L12 - Intro to foot surgery

Question 1

INTRODUCTION

i) give three reasons why the foot is important

Answer 1

i) ensure we have a smooth gait cycle,
- is foot anatomy is compromised then foot function is also compromised
- need to be able to weight bear without discomfort

Question 2

BASIC FOOT AND ANKLE PATHOLOGY

i) what are the three sections of the foot?
ii) which part of the foot elevates it off the ground?
iii) which part is normally/physiologically valgus? what happens if this valgus is too much?
iv) what does a pathology in one area cause?

Answer 2

i) forefoot, midfoot and hindfoot
ii) mid foot elevates it off the ground
iii) hindfoot is normally valgus - if too much then mid and forefoot will compensate
iv) pathol in one area can cause reciprocating effects in the rest of the foot

Question 3

SURGICAL APPROACHES TO REPAIR

i) what is debridement?
ii) what is tenodesis?
iii) what approach may be taken if there is tendon rupture?
iv) which two approaches can be used to repair ligaments
v) what is an exostectomy? what other appraoch can be used to repair bone problems?

Answer 3

i) debridement is taking away a thickened area
ii) tenodesis is reconstruction of th tendon
iii) if tendon has ruptured then may do direct repair
iv) repair ligaments by indirect repair or tendon transfer

v) exostectomy - removal of part of bone
- can also do osteotomy - cuts/reshapes bone

Question 4

what four things do you want to achieve with foot/ankle treatment?

Answer 4

painless, platigrade, struc normal and func normal foot

Question 5

ACHILLES TENDON

i) what is it aka?
ii) which three muscles unite to form it? where does it attach on the foot?
iii) how may cm is it in length approx?
iv) what action does it have
v) why is it vulnerable to pathology?

Answer 5

i) heel cord

ii) gastrocnemius, soleus and plantaris
- attaches to the calcaneal tuberosity

iii) approx 15cm length
iv) plantar flexes the foot
v) vulnerable to pathol as it does not have a tendon sheath and has a poor blood supply

Question 6

ACHILLES TENDON PATHOLOGY

i) what is it surrounded by? what does this allow?
ii) what is the main reason its vulnerable to pathology?
iii) which arteries supply the prox/mid/distal section
iv) where is blood supply the weakest? what does that mean for this area?

Answer 6

i) surrounded by a paratendon - connective tissue to ensure gliding
ii) main reason its vulnerable is because it has a poor blood supply

iii) posterior tibial > prox and distal section
- peroneal (fib) artery > mid section

iv) blood supply is weakest at the bone/tendon interface eg 2-6cm from the calcaneal attachment > vulnerable to rupture here

Question 7

ACHILLES RUPTURE

i) what does it occur after? (2)
ii) where does it usually rupture in relation to the calcaeneal insertion?
iii) what can form after the tendon has ruptured?
iv) what is a non surgical treatment?
v) name three possible surgical repairs? give an indication for each
vi) which tendon is used for tendon transfer?

Answer 7

i) occ after sudden/forced plantarflexion to the foot
- or violent dorsiflextion in a plantar flexed foot

ii) usually ruptures 4-6cm above calcaneal insertion
iii) can form a haematoma
iv) non sx > functional bracing - put in boot with wedges

v) end to end repair (low re rupture rate),
- VY advancement (if long distance of tear)
- tendon transfer (if fails to heal)

vi) use flexor hallicus longus tendon as its close proximity

Question 8

SURGICAL APPROACH TO ACHILLES

i) why do you make the incision medially? which nerve is susceptible to damage here?
ii) if there was damage to the nerve, what would the patient experience?
iii) why do you need to avoid going too medial to FHL tendon?

Answer 8

i) to avoid the sural nerve
ii) sural nerve damage > numbness to base of foot
iii) medial to FHL = neurovascular bundle

Question 9

TIBIALIS POSTERIOR TENDON

i) where does it arise from? how many insertions does it have on the foot?
ii) give three actions
iii) which three arteries supply it?
iv) what pathology can occur in this tendon?
v) what part of the foot does it support

Answer 9

i) arises from posterior aspect of IO membrane bet fib and tib
- has 9 insertions into the foot

ii) plantar flex, principal inverter, adducts/supinates foot
iii) sup by posterior tibial, peroneal and sural artery
iv) tib posterior insufficiency
v) supports the medial arch

Question 10

TIBIALIS POSTERIOR INSUFFICIENCY

i) where may pain be felt? (2)
ii) what type of deformity may be seen? what does this progress to?
iii) what is rarely seen?
iv) how many toes should you be able to see when looking at the foot posterior? what may be seen in TPI

Answer 10

i) post malleloar and arch pain
ii) see progressive flat foot deformity > forefoot problems eg bunion
iii) rarely see tarsal tunnel syndrome

iv) should only be able to see one or two toes
- in TPI may be able to see all the toes

Question 11

what condition is characterised by valgus hindfoot, acquired flat foot and forefoot abduction?

Answer 11

tibialis posterior insufficiency

Question 12

TIB POSTERIOR INSUFFICIENCY TREATMENT

i) what is the first approach to treatment? give four examples
ii) name two types of sugery that can be done if it gets worse?
iii) which tendon may be used in tendon transfer? how is it tested if this is the right tendon?
iv) which vein and nerve need to be avoided? which tendon is vulnerable?

Answer 12

i) first approach is non surgical if there is no hindfoot deform
- analgesics, shoe wear modification, medial arch support and physiotherapy

ii) if gets worse can do reconstruction (break heel bone and push back in place > tendon transfer)
- or fusion (in secondary arthritis) - correct deformity

iii) use flexor digitorium longus (close prox)
- pull and see if toes flex

iv) avoid long saphenous vein and nerve
- tib posterior tendon is vulnerable

Question 13

ANKLE ARTHRITIS

i) what is it usually secondary to?
ii) which three things does it present with?
iii) what can it lead to in relation to loading? what eventually happens?
iv) what is the first approach to treatment? give three egs
v) which approach is taken in early disease and which approach is taken in late disease? (2)

Answer 13

i) usually secondary to trauma/fractures
ii) presents with pain, swelling, deformity
iii) can lead to abnormal point loading and eventual joint space narrowing
iv) first approach is non surgical eg activity mod, analgesia and steroid injections
v) early disease > joint preservation eg arthroscopy

late disease > joint abolition or replacement

Question 14

ANKLE ARTHROPLASTY

i) what is it?
ii) what two things does it aim to preserve?
iii) what is the gold standard for ankle arthritis treatment? give three indications for this

Answer 14

i) ankle joint replacement
ii) aims to preserve joint mobility and function

iii) gold standard is ankle arthrodesis (fusion)
- indics are pain relief, severe deformity and if total ankle replace is not appropritate

Question 15

TOTAL ANKLE REPLACEMENT

i) which tendons do you go between? which nerve are these supplied by?
ii) which two nerves and one artery need to be avoided?

Answer 15

i) go between EHL and EDL
- supplied by deep peroneal nerve

ii) avoid superficial peroneal nerve, deep peroneal nerve and ant tibial artery

Question 16

ANKLE SPRAIN

i) how many ligaments does the ankle involve?
ii) which two are commonly injured and weakest? what type of movement can make injury occur?
iii) what test would be positive? (2)
iv) how long does it take most people to recover?
v) what are the two main treatments initially

Answer 16

i) three

ii) anterior talofibular and calcaneofibular
- inversion injury

iii) anterior drawer and talar tilt test
iv) 3 months
v) RICE and physio

Question 17

CHRONIC ANKLE INSTABILITY

i) what sign would be seen on a posterior drawer test? describe
ii) which imaging method is useful to visualise it?
iii) when would surgery be done?
iv) what is the last resort surgery? what tendon is used?

Answer 17

i) sulcus sign > dimpling of skin on lateral ankle due to gap
ii) MRI
iii) is there is chronic mechanical instab and non respond to non op rehab
iv) tendon transfer using tibilais brevis tendon

Question 18

HALLUX VALGUS

i) what is it aka? what happens to the big toe?
ii) does it affect more males or females? name two thins that increase risk? is it routinely operated on
iii) name three presenting symptoms
iv) give two examples of non surgical and surgical treatment?
v) what does the surgical technique used depend on?

Answer 18

i) aka bunion

ii) aff more females
- inc risk if family history and wear compromising footwear

iii) pain, deformity, nerve irritation

iv) non sx - analgesics and modify footwear
sx - bunionectomy and osteotomy

v) technique depends on the cause and the amount of correction required

Question 19

SX FOR HALLUX VALGUS

i) which nerve and two tendons need to be aware of?
ii) what would happen if this nerve is damaged?
iii) damage to which tendon can cause hallux valgus?

Answer 19

i) dorsal cutaneous nerve, EH and FH tendon
ii) damage to DCN > numbess on dorsum of foot
iii) damage to tibialis posterior tendon