm distal)
- PTT is harvested subperiosteally from distal to proximal at the naviculocuneiform joint
- Incision ~15cm proximal to the medial malleolus
- The soleus and FDL are retracted posteriorly to expose the PTT, the PTT is then pulled through the proximal incision and tagged with suture
- Incision along the anterior border of the fibula
- EDL is retracted medially and a ~4cm of interosseous membrane is dissected off the fibula and excised
- The PTT is then passed through the window created
- Incision over the lateral cuneiform
- PTT is then tunneled subcutaneously to this incision and anchored to the lateral cuneiform with an interference screw
- Incision distal to medial malleolus (extends 5cm distal)
What conditions cause charcot arthropathy?
[JAAOS 2009;17: 562-571]
- Diabetic neuropathy (most common)
- Others
- Alcohol
- Leprosy
- Tabes dorsalis (tertiary syphilis)
- Myelomeningocele
- Congenital insensitivity to pain
What is the pathogenesis of charcot arthropathy?
[JAAOS 2009;17: 562-571]
- Neurotraumatic theory
* Abnormal sensation prevents normal protective mechanisms after single or repetitive trauma leading to delay in presentation and typical Charcot changes - Neurovascular theory
* Autonomic dysfunction leads to increased blood flow resulting in increased bone turnover - Inflammatory cytokines also implicated in bone resorption
What is the clinical presentation of Acute Charcot Arthropathy of the foot and ankle?
[JAAOS 2009;17: 562-571]
- Hot and swollen foot and ankle
- Bounding distal pulses
- Pain is present ~50% of the time
- May have a history of traumatic episode
What is the radiographic and clinical classification of Charcot Arthropathy?
[JAAOS 2009;17: 562-571]
Eichenholtz classification
- Stage 0
- Xrays – normal
- Clinical
- Swelling
- Erythema
- Warmth
- Dependent rubor decreases with leg elevation (cellulitis does not)
- Stage 1 (fragmentation phase)
- Xrays
- Osteopenia
- Periarticular fragmentation
- Subluxation
- Dislocation
- Clinical
- Swelling
- Warmth,
- Erythema
- Increased ligamentous laxity
- Xrays
- Stage 2 (coalescence phase)
- Xrays
- Absorption of debris
- Early fusion
- Sclerosis
- Clinical
- Decreased swelling, warmth, erythema
- Xrays
- Stage 3 (reconstruction phase)
- Xrays
- Joint arthrosis
- Osteophytes
- Subchondral sclerosis
- Clinical
- Absence of inflammation
- Xrays
What is the anatomic classification based on pattern of collapse in charcot arthropathy of the foot?
[JAAOS 2009;17: 562-571]
Brodsky classification (Trepman modification – added 4 and 5)
- Type 1
- Collapse of tarsometatarsal joints (most common)
- Leads to fixed rocker bottom foot with valgus angulation
- Develop exostosis increasing risk of ulceration
- Collapse of tarsometatarsal joints (most common)
- Type 2
- Collapse of subtalar and Chopart joints
- Unstable, requires prolonged immobilization
- Type 3a
- Collapse of the ankle joint
- Late deformity leads to severe varus or valgus collapse
- Can lead to ulceration and osteomyelitis
- Collapse of the ankle joint
- Type 3b
- Involves fracture of the posterior calcaneal tuberosity
- Type 4
- Combination of above
- Type 5
- Collapse of the forefoot only
How can charcot arthropathy be distinguished from osteomyelitis?
[JAAOS 2009;17: 562-571]
- There is no definitive imaging test to differentiate
- Bone scan followed by WBC scan has sensitivity 93-100% and specificity 80% in localizing osteomyelitis
What is the management based on the Eichenholtz classification?
[JAAOS 2009;17: 562-571]
Stage 0
- Protected WB and foot care
- Serial radiographs to monitor for Stage 1 changes
Stage 1
- Total contact casting with nonWB or partial WB
- Serial radiographs and exam until swelling, warmth and erythema resolve
Stage 2
- Protected WB with total contact cast or CROW (charcot restraint orthotic walker) or clamshell AFO
Stage 3
- If plantigrade foot – custom inlay shoes
- Recurrent ulceration – exostectomy, achilles tendon lengthening if plantar ulcerations
- Severe deformity – arthrodesis
- Recurrent ulceration, infection or failed previous surgeries - amputation
What is the definition of hallux valgus?
[Miller’s, 6th ed.]
Lateral deviation of the great toe with medial deviation of the first metatarsal
Describe the pathoanatomy of hallux valgus?
[Miller’s, 6th ed.]
- Lateral deviation of the proximal phalanx
- Medial deviation of the metatarsal head
- Medial capsular attenuation
- Lateral capsule contraction
- Abductor hallucis migrates plantar and lateral (causes phalanx plantar flexion and pronation)
- Adductor hallucis contracture (deforming force)
- Lateral deviation of the EHL and FHL (deforming force)
- Lateral displacement of the sesamoids relative to the metatarsal head (the crista gradually erodes)
- The medial eminence develops with lateral migration of the proximal phalanx, but it is not characterized by new bone formation or hypertrophy of the medial first metatarsal head [Mann’s Surgery of the Foot and Ankle 2014]
What is the insertion of the adductor hallucis?
Oblique and transverse head insert onto the fibular sesamoid and lateral base of the proximal phalanx
What measurements should be evaluated on a WB AP view in the assessment of hallux valgus?
[AAOS comprehensive review 2, 2014]
- HVA (hallux valgus angle) normal = ≤15°
- HVI (hallux valgus interphalangeus angle) normal = <10°
- IMA (intermetatarsal angle) normal = ≤9°
- DMAA (distal metatarsal articular angle) normal = ≤10°
- PPAA (proximal phalanx articular angle) normal = ≤10°
In addition to measurements, what other radiographic features should be evaluated?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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
- Presence of joint arthrosis at MTP and TMT joint
- Degree of hallux pronation
What are the goals of hallux valgus surgery?
[Mann’s Surgery of the Foot and Ankle 2014]
- Correction of the hallux valgus and 1–2 IM angles
- Creation of a congruent MTP joint with sesamoid realignment
- Removal of the medial eminence
- Retention of functional range of motion of the MTP joint
- Maintenance of normal weight-bearing mechanics of the foot
What is the algorithm to consider when deciding on types of procedures (simplified)?
[Millers]
- IMA ≤13° AND HVA ≤40° = distal metatarsal osteotomy
- IMA >13° OR HVA >40° = proximal metatarsal osteotomy
- Instability of the first TMT = Lapidus procedure
- Arthritis or spasticity of MTP joint = first MTP fusion
- Increased DMAA = distal metatarsal redirectional osteotomy in addition to metatarsal osteotomy
- Increased HVI angle = Akin osteotomy
What are the components of a distal soft tissue procedure?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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) - Medial eminence excision (1-2mm medial to the medial sagittal sulcus)
- Medial capsule plication
What are the components of the Akin osteotomy?
[Mann’s Surgery of the Foot and Ankle 2014]
- Medial closing wedge phalangeal osteotomy
- Medial eminence excision
- Medial capsulorrhaphy
What are the components of a chevron osteotomy?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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
- Medial eminence excision
- Medial capsulorrhaphy
- 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
What are the components of the Mitchell ostetomy?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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
- Medial eminence excision
- Medial capsulorrhaphy
What are the components of the Scarf osteotomy?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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
- Medial eminence resection
- Medial capsule repair
What are the options for a distal soft tissue procedure with proximal osteotomy?
[Mann’s Surgery of the Foot and Ankle 2014]
- Proximal osteotomies include:
- Crescentic ostetomy
- Proximal chevron
- Wedge osteotomy
- Medial opening
- .Lateral closing
- Long oblique (Ludloff)
What is the main indication for a medial opening wedge osteotomy of the medial cuneiform?
[Mann’s Surgery of the Foot and Ankle 2014]
Juvenile patient with an open proximal first metatarsal epiphysis and a hallux valgus deformity characterized by an abnormally widened 1–2 IM angle
What is the main indication for a distal metatarsal closing wedge osteotomy?
[Mann’s Surgery of the Foot and Ankle 2014]
Congruent hallux valgus deformity with an increased DMAA
What are the indications for a metatarsal cuneiform fusion (Lapidus procedure)?
[Mann’s Surgery of the Foot and Ankle 2014]
- Hypermobility of the first ray
- Metatarsal cuneiform degenerative arthritis
- Severe hallux valgus deformity
- Recurrent hallux valgus
What are the components of a Lapidus procedure?
[Mann’s Surgery of the Foot and Ankle 2014]
- Distal soft tissue procedure (modified McBride)
- Medial eminence resection
- First metatarsal cuneiform fusion
What are the indications for a metatarsophalangeal fusion?
[Mann’s Surgery of the Foot and Ankle 2014]
- Severe hallux valgus deformity
- MTP degenerative arthritis
- Rheumatoid arthritis + hallux valgus
- Neurological disorder + hallux valgus (CP, CVA, head injury)
- Failed hallux valgus surgery/recurrent hallux valgus
What are the indications for the Keller procedure?
Elderly, low demand patients with mild to moderate hallux valgus and/or arthritic changes
What are the components of a Keller procedure?
[Mann’s Surgery of the Foot and Ankle 2014]
- Medial eminence resection
- Partial proximal phalangectomy (proximal 1/3)
- Medial capsulorrhaphy
What are the complications following surgical treatment of hallux valgus?
[Mann’s Surgery of the Foot and Ankle 2014]
- 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
- 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
- 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
- Recurrent hallux valgus
- Cockup deformity
- Caused by:
- Dual sesamoid excision
- Keller procedure
- FHL injury
What is the classification system for hallux rigidus?
[JAAOS 2012;20:347-358]
Coughlin and Shurnas Clinical and Radiographic Classification of Hallux Rigidus
What are the clinical features of hallux rigidus?
[JAAOS 2012;20:347-358]
- 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
- 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
What portion of the MTP joint is affected first in hallux rigidus (volar, dorsal, medial, lateral)?
[JAAOS 2012;20:347-358]
Dorsal
What are the treatment options for symptomatic hallux rigidus?
[JAAOS 2012;20:347-358]
- Nonoperative
- NSAIDs
- Corticosteroid injections
- Shoe modifications
- eg. Morton extension to limit dorsiflexion, rockerbottom sole, wide or high toebox
- Activity modification
- 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
- Indication – grade 1 or 2 without midrange pain
- Cheilectomy
- 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
- Arthrodesis
- 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)
- Keller resection arthroplasty
What is the classification of Bunionettes?
[JAAOS 2007;15:300-307]
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
What is the management of bunionettes?
[JAAOS 2007;15:300-307]
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
What is the blood supply to the navicular?
[JAAOS 2016;24:379-389]
- Medial tarsal branch of the dorsalis pedis (dorsal surface)
- Superficial and deep plantar arteries (plantar surface)
What is the classification of navicular fractures?
[JAAOS 2016;24:379-389]
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
- Type I
What foot anatomical features can contribute to the development of navicular stress fractures?
[JAAOS 2016;24:379-389]
- Long second metatarsal
- Metatarsal adduction
- Equinus contracture
What is the point of maximal tenderness in patients with a navicular stress fracture?
[JAAOS 2016;24:379-389]
Dorsal navicular prominence (‘N spot’)
What structures are responsible for avulsion fractures of the dorsal, medial and plantar navicular?
[JAAOS 2016;24:379-389]
- Dorsal – dorsal capsule and/or superficial deltoid ligament
- Medial – posterior tibialis tendon
- Plantar – plantar capsule and spring ligament
What is the nonoperative management for navicular avulsion fractures?
[JAAOS 2016;24:379-389]
- Low-energy, minimal soft tissue swelling = short leg WB cast or boot for 4-6 weeks
- Substantial soft tissue swelling = nonWB cast or boot for 6-8 weeks
What are indications for surgery in navicular avulsion fractures?
[JAAOS 2016;24:379-389]
- Tuberosity avulsion fractures
* Untreated can lead to traumatic insufficiency of the posterior tibialis tendon and progressive flat foot deformity - Large intra-articular fragments
What are the surgical indications for navicular body fractures?
[JAAOS 2016;24:379-389]
- Joint incongruity >2mm
- Medial column shortening >3mm
- Inability to attain or maintain a joint reduction
- Open fracture
- Concomitant compartment syndrome
- Skin tenting/at risk
What are the functions of the extrinsic and intrinsic muscles at the MTP, PIP and DIP joints of the lesser toes?
[JAAOS 2011;19: 505-514]
- Extrinsic muscles (originate proximal to the midfoot)
- EDL, EDB, FDL
- Extend MTP and flex the PIP and DIP
- Intrinsic muscles (originate distal to the midfoot)
- FDB, lumbricals, interosseos
- Flex the MTP and extend the PIP and DIP
How do you assess for flexible vs. fixed deformity of lesser deformities?
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
What is the deformity and management of Mallet Toe?
[JAAOS 2011;19: 505-514]
- 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 - Nonoperative management
- Cushioned toe sleeves
- Padding
- Roomy toe box with low heel
- 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
What is the deformity and management of Hammer Toe?
[JAAOS 2011;19: 505-514]
- Deformity is PIP flexion, DIP extension, MTP extension or neutral
- Nonoperative management
- High and wide toe box
- Soft uppers
- Padding or sleeves to protect dorsum of PIP joint
- 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.]
- FDL tendon transfer
- Fixed Hammer Toe
- PIP resection arthroplasty or fusion
What is the deformity and management of claw toe?
[JAAOS 2011;19: 505-514]
- Deformity is PIP and DIP flexion, MTP extension
- Nonoperative management
- Same as hammer toe
- High and wide toe box
- Soft uppers
- Padding or sleeves to protect dorsum of PIP joint
- 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.]
- FDL tendon transfer
- Fixed Claw Toe
- PIP resection arthroplasty or fusion
- Flexible Claw Toe
What is the deformity of curly toe?
[JAAOS 2011;19: 505-514]
Deformity is PIP and DIP flexion, MTP flexion or neutral
What is the cause and management of MTP joint instability?
[JAAOS 2011;19: 505-514]
- Plantar plate and capsule insufficiency due to trauma, inflammatory arthritis, synovitis (can be due to excessively long metatarsal)
- Nonsurgical management
- Metatarsal pad proximal to MT head
- Budin splint
- 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
- Dorsal capsule release and extensor tendon Z-lengthening
- Irreducible with soft tissue procedures
- Weil osteotomy
- MT shortening osteotomy
- Weil osteotomy
What are the deformities of the rheumatoid forefoot?
[International Orthopaedics (SICOT) (2013) 37:1719–1729]
- Hallux valgus
- Lesser toe MTP subluxation and dislocation
* dorsal and lateral - Claw toes
- Plantar fat pad displaces distal to MT head
- Loss of medial longitudinal arch
- Broadening of the forefoot
What are the operative procedures performed in the typical rheumatoid foot?
[Campbells]
- 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
- 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
Management of a postoperative pale lesser toe? [Campbells]
- Take down dressing
- Compress the toe down the K-wire if overlengthened
- Remove K-wire
What is the most common cause of adult-acquired flat foot deformity?
[Miller’s, 6th ed.]
PTTD (Posterior tibial tendon dysfunction)