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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
Q

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
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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26
Q

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
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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27
Q

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
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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28
Q

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
A
  • 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
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29
Q

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 …
A
  • 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
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30
Q

What tendon is this?

A

Tibialis posterior tendon

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31
Q

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
A

​

  • Stabilise lower leg
  • Facilitates foot inversion
  • Supports the foot’s medial arch
  • Plays a critical role in hindfoot inversion during the gait cycle
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32
Q

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
A

​

  • Stabilise lower leg
  • Facilitates foot inversion
  • Supports the foot’s medial arch
  • Plays a critical role in hindfoot inversion during the gait cycle
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33
Q

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
A
  • 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
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34
Q

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
A
  • 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
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35
Q

Tibialis Posterior Insufficiency

A
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36
Q

Tibialis Posterior Insufficiency- Treatment

  • Non-surgical
    • …
    • … wear modification
    • Orthotics- … arch supports
    • Physiotherapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
A
  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • Orthotics - medial arch supports
    • Physiotherapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
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37
Q

Tibialis Posterior Insufficiency- Treatment

  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • …- medial arch supports
    • …therapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
A
  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • Orthotics- medial arch supports
    • Physiotherapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
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38
Q

Tibialis Posterior Insufficiency- Treatment

  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • Orthotics- medial arch supports
    • Physiotherapy
  • Surgery
    • … (… transfer)
    • … (if secondary arthritis)
A
  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • Orthotics- medial arch supports
    • Physiotherapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
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39
Q

Tibialis Posterior Insufficiency- Treatment

  • Non-…
    • Analgesics
    • Shoe wear modification
    • Orthotics - … arch supports
    • Physiotherapy
  • …
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
A
  • Non-surgical
    • Analgesics
    • Shoe wear modification
    • Orthotics - medial arch supports
    • Physiotherapy
  • Surgery
    • Reconstruction (tendon transfer)
    • Fusion (if secondary arthritis)
40
Q

What are the two surgical options for tibialis posterior insufficiency?

A

reconstruction (tendon transfer) or fusion (if secondary arthritis)

41
Q

Tibialis Posterior Dysfunction - Which tendon to use for the transfer?

A

Tibialis Posterior Dysfunction - Which tendon to use for the transfer? (flexor digitorum)

42
Q

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
A
  • 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
Q

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
A
  • 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
Q

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
A
  • 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
Q

Danger of surgical approach to tibialis posterior tendon - … nerve and the tibialis posterior tendon are particularly vulnerable

A

Danger of surgical approach to tibialis posterior tendon - Saphenous nerve and the tibialis posterior tendon are particularly vulnerable

46
Q

Tibialis Posterior Dysfunction

  • Identifying it
47
Q

Ankle Arthritis

  • Usually post-…
  • Presentation:
    • Pain
    • …
    • Deformity
A
  • Usually post-traumatic
  • Presentation:
    • Pain
    • Swelling
    • Deformity
48
Q

Ankle Arthritis

  • Usually post-traumatic
  • Presentation:
    • …
    • Swelling
    • …
A
  • Usually post-traumatic
  • Presentation:
    • Pain
    • Swelling
    • Deformity
49
Q

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
A
  • 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
Q

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
A
  • 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
Q

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
A
  • 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
Q

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
A
  • 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
Q

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)
A
  • 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
Q

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)
A
  • 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
Q

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)
A
  • 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
Q

Ankle Arthroplasty

  • … relief
  • Preservation of joint …
  • Preservation of function
  • Polyarthropathy; Subtalar / Triple complex
    • Compare with ankle arthrodesis
A
  • Pain relief
  • Preservation of joint mobility
  • Preservation of function
  • Polyarthropathy; Subtalar / Triple complex
    • Compare with ankle arthrodesis
57
Q

Ankle Arthroplasty

  • Pain relief
  • Preservation of joint mobility
  • Preservation of …
  • …; Subtalar / Triple complex
    • Compare with ankle …
A
  • Pain relief
  • Preservation of joint mobility
  • Preservation of function
  • Polyarthropathy; Subtalar / Triple complex
    • Compare with ankle arthrodesis
58
Q

Ankle Fusion/ Arthrodesis

  • Indications
    • … Relief
    • Severe …
    • TAR not appropriate
A
  • Indications
    • Pain Relief
    • Severe Deformity
    • TAR not appropriate
59
Q

Ankle Fusion/ Arthrodesis

  • Indications
    • Pain Relief
    • Severe Deformity
    • … not appropriate
A
  • Indications
    • Pain Relief
    • Severe Deformity
    • TAR not appropriate
60
Q

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
A
  • 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
61
Q

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
A
  • 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
62
Q

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
A
  • 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
63
Q

Anterior Approach to the Ankle for TAR - dangers (Which nerves (2) and artery)

A

Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery

64
Q

Tibiotalocalcaneal Arthrodesis (TTC)

  • Severe …
  • … ankle fractures
  • Complex failed ankle fixation
  • Failed TAR
  • * If TNJ / CCJ involved – consider pantalar arthrodesis
A
  • Severe deformity
  • Osteoporotic ankle fractures
  • Complex failed ankle fixation
  • Failed TAR
  • * If TNJ / CCJ involved – consider pantalar arthrodesis
65
Q

Tibiotalocalcaneal Arthrodesis (TTC)

  • Severe deformity
  • Osteoporotic ankle fractures
  • Complex failed ankle …
  • Failed TAR
  • * If TNJ / CCJ involved – consider pantalar …
A
  • Severe deformity
  • Osteoporotic ankle fractures
  • Complex failed ankle fixation
  • Failed TAR
  • * If TNJ / CCJ involved – consider pantalar arthrodesis
66
Q

Tibiotalocalcaneal Arthrodesis (TTC)

  • Severe deformity
  • Osteoporotic ankle fractures
  • Complex … ankle fixation
  • Failed …
  • * If TNJ / CCJ involved – consider pantalar arthrodesis
A
  • Severe deformity
  • Osteoporotic ankle fractures
  • Complex failed ankle fixation
  • Failed TAR
  • * If TNJ / CCJ involved – consider pantalar arthrodesis
67
Q

Ankle “Sprains”

  • … ligament
  • Passes form anterior margin of the fibular malleolus, to the talus bone
A
  • Lateral ligament
  • Passes form anterior margin of the fibular malleolus, to the talus bone
68
Q

Ankle “Sprains”

  • Lateral ligament
  • Passes from anterior margin of the … malleolus, to the … bone
A
  • Lateral ligament
  • Passes form anterior margin of the fibular malleolus, to the talus bone
69
Q

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
A
  • 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
70
Q

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
A
  • 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
71
Q

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
A
  • 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
72
Q

Ankle “Sprains”

  • Majority sprains recover within 3 months
  • Beware the sprain that …
  • Back to basics – clinical …
A
  • Majority sprains recover within 3 months
  • Beware the sprain that persists…..
  • Back to basics – clinical reassessment
73
Q

The majority of ankle sprains recover within … months

74
Q

Ankle “Sprains” - Acute lateral ligament strain (ATFL) / CFL

  • RICE (… … COMPRESSION ELEVATION)
  • Physiotherapy directed …
    • Loading injured ligaments
    • Proprioception
    • Strength and return to …
A
  • RICE (REST ICE COMPRESSION ELEVATION)
  • Physiotherapy directed rehabilitation
    • Loading injured ligaments
    • Proprioception
    • Strength and return to function
75
Q

Ankle “Sprains” - Acute lateral ligament strain (ATFL) / CFL

  • RICE (REST ICE … …)
  • Physiotherapy directed rehabilitation
    • … injured ligaments
    • …ception
    • Strength and return to function
A
  • RICE (REST ICE COMPRESSION ELEVATION)
  • Physiotherapy directed rehabilitation
    • Loading injured ligaments
    • Proprioception
    • Strength and return to function
76
Q

After ankle sprain - may get Diagnosis of Chronic …

A

After ankle sprain, may be left with chronic instability - may get a diagnosis: Chronic Instability

77
Q

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)

A
  • 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)

78
Q

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)

A
  • 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)

79
Q

Indications For Surgery - ankle sprain

  • Do we in acute rupture?
  • In chronic mechanical instability symptoms not responding to non operative rehabilitation?
A
  • Do we in acute rupture? - no
  • In chronic mechanical instability symptoms not responding to non operative rehabilitation? - yes
80
Q

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)
A
  • 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)
81
Q

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)
A
  • 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)
82
Q

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
A
  • 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
83
Q

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
A
  • 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
84
Q

Hallux Valgus - Symptoms and Signs (5)

A
  • Pain
  • Deformity
  • Modification of shoe wear
  • Nerve irritation
  • Lesser toe deformity
85
Q

Hallux Valgus - Symptoms and Signs (5)

  • Pain
  • Deformity
  • … of shoe wear
  • … irritation
  • … toe deformity
A
  • Pain
  • Deformity
  • Modification of shoe wear
  • Nerve irritation
  • Lesser toe deformity
86
Q

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
A
  • 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
87
Q

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
A
  • 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
88
Q

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)
A
  • Medial deviation of the 1st ray (The first ray is the segment of the foot composed of the first metatarsal and first cuneiform bones)
89
Q

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
A
  • 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
90
Q

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
A
  • 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
91
Q

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
A
  • 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
92
Q

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
A
  • 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
93
Q

Dorsomedial Approach to the Great Toe​ (hallux valgus deformity) - Dangers

  • i. … … nerve ii. … hallucis tendon iii, … hallucis longus
A
  • i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus
94
Q

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
A
  • 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
95
Q

Take home message - surgery of foot and ankle

A
  • 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

Year 2 Medicine (162 decks)

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