Introduction to surgery of the foot and ankle

Question 1

Why is the foot important?

Answer 1

To ensure that we have a smooth gait cycle

If foot anatomy is abnormal foot function is compromised

Question 2

List the 3 sections of the foot

Answer 2

hindfoot, midfoot and forefoot

Question 3

What does the hindfoot normally have?

Answer 3

Valgus

Question 4

What are the aims of treating foot and ankle pathology?

Answer 4

Is always to achieve a foot which is :

- Painless
- Plantigrade
- Structurally normal
- Functionally normal

Question 5

Describe the achilles tendon

Answer 5

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

Question 6

Why is the achilles tendon vulnerable to pathology?

Answer 6

Unlike other tendons it has no tendon sheath
It is surrounded by a paratenon
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

Question 7

When does achilles rupture occur?

Answer 7

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

Question 8

How is Achilles rupture treated?

Answer 8

In Functional bracing 
Surgery 
End to end repair
VY advancement
Failure to heal- Tendon transfer

Question 9

Which tendon is used to treat achilles tendon

Answer 9

FLEXOR HALLUCIS LONGUS

Question 10

Describe the surgical approach to the achilles tendon

Answer 10

Patient is prone 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

Question 11

Describe the tibialis posterior tendon

Answer 11

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

Question 12

What is the function of tibialis posterior

Answer 12

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

Question 13

How does tibialis posterior insufficiency present?

Answer 13

Post-malleolar pain 
Arch pain + aching 
Progressive flat foot deformity
Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities 
Rarely, tarsal tunnel syndrome
Valgus hindfoot
Aquired flatfoot
Forefoot abduction

Question 14

Describe the treatment of tibialis posterior insufficiency

Answer 14

Non-surgical

- Analgesics
- Shoe wear modification
- Orthotics- medial arch supports
- Physiotherapy

Surgery

- Reconstruction (tendon transfer)
- Fusion (if secondary arthritis)

Question 15

Describe the surgical approach to posterior tibialis anterior

Answer 15

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 : Avid damage to the long saphenous vein and nerve
Divide the retinaculum and identify the tibialis posterior tendon by pulling on it
( FHL will plantart flex the great toe and FDL will plantarflex the lesser toes)
Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable

Question 16

Describe the presentation of ankle arthritis

Answer 16

Usually post-traumatic
Presentation:
	Pain
	Swelling
	Deformity

Question 17

Describe the pathology of ankle arthritis

Answer 17

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

Question 18

Describe the surgical management of ankle arthritis

Answer 18

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)

Question 19

Describe ankle arthroplasty

Answer 19

Indications

Pain relief

Preservation of joint mobility

Preservation of function

Polyarthropathy; Subtalar / Triple complex

Question 20

List the indications for ankle fusion/arthrodesis

Answer 20

Pain relief

Severe deformity

Question 21

Describe Anterior Approach to the Ankle for TAR

Answer 21

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 iv.

Question 22

Describe Tibiotalocalcaneal Arthrodesis(TTC)

Answer 22

Severe deformity
Osteoporotic ankle fractures
Complex failed ankle fixation
Failed TAR

Question 23

Describe ankle sprains

Answer 23

Lateral ligament

Passes form anterior margin of the fibular malleolus, to the talus bone

Question 24

List the 3 elements of the lateral ligament

Answer 24

Anterior talofibular ATFL
Calcaneofibular CFL
Posterior talofibular PTFL

Question 25

Describe ATFL/CFL

Answer 25

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

Question 26

Describe the treatment of ankle sprains

Answer 26

Majority sprains recover within 3 months

Beware the sprain that persists…..

Back to basics – clinical reassessment

Question 27

Describe Acute lateral ligament sprain (ATFL)

Answer 27

RICE
Physiotherapy directed rehabilitation
 Loading injured ligaments
 Proprioception
 Strength and return to function

Question 28

How is chronic instability diagnosed?

Answer 28

Examination: Positive anterior draw
Further investigations
Stress radiographs
MRI (very useful to demonstrate related pathology)

Question 29

Describe hallux valgus

Answer 29

Commonly incidental finding
Female&raquo_space;> Male
Family history +/- footwear
No symptoms = No surgery

Question 30

List the symptoms of hallux valgus

Answer 30

Pain
	Deformity
	Modification of shoe wear
	Nerve irritation
	Lesser toe deformity

Question 31

Describe the treatment of hallux valgus

Answer 31

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

Question 32

Describe the dorsomedial approach to the great toe

Answer 32

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