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RCPSC Shay > Foot and Ankle (Complete) > Flashcards

Foot and Ankle (Complete) Flashcards

1
Q

What joints comprise the Chopart joint?

[JAAOS 2016;24:379-389]

A

Calcaneocuboid and talonavicular

  • aka. Transverse tarsal joint
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2
Q

What is the most common accessory bone in the foot?

[JAAOS 2016;24:379-389]

A

Accessory navicular

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3
Q

What is the differential for lateral ankle pain?

[AAOS comprehensive review 2, 2014]

A
  1. Acute or chronic lateral ankle instability
  2. Lateral talar process fracture
  3. Osteochondral lesion of the talus
  4. Anterior process of the calcaneus fracture
  5. Fifth metatarsal base fracture
  6. Peroneal tendon pathology
  7. Subtalar instability
  8. Soft tissue impingement
  9. Bone impingement lesion
  10. Tarsal coalition
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4
Q

What is the differential for heel pain?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Plantar fasciitis
  2. Calcaneal stress fracture
  3. Entrapment of Baxter’s nerve
  4. Subcalcaneal bursitis
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5
Q

What are the three components of the spring ligament?

[Mann’s Surgery of the Foot and Ankle 2014]

A

AKA Plantar calcaneonavicular ligament

  1. Superomedial (largest)
  2. Medial plantar oblique
  3. Plantar inferior
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6
Q

Describe the coleman block test?

A
  1. 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
  2. If the hindfoot varus corrects = hindfoot is flexible, forefoot driven deformity
  3. If the hindfoot varus does not correct = hindfoot is rigid

***Used for varus/cavovarus foot

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7
Q

What is the most common compressive neuropathy of the lower limb?

[JAAOS 2016;24:1-10]

A

Common peroneal nerve palsy

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8
Q

What is the most common site of compression of the CPN?

[JAAOS 2016;24:1-10]

A

Fibular neck

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9
Q

What are potential causes of CPN palsy?

[JAAOS 2016;24:1-10]

A
  1. Compressive (most common)
  2. Others:
  • Knee dislocation
  • Severe ankle inversion injury
  • Laceration
  • Blunt trauma
  • Iatrogenic
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10
Q

What is the classic gait associated with a CPN palsy?

[JAAOS 2016;24:1-10]

A

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
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11
Q

What resulting foot deformity occurs in untreated CPN palsy?

[JAAOS 2016;24:1-10]

A

Equinovarus deformity

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12
Q

Following a postoperative or traumatic CPN palsy when should an EMG/NCV study be performed?

[JAAOS 2016;24:1-10]

A

2-6 weeks

  • Repeated every 3 months to monitor for improvement or deterioration
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13
Q

Why is the EMG/NCV study recommended to be delayed 2-6 weeks?

[HSS J. 2006 Feb; 2(1): 19–21.]

A
  1. 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
  1. If the study is done too early it may underestimate the extent of injury
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14
Q

What is the management of a postoperative compression CPN palsy?

[JAAOS 2016;24:1-10]

A
  1. 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)
  1. 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
  1. 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
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15
Q

What conditions cause charcot arthropathy?

[JAAOS 2009;17: 562-571]

A
  1. Diabetic neuropathy (most common)
  2. Others
  • Alcohol
  • Leprosy
  • Tabes dorsalis (tertiary syphilis)
  • Myelomeningocele
  • Congenital insensitivity to pain
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16
Q

What is the pathogenesis of charcot arthropathy?

[JAAOS 2009;17: 562-571]

A
  1. Neurotraumatic theory
    * Abnormal sensation prevents normal protective mechanisms after single or repetitive trauma leading to delay in presentation and typical Charcot changes
  2. Neurovascular theory
    * Autonomic dysfunction leads to increased blood flow resulting in increased bone turnover
  3. Inflammatory cytokines also implicated in bone resorption
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17
Q

What is the clinical presentation of Acute Charcot Arthropathy of the foot and ankle?

[JAAOS 2009;17: 562-571]

A
  • Hot and swollen foot and ankle
  • Bounding distal pulses
  • Pain is present ~50% of the time
  • May have a history of traumatic episode
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18
Q

What is the radiographic and clinical classification of Charcot Arthropathy?

[JAAOS 2009;17: 562-571]

A

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
  • Stage 2 (coalescence phase)
    • Xrays
      • Absorption of debris
      • Early fusion
      • Sclerosis
    • Clinical
      • Decreased swelling, warmth, erythema
  • Stage 3 (reconstruction phase)
    • Xrays
      • Joint arthrosis
      • Osteophytes
      • Subchondral sclerosis
    • Clinical
      • Absence of inflammation
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19
Q

What is the anatomic classification based on pattern of collapse in charcot arthropathy of the foot?

[JAAOS 2009;17: 562-571]

A

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
  • 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
  • Type 3b
    • Involves fracture of the posterior calcaneal tuberosity
  • Type 4
    • Combination of above
  • Type 5
    • Collapse of the forefoot only
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20
Q

How can charcot arthropathy be distinguished from osteomyelitis?

[JAAOS 2009;17: 562-571]

A
  1. There is no definitive imaging test to differentiate
  2. Bone scan followed by WBC scan has sensitivity 93-100% and specificity 80% in localizing osteomyelitis
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21
Q

What is the management based on the Eichenholtz classification?

[JAAOS 2009;17: 562-571]

A

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
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22
Q

What is the definition of hallux valgus?

[Miller’s, 6th ed.]

A

Lateral deviation of the great toe with medial deviation of the first metatarsal

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23
Q

Describe the pathoanatomy of hallux valgus?

[Miller’s, 6th ed.]

A
  1. Lateral deviation of the proximal phalanx
  2. Medial deviation of the metatarsal head
  3. Medial capsular attenuation
  4. Lateral capsule contraction
  5. Abductor hallucis migrates plantar and lateral (causes phalanx plantar flexion and pronation)
  6. Adductor hallucis contracture (deforming force)
  7. Lateral deviation of the EHL and FHL (deforming force)
  8. Lateral displacement of the sesamoids relative to the metatarsal head (the crista gradually erodes)
  9. 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]
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24
Q

What is the insertion of the adductor hallucis?

A

Oblique and transverse head insert onto the fibular sesamoid and lateral base of the proximal phalanx

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25
Q

What measurements should be evaluated on a WB AP view in the assessment of hallux valgus?

[AAOS comprehensive review 2, 2014]

A
  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°
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26
Q

In addition to measurements, what other radiographic features should be evaluated?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
      1. Presence of joint arthrosis at MTP and TMT joint
      2. Degree of hallux pronation
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27
Q

What are the goals of hallux valgus surgery?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
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28
Q

What is the algorithm to consider when deciding on types of procedures (simplified)?

[Millers]

A
  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
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29
Q

What are the components of a distal soft tissue procedure?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
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30
Q

What are the components of the Akin osteotomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Medial closing wedge phalangeal osteotomy
  2. Medial eminence excision
  3. Medial capsulorrhaphy
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31
Q

What are the components of a chevron osteotomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
      1. Medial eminence excision
      2. Medial capsulorrhaphy
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32
Q

What are the components of the Mitchell ostetomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
      1. Medial eminence excision
      2. Medial capsulorrhaphy
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33
Q

What are the components of the Scarf osteotomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
      1. Medial eminence resection
      2. Medial capsule repair
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34
Q

What are the options for a distal soft tissue procedure with proximal osteotomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Proximal osteotomies include:
  • Crescentic ostetomy
  • Proximal chevron
  • Wedge osteotomy
    • Medial opening
    • .Lateral closing
  • Long oblique (Ludloff)
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35
Q

What is the main indication for a medial opening wedge osteotomy of the medial cuneiform?

[Mann’s Surgery of the Foot and Ankle 2014]

A

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

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36
Q

What is the main indication for a distal metatarsal closing wedge osteotomy?

[Mann’s Surgery of the Foot and Ankle 2014]

A

Congruent hallux valgus deformity with an increased DMAA

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37
Q

What are the indications for a metatarsal cuneiform fusion (Lapidus procedure)?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Hypermobility of the first ray
  2. Metatarsal cuneiform degenerative arthritis
  3. Severe hallux valgus deformity
  4. Recurrent hallux valgus
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38
Q

What are the components of a Lapidus procedure?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Distal soft tissue procedure (modified McBride)
  2. Medial eminence resection
  3. First metatarsal cuneiform fusion
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39
Q

What are the indications for a metatarsophalangeal fusion?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
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40
Q

What are the indications for the Keller procedure?

A

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

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41
Q

What are the components of a Keller procedure?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Medial eminence resection
  2. Partial proximal phalangectomy (proximal 1/3)
  3. Medial capsulorrhaphy
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42
Q

What are the complications following surgical treatment of hallux valgus?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
  1. 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
  1. 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
  1. Recurrent hallux valgus
  2. Cockup deformity
  • Caused by:
    • Dual sesamoid excision
    • Keller procedure
    • FHL injury
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43
Q

What is the classification system for hallux rigidus?

[JAAOS 2012;20:347-358]

A

Coughlin and Shurnas Clinical and Radiographic Classification of Hallux Rigidus

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44
Q

What are the clinical features of hallux rigidus?

[JAAOS 2012;20:347-358]

A
  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
  1. 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
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45
Q

What portion of the MTP joint is affected first in hallux rigidus (volar, dorsal, medial, lateral)?

[JAAOS 2012;20:347-358]

A

Dorsal

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46
Q

What are the treatment options for symptomatic hallux rigidus?

[JAAOS 2012;20:347-358]

A
  1. Nonoperative
  • NSAIDs
  • Corticosteroid injections
  • Shoe modifications
    • eg. Morton extension to limit dorsiflexion, rockerbottom sole, wide or high toebox
  • Activity modification
  1. 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)
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47
Q

What is the classification of Bunionettes?

[JAAOS 2007;15:300-307]

A

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
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48
Q

What is the management of bunionettes?

[JAAOS 2007;15:300-307]

A

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
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49
Q

What is the blood supply to the navicular?

[JAAOS 2016;24:379-389]

A
  1. Medial tarsal branch of the dorsalis pedis (dorsal surface)
  2. Superficial and deep plantar arteries (plantar surface)
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50
Q

What is the classification of navicular fractures?

[JAAOS 2016;24:379-389]

A

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
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51
Q

What foot anatomical features can contribute to the development of navicular stress fractures?

[JAAOS 2016;24:379-389]

A
  • Long second metatarsal
  • Metatarsal adduction
  • Equinus contracture
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52
Q

What is the point of maximal tenderness in patients with a navicular stress fracture?

[JAAOS 2016;24:379-389]

A

Dorsal navicular prominence (‘N spot’)

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53
Q

What structures are responsible for avulsion fractures of the dorsal, medial and plantar navicular?

[JAAOS 2016;24:379-389]

A
  1. Dorsal – dorsal capsule and/or superficial deltoid ligament
  2. Medial – posterior tibialis tendon
  3. Plantar – plantar capsule and spring ligament
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54
Q

What is the nonoperative management for navicular avulsion fractures?

[JAAOS 2016;24:379-389]

A
  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
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55
Q

What are indications for surgery in navicular avulsion fractures?

[JAAOS 2016;24:379-389]

A
  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
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56
Q

What are the surgical indications for navicular body fractures?

[JAAOS 2016;24:379-389]

A
  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
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57
Q

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]

A
  1. Extrinsic muscles (originate proximal to the midfoot)
  • EDL, EDB, FDL
  • Extend MTP and flex the PIP and DIP
  1. Intrinsic muscles (originate distal to the midfoot)
  • FDB, lumbricals, interosseos
  • Flex the MTP and extend the PIP and DIP
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58
Q

How do you assess for flexible vs. fixed deformity of lesser deformities?

A

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
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59
Q

What is the deformity and management of Mallet Toe?

[JAAOS 2011;19: 505-514]

A
  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
  1. 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
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60
Q

What is the deformity and management of Hammer Toe?

[JAAOS 2011;19: 505-514]

A
  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
  1. 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
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61
Q

What is the deformity and management of claw toe?

[JAAOS 2011;19: 505-514]

A
  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
  1. 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
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62
Q

What is the deformity of curly toe?

[JAAOS 2011;19: 505-514]

A

Deformity is PIP and DIP flexion, MTP flexion or neutral

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63
Q

What is the cause and management of MTP joint instability?

[JAAOS 2011;19: 505-514]

A
  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
  1. 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
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64
Q

What are the deformities of the rheumatoid forefoot?

[International Orthopaedics (SICOT) (2013) 37:1719–1729]

A
  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
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65
Q

What are the operative procedures performed in the typical rheumatoid foot?

[Campbells]

A
  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
  1. 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
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66
Q

Management of a postoperative pale lesser toe? [Campbells]

A
  1. Take down dressing
  2. Compress the toe down the K-wire if overlengthened
  3. Remove K-wire
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67
Q

What is the most common cause of adult-acquired flat foot deformity?

[Miller’s, 6th ed.]

A

PTTD (Posterior tibial tendon dysfunction)

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68
Q

What is the insertion of the PTT?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Sustentaculum tali
  2. Navicular
  3. Medial/intermediate/lateral cuneiforms
  4. Cuboid
  5. Bases of 2,3,4 metatarsals
69
Q

What is the function of the PTT?

A
  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
70
Q

What are the clinical features of PTTD?

[AAOS comprehensive review 2, 2014]

A
  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]
71
Q

What are the radiographic measurements/findings associated with PTTD?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. AP foot WB
  • Talocalcaneal angle
    • Normal = 15-30 (abnormal >30)
  • Talometatarsal angle (Simmon angle)
    • Normal = +4 to -4 (abnormal <-4)
  • Talonavicular coverage angle
    • Normal = upper limit ~20 (abnormal >20)
      1. 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
72
Q

What is the classification of PTTD based on clinical and radiographic findings?

A

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
73
Q

What is the treatment for STAGE I PTTD?

[Instr. Course Lect 2015; 64:441]

A

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
74
Q

What is the treatment for STAGE II PTTD?

A

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)
75
Q

What is the treatment for STAGE III PTTD?

[Mann’s Surgery of the Foot and Ankle 2014]

A

Nonoperative

  • AFO

Operative

  • Triple arthrodesis (talonavicular, subtalar, calcaneocuboid)
    • May include MDCO, Cotton osteotomy, 1st MT-tarsal fusion, gastrocnemius recession
76
Q

What is the treatment of STAGE IV PTTD?

[Miller’s, 6th ed.]

A

Operative

  • If ankle valgus passively correctible – consider deltoid ligament reconstruction and triple arthrodesis
  • Fixed ankle valgus, arthritis – tibiotalocalcaneal arthrodesis
77
Q

Why is the FDL suitable for tendon transfer in PTTD?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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)
78
Q

What are prerequisites prior to performing an FDL transfer?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Adequate subtalar motion (~15° of subtalar inversion)
  2. Supple transverse tarsal motion (at least 10° of adduction)
79
Q

What are contraindications for a FDL transfer?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Inadequate subtalar and transverse tarsal motion
  2. Fixed forefoot varus deformity >10°
  3. Symptomatic arthritis (subtalar, talonavicular, calcaneocuboid)
  4. Obesity
80
Q

What is the purpose of the MDCO?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  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
81
Q

What are the technical goals when performing a triple arthrodesis?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Reduction of talonavicular and subtalar joints
  2. Even plantar tripod (heel, first MT head and 5th MT head)
82
Q

What is the technique for the MDCO?

[Wiesel 2017]

A
  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
83
Q

What is the technique for the FDL transfer in PTTD?

[Wiesel 2017]

A
  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
84
Q

What is the technique for a Cotton osteotomy?

[Wiesel 2017]

A
  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)
85
Q

What is the most common cause of ankle arthritis?

[AAOS comprehensive review 2, 2014][JAAOS 2016;24:e29-e38]

A
  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
86
Q

How does the pain history correspond with the pattern of ankle arthrtis?

[JAAOS 2016;24:e29-e38]

A

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
87
Q

What is the COFAS (Canadian Orthopaedic Foot and Ankle Society) classification of end stage ankle arthritis?

A

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

88
Q

What are surgical options for management of ankle arthritis?

A
  1. Ankle arthroscopy
  2. Autologous chondrocyte implantation
  3. Supramalleolar osteotomy
  4. Distraction arthroplasty
  5. Arthrodesis
  6. Arthroplasty
89
Q

What is the main indication for ankle arthroscopy in the setting of ankle OA?

A

Anterior impingement in the absence of global disease

90
Q

What are the goals of supramalleolar osteotomy for ankle arthritis?

[JAAOS 2016;24:424-432]

A
  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
91
Q

What are the indications for a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A
  1. Asymmetric varus or valgus ankle OA with ≥50% preserved tibiotalar joint surface
  2. Optimization of alignment in total ankle arthroplasty and ankle arthrodesis
92
Q

What are the contraindications for a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A
  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)
93
Q

What is the significance of the center of rotation of angulation (CORA) – apex through which the deformity occurs – when planning a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A

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)

94
Q

What defines a congruent vs. an incongruent tibiotalar joint?

[JAAOS 2016;24:424-432]

A
  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
95
Q

What is the management of varus arthritis with a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A
  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°
96
Q

What is the management of valgus arthritis with a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A
  1. Medial closing wedge osteotomy
  2. Goal is to achieve 2-4°of varus
  3. Dome osteotomy with fibular osteotomy indicated if correction >15°
97
Q

What are the complications with a supramalleolar osteotomy?

[JAAOS 2016;24:424-432]

A
  1. Delayed or nonunion
  2. Overcorrection or undercorrection
  3. Nerve injuries
  4. Acute tarsal tunnel syndrome (varus to valgus correction)
98
Q

What are the pros and cons of ankle fusion?

A
  1. Pros
  • More reliable pain relief
  • Revision surgery rare (occasional hardware removal)
  1. 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
99
Q

What is the recommended position of fusion for the ankle?

[Miller’s, 6th ed.] [JAAOS 2016;24:e29-e38]

A
  1. 5° of hindfoot valgus
  2. Neutral plantar/dorsiflexion
  3. 5-10° of external rotation
100
Q

What are 5 techniques for ankle arthrodesis and indications/contraindications and pros/cons for each?

[JAAOS 2016;24:e29-e38]

A
  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
  1. 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
  1. 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
  1. 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
  1. Circular external fixator
  • Indications:
    • Previously failed arthrodesis
    • Talar osteonecrosis
    • Soft-tissue compromise
    • Severe deformity
101
Q

What are fixation options for ankle arthrodesis?

[JAAOS 2016;24:e29-e38]

A
  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
      1. Anterior plating
102
Q

What are contraindication for total ankle arthroplasty?

[JAAOS 2016;24:e29-e38][JAAOS 2008;16:249-259]

A
  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
103
Q

What should be included in the workup of a painful total ankle arthroplasty?

[JAAOS 2015;23:272-282]

A
  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
104
Q

What is the incidence of TAA failure?

[JAAOS 2016;24:e29-e38]

A

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
105
Q

What are causes of TAA failure?

[JAAOS 2015;23:272-282]

A
  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
  1. 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
  1. Ankle stiffness
  • Due to:
    • Significant lack of preop ROM
    • Oversized components (overstuffing)
    • Inadequate tibial resection
    • Component malposition
    • Soft tissue or bony impingement
    • Arthrofibrosis
  1. Infection
  • Risk factors:
    • Previous ankle surgery
    • Prolonged surgical time
    • Low preop AOFAS ankle-hindfoot scores
  • Anterior approach associated with infection in 7% of TAA
106
Q

What is the management of osteolysis and cysts in TAA?

[JAAOS 2015;23:272-282]

A
  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
  1. Symptomatic cysts
    * Curettage of cysts and bone grafting +/-poly exchange or metal component revision
107
Q

What is the management of an infected TAA?

[JAAOS 2015;23:272-282]

A
  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
108
Q

What is the management of postoperative arthrofibrosis in TAA?

[JAAOS 2015;23:272-282]

A

Open arthrolysis and TAL or gastroc recession

109
Q

When is arthrodesis indicated in failed TAA?

[JAAOS 2015;23:272-282]

A
  • Severe osteolysis
  • Component subsidence
  • Severe talar bone loss
110
Q

When is structural allograft needed in tibiotalar fusion following TAA?

[JAAOS 2015;23:272-282]

A

Bone loss >2cm (often use femoral head)

111
Q

When is TTC fusion recommended over tibiotalar fusion in failed TAA?

[JAAOS 2015;23:272-282]

A
  1. Severe subtalar arthritis and pain
  2. Large talar bone loss
  3. Nonreconstructable subsidence of talar component into subtalar joint
112
Q

What is the surgical technique for subtalar fusion?

A
  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
  1. 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
  1. Subtalar joint is positioned in 5 degrees of valgus
    * Provisional fixation is held with K-wires and alignment confirmed on fluoro
  2. 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
113
Q

What is the surgical technique for traditional 2 incision triple arthrodesis?

A
  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
  1. 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
  2. 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
  1. 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)
114
Q

What are the characteristic features of Charcot-Marie-Tooth diseases in the foot and ankle?

[JAAOS 2013;21:276-285]

A
  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)
115
Q

What is the surgical management of CMT with flexible cavovarus and drop foot?

[JAAOS 2013;21:276-285]

A
  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)
116
Q

What is the most significant risk factor for subsequent amputation in diabetic foot?

[JAAOS 2012;20:684-693]

A

Foot ulceration

117
Q

What are the features of the diabetic foot?

[JAAOS 2012;20:684-693]

A
  1. Sensory neuropathy
  • Stocking distribution
  • Lacks protective sensation
  • Result = unnoticed repetitive trauma
  1. Autonomic neuropathy
  • Dry skin and decreased integrity
  • Result = cracks and fissures in skin
  1. Ischemia secondary to PVD
    * Result = ulcer and gangrene
  2. Deformity
  • Cavus, ‘rocker bottom’, claw toes
  • Result = improper loading and increased plantar pressures
118
Q

What are negative prognostic factors for diabetic foot ulcer healing?

[orthobullets]

A
  1. ABI <0.45
  2. Transcutaneous oxygen pressure <30mmHg
  3. Albumin <3.0g/dL
  4. Total lymphocyte count <1,500/mm3
119
Q

What is the classification of diabetic ulcers and their management?

[JAAOS 2012;20:684-693]

A

Wagner Classification

120
Q

What is the origin of Baxter’s nerve?

[Mann’s Surgery of the Foot and Ankle 2014]

A

First branch of the lateral plantar nerve

121
Q

What do the 3 branches of Baxter’s nerve innervate?

[Mann’s Surgery of the Foot and Ankle 2014]

A
  1. Periosteum of the medial process of the calcaneal tuberosity
  2. Flexor digitorum brevis
  3. Abductor digiti minimi
122
Q

What is the site of entrapment of Baxter’s nerve?

[Mann’s Surgery of the Foot and Ankle 2014]

A

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

123
Q

Describe the anatomy of the peroneal tendon synovial sheath?

[JAAOS 2009;17:306-317]

A

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)

124
Q

What is the relationship of the peroneus longus and brevis tendons at the level of the distal fibula?

[JAAOS 2009;17:306-317]

A

Peroneus brevis is anterior and medial to the peroneus longus

125
Q

What is the relationship of the peroneus longus and brevis tendons with respect to the peroneal tubercle?

[JAAOS 2009;17:306-317]

A

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

126
Q

What are the restraints to subluxation and dislocation of the peroneal tendons?

[JAAOS 2009;17:306-317]

A
  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
  1. Peroneal groove
    * Sulcus on posterior aspect of the distal fibula
  2. Fibrocartilaginous rim
    * Laterally deepens groove by 2-4mm
127
Q

What radiographic findings may suggest a peroneal tendon injury?

[JAAOS 2009;17:306-317]

A
  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)
128
Q

What MRI finding is highly specific of peroneal tenosynovitis?

[JAAOS 2009;17:306-317]

A

Circumferential fluid within the common synovial sheath wider than 3mm

129
Q

What is the location of peroneus brevis tears?

[JAAOS 2009;17:306-317]

A

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

130
Q

What is the management of peroneus brevis or longus tears?

[JAAOS 2009;17:306-317]

A
  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
131
Q

What is the management of both peroneus longus and brevis tears?

[JAAOS 2009;17:306-317]

A
  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
132
Q

What is the usual mechanism of injury for a peroneal tendon subluxation or dislocation?

[JAAOS 2009;17:306-317]

A

Forceful dorsiflexion and eversion injury

133
Q

What is the classification of SPR injuries?

[JAAOS 2009;17:306-317]

A
  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
134
Q

What is the treatment for peroneal tendon subluxation/dislocation?

[JAAOS 2009;17:306-317]

A
  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)
135
Q

What is the blood supply to the Achilles tendon and overlying skin?

[Clinical Anatomy 22:377–385 (2009)]

A
  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
  1. Best approach for open surgery
    * Posteromedially
136
Q

What are risk factors for acute achilles tendon tear?

[Foot Ankle Int. 2016 Feb;37(2):233-9]

A
  1. Male
  2. Fluoroquinolone
  3. Corticosteroids
  4. Tendinopathy
  5. Haglund’s deformity
  6. Contralateral Achilles repair
137
Q

What is the nonoperative management of Achilles tendon tears?

[JAAOS 2017;25:23-31]

A
  1. Historical
  • Cast immobilization 6-8 weeks
  • Outcomes:
    • Higher re-rupture compared to surgical
  1. 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
138
Q
A
139
Q

What are the surgical options for acute Achilles repair?

[JAAOS 2017;25:23-31]

A
  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

140
Q

What is the recommended postoperative protocol for Achilles tendon repair?

[JAAOS 2017;25:23-31]

A
  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
141
Q

When is an achilles tendon tear considered chronic?

[Foot Ankle Clin N Am 22 (2017) 715–734]

A

>4 weeks

142
Q

What are the clinical signs of a chronic achilles tear?

[CORR course]

A
  • Thompson test
  • Palpable gap
  • Decreased plantarflexion strength
  • Limp
  • Relative dorsiflexion resting position
143
Q

What is the Matles test for chronic achilles tears?

[JBJS Am. 2008;90:1348-60]

A

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)

144
Q

What factors are considered in deciding on treatment options for chronic achilles tears?

A
  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
145
Q

What are the surgical options for chronic achilles tendon tear based on size of defect (post debridement)?

[Foot Ankle Clin N Am 22 (2017) 715–734] [JBJS Am. 2008;90:1348-60]

A
  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
  1. Gap >5cm
  • Autograft (gracilis, semitendinosus, fascia lata, quads with bone block)*
  • Allograft (achilles)
  • FHL Tendon transfer +/- VY advancement or Turndown
146
Q

Why is the FHL tendon preferred over FDL or peroneus brevis for Achilles repair augmentation?

[JAAOS 2018;26:753-763]

A
  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
147
Q

What are the two types of FHL transfer?

[JAAOS 2018;26:753-763]

A
  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)
  1. 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
148
Q

What are the treatment options for chronic achilles tendon tear based on size of defect?

[JAAOS 2018;26:753-763]

A
  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)
  1. 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
  1. Very large (>10cm)
    * FHL transfer and Achilles allograft
149
Q

Which lateral ankle ligament is the weakest?

[JAAOS 2008;16:608-615]

A

ATFL

150
Q

What are the surgical procedures available to address chronic ankle instability?

[JAAOS 2008;16:608-615]

A
  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)
151
Q

What foot malalignment must be identified to avoid treatment failure of ankle instability correction and how is it addressed?

[AAOS comprehensive review 2, 2014]

A

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
152
Q

What are the associated pathologies with chronic lateral ankle instability?

[AAOS comprehensive review 2, 2014]

A
  1. Peroneal tenosynovitis/tears
  2. Attenuated superior peroneal retinaculum
  3. Anterolateral impingement
  4. Ankle synovitis
  5. Loose bodies
  6. OCL of talus
153
Q

Describe the Brostrom technique

[AJSM 2012; 40(11):2590]

A
  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
154
Q

What is the primary restraint to inversion stress with ankle in plantarflexion?

[JAAOS 2018;26:223-230]

A

ATFL

155
Q

What are the available treatment options for chronic lateral ankle instability?

[JAAOS 2018;26:223-230]

A
  1. Anatomic direct repair
  2. Reconstruction
  • Anatomic
  • Nonanatomic
  1. Arthroscopic repair
156
Q

What is the first line surgical treatment for chronic lateral ankle instability?

[JAAOS 2018;26:223-230]

A
157
Q

With respect to anatomic direct repair for chronic lateral ankle instability:

  1. What are the 3 most common types?
  2. What are the advantages?
  3. What are the contraindications?

[JAAOS 2018;26:223-230]

A

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
158
Q

With respect to anatomic reconstructions for chronic lateral ankle instability:

  1. What are the two main types?
  2. What are the indications?

[JAAOS 2018;26:223-230]

A

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
159
Q

With respect to nonanatomic reconstructions for chronic lateral ankle instability:

  1. What are the 3 main types?
  2. What are the cons?
  3. What are the indications?

[JAAOS 2018;26:223-230]

A

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
160
Q

What are the causes and predisposing factors to recurrent ankle instability?

[JAAOS 2018;26:223-230]

A
  1. Causes:
  • Inadequate anatomic reconstruction
  • Functional instability
  • Reinjury
  • Predisposing factors
  1. Predisposing factors:
  • Ligamentous laxity
  • Long-standing instability
  • High functional demand
  • Cavovarus deformity
161
Q

What are other considerations with chronic lateral ankle instability?

[JAAOS 2018;26:223-230]

A
  1. Surgery may not prevent posttraumatic ankle arthritis
  2. Cavovarus is correlated with chronic lateral ankle instability
162
Q

What are the features of a medial OCL vs. lateral OCL?

[AAOS comprehensive review 2, 2014]

A
  1. Medial
  • More common
  • Nontraumatic
  • Larger and deeper
  • More posterior
  1. Lateral
  • Traumatic
  • Smaller and shallower
  • More anterior
163
Q

What are the imaging classifications of OCL of the talus?

[Foot & Ankle International 2016; 37:9 1023–1034]

A
  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
  1. 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
  1. 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
164
Q

What are the surgical indications for management of OCL of the talus?

[Cartilage 2017;8(1):19-30]

A
  1. Acute OCL displacement
  2. Chronic OCL failing 3-6 months of nonoperative management
165
Q

What are the 3 classifications of cartilage treatment options for ankle OCL?

[Foot & Ankle Orthopaedics 2018. doi.org/10.1177/2473011418779559]

A
  1. Cartilage repair
  • Microfracture
  • Retrograde drilling
  1. Cartilage regeneration
  • Autologous chondrocyte implantation (ACI)
  • Matrix-induced autologous chondrocyte implantation
  • Autologous matrix induced chondrogenesis
  1. Cartilage replacement
  • Osteochondral autograft transfer (OAT)
  • Osteochondral allograft
  • Particulated juvenile cartilage allograft transplantation
166
Q

What is the gold standard for OCL of the talus <1.5cm2?

A

Microfracture

167
Q

What is the algorithm for management of OCL of the talus?

[Foot & Ankle Orthopaedics 2018. doi.org/10.1177/2473011418779559]

A
  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
  1. Intact cartilage cap = Retrograde drilling

***Note -Medial lesions approached through sinus tarsi and lateral lesions through anteromedial incision (??)

168
Q

What are the arthroscopic ankle portals?

[JAAOS 2008;16:635-646]

A
  1. Anteromedial
  • Medial to tibialis anterior
  • Risk = saphenous vein and nerve
  1. Anterolateral
  • Lateral to peroneus tertius
  • Risk = superficial peroneal nerve (intermediate dorsal cutaneous branch)
  1. Posterolateral
  • At the level of the tip of the fibula just lateral to the Achilles tendon
  • Risk = sural nerve and small saphenous vein
  1. Posteromedial
    * At the level of the tip of the fibula just medial to the Achilles tendon
169
Q

What is the technique for a gastroc recession?

[Foot & Ankle International 25(4):247-50]

A

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

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