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Year 2 Medicine > Introduction to Surgery of the Foot and Ankle > Flashcards

Introduction to Surgery of the Foot and Ankle Flashcards

1
Q

Basics of Foot & Ankle Pathology

  • 3 Sections- …, … and …
  • Pathology in any one of these areas has a reciprocating effect in the rest of the foot
  • The foot is like a tripod
A
  • 3 Sections- hindfoot, midfoot and forefoot
  • Pathology in any one of these areas has a reciprocating effect in the rest of the foot
  • The foot is like a tripod
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2
Q

Basics of Foot & Ankle Pathology

  • 3 Sections- hindfoot, midfoot and forefoot
  • Pathology in any one of these areas has a reciprocating effect in the rest of the foot
  • The foot is like a …
A
  • 3 Sections- hindfoot, midfoot and forefoot
  • Pathology in any one of these areas has a reciprocating effect in the rest of the foot
  • The foot is like a tripod
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3
Q

Why is the foot so important?

  • To ensure that we have a smooth … cycle
  • If foot anatomy is abnormal foot … is compromised
A
  • To ensure that we have a smooth gait cycle
  • If foot anatomy is abnormal foot function is compromised
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4
Q

Basics of Foot and Ankle

  • Have a natural … valgus
  • Further valgus your … and … will compensate
  • If you go into varus it will also compensate
A
  • Have a natural hindfoot valgus
  • Further valgus your midfoot and forefoot will compensate
  • If you go into varus it will also compensate
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5
Q

Basics of Foot and Ankle

  • Have a natural hindfoot …
  • Further … your midfoot and forefoot will compensate
  • If you go into … it will also compensate
A
  • Have a natural hindfoot valgus
  • Further valgus your midfoot and forefoot will compensate
  • If you go into varus it will also compensate
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6
Q

How do we achieve this surgically? (natural hindfoot valgus)

  • Tendons
    • Debridement
    • Tenodesis
    • Tendon …
    • … repair
  • Ligaments
    • … repair
    • Tendon transfer
  • Bone
    • …tomy
    • …stectomy
A
  • Tendons
    • Debridement
    • Tenodesis
    • Tendon transfer
    • Direct repair
  • Ligaments
    • Indirect repair
    • Tendon transfer
  • Bone
    • Osteotomy
    • Exostectomy
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7
Q

How do we achieve this surgically? (natural hindfoot valgus)

  • Tendons
    • …ment
    • …
    • … transfer
    • Direct repair
  • Ligaments
    • Indirect repair
    • Tendon transfer
  • Bone
    • Osteotomy
    • Exostectomy
A
  • Tendons
    • Debridement
    • Tenodesis
    • Tendon transfer
    • Direct repair
  • Ligaments
    • Indirect repair
    • Tendon transfer
  • Bone
    • Osteotomy
    • Exostectomy
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8
Q

Aims of treating Foot and Ankle Pathology

  • Is always to achieve a foot which is :
    • …
    • Plantigrade
    • … normal
    • Functionally normal
A
  • Is always to achieve a foot which is :
    • Painless
    • Plantigrade
    • Structurally normal
    • Functionally normal
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9
Q

Aims of treating Foot and Ankle Pathology

  • Is always to achieve a foot which is :
    • Painless
    • …
    • Structurally normal
    • … normal
A
  • Is always to achieve a foot which is :
    • Painless
    • Plantigrade
    • Structurally normal
    • Functionally normal
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10
Q

Achilles Tendon

  • Also known as the … cord
  • The gastrocnemius, soleus and plantaris muscle unites to form a band of fibrous tissue which becomes the Achilles tendon which attaches to the … tuberosity
  • … and … tendon
  • Approximately 15 cm in length
  • … of the foot
A
  • Also known as the heel cord
  • The gastrocnemius, soleus and plantaris muscle unites to form a band of fibrous tissue which becomes the Achilles tendon which attaches to the calcaneal tuberosity
  • Largest and strongest tendon
  • Approximately 15 cm in length
  • Plantarflexor of the foot
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11
Q

Achilles Tendon

  • Also known as the heel cord
  • The …, soleus and … muscle unites to form a band of fibrous tissue which becomes the Achilles tendon which attaches to the calcaneal tuberosity
  • Largest and strongest tendon
  • Approximately … cm in length
  • Plantarflexor of the foot
A
  • Also known as the heel cord
  • The gastrocnemius, soleus and plantaris muscle unites to form a band of fibrous tissue which becomes the Achilles tendon which attaches to the calcaneal tuberosity
  • Largest and strongest tendon
  • Approximately 15 cm in length
  • Plantarflexor of the foot
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12
Q

Achilles tendon is approximately … cm in length

A

Achilles tendon is approximately 15 cm in length

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13
Q

Label the diagram

A
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14
Q

Why is the achilles tendon vulnerable to pathology?

  • Unlike other tendons it has no … …
  • It is surrounded by a … (connective tissue sheath to ensure gliding )
  • It has a poor blood supply
    • i. Posterior tibial artery ( proximal and distal section)
    • ii. Peroneal artery ( supplies midsection)
  • Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
A
  • Unlike other tendons it has no tendon sheath
  • It is surrounded by a paratenon ( connective tissue sheath to ensure gliding )
  • It has a poor blood supply
    • i. Posterior tibial artery ( proximal and distal section)
    • ii. Peroneal artery ( supplies midsection)
  • Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
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15
Q

Why is the achilles tendon vulnerable to pathology?

  • Unlike other tendons it has no tendon sheath
  • It is surrounded by a paratenon ( connective tissue sheath to ensure …)
  • It has a poor … …
    • i. Posterior … artery (proximal and distal section)
    • ii. … artery ( supplies midsection)
  • Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
A
  • Unlike other tendons it has no tendon sheath
  • It is surrounded by a paratenon ( connective tissue sheath to ensure gliding )
  • It has a poor blood supply
    • i. Posterior tibial artery ( proximal and distal section)
    • ii. Peroneal artery ( supplies midsection)
  • Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
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16
Q

Why is the achilles tendon vulnerable to pathology?

  • Unlike other tendons it has no tendon sheath
  • It is surrounded by a paratenon ( connective tissue sheath to ensure gliding )
  • It has a poor blood supply
    • i. Posterior tibial artery ( proximal and distal section)
    • ii. Peroneal artery ( supplies midsection)
  • Blood vascularity weakest at the … –… interface
  • Blood supply weakest at 2 to 6 cm from the … attachment
A
  • Unlike other tendons it has no tendon sheath
  • It is surrounded by a paratenon ( connective tissue sheath to ensure gliding )
  • It has a poor blood supply
    • i. Posterior tibial artery ( proximal and distal section)
    • ii. Peroneal artery ( supplies midsection)
  • Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
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17
Q
  • Achilles tendon - Blood vascularity weakest at the … –tendon interface
  • Blood supply weakest at .. to … cm form the calcaneal attachment
A
  • Achilles tendon - Blood vascularity weakest at the bone –tendon interface
  • Blood supply weakest at 2 to 6 cm form the calcaneal attachment
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18
Q

Achilles rupture

  • Occurs after a sudden forced … to the foot
  • Violent … in a planatar flexed foot
  • Usually ruptures 4 to 6 cm above the calcaneal insertion in the hypovascular region
A
  • Occurs after a sudden forced plantarflexion to the foot
  • Violent dorsiflexion in a plantar flexed foot
  • Usually ruptures 4 to 6 cm above the calcaneal insertion in the hypovascular region
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19
Q

Achilles rupture

  • Occurs after a sudden forced … to the foot
  • Violent dorsiflexion in a … foot
  • Usually ruptures 4 to 6 cm above the … insertion in the hypovascular region
A
  • Occurs after a sudden forced plantarflexion to the foot
  • Violent dorsiflexion in a plantar flexed foot
  • Usually ruptures 4 to 6 cm above the calcaneal insertion in the hypovascular region
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20
Q

Achilles Rupture - Treatment

  • Most common - In Functional …
  • Surgery
    • … to … repair
    • VY advancement
  • Failure to heal- Tendon …
  • Tendon used is the one closest in proximity – FLEXOR HALLUCIS LONGUS
A
  • In Functional bracing
  • Surgery
    • End to end repair
    • VY advancement
  • Failure to heal- Tendon transfer
  • Tendon used is the one closest in proximity – FLEXOR HALLUCIS LONGUS
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21
Q

Achilles Rupture - Treatment

  • Most common - In Functional bracing
  • Surgery
    • End to end repair
    • … advancement
  • Failure to heal- … transfer
  • Tendon used is the one closest in proximity – FLEXOR … …
A
  • In Functional bracing
  • Surgery
    • End to end repair
    • VY advancement
  • Failure to heal- Tendon transfer
  • Tendon used is the one closest in proximity – FLEXOR HALLUCIS LONGUS
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22
Q

What is tendon transfer?

A

This procedure repositions the flexor hallucis longus tendon, (commonly called the “FHL” tendon) to reinforce a diseased Achilles tendon.

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23
Q

When is tendon transfer used?

A

This procedure repositions the flexor hallucis longus tendon, (commonly called the “FHL” tendon) to reinforce a diseased Achilles tendon.

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24
Q

Surgical approach to the Achilles

  • Patient is … (Requires intubation) or in lazy … position
  • Landmarks: The malleoli and the Achilles tendon- which is easily …
  • Incision: Longitudinal – slightly medially based ( but can go laterally as well)
  • Structure to avoid : … nerve laterally
  • Avoid going medial to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
A
  • Patient is prone (Requires intubation) or in lazy lateral position
  • Landmarks: The malleoli and the Achilles tendon- which is easily palpable
  • Incision: Longitudinal – slightly medially based ( but can go laterally as well)
  • Structure to avoid : Sural nerve laterally
  • Avoid going medial to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
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25
_Surgical approach to the Achilles_ * Patient is prone (Requires intubation) or in lazy lateral position * Landmarks: The ... and the Achilles tendon- which is easily palpable * Incision: Longitudinal – slightly ... based ( but can go ... as well) * Structure to avoid : Sural nerve laterally * Avoid going medial to Flexor ... ... (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
* Patient is prone (Requires intubation) or in lazy lateral position * Landmarks: The **malleoli** and the Achilles tendon- which is easily palpable * Incision: Longitudinal – slightly **medially** based ( but can go **laterally** as well) * Structure to avoid : Sural nerve laterally * Avoid going medial to **Flexor hallucis longus** (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
26
_Surgical approach to the Achilles_ * Patient is prone (Requires ...) or in lazy lateral position * Landmarks: The malleoli and the Achilles tendon- which is easily palpable * Incision: ... – slightly medially based ( but can go laterally as well) * Structure to avoid : Sural nerve laterally * Avoid going medial to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - ... BUNDLE MEDIALLY
* Patient is prone (Requires **intubation**) or in lazy lateral position * Landmarks: The malleoli and the Achilles tendon- which is easily palpable * Incision: **Longitudinal** – slightly medially based ( but can go laterally as well) * Structure to avoid : Sural nerve laterally * Avoid going medial to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - **NEUROVASCULAR** BUNDLE MEDIALLY
27
_Surgical approach to the Achilles_ * Patient is prone (Requires intubation) or in lazy lateral position * Landmarks: The ... and the Achilles tendon- which is easily palpable * Incision: Longitudinal – slightly medially based ( but can go laterally as well) * Structure to avoid : Sural nerve laterally * Avoid going .... to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
* Patient is prone (Requires intubation) or in lazy lateral position * Landmarks: The **malleoli** and the Achilles tendon- which is easily palpable * Incision: Longitudinal – slightly medially based ( but can go laterally as well) * Structure to avoid : Sural nerve laterally * Avoid going **medial** to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY
28
_Tibialis Posterior Tendon_ * ... aspect of .... membrane, fibula and tibia and has ... insertions in the foot * Action- * Plantarflexes the ... joint * Principal invertor of the foot * Adducts and supinates the foot * Arterial supply form the Posterior tibial, peroneal and sural nerve * Has a watershed area around the medial malleoli
* **Posterior** aspect of **interosseous** membrane, fibula and tibia and has **9** insertions in the foot * Action- * Plantarflexes the **ankle** joint * Principal invertor of the foot * Adducts and supinates the foot * Arterial supply form the Posterior tibial, peroneal and sural nerve * Has a watershed area around the medial malleoli
29
_Tibialis Posterior Tendon_ * Posterior aspect of interosseous membrane, fibula and tibia and has 9 insertions in the foot * Action- * .... the ankle joint * Principal ... of the foot * Adducts and ... the foot * ... supply form the Posterior tibial, peroneal and sural nerve * Has a watershed area around the medial ...
* Posterior aspect of interosseous membrane, fibula and tibia and has 9 insertions in the foot * Action- * **Plantarflexes** the ankle joint * Principal **invertor** of the foot * Adducts and **supinates** the foot * **Arterial** supply form the Posterior tibial, peroneal and sural nerve * Has a watershed area around the medial **malleoli**
30
What tendon is this?
Tibialis posterior tendon
31
_Function of Tibialis Posterior Tendon​_ * ... lower leg * Facilitates foot ... * Supports the foot’s ... arch * Plays a critical role in hindfoot inversion during the gait cycle
​ * **Stabilise** lower leg * Facilitates foot **inversion** * Supports the foot’s **medial** arch * Plays a critical role in hindfoot inversion during the gait cycle
32
_Function of Tibialis Posterior Tendon​_ * Stabilise ... leg * Facilitates foot inversion * Supports the foot’s medial arch * Plays a critical role in ... inversion during the ... cycle
​ * Stabilise **lower** leg * Facilitates foot inversion * Supports the foot’s medial arch * Plays a critical role in **hindfoot** inversion during the **gait** cycle
33
_Tibialis Posterior Insufficiency_ * Presenting symptoms/signs * Post-... pain * ... pain + aching * Progressive ... foot deformity * Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities * Rarely, tarsal tunnel syndrome
* Presenting symptoms/signs * Post-**malleolar** pain * **Arch** pain + aching * Progressive **flat** foot deformity * Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities * Rarely, tarsal tunnel syndrome
34
_Tibialis Posterior Insufficiency_ * Presenting symptoms/signs * Post-malleolar pain * Arch pain + aching * Progressive flat foot deformity * ... problems: progressive hallux ..., metatarsalgia, ... toe deformities * Rarely, ... tunnel syndrome
* Presenting symptoms/signs * Post-malleolar pain * Arch pain + aching * Progressive flat foot deformity * **Forefoot** problems: progressive hallux **valgus**, metatarsalgia, **lesser** toe deformities * Rarely, **tarsal** tunnel syndrome
35
_Tibialis Posterior Insufficiency_
36
_Tibialis Posterior Insufficiency- Treatment_ * Non-surgical * ... * ... wear modification * Orthotics- ... arch supports * Physiotherapy * Surgery * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
* Non-surgical * **Analgesics** * **Shoe** wear modification * Orthotics - **medial** arch supports * Physiotherapy * Surgery * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
37
_Tibialis Posterior Insufficiency- Treatment_ * Non-surgical * Analgesics * Shoe wear modification * ...- medial arch supports * ...therapy * Surgery * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
* Non-surgical * Analgesics * Shoe wear modification * **Orthotics**- medial arch supports * **Physiotherapy** * Surgery * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
38
_Tibialis Posterior Insufficiency- Treatment_ * Non-surgical * Analgesics * Shoe wear modification * Orthotics- medial arch supports * Physiotherapy * Surgery * ... (... transfer) * ... (if secondary arthritis)
* Non-surgical * Analgesics * Shoe wear modification * Orthotics- medial arch supports * Physiotherapy * Surgery * **Reconstruction** (**tendon** transfer) * **Fusion** (if secondary arthritis)
39
_Tibialis Posterior Insufficiency- Treatment_ * Non-... * Analgesics * Shoe wear modification * Orthotics - ... arch supports * Physiotherapy * ... * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
* Non-**surgical** * Analgesics * Shoe wear modification * Orthotics - **medial** arch supports * Physiotherapy * **Surgery** * Reconstruction (tendon transfer) * Fusion (if secondary arthritis)
40
What are the two surgical options for tibialis posterior insufficiency?
reconstruction (tendon transfer) or fusion (if secondary arthritis)
41
Tibialis Posterior Dysfunction - Which tendon to use for the transfer?
Tibialis Posterior Dysfunction - Which tendon to use for the transfer? **(flexor digitorum)**
42
_Surgical Approach to Tibialis Posterior tendon_ * Position: ... * Landmark: Tip of medial ... and the base of the ... * Incision : 10 cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long saphenous vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the great toe and FDL will plantarflex the lesser toes) * Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable
* Position: **Supine** * Landmark: Tip of medial **malleoli** and the base of the **navicular** * Incision : 10 cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long saphenous vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the great toe and FDL will plantarflex the lesser toes) * Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable
43
_Surgical Approach to Tibialis Posterior tendon_ * Position: Supine * Landmark: Tip of medial malleoli and the base of the navicular * Incision : ... cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long ... vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the great toe and FDL will plantarflex the lesser toes) * Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable
* Position: Supine * Landmark: Tip of medial malleoli and the base of the **navicular** * Incision : **10** cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long **saphenous** vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the great toe and FDL will plantarflex the lesser toes) * Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable
44
_Surgical Approach to Tibialis Posterior tendon_ * Position: Supine * Landmark: Tip of ... malleoli and the base of the navicular * Incision : 10 cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long saphenous vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the ... toe and FDL will plantarflex the ... toes) * Dangers: Saphenous nerve and the ... ... tendon are particularly vulnerable
* Position: Supine * Landmark: Tip of **medial** malleoli and the base of the navicular * Incision : 10 cm longitudinal incision from tip of MM * Internervous plane : None * Dissection : Avoid damage to the long saphenous vein and nerve * Divide the retinaculum and identify the tibialis posterior tendon by pulling on it * (FHL will plantar flex the **great** toe and FDL will plantarflex the **lesser** toes) * Dangers: Saphenous nerve and the **tibialis posterior** tendon are particularly vulnerable
45
Danger of surgical approach to tibialis posterior tendon - ... nerve and the tibialis posterior tendon are particularly vulnerable
Danger of surgical approach to tibialis posterior tendon - **Saphenous** nerve and the tibialis posterior tendon are particularly vulnerable
46
_Tibialis Posterior Dysfunction_ * Identifying it
47
_Ankle Arthritis_ * Usually post-... * Presentation: * Pain * ... * Deformity
* Usually post-**traumatic** * Presentation: * Pain * **Swelling** * Deformity
48
_Ankle Arthritis_ * Usually post-traumatic * Presentation: * ... * Swelling * ...
* Usually post-traumatic * Presentation: * **Pain** * Swelling * **Deformity**
49
_Pathology - Ankle Arthritis_ * Nasty ... – cartilage damage * Malalignment – leads to abnormal loading * ... altered in the ankle joint * Leads to abnormal point loading * Eventual joint space narrowing and pain
* Nasty **fracture** – cartilage damage * Malalignment – leads to abnormal loading * **Biomechanics** altered in the ankle joint * Leads to abnormal point loading * Eventual joint space narrowing and pain
50
_Pathology - Ankle Arthritis_ * Nasty fracture – cartilage damage * ... – leads to abnormal loading * Biomechanics altered in the ankle joint * Leads to abnormal ... loading * Eventual joint space narrowing and pain
* Nasty fracture – cartilage damage * **Malalignment** – leads to abnormal loading * Biomechanics altered in the ankle joint * Leads to abnormal **point** loading * Eventual joint space narrowing and pain
51
_Pathology - Ankle Arthritis_ * Nasty fracture – cartilage damage * Malalignment – leads to abnormal ... * Biomechanics altered in the ankle joint * Leads to abnormal point loading * Eventual joint space ... and pain
* Nasty fracture – cartilage damage * Malalignment – leads to abnormal **loading** * Biomechanics altered in the ankle joint * Leads to abnormal point loading * Eventual joint space **narrowing** and pain
52
_Pathology - Ankle Arthritis_ * Nasty fracture – cartilage ... * ... – leads to abnormal loading * Biomechanics altered in the ankle joint * Leads to abnormal point loading * Eventual joint space narrowing and pain
* Nasty fracture – cartilage **damage** * **Malalignment** – leads to abnormal loading * Biomechanics altered in the ankle joint * Leads to abnormal point loading * Eventual joint space narrowing and pain
53
_Surgical Management of Ankle Arthritis_ * Failed medical / non-operative control………… * “Early” disease - joint ... * Arthroscopy (or open procedure) * Debridement / synovectomy * “Late” disease – joint ... or replacement * Arthrodesis (fusion) * Arthroplasty (replacement) * Excision Arthroplasty (excision joint)
* Failed medical / non-operative control………… * “Early” disease - joint **preservation** * Arthroscopy (or open procedure) * Debridement / synovectomy * “Late” disease – joint **abolition** or replacement * Arthrodesis (fusion) * Arthroplasty (replacement) * Excision Arthroplasty (excision joint)
54
_Surgical Management of Ankle Arthritis_ * Failed medical / non-operative control………… * “...” disease - joint preservation * Arthroscopy (or open procedure) * Debridement / synovectomy * “...” disease – joint abolition or ... * Arthrodesis (...) * Arthroplasty (replacement) * Excision Arthroplasty (excision joint)
* Failed medical / non-operative control………… * “**Early**” disease - joint preservation * Arthroscopy (or open procedure) * Debridement / synovectomy * “**Late**” disease – joint abolition or **replacement** * Arthrodesis (**fusion**) * Arthroplasty (replacement) * Excision Arthroplasty (excision joint)
55
_Surgical Management of Ankle Arthritis_ * Failed medical / non-operative control………… * “Early” disease - joint preservation * Arthroscopy (or open procedure) * ... / synovectomy * “Late” disease – joint abolition or replacement * Arthrodesis (fusion) * ... (replacement) * Excision ... (excision joint)
* Failed medical / non-operative control………… * “Early” disease - joint preservation * Arthroscopy (or open procedure) * **Debridement** / synovectomy * “Late” disease – joint abolition or replacement * Arthrodesis (fusion) * **Arthroplasty** (replacement) * Excision **Arthroplasty** (excision joint)
56
_Ankle Arthroplasty_ * ... relief * Preservation of joint ... * Preservation of function * Polyarthropathy; Subtalar / Triple complex * Compare with ankle arthrodesis
* **Pain** relief * Preservation of joint **mobility** * Preservation of function * Polyarthropathy; Subtalar / Triple complex * Compare with ankle arthrodesis
57
_Ankle Arthroplasty_ * Pain relief * Preservation of joint mobility * Preservation of ... * ...; Subtalar / Triple complex * Compare with ankle ...
* Pain relief * Preservation of joint mobility * Preservation of **function** * **Polyarthropathy**; Subtalar / Triple complex * Compare with ankle **arthrodesis**
58
_Ankle Fusion/ Arthrodesis_ * Indications * ... Relief * Severe ... * TAR not appropriate
* Indications * **Pain** Relief * Severe **Deformity** * TAR not appropriate
59
_Ankle Fusion/ Arthrodesis_ * Indications * Pain Relief * Severe Deformity * ... not appropriate
* Indications * Pain Relief * Severe Deformity * **TAR** not appropriate
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_Anterior Approach to the Ankle for TAR_ * Position : ... * Landmarks: Both the ... which are subcutaneous * Incision : 15 cm longitudinal incision midway between the malleoli * Internervous Plane: None * Intermuscular plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the ... bundle and mobilise laterally * Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery
* Position : **Supine** * Landmarks: Both the **malleoli** which are subcutaneous * Incision : 15 cm longitudinal incision midway between the **malleoli** * Internervous Plane: None * Intermuscular plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the **neurovascular** bundle and mobilise laterally * Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery
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_Anterior Approach to the Ankle for TAR_ * Position : Supine * Landmarks: Both the malleoli which are sub... * Incision : ... cm longitudinal incision midway between the malleoli * Internervous Plane: None * Intermuscular plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the neurovascular bundle and mobilise ... * Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery
* Position : Supine * Landmarks: Both the malleoli which are **subcutaneous** * Incision : **15** cm longitudinal incision midway between the malleoli * Internervous Plane: None * Intermuscular plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the neurovascular bundle and mobilise **laterally** * Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery
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_Anterior Approach to the Ankle for TAR_ * Position : Supine * Landmarks: Both the malleoli which are subcutaneous * Incision : 15 cm longitudinal incision midway between the malleoli * ... Plane: None * ... plane : Between EHL and EDL (both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the neurovascular bundle and mobilise laterally * Dangers: i. Superficial ... nerve ii. Deep ... nerve iii. Anterior tibial artery
* Position : Supine * Landmarks: Both the malleoli which are subcutaneous * Incision : 15 cm longitudinal incision midway between the malleoli * **Internervous** Plane: None * **Intermuscular** plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision) * Dissection : Find the neurovascular bundle and mobilise laterally * Dangers: i. Superficial **peroneal** nerve ii. Deep **peroneal** nerve iii. Anterior tibial artery
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Anterior Approach to the Ankle for TAR - dangers (Which nerves (2) and artery)
**Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery**
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_Tibiotalocalcaneal Arthrodesis (TTC)_ * Severe ... * ... ankle fractures * Complex failed ankle fixation * Failed TAR * \* If TNJ / CCJ involved – consider pantalar arthrodesis
* Severe **deformity** * **Osteoporotic** ankle fractures * Complex failed ankle fixation * Failed TAR * \* If TNJ / CCJ involved – consider pantalar arthrodesis
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_Tibiotalocalcaneal Arthrodesis (TTC)_ * Severe deformity * Osteoporotic ankle fractures * Complex failed ankle ... * Failed TAR * \* If TNJ / CCJ involved – consider pantalar ...
* Severe deformity * Osteoporotic ankle fractures * Complex failed ankle **fixation** * Failed TAR * \* If TNJ / CCJ involved – consider pantalar **arthrodesis**
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_Tibiotalocalcaneal Arthrodesis (TTC)_ * Severe deformity * Osteoporotic ankle fractures * Complex ... ankle fixation * Failed ... * \* If TNJ / CCJ involved – consider pantalar arthrodesis
* Severe deformity * Osteoporotic ankle fractures * Complex **failed** ankle fixation * Failed **TAR** * \* If TNJ / CCJ involved – consider pantalar arthrodesis
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_Ankle “Sprains”_ * ... ligament * Passes form anterior margin of the fibular malleolus, to the talus bone
* **Lateral** ligament * Passes form anterior margin of the fibular malleolus, to the talus bone
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_Ankle “Sprains”_ * Lateral ligament * Passes from anterior margin of the ... malleolus, to the ... bone
* Lateral ligament * Passes form anterior margin of the **fibular** malleolus, to the **talus** bone
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_ATFL (Anterior talofibular ) /CFL (Calcaneofibular)_ * In ankle '...' ligaments affected (+posterior talofibular) * Weakest and commonly ... * Commonly gets bruised and stretched during inversion injuries * Prevents talar tilt * If weak then the ankle feels ... * Positive anterior drawer test * Positive talar tilt test
* In ankle '**sprain**' ligaments affected (+posterior talofibular) * Weakest and commonly **injured** * Commonly gets bruised and stretched during inversion injuries * Prevents talar tilt * If weak then the ankle feels **unstable** * Positive anterior drawer test * Positive talar tilt test
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_ATFL (Anterior talofibular ) /CFL (Calcaneofibular)_ * In ankle 'sprain' ligaments affected (+posterior talofibular) * Weakest and commonly injured * Commonly gets ... and stretched during inversion injuries * Prevents ... tilt * If weak then the ankle feels unstable * Positive ... drawer test * Positive talar tilt test
* In ankle 'sprain' ligaments affected (+posterior talofibular) * Weakest and commonly injured * Commonly gets **bruised** and stretched during inversion injuries * Prevents **talar** tilt * If weak then the ankle feels unstable * Positive **anterior** drawer test * Positive talar tilt test
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_ATFL (Anterior talofibular ) /CFL (Calcaneofibular)_ * In ankle 'sprain' ligaments affected (+posterior talofibular) * Weakest and commonly injured * Commonly gets bruised and ... during ... injuries * Prevents talar tilt * If weak then the ankle feels unstable * Positive anterior drawer test * Positive ... ... test
* In ankle 'sprain' ligaments affected (+posterior talofibular) * Weakest and commonly injured * Commonly gets bruised and **stretched** during **inversion** injuries * Prevents talar tilt * If weak then the ankle feels unstable * Positive anterior drawer test * Positive **talar tilt** test
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_Ankle “Sprains”_ * Majority sprains recover within 3 months * Beware the sprain that ... * Back to basics – clinical ...
* Majority sprains recover within 3 months * Beware the sprain that **persists**….. * Back to basics – clinical **reassessment**
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The majority of ankle sprains recover within ... months
3 months
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_Ankle “Sprains” - Acute lateral ligament strain (ATFL) / CFL_ * RICE (... ... COMPRESSION ELEVATION) * Physiotherapy directed ... * Loading injured ligaments * Proprioception * Strength and return to ...
* RICE **(REST ICE** COMPRESSION ELEVATION) * Physiotherapy directed **rehabilitation** * Loading injured ligaments * Proprioception * Strength and return to **function**
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_Ankle “Sprains” - Acute lateral ligament strain (ATFL) / CFL_ * RICE (REST ICE ... ...) * Physiotherapy directed rehabilitation * ... injured ligaments * ...ception * Strength and return to function
* RICE (REST ICE **COMPRESSION ELEVATION)** * Physiotherapy directed rehabilitation * **Loading** injured ligaments * **Proprioception** * Strength and return to function
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After ankle sprain - may get Diagnosis of Chronic ...
After ankle sprain, may be left with chronic instability - may get a diagnosis: Chronic **Instability**
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_Diagnosis: Chronic Instability (ankle)_ * Examine - ... ... draw (sulcus sign) * Diagnose - further investigations - used to do stress ... but MRI more common now (very useful to demonstrate related pathology)
* Examine - **positive anterior** draw (sulcus sign) * Diagnose - further investigations - used to do stress **radiographs** but MRI more common now (very useful to demonstrate related pathology)
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_Diagnosis: Chronic Instability (ankle)_ * Examine - positive anterior draw (... sign) * Diagnose - further investigations - used to do stress radiographs but ... more common now (very useful to demonstrate related pathology)
* Examine - positive anterior draw (**sulcus** sign) * Diagnose - further investigations - used to do stress radiographs but **MRI** more common now (very useful to demonstrate related pathology)
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_Indications For Surgery - ankle sprain_ * Do we in acute rupture? * In chronic mechanical instability symptoms not responding to non operative rehabilitation?
* **Do we in acute rupture? - no** * **In chronic mechanical instability symptoms not responding to non operative rehabilitation? - yes**
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_Surgical Options - Ankle sprain_ * ... ... tissue over eachother with ... to tighten - sometimes tissue too flimsy = use anchors within bone to gain strength * Can use ... also - adjunct * If fail - tendon transfer (peroneus brevis tendon)
* **Double breast** tissue over eachother with **sutures** to tighten - sometimes tissue too flimsy = use anchors within bone to gain strength * Can use **tapes** also - adjunct * If fail - tendon transfer (peroneus brevis tendon)
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_Surgical Options - Ankle sprain_ * Double breast tissue over eachother with sutures to tighten - sometimes tissue too flimsy = use ... within bone to gain strength * Can use tapes also - adjunct * If fail - tendon transfer (... ... tendon)
* Double breast tissue over eachother with sutures to tighten - sometimes tissue too flimsy = use **anchors** within bone to gain strength * Can use tapes also - adjunct * If fail - tendon transfer (**peroneus brevis** tendon)
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_Hallux Valgus_ * Hallux valgus - deformity - big toe into valgus * Often called ... - which is the prominent median eminence * Commonly ... finding * Occur in females more than males * Family history +/- ... * No symptom = no surgery
* Hallux valgus - deformity - big toe into valgus * Often called **bunion** - prominent median eminence is the **bunion** * Commonly **incidental** finding * Occur in females more than males * Family history +/- **footwear** * No symptom = no surgery
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_Hallux Valgus_ * Hallux valgus - deformity - big toe into valgus * Often called bunion - prominent median eminence is the bunion * Commonly incidental finding * Occur in ... more than ... * ... history +/- footwear * No ... = no surgery
* Hallux valgus - deformity - big toe into valgus * Often called bunion - prominent median eminence is the bunion * Commonly incidental finding * **Occur in females more than males** * **Family history +/- footwear** * **No symptom = no surgery**
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_Hallux Valgus - Symptoms and Signs (5)_
* Pain * Deformity * Modification of shoe wear * Nerve irritation * Lesser toe deformity
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_Hallux Valgus - Symptoms and Signs (5)_ * Pain * Deformity * ... of shoe wear * ... irritation * ... toe deformity
* Pain * Deformity * **Modification of shoe wear** * **Nerve irritation** * **Lesser toe deformity**
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_Hallux Valgus - Treatment_ * Non- Surgical * Surgical * ...nectomy * ...tomy * Proximal * Metatarsal shaft * Distal * Ist TMT joint fusion * *Technique used depends on the cause and the amount of correction required*
* Non- Surgical * Surgical * **Bunio**nectomy * **Osteo**tomy * Proximal * Metatarsal shaft * Distal * Ist TMT joint fusion * *Technique used depends on the cause and the amount of correction required*
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_Hallux Valgus - Treatment_ * Non- Surgical * Surgical * Bunionectomy * Osteotomy * Proximal * ... shaft * Distal * Ist ... joint fusion * *Technique used depends on the cause and the amount of correction required*
* Non- Surgical * Surgical * Bunionectomy * Osteotomy * Proximal * **Metatarsal** shaft * Distal * Ist **TMT** joint fusion * *Technique used depends on the cause and the amount of correction required*
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_Biomechanics - Hallux Valgus Deformity_ * ... deviation of the 1st ray (The first ray is the segment of the foot composed of the first metatarsal and first cuneiform bones)
* **Medial** deviation of the 1st ray (The first ray is the segment of the foot composed of the first metatarsal and first cuneiform bones)
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity)_ * Position: ... * Landmarks: easily palpable 1st ... joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
* Position: **Supine** * Landmarks: easily palpable 1st **MTP** joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity)_ * Position: Supine * Landmarks: easily palpable 1st MTP joint * Incision: ... to the IP joint and curve over the ... eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
* Position: Supine * Landmarks: easily palpable 1st MTP joint * Incision: **Proximal** to the IP joint and curve over the **medial** eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity)_ * Position: Supine * Landmarks: easily ... 1st MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide ... and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
* Position: Supine * Landmarks: easily **palpable** 1st MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide **fascia** and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity)_ * Position: Supine * Landmarks: easily palpable ... MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal ... nerve ii. Extensor ... tendon iii, Flexor ... longus
* Position: Supine * Landmarks: easily palpable **1st** MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL * Internervous Plane : none * Dissection: divide fascia and then **periosteum** * Dangers: i. Dorsal **cutanous** nerve ii. Extensor **hallucis** tendon iii, Flexor **hallucis** longus
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity) - Dangers_ * i. ... ... nerve ii. ... hallucis tendon iii, ... hallucis longus
* **i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus**
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_Dorsomedial Approach to the Great Toe​ (hallux valgus deformity)_ * Position: Supine * Landmarks: easily palpable 1st MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying ... to EHL * Internervous Plane : ... * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
* Position: Supine * Landmarks: easily palpable 1st MTP joint * Incision: Proximal to the IP joint and curve over the medial eminence staying **medial** to EHL * Internervous Plane : **none** * Dissection: divide fascia and then periosteum * Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
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Take home message - surgery of foot and ankle
* Do not rely on x rays to define the injury * History taking and examination is the key to an accurate diagnosis * Think of the anatomy to understand the pathology * Exhaust non-surgical options first before considering surgical intervention * Before you operate : think of using the best surgical approach for that case
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Year 2 Medicine (162 decks)

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