Foot & Ankle Flashcards
1
Q
Name and describe 2 classifications for charcot foot
A
Eichenholtz:
Stage 0: joint edema, x-rays negative
Stage 1: fragmentation
- Local edema
- osseous fragmentation with joint dislocation
Stage 2: coalescence:
- decreased local edema
- x-rays show coalescence of fragments and absorption of fine bone debris
Stage 3: Reconstruction
- no local edema
- x-rays show consolidation and remodeling of fracture fragments
Brodsky
Type 1: (midfoot)
- TMT and naviculocuneiform joints (60%)
Type 2 (Hindfoot):
- subtalar, TN, CC joints
Type 3: Ankle of calcaneus
- A: tibiotalar joint
- B: Follows fracture of calcaneal tuberosity
Type 4: Combination of areas
Type 5: solely in forefoot
2
Q
How many people get subtalar arthritis 10 years post tibiotalar arthrodesis?
A
50%
3
Q
Syndesmosis screw technique
Be specific
A
2 x 3.5 or 4.5mm syndesmotic screws
Through 3-4 cortices
2-5cm above plafond
Screw material:
No difference between types of metal or bioabsorbable
Cortices:
No difference between 3-4
Number of screws:
2 is better
Position of foot
Recent studies challenge the principle of holding the ankle in maximal dorsiflexion to avoid over tightening
Post-operative care:
Typically non-weight bearing 6-12 weeks
May prolong if screw breakage is a concern
4
Q
Name 3 gait advantages of total ankle replacement vs. arthrodesis
A
Increased stride length
Improved cadence
Increased stride velocity
5
Q
4 common technical errors in Total ankle arthroplasty
A
Prosthesis is too lateral
Prosthesis is too small - will subside
Failing to solve preoperative varus/valgus malalignment
Attempting to replace an ankle that is too anteriorly subluxed
6
Q
os trigonum syndrome is associated with pathology in what structure?
A
FHL
7
Q
What are Scarf and Ludloff osteotomies used for? Differentiate them in one sentence.
A
Promixal metatarsal osteotomies for the treatment of moderate hallux valgus, usually in combination with a modified McBride distally.
See picture for differences.
8
Q
Recalcitrant forefoot plantar ulcers
What is an important aspect of treatment
A
TAL vs. gastrocs lengthening
Decreaes plantarflexion and decreases pressure on forefoot
9
Q
Neuropathic joint
Technetium bone scan will be
Indium WBC scan will be
A
Tc: ± positive in charcot (positive for OM)
indium WBC scan: negative in charcot (+OM)
10
Q
Sectioning of which collateral ligament leads to more instability?
A
Accessory
B/c it attaches directly to the plantar plate
(vs. proper collateral, attaches to the proximal aspect of the phalanx)
11
Q
Three differentials for posterior ankle pain not involving the Achilles.
A
- Os Trigonum Syndrome
- Posterior impingement
- FHL Tendonitis
12
Q
Describe ankle arthroscopy portals
A
Anteromedial
- Primary viewing portal
- Established 1st
- medial to tib ant & lateral to medial malleolus
- Danger: saphenous nerve & vein
Anterolateral:
- Primary viewing portal
- Lateral to peroneus tertius & superficial peroneal nerve & medial to lateral malleolus
- Danger: Dorsal cutaneous branch of SPN
Anterocentral
- Anterior viewing portal
- Medial to EDC and lateral to EHL
- Not commonly used due to risk to DP artery
Posterolateral
- Posterior viewing portal
- 2cm proximal to tip of lateral malleolus
- Between peroneal tendons and achilles tendon
- Danger: sural nerve and small saphenous vein
Posteromedial
- posterior viewing portal
- just medial to achilles
- Risks: posterior tibial artery
13
Q
Diagnosis & Treatment (chronic)
A
Ankle synovitis
Arthroscopy and synovectomy
14
Q
What are 2 associated conditions of anterior ankle impingement?
A
Ankle instability (up to 35% will continue to have pain after stabilization procedure)
OCD
(Technically NOT OA, b/c this is pre-OA)
15
Q
Best predictor of post-op ROM with TAA
A
Pre-op ROM
16
Q
Differenes of Juvenile HV vs. Adult:
A
Juvenile is:
- Often bilateral
- Often familial
- Pain is not the primary complaint
- varus 1st MT with widened IMA usually present
- DMAA usually increased
- often associated with flexible flatfoot
17
Q
In os trigonum syndome, in the absence of an obvious os trigonum, what may be another cause?
A
scar tissue behind posterior talus (where the os should be)
Found on MRI
18
Q
4 pathologic conditions secondary to cavus foot
(what does cavus foot cause, NOT what causes cavus foot)
A
Lateral column stress fractures
Lateral ligament injury
peroneal tendon injury
Lateral column overload
19
Q
1st step in lisfranc ORIF?
A
Intercuneiform reduction and fixation
20
Q
Name & Describe classic tendon transfer for foot drop
A
Bridle Procedure
- Classically PTT, TA & PL transfer & tritendon anastomosis
Tib post:
- transferred to middle/lateral cuneiform
- THROUGH split in tib ant
Tib Ant
- Anastomosed to Tib post
Peroneus Longus
- PL: cut 5cm above fibula
- Proximal end sewn to PB
- distal end is anastomosed to newly transferred PTT
Effect
- As tib post pulls, it will also pull on PL and TA, causing dorsiflexion & eversion (motion lost with peroneal nerve injury)
21
Q
Classification of Hallux Rigidus:
A
Coughlin & Shurnas Classification
Grade 0:
- Stiffness with normal x-ray
Grade 1:
- mild pain at extreme range of motion
- X-rays show mild dorsal osteophyte and normal joint space
Grade 2:
- Moderate pain with range of motion
- Moderate dorsal osteotomy
- <50% joint space narrowing
Grade 3:
- Significant stiffness and pain at extreme ROM. No midrange pain
- Xrays show severe dorsal osteophyte >50% joint space nrrowing
Grade 4:
- significant stiffness and pain at extreme ROM AND pain at mid-range
- x-rays: same as grade 3
22
Q
List some differentials for failed treatment of ankle sprain (i.e. missed concommitant injuries/pathology)
A
- injury to the anterior process of calcaneus
- injury to the lateral or posterior process of the talus
- injury to the base of the 5th metatarsal
- osteochondral lesion
- injuries to the peroneal tendons
- injury to the syndesmosis
- tarsal coalition
- impingement syndromes
23
Q
Indications for 1st MTP arthrodesis in HV:
A
CP
Down’s
Ehler-Danlos
RA
Gout
Severe DJD
24
Q
What is the mechanism for injury to the superior peroneal retinaculum?
A
Dorsiflexion & inversion
During reflexive contraction of the peroneal muscles
25
4 medications you can use in Charcot Foot
bisphosphonates
neuropathic pain meds
antidepressants
topical anesthetics
26
Isolated fusion of the calcaneocuboid, subtalar, and talonavicular joint arthrodeses result in how much limitation in motion?
limit hindfoot motion by approximately 25% (CC), 40% (ST), and 90% (TN)
27
Name 2 anatomic risks for peroneal tendon instabiliy or rupture
Low lying peroneus brevis muscle
Presence of peroneus quartus muscle
28
Most common foot position after CVA or TBI
equinovarus
29
Risks of failure in isolated subtalar arthrodesis (5)
smoking
the presence of more than two millimeters of avascular bone at the arthrodesis site
failure of a previous subtalar arthrodesis
Use of structural allograft (should use autografto)
Adjacent ankle arthrodesis
30
What nerve can cause a painful neruoma if damaged during medial capsular imbrication for HV?
Medial branch of dorsal cutaneous nerve (SPN)
31
What must you do after IM screw of 5th MT base fracture (post-op care)
wait until clinical AND radiographic healing before return to sports
32
Post talar neck fracture, patient comes back with this (see picture)
best Management
TTC
?TAR?
33
5 radiographic changes of charcot neuropathy
obliteration of joint spaces
fragmentation of articular surface of a joint leading to subluxation/dislocation
Scattered "chunks" of bone in fibrous tissue
Surrounding soft tissue edema
Joint distension by fluid
HO
34
Which 1st toe sesamoid is larger?
Tibial (medial)
35
Medial supramalleolar osteotomy done usually for what?
Usually opening wedge for
varus ankle alignment & medial joint space narrowing
36
What is this deformity?
Hammer Toe
(Boutiennier of the foot)
37
Patient 3 months after TBI and has equinovarus foot
Surgical plan?
WAIT
Takes:
6-18 months post CVA for full extent of recovery
1-2 years (or several) post TBI for full extent of recovery
wait until after these times for surgery
38
What is removed with a cheilectomy?
Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head.
(Hallux rigidus)
39
Cause and deformity of Hammer toe?
Overpull of the EDL
Causes Flexion of PIP and extension of DIP
40
Hallux valgus obviously involves valgus. What is the secondary deformity and what causes it?
Pronation.
This is caused by abductor hallicus as it migrates plantarly and medially.
41
What amount of dorsiflexion is requried for normal gait?
Unknown
Ranges fro 15-90 degrees
(**WHat joint are we talking about? Nothing dorsiflexes 90 degrees)**
42
Muscle imbalance in spastic equinovarus foot
Surgical treamtent
Strong TA (major) and PT, FHL, FDL (minor)
SPLATT, TAL, ± tib post transfer to dorsum of foot
43
Classification system of Hallux Rigidis
Based on radiographic & exam findings
0:
* exam: Stiffness
* xrays: normal xrays
I:
* exam: mild pain at extreme ROM
* Xrays: mild dorsal osteophyte with normal joint space
II:
* exam: moderate pain with ROM
* x-rays: moderate dorsal osteophyte with
III:
* exam: significant stiffness & pain at extreme ROM. No mid-range pain
* x-rays: severe dorsal osteophyte with \>50% joint space narrowing
IV:
* exam: significant stiffness & pain at extreme ROM. **(+) mid-range pain**
* x-rays: same as III (severe dorsal osteophytes with \>50% joint space narrowing)
44
Surgical approach for total ankle replacement?
Anterior
between EHL & TA
45
Risk of OM if a diabetic foot ulcer probes to bone?
65%
46
What are this?
What do you have to do before definitive management
What's definitive manageent
Digital artery aneurysm
Must see if there is adequate collateral circulation
Treatment
Resection if there is adequate collateral circulation
Graft and repair if there is not adequate circulation
47
Treatment of midfoot arthritis that failed non-op management
Be specific
Outcomes?
1st ray TMT arthrodesis
2nd/3rd naviculocuneiform/intercuneiform joint arthrodesis
4th/5th ray - don't fuse as it allows for accomodation of the foot during gait
Can do interpositional arthroplasties of 4th/5th in certain cases
Can fuse b/c non essential
Will lead to good outcomes with near anatomic function of the foot preserved
48
Contraindications to TCC
Absolute: infection
Relative
marginal arterial supply to area
patients unable to comply with cast care
patient unable to tolerate case (cast claustrophobia)
49
Patient has viral destruction of anterior horn cells.
Clinically she has motor weakness without sensory changes.
Diagnosis?
Poliomyositis.
\*\*\* patients can get post-polio syndrome 20-30 years after initial infection which invovles further brreakdown of nerves.
50
Tib ant contracts eccentrcialyl during what phase of gait?
Heel strike
51
Diabetic foot ulcer: Describe classification and treatment by Wagner
_Grade 0:_
* Skin intact
* "Foot at risk" due to deformities
* Treat with shoe modification & serial exam
_Grade 1:_
* Superficial ulcer
* Office debridment & TCC
_Grade 2:_
* Deeper, full thickness ulcer
* Formal operative debridement & TCC
_Grade 3:_
* Deep abscess or OM
* Formal operative debridement & TCC
_Grade 4:_
* Partial gangrene of forefoot
* Local vs. larger amputation
_Grade 5:_
* Extensive gangrene
* Amputation
52
Provocative test fo Morton's neuroma (2)
Mulder's click
bursal click may be elicited by squeezing MT heads together
Webspace compression test
Pain with compression of MT
53
4 technical risk factors for intraoperative fracture in total ankle arthroplasty
Overextending the plafond cut too medially or laterally
Making a cut too proximal in the tibia
Using an over-sized tibial component
Distraction of the ankle with an ex-fix
54
Ottawa ankle rule criteria
inability to bear weight
medial or lateral malleolus point tenderness
5MT base tenderness
navicular tenderness
55
Name 3 surgical options for severe hallux rigidus. Which one would you recommend?
MTP arthrodesis: gold standard
MTP arthroplasty: don't do this! Long term results lead to osteolysis & synovitis
Keller Resection Arthroplasty: for low demand patients
56
Most common complication wiht total ankle arthroplasty
2 ways to prevent it
Wound complications
Prevent by:
Long incision to prevent tension on wound
Avoid incising tib ant sheath - prevents bowstringing and wound issues
57
Treatment algorithm for talar OCD
_SLC + NWB x6 weeks:_
* Nondisplaced, acute injury
_Removal of loose fragment & Microfracture_
* displaced small fragment with minimal bone on the osteochondral fragment
* Size \<1cm
_Retrograde drilling_
* Size \>1cm with intact cartilage cap
_ORIF vs. osteochondral grafting_
* Displaced \>0.5cm
58
When do you operate in Charcot foot?
Once inflammation has gone down
so
Coalescence phase
59
4 muscles causing deformity in hallux valgus
Valgus of 1st toe leads to:
lateralization of sesamoids and respective heads of **FHB**
**Adductor hallucis**, attached to fibular sesamoid and lateral proximal phalanx, becomes deforming force
lateral deviation of **EHL** worsens deformity
Plantar and lateral migration of **abductor hallucis** casues plantar flexion & pronation
60
Best shoe modifiaction for reducing risk of plantar apex deformity in Charcot foot?
Double rocker bottom
61
Normal tibi/fib overlap
\>6mm (some say 10mm) on AP
\>1mm on mortise
62
Stance and swing make up how much of the gait cycle?
Stance: 60%
Swing: 40%
63
Main restraint to proximal migration of the talus?
Interosseous ligament (part of distal tibiofibular syndesmosis)
64
4 things you must do in tarsal tunnel release
ID the tibial nerve proximally and trace it down
Release Flexor retinaculum
Release Deep investing fascia of lower leg
Release Superficial and deep fascia of abductor hallucis
65
Surgial indications in Charcot foot
Recurrent ulcers
Instability not controlled by a brace
66
Where does Baxter's nerve get entrapped?
Becomes compressed between;
fascia of abductor hallucis longus
&
medial side of quadratus plantae
67
Define turf toe & give 2 defining features
Hyperextesion injury to plantar plate and sesamoid complex of the 1st MTP
_Characteristic features:_
* inability to push off
* reduced agility
1st line treatment is conservative
68
During gait, when do the Quads fires concentrically ?
Midstance
69
2 options for tendon transfers in CMT?
TP to dorsum of foot
PL to brevis
70
What is the treatment for juvenile HV and how long should this be done for?
Non-operative until physes close
71
3 reconstruction options for tibialis anterior ruptures:
Sliding tendon graft
EHL tenodesis/transfer
Free tendon autograft
Allograft
72
how do you treat the bony deformity assciated with plantar ulcers?
Excise them
Helps prevent recurrence
73
How much ROM can TAA be expected to add?
None.
Expect no more than the pre-op ROM.
74
Mueller-Weiss Disease
Adult onset Navicular AVN
vs. Kohler's disease (paediatric onset)
75
In ankle fusion, what should you do with the lateral malleolus?
Retain it - leaves the option for total ankle arthroplasty in the future
76
Treatment options for bunionette
_Non-op_
* works in up to 90%
_Surgical_
_Type I:_
* lateral condelectomy
_Type II/III_
* Distal MT Medializing osteotomy (if low IMA)
* Oblique diaphyseal rotational osteotomy (if high IMA)
* AVOID proximal osteotomy as poor healing (think Jones)
77
What clinical test differentiates between high ankle sprain and low ankle sprain?
Compression test
They will use this on the exam stem to differentiate between the two
78
Approach to foot compartment syndrome fasciotomy
3 incision
_2x dorsal_
one just lateral to 4th MT
one just medial to 2nd MT
_1 medial_
start: 4cm anterior to posterior heel & 3cm superior to plantar surface
79
Cause and deformity of Mallet Toe?
FDL contracture causing DIP hyperflexion
80
Tarlar OCD location with a traumatic hx?
3 characteristics of this lesion
Lateral talar dome
(medial has atraumtic history)
Less common
More superficial and smaller
Lower incidence of spontaneous healing
More often displaced and symptomatic
More central or anterior
81
What is the relationship of teh subtalar joint and the transverse tarsal joint?
When is this important?
Inversion of teh subtalar joint locks the transverse tarsal joint
Allows for a stable hindfoot/midfoot during toe-off
82
Name the foot deformity associated the myelomeningocoele at:
L1
L2
L3
L4
L5
S1
L1-L3: equinovarus
L4: cavovarus
L5: calcaneovalgus
S1: foot deformity only (no ankle)
83
Most sensitive test for diagnosing OM
MRI
84
Contrast OCDs of the medial versus lateral talar dome.
## Footnote
**_medial talar dome_**
usually no history of trauma
more common
more posterior
larger and deeper than lateral lesions
**_lateral talar dome_**
usually have a traumatic history
more superficial and smaller
more central or anterior
lower incidence of spontaneous healing
more often displaced and symptomatic
85
What is the gold standard to determine whether a diabetic ulcer will heal?
What are 2 things that must be present for an ulcer to heal
_Gold standard:_
transcutaneous oxygen pressure \>30mmHg (or 40 depending on the resource)
_To heal an ulcer, you must have:_
transcutaneous O2 pressure \>30mmHg
ABI \>0.45
86
Foot position in ankle fusion
Neutral plantar/dorsiflexion
5 degrees of hidnfoot valgus
rotation equal to contralateral foot
87
What is this deformity?
Mallet Toe
88
List the treatment options in relation to gap present in achilles tendon
0-2 cm: reapproximation
2-5 cm: V-Y Lengthening
5-8/10 cm: Gastrocs turndown +/- FHL augment
\>10 cm: allograft
89
Who gets os trigonum syndrome
What are the main symptoms?
Dancers and soccer players
Posterior ankle pain exacerbated by:
* dancing on pointe or demi-point
* doing pushoff maneuvers
90
What is the treatment for a failed silicone implant used to treat hallux rigidus?
1. Removal of implant and synovectomy
2. If there is lesser toe metatarsalgia then fuse the 1st MTP
91
In isolated MT fracture, what holds the MT in place leading to minimal displacement?
What happens in multiple fractures?
Intermetatarsal ligaments
Displacement b/c of inability of IMT ligaments to hold MT in place
92
What is the most common foot deformity after stroke?
Name 3 surgical options specifically for this?
equinovarus
* split anterior tibial tendon transfer (SPLATT)
* flexor hallucis longus tendon transfer to the dorsum of the foot and release of the flexor digitorum longus and brevis tendons at the base of each toe
* gastrocnemius or achilles lengthening
93
What is the main structure for load/force transfer bewteen the hindfoot and forefoot during stance?
Plantar aponeurosis
94
How does autonomic dysfunction play a role in diabetic foot ulcers?
Leads to excess dryness of skin
this combined with insensate foot leads to risk of ulceration
Increased pressure/trauma (due to lack of protective sensation) on more friable skin leads to ulceration
95
T/F: Excision of fibular sesamoid causes hallux varus.
True.
Other causes are over releasing lateral structures, over tightenign medially and overcorrecting IMA.
96
Normal medial clear space (ankle)
\<5mm
97
Weil osteotomy: most common complications
What is it due to?
Floating toe
Caused by improper cut, leading to intrisics migrating dorsal to the joint and acting as MTP extensors
98
Risk factors for Hallux Valgus
_Intrinsic_:
* Genetic
* increased DMAA
* ligamentous laxity
* convex MT head
* 2nd toe deformity/amputation
* pes planus
* RA
* CP
_Extrinsic_:
* High heeled shoes with narrow toe box
99
In achilles tendinosis, when do you perform an tendon transfer?
When \>50% of the tendon is diseased/debrided
100
What structure is the floor of the tarsal tunnel?
Abductor Hallicus
101
what is the mainstay of non-operative treatment for hallux rigidis?
Orthotics: Morton's extension with stiff foot plate
102
What tendon are the 1st toe sesamoids attached to?
FHB
103
T/F: Excision of tibial sesamoid causes hallux varus.
False.
(It's caused by excision on fibular sesamoid)
104
Which sesamoid is more likely to be bipartate?
Tibial
(97% of bipartate are tibial)
105
Triad of symptoms for tibialis anterior rupture
(1) a pseudotumor at the anterior part of the ankle that corresponded with the ruptured tendon end
(2) loss of the normal contour of the tendon
(3) weak dorsiflexion of the ankle accompanied by hyperextension of all of the toes
106
What issue is associated with anteriro impingement with anterior tibial and talar osteophytes?
Lateral instability
35% will continue to have the problem even after arthroscopic debridement
107
Pain 10 months post op.
What's the problem?
(It's not an infection)
Syndesmotic nonunion
Below is a picture of a WELL-united syndesmosis
108
Classification for Charcot Foot (Eichenholtz)
_Stage 0:_
* joint edema
* Radiographs are negative
* Bone scan may be positive in all stage
_Stage 1: Fragmentation_
* joint edema
* Osseous fragmentation with joint dislocation
_Stage 2: Coalescence_
* Decreased local edema
* X-rays show coalescence of fragments and absorption of the fine bone debris
_Stage 3: Reconstruction_
* No local edema
* radiographs show consolidation and remodelling of fracture fragments
109
When do you want to operate in a charcot foot?
What is the risk?
Coalescence/consolidation phase
wait until the inflammatory phase is over b/c there is a higher rate of:
* nonunion
* infection
* wound complications
* late deformity
* eventual amputation
There is a debate over early stabilization (but don't say that)
110
COntraindications to TAA?
uncorrectable deformity
severe osteoporosis
talus osteonecrosis
charcot joint, ankle instability
obesity
young laborers increase the risk of failure and revision
111
What muscles share an origin with the plantar aponeurosis?
abductor hallucis, flexor digitorum brevis, and quadratus plantae
112
In DM, what is the best predictor of eventual LE amputation?
Presence of Diabetic foot ulcer
113
Bunionette classification
Type I: widening of lateral condyle
Type II: lateral bowing if distal 5th MT
Type III: Increased IMA of 4th/5th MT
114
What is the first line treatment of Charcot foot?
TCC x 2-4 months
Cast changed q2-4 weeks
± Then CROW walker
115
Indications for primary arthrodesis in lisfranc injury
purley ligamentous injury
delayed presentation
116
How do you differentiate erythema caused by charcot neuropathy from that of infection?
In charcot, it will decrease with elevation of foot
No change with elevation in infection
117
6 characteristics of juvenile hallux valgus
often bilateral and familial
pain usually not primary complaint
varus of first MT with widened IMA usually present
DMAA usually increased
often associated with flexible flatfoot
Highly recurrent (50%)
118
What is the most common deformity of the lesser toes?
Hammer toe
119
7 complications specific to Hallux Valgus Surgical Correction
Recurrence
AVN to metatarsal head
Dorsal malunion with transfer metatarasalgia
Hallux Varus
Cock up toe deformity
2nd MT transfer metatarsalgia
Neuropraxia
120
Complication of excision of tibial & fibular sesamoids?
Cock-up deformity
121
A major dDx for 2nd MTP synovitis is Morton's neuroma
Why is it important to make the correct diagnosis?
Injection of steroids for MTP synovitis misdiagnosed as Morton's neuroma will accelerate capsuloligamentous attenuation, leading to complications (crossed-toe, MTP dislocation etc)
122
Indications to fix navicular fracture
avulsion fractures involving \> 25% of articular surface
tuberosity fractures with \> 5mm diastasis or large intra-articular fragment
displaced or intra-articular Type I and II navicular body fractures
123
What is the operative management of Baxters nerve compression?
Release of fascia of Abductor hallicus
124
At the level of the fibular groove, what peroneal tendon is posterior?
Longus
125
Name 1 contraindication and 3 complications of Keller Resection Arthroplasty
Resection arthroplasty of 1st MTP
* Contraindication: pre-existing hyperextension deformity
Complications:
* hyperextension deformity (cock-up deformity)
* Push-off weakness
* Transfer metatarsalgia: decreased with capsular interposition
126
What are two risks specific to sesamoidectomy procedure?
1. Cock-up toe (need to meticulously repair FHB)
2. Nerve injury (medial plantar nerve)
127
At heel strike, is the hindfoot in varus or valgus?
Valgus with transverse tarsal joint UNlocked
Helps dissipate up to 50% of the force
128
3 indications to emergent lisfranc operative management
What implant do you use in this case?
the presence of compartment syndrome
open injury
irreducible dislocations
* Consider ex-fix due to soft tissue compromise
129
Classification of plantar plate injury
130
Name 5 causes of Charcot arthropathy of the foot & ankle
DM
Alcoholism
Syrinx
Syphylis
Leprosy
(This was a previous SAQ)
131
3 surgical options for Freiberg's Infraction
MTP arthrotomy for I&D and removal of loose bodies
Dorsal closing wedge osteotomy (moves plantar, intact, cartilage into articulation with joint)
DuVries arthroplasty: partial MT head resection (see picture)
132
Positive prognostic indicators for tarsal tunnel release (5)
Compressive anatomy structure is identified and removed
Symptoms in a distribution of the tibial nerve (or DPN)
a positive nerve compression sign
Positive electrodiagnostic study
a space occupying mass
133
Most common complication in correction of Juvenlie HV?
Recurrence: \> 50%
134
What peroneal tendon is more commonly torn?
brevis
135
How many patients will get subtalar arthritis 10 years after arthrodesis?
50%
136
What muscle imbalance causes the primary deformity in CMT?
peroneus longus overpowering TA
PL causes plantarflexion of 1st ray in the absence of TA. This drives the remaining deformities of the foot
137
During gait, when is the center of gravity the highest and lowest?
Highest: during midstance
Lowest: double limb support
138
2 indications for MTP fusion in the treatment of hallux valgus (broadly speaking)
1. Connective tissue disorders/ "Loosey-goosey" (ED, CP, DOWNS)
2. Arthritis (OA or Gout)
139
What kind of shoe for a diabetic foot at risk?
Rocker bottom
140
Treatment algorithm for hallux valgus
141
Knot of Henry, which tendon is dorsal?
Crossing of FHL and FDL
FHL is dorsal
142
List poor prognostic indicators for tarsal tunnel release
Double crush syndrome
inadequate release
Post-op hematoma
Scarring around the nerve
Improper diagnosis
143
Position of fusion of 1st MTP?
10-15 degrees of dorsiflexion *relative to the floor*
* (be careful, sometimes they as in relation to the metatarsal, in which case it would be 25-35 degrees relative to 1st MT)
10-15 degrees of valgus relative to MT shaft
Neutral rotation
144
Treatment of Hallux Rigidus by grade:
_0-1:_
* Nonoperative, Activity modification with Morton's extension
_1&2:_
* Dorsal cheilectomy ± Moberg's
_3&4:_
* MTP Arthrodesis
* MTP Arthroplasty - controversial
* Poor long term results with silicone implants due to osteolysis. Capsular interpositional arthroplasty gaining popularity
_Old & low demand:_
* Keller resection arthroplasty
_Acute osteochondral or chondral defects:_
* Synovectomy & debridement
145
Brodksy classificaiton for charcot foot
stage 1: midfoot (60%)
Stage 2: hindfoot: (30%)
Stage 3: ankle or calcaneal tubeosity: 5-10%
Stage 4: combination
Stage 5: Forefoot only
146
Indications for surgery in base of 5th MT fracture
Failure of nonop
Zone 2 in elite athletes
Zone 3 with sclerosis or nonunion or in athletic individual
147
Best shoe modification for Eichenholtz stage 3
Double rocker bottom shoe
148
What is the first deforming factor in HMSN?
Plantarflexion of 1st ray
149
Risk factors for charcot foot.
Give 4
1. diabetic neuropathy
2. alcoholism
3. leprosy
4. myelomeningocele
5. tabes dorsalis/syphilis
6. syringomyelia
150
What is this deformity?
Claw Toe
(Intrinsic Minus of the foot)
151
Location of anteromedial ankle portal scope
between saphenous vein and tib ant
Just medial to tib ant
152
What s Baxter's nerve?
What does it inneravate?
Name 1 common pathology with it:
1st branch of lateral plantar nerve
Innervates abductor digiti quinti
Can be a source of medial heel pain
153
In infected diabetic foot ulcer, how often are temperature, WBC, ESR and CRP increased?
Only 50% of the time
do not rely on this - exam and MRi/imaging are critical
154
Name 3 surgical options for charcot foot
exostectomy + TAL
reconstruction with osteotomy and fusion
Amputation
155
Risk factors for achilles tear
episodic athletes, "weekend warrior"
flouroquinolone antibiotics
steroid injections
Male
Long distance runners
156
Cause and clinical of claw toe
MTP hyperextension
Causes PIP and DIP flexion
157
If operating on a HV patient with open physes, where can you do your osteotomy?
Cuneiform
DO NOT peform at proximal metaphysis if physis is open
158
What are the 8 phases of gait?
_Weight acceptance (stance):_
1. initial contact
2. limb-loading response
_Single-Limb support (stance):_
3. Midstance
4. Terminal stance
5. Preswing
_Limb-advancement (Swing):_
6. initial swing
7. midswing
8. terminal swing
159
Name the muscle imbalances in HMSN?
Strong tib post & weak tib ant
Strong PL & weak PB
160
4 surgical interventions for hammertoe
_Flexible deformity_
FDL to extensor tendon transfer
_Fixed Deformity_
Resection arthroplasty ± tenotomy and tendon transfer
Girdlestone procedure (flexor to extensor transfer)
Arthrodesis
161
Worse with plantarflexion (pointe position in Ballet)
Dx and treamtent/
Os trigonum
arthroscopic excision is symptomatic
162
Mechanism of high ankle sprain
external rotation injury
vs low ankle sprain: eversion
163
Risks of nonunion in ankle fusion
Smoking
adjacent joint fusion
Previously failed arthrodesis
Avascular necrosis
164
What are this??
What are it for?
Morton's extension with stiff foot plate
Used for hallux rigidus
165
In hallux rigidus, what happens to plantar pressure across 1st MTP?
It increases
166
Two specific tests that differentiate charcot from infection?
1) elevation of foot will decrease erythema in charcot but not infection
2) indium WBC scan - cold in charcot
(Bone scan hot in both)
167
Gold standard care for diabetic foot ulcers
Multidisciplinary foot care
always say this
168
Complication of sesamoidectomy?
Bilateral
Tibial
Fibular
Bilateral: cock-up deformity due to weak FHB
Tibial: hallux valgus
Fibular: Hallux varus
169
What is the most common cause of hallux VARUS?
Iatrogenic from over-correction of Hallux Valgus
170
What injury is most likely to result in a Posttraumatic tibiofibular synostosis?
Weber C
171
What must you do to correct flatfoot after excising an accessory navicular?
Calcaneal osteotomy
Rerouting the Posterior tibial tendon will not correct flatfoot
172
How much MTP dorsiflexion is needed to run properly?
60 degrees.
For stiff MTP in rigidus, a Moberg closing dorsal wedge can be used to increase dorsiflexion.
173
In hallux rigidus, what happens to the axis of rotation?
It is altered and becomes eccentric
174
A patient has a bunionette with an IMA \> 12.
WHat is the treatment?
Diaphyseal rotation osteotomy.
**Not a proximal osteotomy. Poor blood supply there.**
175
Contraindications to total ankle arthroplasty: (7)
uncorrectable deformity
severe osteoporosis
talar osteonecrosis
Charcot joint
ankle instability
obesity
Young laboureres (increased risk of failure/revision)
176
The Center of Mass is located anterior to which vertebra?
S2
177
Rate of nonunion and infeection in foot surgery/reconstruction in diabetics
10x increased risk of infection in DM, associated neuropathy or peripheral artery disease
50% risk of nonunion in complicated diabetics
178
Classification of accessory navicular
I: sesamoid in tib post
II: separate accessory bone attached via synchondrosis
III: complete bony enlargement
179
What are the 2 most common causes of an unsatisfactory Symes amputation
Migration of the posterior heel pad
(avoid by securing achilles to tibia via transosseous anchors)
sloughing due to overaggressive debridement of fishmouths
180
Type of shoe sole/shape for tibiotalar arthritis
single rocker bottom
181
Complication of excision of fibular sesamoid in HV correction?
Hallux varus
182
Goal of treatment of charcot foot (and all foot issues)
The creation of a stable, plantigrade, shoeable foot and the absence of recurrent ulceration
183
What ankle portal is established first?
Antero medial = primary viewing portal
nick and spread method
184
What are the three radiologic signs of bunionette deformity?
1. increased 4-5 IMA (normal 6.5-8 degrees)
2. increased lateral deviation angle (normal 0-7 degrees)
3. increased width of MT head (normal \<13mm)
185
muscle imbalance in equinovarus foot
Strong: TA, TP ±FHL/FDL, gastrocs
Weak: peroneus longus/brevis
Equinus: gastrocs
varus: TP, TA
186
Most common location of *atraumatic* talar OCD
Give 3 characteristics?
medial/posteromedial talar dome
Most common overall
more posterior
larger and deeper than lateral lesions
187
What is the effect of the windlass mechanism?
Increases arch height as toes dorsiflex during toe off
Keeps everythng taught for toe off power
188
Where do peroneus brevis tears occur? Longus?
Brevis: fiblar groove (aka retromalleolar sulcus)
Longus: peroneal tubercle/cuboid tunnel
189
What are the branches of the tibial nerve? Where does it normally branch?
Medial and lateral plantar nerves, medial calcaneal nerve
Usually branches within the lacinate ligament (flexor retinaculum)
190
How much bone is removed in a Girdlestone of the toe for claw toe?
**None.**
Trick question.
Toe girdlestone is EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer.
Deformity must be **flexible**.
191
A patient has tarsal tunnel release and comes back with recalcitrant symptoms. Plan
DO NOT do repeat surgery
It is worse than the original
192
During heel strike, the transverse tarsal (Chopart) joint axes are \_\_\_\_\_\_\_\_\_\_\_\_\_
Parallel
193
What is going on here and what is management?
Posttraumatic tibiofibular synostosis
## Footnote
Resection reserved for persistent pain that fails to respond to nonsurgical management.
194
Most diabetic foot ulcers recur within what time frame after TCC?
4 -6 weeks (closer to 4)
195
Describe borders and contents of tarsal tunnel**_s_**
_Posterior_:
* Flexor retinaculum (lacinate ligament)
* calcaneus (medial)
* talus (medial)
* abductor hallucis (inferior)
* Contains
* Tom, Dick, A Very Nervous Harry
_Anterior_
* Inferior Retinaculum
* fascia overlying the talus and navicular
* Contents:
* DPN, EHL, EDL, DP artery
196
Diagnosis & treatment?
| (see picture)
Kohler's disease: self-limiting AVN of navicular
_Treatment_:
SLC (walking cast) - studies show this decreases symptom duration
SURGERY NOT INDICATED
197
5th MT fracture: increased nonunion in what zones
Zone 2 (Jones)
Zone 3: diaphysis
198
Treatment of dorsal MTP dislocation
Nonoperative: 1st line but won't correct defority
_Operative_
* Weil osteotomy
* Plantar plate repair
* Flexor to extensor tendon transfer (Girdelstone-Taylor)
* EDB transfer under intermetatarsal ligament
199
Muscle imbalance in cavovarus foot
Strong PL, TP
Weak: TA, PB
200
What should you consider doing when doing a plantar fascia release?
Release of Baxter's nerve, as this is often confused with plantar fascitis
Remember only do partial release of plantar fascia
201
4 favourable patient factors for total ankle arthroplasty
Older, low demand, reasonably mobile patients with no siginificant co-morbidities
Normal or low BMI
Well-aligned and stable hindfoot
Good soft tissues
202
Contraindications to total ankle arthroplasty (10)
* Unresectable osteonecrotic bone
* peripheral vascular disease
* neuropathy
* neuropathic joint disease (Charcot arthropathy)
* ankle infection
* severe joint laxity
* nonreconstructible ankle ligaments
* loss of lower leg muscular control
* severe osteopenia or osteoporosis
* Heavy labourer
203
Normal tib/fib clear space
\<6mm on both AP and mortise, 1cm above joint
204
Normal values for:
Hallux valgus angle
Intermetatarsal angle
Distal metatarsal articular angle
Hallux valgus interphalangeus angle
HVA:
IMA:
DMAA:
HVI:
205
This diagnosis recalcitrant to conservative therapy.
Next step?
tibial sesamoidectomy
206
Risk of fixation failure in base of 5th MT IM screw
elite athletes
failure to wait until radiographic healing to return to sports
fracture distraction or malreduction due to screw being too long (will straighten the curved MT shaft or perforate the medial cortex)
207
dDx for medial heel pain (5)
Plantar fascitis
heel pad atrophy
Baxter's nerve entrapment
Calcaneal stress fracture
Tarsal tunnel syndrome
208
6 risk factors for Charcot Neuropathy
Diabetic neuropathy
Alcoholism
Leprosy
Myelomeningocoele
Tabes dorsalis/syphylis
Syringomyelia
209
Broadly speaking, what are 2 types of syndesmotic fixation
screws
tightrope
210
3 theories for pathophysiology of charcot foot
**_Neurotraumatic:_**
Insensate joint subjected to repetitive microtrauma
Body unable to adopt protective mechanisms to compensate for microtrauam due to abnormal sensation
**_Neurovascular_**
Autonomic dysfunction increases blood flow though AV shunting
Leads to bone resorption and weakening
**_Molecular Biology_**
Inflammatory cytokines may cause destruction
IL-1, TNF-alpha lead to increased production of transcription factor kB
RANK/RANKL/OPG triad pathway
211
3 indications for syndesmotic screws?
1. syndesmotic sprain (without fracture) with instability on stress radiographs
2. syndesmotic sprain refractory to conservative treatment
3. syndesmotic injury with associated fracture that remains unstable after fixation of fracture
212
What is a Morton's extension orthotic used for?
Hallux Rigidus
213
WHat's a Lapidus procedure. What are it's indications?
lapidus: 1st TMT arthrodesis + McBride
_Indications:_
* TMT arthritis
* instability
* Metatarsus Primus Varus
* Severe deformity with large IMA
214
Options for tendon transfers in foot drop: (2)
Simple tib post transfer
Bridle procedure (tri-tendon anastomosis)
215
Most common complication following this:
Initial management?
Navicular stress fracture
most common complication: nonunion
Initial mangaement; cast and NWB x 6-8 weeks
High success rate
216
3 specific options for management of Morton's Neuroma (surgical an non)
Nonop
Wide toe box shoes and MT pad: 1st line. OK results only
Corticosteroid injection: benefit in short term RCTs
Neurectomy: dorsal approach \> plantar
217
Gastrocs contraction leads to what motion?
Flexion of knee
Plantarflexion of ankle
Pronation of subtalar joint
218
What is Morton's neuroma
What causes it?
Compression neuropathy of the interdigital nerve
Most commonly involves 2nd/3rd interdigital nerves
Cause unknown but likely compression around transverse intermetatarsal ligament
219
Best test for syndesmosis injury?
Cotton test (intraop)
fewest false-positive results and smallest inter-observer variance
220
Name the ligaments of the ankle syndesmosis
_AITFL_
_PITFL_
_Interosseous membrane_
_inferior transverse ligament_
* AKA inferior part of IoM
_interosseous ligament_
* distal continuation of the interosseous membrane
* main restraint to proximal migration of the talus
221
2 reasons to include a Weil osteotomy in the treatment of claw toe?
1. **Multiple toes involved** (i.e. treatment of multiple flexible claw toes = girdlestone and Weils)
2. **Fixed deformities** = resection arthroplasty, capsulotomy and Weil
222
How many articulations are there in the lisfranc joint complex?
3:
TMT
intermetatarsal
intertarsal
223
What are the comparmtnets of the foot?
9 compartments (as per JAAOS)
_Medial_
* Abductor hallucis
* FHB
_Lateral_
* Abductor digiti minimi
* FDMB
_Interossei x 4_
_Central_
* quadratus plantae
_Superficial_
* FDB
_Deep_
* Adductor hallucis
* tib post neurovascular bundle
224
Which test for acute syndesmotic injury of the ankle has the fewest false-positive results and smallest inter-observer variance when used intraoperatively?
Cotton test
(Pull fibula laterally)
225
Name 3 surgical options for low grade hallux rigidus
**Joint debridmenet & synovectomy**
**Dorsal chielectomy:**
* pain with dorsiflexion is a good predictor of good results
**Moberg's extension osteotomy**
* Dorsal closing wedge osteotomy of proximal phalanx
226
Natural history of accessory navicular?
most become asymptomatic by skeletal maturity
227
Name 2 tests specific for the lateral ankle ligments
Anterior drawer test
Talar tilt test
228
Describe the gold standard surgical treatment for lateral ankle instability
Modified Brostrum
Lateral approach to ankle
Dissect out remnants of ATFL & CFL (often torn off fibula)
Dissect out extensor retinaculum
With suture anchors or trans-osseous tunnels, anatomically repair the ATFL & CFL ligaments to their origins along with a bite of the extensor retinaculum
±tendon transfer & tenodesis (ie Evans split peroneus brevis)
