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204-theme 1 > L17: Introduction to surgery of the foot and ankle > Flashcards

L17: Introduction to surgery of the foot and ankle Flashcards

1
Q

what is the importance of the foot

A
  • To ensure that we have a smooth gait cycle

- If foot anatomy is abnormal foot function is compromised

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2
Q

what are the sections of the foot

A

3 Sections- hindfoot,

midfoot and
forefoot

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3
Q

what does pathology in the foot cause

A

Pathology in any one of these areas has a reciprocating effect in the rest of the foot

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4
Q

describe the shape of the foot

A

Have a natural hindfoot valgus

Further valgus your midfoot and forefoot will compensate

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5
Q

what are the 4 main outcomes required for a foot surgery

A
  • Painless
    • Plantigrade
    • Structurally normal
    • Functionally normal
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6
Q

describe the achilles tendon

A

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

Plantar flexor of the foot

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7
Q

why is the achilles tendon vulnerable to pathology

A

Unlike other tendons it has no tendon sheath

It is surrounded by a paratenon

It has a poor blood supply:

  • 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
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8
Q

what is the achilles rapture

A
  • 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
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9
Q

how do you treat achilles rapture

A

Treatment:

In Functional bracing

Surgery :

  • End to end repair
  • VY advancement
  • Failure to heal- Tendon transfer

Tendon used is the one closest in proximity – FLEXOR HALLUCIS LONGUS

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10
Q

what is the surgical approach to the Achilles

A

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

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11
Q

describe the tibialis posterior tendon

A

Posterior aspect of interosseous membrane, fibula and tibia and has 9 insertions in the foot

Action-
-Plantar flexes 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

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12
Q

what are the functional features of the tibialis posterior insufficiency

A

Function of Tibialis Posterior Tendon:

  • Stabilise lower leg
  • Facilitates foot inversion
  • Supports the foot’s medial arch
  • Plays a critical role in hindfoot inversion during the gait cycle
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13
Q

describe some symptoms of tibialis posterior insufficiency

A

Post-malleolar pain

Arch pain + aching

Progressive flat foot deformity

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

Rarely, tarsal tunnel syndrome

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14
Q

describe the appearance of tibialis posterior insufficiency

A

1) Valgus hindfoot
2) Aquired flatfoot
3) Forefoot abduction

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15
Q

what is the treatment for the tibialis posterior insufficiency

A

Non-surgical
-Analgesics

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

Surgery
-Reconstruction (tendon transfer)

  • Fusion (if secondary arthritis)
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16
Q

what occurs in the surgery of the tibialis posterior

A
  • tibialis posterior tendon attenuated
  • FDL sutured to both stumps of tibialis posterior
  • FDL sutured to FL
  • Tibialis posterior debrided, drill hole in navicular
  • FDL released at knot of henry
17
Q

what is the surgical approach to tibialis posterior tendon

A

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

18
Q

what are the symptoms of ankle arthritis

A

Presentation:
-Pain

  • Swelling
  • Deformity
19
Q

describe the pathology of ankle arthritis

A

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

20
Q

what is the surgical management of ankle arthritis

A

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)
21
Q

describe ankle arthroplasty

A

Pain relief

Preservation of joint mobility

Preservation of function

Polyarthropathy; Subtalar / Triple complex

22
Q

describe the presentation of ankle fusion/ arthrodesis

A

Pain Relief

  • Severe Deformity
  • TAR not appropriate
23
Q

what is the anterior surgical approach to the ankle for TAR

A

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.

24
Q

describe Tibiotalocalcaneal Arthrodesis(TTC) presentation

A

Severe deformity

Osteoporotic ankle fractures

Complex failed ankle fixation

Failed TAR

25
Q

describe ankle sprains

A

Lateral ligament

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

3 elements
1-Anterior talofibular ATFL

2-Calcaneofibular CFL

3-Posterior talofibular PTFL

26
Q

describe the incidence of Acute lateral ligament sprain ATFL /CFL

A

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
27
Q

Describe treatment for Acute lateral ligament sprain (ATFL)

A

RICE

Physiotherapy directed rehabilitation

  • Loading injured ligaments
  • Proprioception
  • Strength and return to function
28
Q

how do you diagnose chronic instability

A

on examination - posterior anterior draw

further investigation: - stress radiographs
- MRI (very useful to demonstrate related pathology)

  • > 1cm ->15cm
29
Q

what are the indications for surgery

A

no surgery if its just an acute rapture

perform surgery if there is chronic mechanical instability symptoms that are not responding to non-operative rehabilitation

30
Q

what are some surgery options for chronic instability

A
  • sutures

- tendon transfers

31
Q

name the 2 conditions involved in hallux valgus

A
  • hallux valgus

- bunion

32
Q

describe the pathology of hallux valgus

A

Hallux valgus, often referred to as “a bunion,” is a deformity of the big toe.

The toe tilts over towards the smaller toes and a bony lump appears on the inside of the foot.

(A bony lump on the top of the big toe joint is usually due to a different condition, called hallux rigidus.) Sometimes a soft fluid swelling develops over the bony lump.

The bony lump is the end of the “knuckle-bone” of the big toe (the first metatarsal bone) which becomes exposed as the toe tilts out of place.

33
Q

describe the epidemiology of hallux valgus

A
  • commonly incidental finding
  • female&raquo_space;> male
  • family history + foot wear
  • no symptoms - no surgery
34
Q

what are the symptoms of hallux valgus

A

the presenting symptoms:

  • pain
  • deformity
  • modification of shoe wear
  • nerve irritation
  • lesser toe deformity
35
Q

what are the treatments for hallux valgus

A
  • non-surgical
  • surgical :
  • Bunionectomy
  • osteotomy- proximal, metatarsal shaft, distal
  • 1st TMT joint fusion
36
Q

how do tendons exacerbate hallux valgus

A
  • all the tendons of the 1st metatarsophalangeal joint which normalize stabilise the articulation Sublux
37
Q

what are the surgical approaches to the great toe

A

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: dorsal cutaneous nerve

extensor hallicus tendon

flexor hallucis longus

204-theme 1 (15 decks)

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