Introduction to surgery of the foot and ankle

Question 1

3 sections of the foot

Answer 1

Hindfoot

Midfoot

Forefoot

Question 2

Aims of treating foot and ankle pathology

Answer 2

Painless

Plantigrade

Structurally normal

Functionally normal

Question 3

Achilles tendon

Answer 3

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

Question 4

Achilles is vulnerable to pathology

Answer 4

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

Question 5

Achilles rupture

Answer 5

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

Question 6

Treatment of achilles rupture

Answer 6

In functional bracing

Surgery

• end to end repair
• VY advancement
• failure to heal- tendon transfer

Question 7

Surgical approach to the achilles

Answer 7

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

Question 8

Tibialis posterior tendon

Answer 8

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

Question 9

Action of the tibialis posterior tendon

Answer 9

Plantarflexes the ankle joint

Principal invertor of the foot

Adducts and supinates the foot

Question 10

Function of the tibialis posterior tendon

Answer 10

Stabilise the lower leg

Facilitates foot inversion

Supports the foot’s medial arch

Plays a critical role in hindfoot inversion during the gait cycle

Question 11

Presenting symptoms/ signs of tibialis posterior insufficiency

Answer 11

Post malleolar pain

Arch pain and aching

Progressive flat foot deformity

Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities

Rarely, tarsal tunnel syndrome

Question 12

Causes of tibialis posterior insufficiency

Answer 12

Trauma

Chronic flat foot

Inflammatory arthropathy

Degenerative tendonopathy

Question 13

Tibialis posterior insufficiency

Answer 13

Valgus hindfoot

Acquired flatfoot

Forefoot abduction

Question 14

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

Surgical approach to tibialis posterior tendon

Answer 15

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

Question 16

Presentation of ankle arthritis

Answer 16

Pain

Swelling

Deformity

Question 17

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

Surgical management of ankle arthritis

Answer 18

Early disease- joint preservation

• arthroscopy
• debridement/ synovectomy

Late disease- joint abolition or replacement

• arthrodesis
• athroplasty
• excision arthroplasty

Question 19

Ankle arthroplasty

Answer 19

Pain relief

Preservation of joint mobility

Preservation of function

Polarthropathy; subtalar/ triple complex

Question 20

Ankle fusion/ arthrodesis indications

Answer 20

Pain relief

Severe deformity

TAR not appropriate

Question 21

Anterior approach to the ankle for TAR

Answer 21

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

Question 22

Tibiotalocalcaneal arthrodesis

Answer 22

Severe deformity

Osteoporotic ankle fractures

Complex failed ankle fixation

Failed TAR

Question 23

Ankle sprains

Answer 23

Lateral ligament

Passes from anterior margin of the fibular malleolus to the talus bone

3 elements

• anterior talofibular
• calcaneofibular
• posterior talofibular

Question 24

ATFL/ CFL

Answer 24

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 25

Hallux valgus

Answer 25

Commonly incidental funding

Female > male

Family history +/- footwear

No symptoms= no surgery

Question 26

Presenting symptoms/ signs of hallux valgus

Answer 26

Pain

Deformity

Modification of shoe wear

Nerve irritation

Lesser toe deformity

Question 27

Treatment of hallux valgus

Answer 27

Non- surgical

Surgical

• bunionectomy
• osteotomy
• 1st TMT joint fusion

Technique depends on the cause and the amount of correction required

Question 28

Dorsomedial approach to the great toe

Answer 28

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