Introduction to surgery of the foot and ankle Flashcards
3 sections of the foot
Hindfoot
Midfoot
Forefoot
Aims of treating foot and ankle pathology
Painless
Plantigrade
Structurally normal
Functionally normal
Achilles tendon
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 15cm in length
Platarflexor of the foot
Achilles is vulnerable to pathology
It has no tendon sheath
Surrounded by a paratenon
Has poor blood supply
- posterior tibial arterty
- peroneal artery
Blood vascularity weakest at the bone tendon interface
Blood supply weakest at 2 to 6cm from the calcaneal attachment
Achilles rupture
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
Treatment of achilles rupture
In functional bracing
Surgery
- end to end repair
- VY advancement
- failure to heal- tendon transfer
Surgical approach to the achilles
Patient is prone or in lazy lateral position
Landmarks: the malleoli and the achilles tendon- which is easily palpable
Incision: longitudinal- slightly medially based
Structure to avoid: sural nerve laterally
Tibialis posterior tendon
Posterior aspect of interosseous membrane, fibula and tibia and has 9 insertions in the foot
Arterial supply from the posterior tibial, peroneal and sural nerve
Has a watershed area around the medial malleoli
Action of the tibialis posterior tendon
Plantarflexes the ankle joint
Principal invertor of the foot
Adducts and supinates the foot
Function of the tibialis posterior tendon
Stabilise the lower leg
Facilitates foot inversion
Supports the foot’s medial arch
Plays a critical role in hindfoot inversion during the gait cycle
Presenting symptoms/ signs of tibialis posterior insufficiency
Post malleolar pain
Arch pain and aching
Progressive flat foot deformity
Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
Rarely, tarsal tunnel syndrome
Causes of tibialis posterior insufficiency
Trauma
Chronic flat foot
Inflammatory arthropathy
Degenerative tendonopathy
Tibialis posterior insufficiency
Valgus hindfoot
Acquired flatfoot
Forefoot abduction
Treatment of tibialis posterior insufficiency
Non-surgical
- analgesics
- shoe wear modification
- orthotics- medial arch supports
- physiotherapy
Surgery
- reconstruction (tendon transfer)
- fusion (if secondary arthritis)
Surgical approach to tibialis posterior tendon
Position: supine
Landmark: tip of medial malleoli and the base of the navicular
Incision: 10cm longitudinal incision from tip of MM
Avoid damage to the long saphenous vein and nerve
Dangers: saphenous nerve and the tibialis posterior tendon are particularly vulnerable
Presentation of ankle arthritis
Pain
Swelling
Deformity
Pathology of ankle arthritis
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
Surgical management of ankle arthritis
Early disease- joint preservation
- arthroscopy
- debridement/ synovectomy
Late disease- joint abolition or replacement
- arthrodesis
- athroplasty
- excision arthroplasty
Ankle arthroplasty
Pain relief
Preservation of joint mobility
Preservation of function
Polarthropathy; subtalar/ triple complex
Ankle fusion/ arthrodesis indications
Pain relief
Severe deformity
TAR not appropriate
Anterior approach to the ankle for TAR
Position: supine
Landmarks: both the malleoli which are subcutaneous
Incision: 15cm longitudinal incision midway between the malleoli
Find the neurovascular bundle and mobilise laterally
Dangers: superficial peroneal nerve, deep peroneal nerve, anterior tibial artery
Tibiotalocalcaneal arthrodesis
Severe deformity
Osteoporotic ankle fractures
Complex failed ankle fixation
Failed TAR
Ankle sprains
Lateral ligament
Passes from anterior margin of the fibular malleolus to the talus bone
3 elements
- anterior talofibular
- calcaneofibular
- posterior talofibular
ATFL/ CFL
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
Hallux valgus
Commonly incidental funding
Female > male
Family history +/- footwear
No symptoms= no surgery
Presenting symptoms/ signs of hallux valgus
Pain
Deformity
Modification of shoe wear
Nerve irritation
Lesser toe deformity
Treatment of hallux valgus
Non- surgical
Surgical
- bunionectomy
- osteotomy
- 1st TMT joint fusion
Technique depends on the cause and the amount of correction required
Dorsomedial approach to the great toe
Position: supine
Landmarks: easily palpable 1st MTP joint
Incision: proximal to the IP joint and curve over the medial eminence staying medial to EHL
Divide fascia and then periosteum
Dangers: dorsal cutaneous nerve, extensor hallucis tendon, flexor hallucis longus
