Foot & Ankle Speciality Exam No.5 Flashcards
A 21-year-old collegiate basketball player comes down with a rebound and rolls his ankle. He is able to finish the game, but complains of ankle pain and swelling afterwards. Physical exam is notable for moderate inversion laxity with the ankle held in dorsiflexion. With placement of the ankle in plantarflexion, no inversion laxity is appreciated. Which of the following ligaments has been attenuated?
QID:3185
1 Anterior talofibular ligament
2 Calcaneofibular ligament
3 Anterior tibiofibular ligament
4 Posterior tibiofibular ligament
5 Deltoid ligament
Anterior talofibular ligament
19%
(358/1928)
2
Calcaneofibular ligament
71%
(1374/1928)
3
Anterior tibiofibular ligament
5%
(100/1928)
4
Posterior tibiofibular ligament
4%
(68/1928)
5
Deltoid ligament
1%
(23/1928)
The primary static stabilizers of the lateral ankle are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The calcaneofibular ligament becomes most taut with the ankle dorsiflexed and inverted. Conversely, the anterior talofibular ligament is most tensioned with the ankle plantarflexed and inverted. The anterior and posterior tibiofibular ligaments contribute stability to the tibiofibular articulation and syndesmosis. The deltoid ligament is the primary stabilizer medially and is stressed with ankle eversion testing.
A 51-year-old male postal worker presents complaining of ankle pain that makes completing his occupational duties difficult. He has taken nonsteroidal anti-inflammatory medications over the counter on his own, but this is his first time seeking professional consultation for his problem. His ankle has limited range of motion with pain throughout an arc of motion. There is no point tenderness and painless inversion/eversion of the hindfoot. No skin breakdown, swelling, or erythema is noted. Radiographs of his ankle are seen in Figures A and B. What is the next most appropriate intervention?
QID:5642
FIGURES:
A https://upload.orthobullets.com/question/5642/images/ankle_arthritis_ap.jpg
B https://upload.orthobullets.com/question/5642/images/ankle_arthritis_lateral.jpg
1 Opiate pain medications and limited weightbearing for 6 weeks
2 Cast immobilization and non-weight bearing 12 weeks
3 Intraarticular corticosteroid injection and a cushioned rocker-bottom shoe
4 Triple arthrodesis and a cushioned rocker-bottom shoe
5 Pan-talar arthrodesis and a cushioned rocker-bottom shoe
Opiate pain medications and limited weightbearing for 6 weeks
1%
(13/1426)
2
Cast immobilization and non-weight bearing 12 weeks
3%
(38/1426)
3
Intraarticular corticosteroid injection and a cushioned rocker-bottom shoe
66%
(940/1426)
4
Triple arthrodesis and a cushioned rocker-bottom shoe
12%
(173/1426)
5
Pan-talar arthrodesis and a cushioned rocker-bottom shoe
17%
(248/1426)
For this patient with tibiotalar arthritis the first step in treatment would be non-operative measures such as a corticosteroid injection and cushioned rocker-bottom shoe.
Tibiotalar arthritis in high demand patients can be painful and debilitating. The first step in treatment would be non-operative measures such as a corticosteroid injection to help decrease pain, and a cushioned rocker-bottom shoe to limit motion in the ankle during gait. A cane or other supportive device could also be considered. If these modalities fail then surgery can be considered. Young, active patients should be considered for a fusion while older low-demand patients may consider total ankle arthroplasty.
Labib et al. present a review of the treatment of ankle arthritis. They note that non-operative measures should be explored first, and only when those fail should surgical procedures such as arthrodesis or arthroplasty be considered. They note that if pain is present only at the end of dorsiflexion motion, then arthroscopic anterior spur debridement may be beneficial. If malalignment is present, a supramaleolar osteotomy may be needed.
Thomas et al. reviewed intermediate outcomes in 26 patients who underwent ankle arthrodesis for end stage tibiotalar arthritis. Pain relief and patient satisfaction were good, but gait analysis demonstrated significant differences in cadence and stride length, and hindfoot motion was limited. They recommend ankle arthrodesis for relief of pain and improvement of function, but counsel patients on alteration of gait.
Incorrect answers:
Answer 1: While activity modification is a possible non-operative treatment, a 6 week course of limited weight-bearing is unlikely to prevent the pain from his end-stage arthritis from recurring. Also, opiate pain medications should be avoided if possible.
Answer 2: Cast immobilization and non-weight bearing is unlikely to help his end-stage arthritis.
Answers 4 and 5: This patient has not yet tried any non-operative treatment aside from over the counter pain medications, so surgery would not be the next step in treatment. If surgery were pursued it would more likely be a tibiotalar arthrodesis with no indication to fuse additional joints.
(OBQ15.222) A 52-year-old woman underwent the procedure in Figure A for posterior tibial tendon insufficiency. For what stage disease was this most likely performed? Review Topic
QID:5907
FIGURES:
A https://upload.orthobullets.com/question/5907/images/subtalar_flatfoot.jpg
1 Stage I
2 Stage IIA
3 Stage III
4 Stage IV with passively correctable ankle valgus
5 Stage IV with rigid ankle valgus
1 Stage I
2 Stage IIA
3 Stage III
4 Stage IV with passively correctable ankle valgus
5 Stage IV with rigid ankle valgus
The procedure shown in figure A is an isolated subtalar arthrodesis. This treatment is most appropriate in stage III posterior tibial tendon insufficiency (PTTI).
The treatment of PTTI depends on the stage of disease. In patients with stage II disease with subtalar arthritis and stage III disease, arthrodesis can be considered. While triple arthrodesis is the most common procedure, isolated subtalar and subtalar/talonavicular fusion can also be used depending on patient presentation (i.e. location of pain or presence of arthritis). While these procedures do not address the underlying flat foot, they do help improve pain.
Johnson et al. review the surgical management of stage III and IV PTTI. Arthrodesis options include isolated or a combination of subtalar, talonavicular, calcanecuboid and tibiotalar fusions. Depending on patient presentation, adjunctive procedures such as Achilles lengthening and calcaneal osteotomy may be indicated.
Kadakia et al. reviewed arthrodesis options in the hindfoot for PTTI. They state that for certain patients with most significant subtalar symptoms, isolated subtalar fusion may be appropriate.
Figure A is a lateral x-ray of a patient who underwent subtalar arthrodesis.
Incorrect Answers:
Answer 1: Stage I PTTI is typically treated with immobilization and in rare cases tenosynovectomy of the tendon.
Answer 2: Stage IIA PTTI can be surgically managed with flatfoot reconstruction (i.e. FDL transfer, calcaneal osteotomy, lateral column lengthening, spring ligament repair). Stage IIB is sometimes treated with arthrodesis in rare cases.
Answer 4: Stage IV disease with correctable ankle valgus is typically treated with triple arthrodesis and deltoid ligament reconstruction
Answer 5: Stage IV disease with rigid ankle valgus is typically treated with tibiotalocalcaneal arthrodesi
(OBQ10.36) A 58-year-old golfer fell stepping into a sand trap and ruptured his Achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends. Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? Review Topic
QID:3124
1- Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon
2- Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus
3- Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus
4- Reconstruction with hamstring autograft
5- Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program
QID:3124
1- Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon
2- Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus
3- Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus
4- Reconstruction with hamstring autograft
5- Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program
Tendon loss is a complication associated with secondary ruptures of a repaired Achilles tendon and chronic Achilles tendon ruptures. Gastrocnemius turndown utilizes a slip of the central third of the gastrocnemius tendon to bridge the gap. Flexor hallicus longus (FHL) is the preferred tendon transfer to augment tissue loss due to its proximity and vascularity. Answer choice 5 is not a prudent option given the risk of equinus contracture and recurrent rupture.
Wapner et al conducted a case review of 7 patients who underwent FHL augmentation for chronic Achilles tendon rupture. Results included no surgical complications, a small but functionally insignificant decrease in ankle and great toe range of motion, and clinical satisfaction of all 7 patients.
Chiodo et al summarize the AAOS clinical guidelines for evaluation and treatment of acute Achilles tendon ruptures predicated upon an extensive review of the literature.
Illustrations A-C depict the steps for a gastrocnemius turn-down flap consisting of a V-Y incision with the arms of the “V” measuring 6cm.
https://upload.orthobullets.com/question/3124/images/gastroc%20turndown%202b.jpg
(OBQ14.80) A 50-year-old male presents with ongoing plantar medial heel pain for the past few months. It is associated with the first step in the morning and eases up after he takes a few additional steps. He has attempted physical therapy, including Achilles stretching, heel cups, and ice massage with no relief. On physical examination, there is pain over the plantar medial heel with a Tinel’s sign elicited just proximal to the abductor hallucis musculature. The pain radiates to the base of the 5th metatarsal. . A Tinel’s sign over the posterior tibial nerve is not found. Innervation to which anatomic structure is mostly like affected in this patient? Review Topic
QID:5490
1- Abductor hallucis
2- Abductor digiti minimi
3- FDL
4- FHL
5- Plantar fascia
1- Abductor hallucis
2- Abductor digiti minimi
3- FDL
4- FHL
5- Plantar fascia
–
Based on the clinical history and the findings on examination, the patient has entrapment of the first branch of the lateral plantar nerve (Baxter’s nerve). This will implicate nerve supply to the abductor digiti minimi
Compression of the first branch of the lateral plantar nerve (Baxter’s nerve) can be associated with plantar medial heel pain. This may be confused with plantar fasciitis. Patients with this nerve compression often have pain with compression at the origin of the abductor hallucis. The nerve travels dorsal to the fascia of abductor hallucis and plantar to the quadratus plantae. Tapping the nerve at the origin of the abductor hallucis may elicit pain that radiates towards the 5th metatarsal, as this nerve supplies the abductor digiti minimi.
https://upload.orthobullets.com/question/5490/images/trifurcation_of_ptn.jpg.jpg
(OBQ15.268) Neurologic injury is the most common complication of ankle arthroscopy. The nerve most commonly injured is at risk during placement of which portal? Review Topic
QID:5953
1- Anterolateral
2- Anterocentral
3- Anteromedial
4- Posteromedial
5- Posterolateral
1- Anterolateral
2- Anterocentral
3- Anteromedial
4- Posteromedial
5- Posterolateral
The superficial peroneal nerve (SPN) is the most common nerve injured during ankle arthroscopy and is associated with anterolateral portal placement.
Ankle arthroscopy is an important therapeutic tool to manage a variety of pathologies including osteochondral defects and impingement syndrome. The average complication rate is 6-20% and the most common complication is neurologic injury. The SPN is most often injured, in part due to its variation in anatomic location. Identifying and marking important structures, as well as proper portal placement are vital to lessen the risk of neurovascular (NV) injury.
OBQ15.54) A 70-year-old man is referred to your office for the neuropathic interphalangeal (IP) joint ulcer shown in Figure A. He had previously undergone 3 separate total contact castings (TCC) for the same complaint. There is generalized joint stiffness and hypomobility of the metatarsophalangeal and interphalangeal joints. A standing radiograph is shown in Figure B. What is the next best step? Review Topic
QID:5739
FIGURES:
A https://upload.orthobullets.com/question/5739/images/fig_a.jpg
B https://upload.orthobullets.com/question/5739/images/fig_b.jpg
1- Charcot restraint orthotic walker (CROW)
2- Resect the base of the distal phalanx
3- Resect the head of the proximal phalanx
4- Resect the base of the proximal phalanx
5- Resect the head of the metacarpal
1- Charcot restraint orthotic walker (CROW)
2- Resect the base of the distal phalanx
3- Resect the head of the proximal phalanx
4- Resect the base of the proximal phalanx
5- Resect the head of the metacarpal
https://upload.orthobullets.com/question/5739/images/illus_a.jpg
This patient has a plantar IP ulcer that is refractory to TCC, and rigid MTPJ. Keller resection arthroplasty (resection of the proximal phalanx base) is indicated.
Keller arthroplasty was originally developed to treat painful hallux valgus. It is also useful as a salvage procedure for plantar IP ulceration with a rigid forefoot. It is believed that decreased MTPJ motion, a known phenomenon in diabetes, leads to increased pressure over the IP joint of the great toe. The Keller procedure is motion-restoring at the MTPJ, and reduces pressure over the ulcer.
Pinzur et al. present AOFAS guidelines for diabetic foot care. They recommend a screening exam that includes includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Treatment is multimodal and combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care.
Lin et al. retrospectively compared TCC + Keller arthroplasty against TCC alone. Both groups showed ulcer healing in 3 weeks, without recurrence. They concluded that this method may be effective with diabetic neuropathic ulcers in the presence of hallux rigidus.
Figure A shows a plantar IP neuropathic ulcer. Illustration A shows the postoperative appearance after Keller resection arthroplasty maintain a plantigrade toe. A Kirschner wire is inserted to maintain a plantigrade toe, preserve a 5 mm gap at the MTP space, and to prevent cock-up toe deformity postop. Figure B shows severe joint space narrowing and sclerotic subchondral changes at the 1st MTPJ.
Incorrect Answers:
Answer 1: This patient has failed TCC. A TCC decreases high focal contact pressures by increasing the weight-bearing area of the plantar surface through a custom-molded cast. Because of closer customization, it is more effective in pressure distribution than a CROW. Patients transition from TCC (non-removable) to a CROW (removable). CROW is not indicated for failed TCC.
Answers 2, 3, 5: Keller resection arthroplasty involves motion restoration at the MTPJ through basal resection of the proximal phalanx.
(SBQ12FA.38) A 38-year-old man presents to your clinic with long standing great toe pain. He has a positive grind test and a painful arc of motion of approximately 20 degrees. Figures A and B are his radiographs. He has failed conservative management with orthotics and anti-inflammatory medication. Which of the following surgical interventions do you recommend to give this patient the best long-term functional results and pain relief? Review Topic
QID:3845
FIGURES:
A https://upload.orthobullets.com/question/3845/images/ap.jpg
B https://upload.orthobullets.com/question/3845/images/lat.jpg
1- Dorsal synovectomy and joint debridement
2- Resection of dorsal osteophytes and ~25% of dorsal metatarsal head
3- Resurface proximal phalanx base with cobalt chrome implant
4- Joint resection and interposition of capsule and/or EHB tendon
5- Fusion in neutral rotation, 15 degrees of valgus, 10 degrees of dorsiflexion
1- Dorsal synovectomy and joint debridement
2- Resection of dorsal osteophytes and ~25% of dorsal metatarsal head
3- Resurface proximal phalanx base with cobalt chrome implant
4- Joint resection and interposition of capsule and/or EHB tendon
5- Fusion in neutral rotation, 15 degrees of valgus, 10 degrees of dorsiflexion
—
This patient has end stage hallux rigidus and would benefit most from first metatarsophalangeal joint (MTPJ) fusion in neutral rotation, 15 degrees of valgus and 10 degrees of dorsiflexion.
Hallux rigidus (HR), or degenerative joint disease of the first MTPJ, is the second most common pathology affecting the great toe after hallux valgus. Conservative management includes NSAIDs, activity modification and orthotics with a Morton’s extension to shield the first MTPJ. Mild disease (grades 1 and 2) may be treated with synovectomy, debridement and dorsal cheilectomy. The gold standard for advanced HR is first MTPJ arthrodesis.
Raikin et al performed a prospective study of 46 patients with HR who underwent either arthrodesis or metallic hemiarthroplasty. At at mean 6 years follow up, 24% of the hemiarthroplasties failed and required either revision or conversion to arthrodesis. All of the arthrodeses achieved successful fusion. The authors concluded that arthrodesis is a more predictable procedure for alleviating symptoms and restoring function.
Coughlin et al authored a retrospective review of 110 patients with HR who underwent either a dorsal cheilectomy or arthrodesis. Dorsal cheilectomy had predictable success in patients with grade 1 or 2 disease. The authors recommend arthrodesis for patients with grade 3 disease with < 50% of metatarsal head cartilage remaining and all grade 4 disease.
(OBQ15.93) A 22-year-old football player lands on the forefoot with his great toe hyperextended during a football game. He presents with pain at the metatarsophalangeal (MTP) joint and difficulty with cutting drills. Examination demonstrates localized tenderness. Radiographs of both feet are shown in Figure A. Figures B and C are a lateral radiograph and sagittal MRI of the injured side, respectively. Non-operative measures have not been successful. What is the next best step? Review Topic
QID:5778
FIGURES:
A https://upload.orthobullets.com/question/5778/images/fig_a.jpg
B https://upload.orthobullets.com/question/5778/images/fig_b.jpg
C https://upload.orthobullets.com/question/5778/images/fig_c.jpg
1- Resection
2- Tendon repair
3- Tenotomy
4- Capsuloligamentous repair
5- Internal fixation of bone
1- Resection
2- Tendon repair
3- Tenotomy
4- Capsuloligamentous repair
5- Internal fixation of bone
–
https://upload.orthobullets.com/question/5778/images/illus_a.jpg
This patient has Grade III left turf toe with sesamoid retraction that has failed nonoperative measures. Capsuloligamentous repair is indicated.
Turf toe occurs after axial loading on the heel with the ankle plantarflexed and the hallux MTP hyperextended. The incidence is up to 45% in NFL players, with most occurring on artificial turf. Grade I injuries involve attenuation of plantar structures, localized swelling, and minimal ecchymosis. Grade II injuries involve partial tear of plantar structures, moderate swelling, and restricted motion as the result of pain. Grade III injuries involve complete disruption of plantar structures, significant swelling/ecchymosis, hallux flexion weakness, or frank instability of the MTP joint.
(OBQ15.245) A 66-year-old man undergoes total ankle replacement (TAR). An unrecognized intraoperative complication occurred and he now returns for follow-up at 6 weeks. Radiographs are shown in Figure A. Which of the following is NOT a risk factor for this intraoperative complication? Review Topic
QID:5930
FIGURES:
A https://upload.orthobullets.com/question/5930/images/fig_a.jpg
1- saw blade excursion
2- tibial component size
3- tibial component position
4- joint distraction with an external fixator
5- medial malleolar pinning
1- saw blade excursion
2- tibial component size
3- tibial component position
4- joint distraction with an external fixator
5- medial malleolar pinning
https://upload.orthobullets.com/question/5930/images/ia.jpg
https://upload.orthobullets.com/question/5930/images/ib.jpg
Prophylactic intraoperative pinning of the medial malleolus helps to prevent intraoperative medial malleolar fractures, rather than cause them.
Periprosthetic fractures of the medial malleolus are more common than lateral fractures. Known causes include uncontrolled saw blade excursion, excessively medial or lateral placement of the tibia prosthesis, or oversized tibial prosthesis. The fibula lies behind the talus in a posterior position and may be cut if the direction of cut is not appropriate. Repeated pin placement for changes in template position also create stress risers and should also be avoided. Prophylactic K-wire (or screw) insertion through the medial malleolus prior to osteotomy may help prevent fracture.
(OBQ10.138) A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT: Review Topic
QID:3189
FIGURES:
A https://upload.orthobullets.com/question/3189/images/hv2.jpg
B https://upload.orthobullets.com/question/3189/images/hv%201.jpg
1- Multiple screw fixation across the metatarsocuneiform arthrodesis
2- Augmentation of the metatarsocuneiform arthrodesis with bone grafting
3- Dorsiflexion unloading of the first metatarsal
4- Correction of the first intermetatarsal angle
5- Failure of conservative treatments prior to surgery
1- Multiple screw fixation across the metatarsocuneiform arthrodesis
2- Augmentation of the metatarsocuneiform arthrodesis with bone grafting
3- Dorsiflexion unloading of the first metatarsal
4- Correction of the first intermetatarsal angle
5- Failure of conservative treatments prior to surgery
The clinical photograph and radiograph demonstrate hallux valgus with a large first intermetatarsal angle. Metatarsus primus varus and hypermobility of the first ray are both indications for including metatarsocuneiform arthrodesis in the surgical correction of hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to prevent loading of the lesser metatarsals following surgery.
Myerson et al reports the results of 53 patients treated with metatarsocuneiform arthrodesis for hallux valgus and metatarsus primus varus. They found that 92% acheived clinical satisfaction despite numerous complications including 7 superficial pin tract infections, 3 dorsal bunions, 7 nonunions, 1 hallux varus, and 3 neuromas of the deep peroneal nerve. Only 1 of the complications needed secondary surgery.
Sangeorzan et al reports the results of metatarsocuneiform arthrodesis in 33 patients with hallux valgus and a hypermobile first ray and 7 patients with previous failed bunion surgery. Successful union occurred in 90%, and 75% were considered successful clinical results. Best results were achieved with bone grafting, multiple screw fixation, and accurate plantarflexion of the first metatarsal.
(SBQ12FA.19) A 42-year-old patient complains of anterior and lateral ankle pain, as well as limited dorsiflexion, after non-surgical management of a displaced intra-articular calcaneus fracture. Imaging shows subtalar joint arthrosis, lateral wall exostosis and loss of calcaneus height. What would be the BEST management? Review Topic
QID:3826
1- Posterior tibial tendon transfer +/- vertical slide calcaneal osteotomy
2- Achilles tendon lengthening and lateral wall exostectomy
3- Superior peroneal retinaculum repair +/- sural nerve neurolysis
4- Subtalar bone block arthrodesis, lateral wall exostectomy +/- achilles tendon lengthening
5- Tibiotalocalcaneal nailing
1- Posterior tibial tendon transfer +/- vertical slide calcaneal osteotomy
2- Achilles tendon lengthening and lateral wall exostectomy
3- Superior peroneal retinaculum repair +/- sural nerve neurolysis
4- Subtalar bone block arthrodesis, lateral wall exostectomy +/- achilles tendon lengthening
5- Tibiotalocalcaneal nailing
Calcaneal malunion is a common problem with non-operative management. The classic indication for bone block arthrodesis is ANTERIOR ankle pain (and limited dorsiflexion) secondary to impingement of the horizontal talus on the tibia. Lateral ankle pain may be due to peroneal dislocation, subfibular impingement, or subtalar arthritis. In this scenario, lateral wall exostectomy would help to address the subfibular impingement.
The calcaneal malunion is evaluated with plain radiographs and CT scan and classified according to the Stephens-Sanders classification (see Illustration A). Type I malunions can be managed with a lateral wall exostectomy and a peroneal tenolysis. Type II malunions can be managed with a lateral wall exostectomy, peroneal tenolysis, and a subtalar bone block arthrodesis, using bone graft. Type III malunions can be managed with a lateral wall exostectomy, peroneal tenolysis, subtalar bone block arthrodesis, closing wedge calcaneal osteotomy to correct varus hindfoot malalignment, or triple arthrodesis.
Sanders et al. reviewed displaced calcaneal fractures. He states that peroneal tendinitis can occur with nonsurgical management of intra-articular calcaneal fractures. The expanded lateral wall often subluxates the peroneal tendons against the distal tip of the fibula causing impingement and pain.
(OBQ10.184) A 57-year-old woman complains of pain and deformity of the second toe that is limiting ambulation. Shoe accomodations and NSAIDs have failed to provide relief. She has a fixed flexion deformity of 40 degrees at the PIP joint, but the MTP joint is not involved. The hallux is normal, but painless PIP flexion contractures are present in the other lesser toes. Which of the following is an indication for PIP resection arthroplasty as opposed to soft-tissue balancing and realignment? Review Topic
QID:3277
1- Fixed deformity
2- Pain with shoe wear
3- Presence of hammertoe deformity in all lesser toes
4- Absence of metatarsophalangeal joint deformity
5- Absence of a concomitant hallux valgus deformity
1- Fixed deformity
2- Pain with shoe wear
3- Presence of hammertoe deformity in all lesser toes
4- Absence of metatarsophalangeal joint deformity
5- Absence of a concomitant hallux valgus deformity
Hammertoe is defined as a flexion deformity of the proximal interphalangeal joint. A diagram of the deformity is provided in illustration A. There are many causes including neurogenic, degenerative, and metabolic processes. Hammertoe can also be secondary to another deformity in the foot such as hallux valgus or curly toe. Consequently, there are numerous surgical procedures available for treatment including soft tissue releases, tendon transfers, resection arthroplasty, and arthrodesis. The presence of fixed deformity precludes success with soft tissue procedures alone.
O’Kane et al review 100 cases of excisional arthroplasty for second digit hammertoe. High rates of clinical satisfaction were achieved with only 2 revision surgeries. Floating toe was the most frequent complication (7). However, floating toe did not adversely affect shoe wear in any patient experiencing this complication.
Coughlin et al review 63 cases of excisional arthroplasty for fixed hammertoe. The resection arthroplasty was stabilized with K-wire fixation that led to bony fusion in 81% and fibrous union in the remaining 19%. Only minor complications occurred and 84% of patients reported high clinical satisfaction.
(OBQ15.260) A 35-year-old patient has had untreated Achilles tendon pain for 4 months. Physical examination reveals an intact Achilles tendon with normal plantar flexion power. MR imaging of the tendon reports areas with increased signal intensity. Color and power doppler ultrasound shows areas with increased blood flow in the tendon, as shown in Figure A. What would be the the next step in management of this patient? Review Topic
QID:5945
FIGURES:
A https://upload.orthobullets.com/question/5945/images/image11.jpg
1- Corticosteroid injection and close follow-up
2- CT chest, abdomen and pelvis
3- Eccentric closed-chain exercises
4- Plasma-rich protein injection with delayed arthroscopic tendon debridement
5- Achilles tendon resection, FHL tendon transfer and gastrocnemius-soleus fascia turndown graft
1- Corticosteroid injection and close follow-up
2- CT chest, abdomen and pelvis
3- Eccentric closed-chain exercises
4- Plasma-rich protein injection with delayed arthroscopic tendon debridement
5- Achilles tendon resection, FHL tendon transfer and gastrocnemius-soleus fascia turndown graft
**This patient’s presentation is consistent with Achilles tendinopathy. The next step in management should be focused physiotherapy with eccentric closed-chain exercises.
Conservative treatment of Achilles tendinopathy is recommended as the initial strategy by most orthopaedic surgeons. Generally, this consists of the combination of rest (complete or modified activity), medication (NSAIDs), orthotic treatment (heel lift, change of shoes, corrections of malalignments), stretching and strength training (eccentric closed-chain exercises). If conservative treatment fails, surgical treatment may be instituted.
Verall et al. assessed the efficacy of a modified 6-week eccentric heel-drop program in symptomatic athletes with Achilles tendinopathy. Pain, as assessed by Visual Analogue Scale (VAS), reduced from a mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Overall mean time to return to pre-morbid activity was 10 weeks. They concluded that results were best for mid-substance involvement rather than insertional tendinopathy.
Shalabi et al. evaluated the tendon response after acute eccentric strength training in chronic Achilles tendinosis using magnetic resonance imaging (MRI). They showed there was no significant difference in tendon volume or the intratendinous signal between the eccentrically heavily loaded symptomatic tendons and the concentrically loaded contralateral tendons**
(OBQ11.95) A 35-year-old man injured his ankle while playing soccer two years ago. Ever since he has had persistent right ankle pain that has failed to improve with nonoperative modalities including physical therapy. A video of his right ankle is found below. Radiographs are shown in Figures A through C. What is the most appropriate next step in management? Review Topic
QID:3518
FIGURES:
V
https://video.orthobullets.com/thumbs/abc123-Peroneal-subluxation/frame_0000.jpg
A
B
C
1- Physical therapy directed at proprioception and strengthening
2- Fibular shortening osteotomy
3- Surgical repair of the anterior talofibular ligament (ATFL)
4- Surgical repair of the calcaneofibular ligament (CFL)
5- Fibular groove deepening and superior peroneal retinaculum repair
1- Physical therapy directed at proprioception and strengthening
2- Fibular shortening osteotomy
3- Surgical repair of the anterior talofibular ligament (ATFL)
4- Surgical repair of the calcaneofibular ligament (CFL)
5- Fibular groove deepening and superior peroneal retinaculum repair
The patient in this scenario has chronic peroneal subluxation. Radiographs are often normal in this condition. On physical exam, a consistent finding is subluxation of the tendons with resisted dorsiflexion and eversion of the ankle. This is most likely secondary to a disruption of the superior peroneal retinaculum (SPR). After a trial of non-operative management, surgical options include repair of the SPR, with or without fibular groove deepening.
Philbin et al reviewed peroneal tendon injuries. As 40% lead to chronic lateral ankle pain, they emphasized an accurate physical exam. They concluded that low-demand patients do well with a nonsurgical approach while high-demand patients may benefit from surgery.
Heckman et al reviewed operative techniques for peroneal disorders. They determined that operative repair consists of surgical repair of the (SPR) with or without fibular groove deepening for subluxation. Primary repair of the tendon is indicated for tears <50% while tenodesis is indicated for tears >50%.
