L12- Introduction to surgery of foot and ankle Flashcards
What are the aims of treating foot and ankle patholgy?
Is always to achieve a foot which is:
- Painless
- Plantigrade
- Structurally normal
- Functionally normal
What is achilles tendon?
- Aka heel cord
- the gastrocnemius, soleus and plantaris muscle unites to form a band of fibrous tissue which becomes the achilles tendon which attached to the calcaneal tuberosity
- Largest and strongest tendon
- Approximately 15cm in length
- Plantarflexor of the foot
Why is the achilles tendon more prone to damage?
- Unlike other tendons it has no sheath
- it is surrounded by paratenon
- poor blood supply
- Blood vascularity weakest at the bone
- Blood supply weakest at 2 to 6 cm form the calcaneal attachment
Why does the achilles tendon rupture?
- Occurs after a sudden forced plantarflexion to the foot
- Violent dorsiflexion in a plantar flexed foot
- Usually ruptures 4-6 cm above the calcaneal insertion in the hypovascular region
What are the achilles rupture treatment?
- In functional bracing
- surgery: end to end repair
- VY advancement
- Failure to heal- tendon transfer
Which tendon is used for repair?
Tendon that is used is one closest in proximity- Flexor hallucis longus
What are the surgical approaches to the achilles?
- Patient is prone or in lazy lateral position
- Landmarks: the malleoli and the achillies tendon- which is easily palpable
- Incision: Longitudinal- slightly medially based (but can go laterally as well)
Which structures are the to avoid during the achillies surgery?
- Sural nerve laterally
- avoid going medial to flexor hallucis longus
- Neurovascular bundle medially
Describe the position of tibialis posterior tendon?
-Posterior aspect of interosseous membrane, fibula, and tibia and has 9 insertions in the foot
Describe the actions of Tibialis posterior tendon?
- Plantarflexes the ankle joint
- principle invertor of the foot
- adducts and suppinates the foot
Describe the arterial supply to the tibialis posterior tendon?
- Arterial supply from the posterior tibial, peroneal
- Nerve supply from sural nerve
What are the functions of tibialis posterior tendon?
- Stabilise lower leg
- facilitates foot inversion
- supports the foot’s medial arch
- plays a critical in hindfoot
What are the signs and symptoms of tibialis posterior insufficiency?
- Post malleolar pain
- arch pain + aching
- Progressive flat foot deformity
- progressive flat foot deformity
What are the forefoot problems?
- Progressive hallux valgus, metatarsalgia, lesser toe deformaties
- Rarely tarsal tunnel syndrome
What are the treatment options for tibialis posterior insufficiency?
1) Non surgical:
- Analgesics
- Shoe wear modification
- Orthotics: medial arch support
- Physiotherapy
2) Surgery
- Reconstruction
- Fusion (if secondary arthritis)
What is the reason ankle arthritis?
-Usually post traumatic
Describe the typical presentation of ankle arthritis?
- pain
- swelling
- deformity
Describe the typical pathology of ankle arthiritis?
- Nasty fracture: cartilage damage
- Malalighnment- leads to abnormal loading
- Biomechanics: altered in the ankle joint
- Leads to abnormal point loading
- Eventual joint space narrowing and pain
What are the surgical management of ankle arthiritis?
- Failed medical/non-operative control
1) Early disease: joint preservation - Arthroscopy (open procedure)
- Debridement/synovectomy
2) Late disease: Joint abolition or replacement - Arthrodesis (fusion)
- Arthroplasty (replacement)
- Excision arthroplasty (excision joint)
What are the purpose of the ankle arthroplasty?
- Pain relief
- Preservation of joint mobility
- Preservation of function
- Polyarthropathy; subtalar/triple complex
What are the indication for ankle fusion?
- Pain relief
- Severe deformity
- TAR not appropriate
What are the indications of tibiotalocalcaneal arthrodesis (TTC)?
- Severe deformity
- Osteoporotic ankle fracture
- Complex failed ankle fixation
- Failed TAR
What is the main ligament that may be responsible for ankle sprain?
- Lateral ligament
- Passed from anterior margin of the fibular melleolus to the talus bone.
- Includes 3 ligaments:
- Anterior talofibular (ATFL)
- Calcaneofibular (CFL)
- Posterior talofibular
What are the roles of ATFL/CFL in ankle sprains?
- Weakest/commonly injured
- commonly gets bruised and stretched during inversion injuries
What happens when ATFL/CFL are weak?
- Prevents talar tilt
- If weak then the ankle feels unstable
What are the tests to check the integrity of ATFl/CFL?
- Positive anterior drawer test
- positive talar tilt test
What is the prognosis of ankle sprains?
- Majority sprains recover within 3 months
- Beware the sprain that persists
Describe the treatment options for acute lateral ligament sprain?
- RICE
- Physiotherapy directed rehab
- Loading injured ligaments
- proprioception
- Strength and return to function
How is the diagnosis of chronic instability diagnosed?
- Via examination
- Positive anterior draw
What are the further investigations required to confirm the diagnosis of chronic instability?
- Stress radiographs
- MRI- very useful to demonstrate related pathology
when is the surgery considered for chronic instabilty?
- Acute rupture
- Chronic mechanical instability symptoms not responding to non-operative rehab
Which surgery is the most suitable?
-Tendon transfer
describe the presentation of hallux valgus?
- common incidental finding
- female>male
- Family history +/- footwear
- If no symptoms then no surgery
What are the preseting symptom/signs of hallux valgus?
- Pain
- Defority
- Modification of shoe wear
- Nerve irritation
- Lesser toe deformity
What are the treatment options for hallux valgus?
1) Non surgical
2) Surgical
- bunionectomy
- osteotomy
Which surgical techniques are used for osteotomy?
-proximal
-metatarsal shaft
-distal
-1st TMT joint fusion
Techniques depend on the cause and the amount of correction required
