L17: Introduction to surgery of the foot and ankle Flashcards
what is the importance of the foot
- To ensure that we have a smooth gait cycle
- If foot anatomy is abnormal foot function is compromised
what are the sections of the foot
3 Sections- hindfoot,
midfoot and
forefoot
what does pathology in the foot cause
Pathology in any one of these areas has a reciprocating effect in the rest of the foot
describe the shape of the foot
Have a natural hindfoot valgus
Further valgus your midfoot and forefoot will compensate
what are the 4 main outcomes required for a foot surgery
- Painless
- Plantigrade
- Structurally normal
- Functionally normal
describe the 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 15 cm in length
Plantar flexor of the foot
why is the achilles tendon vulnerable to pathology
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
what is the achilles rapture
- 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
how do you treat achilles rapture
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
what is the 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 ( 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
describe the tibialis posterior tendon
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
what are the functional features of the tibialis posterior insufficiency
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
describe some symptoms of tibialis posterior insufficiency
Post-malleolar pain
Arch pain + aching
Progressive flat foot deformity
Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
Rarely, tarsal tunnel syndrome
describe the appearance of tibialis posterior insufficiency
1) Valgus hindfoot
2) Aquired flatfoot
3) Forefoot abduction
what is the treatment for the tibialis posterior insufficiency
Non-surgical
-Analgesics
- Shoe wear modification
- Orthotics- medial arch supports
- Physiotherapy
Surgery
-Reconstruction (tendon transfer)
- Fusion (if secondary arthritis)
what occurs in the surgery of the tibialis posterior
- 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
what is the surgical approach to tibialis posterior tendon
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
what are the symptoms of ankle arthritis
Presentation:
-Pain
- Swelling
- Deformity
describe the 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
what is the surgical management of ankle arthritis
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)
describe ankle arthroplasty
Pain relief
Preservation of joint mobility
Preservation of function
Polyarthropathy; Subtalar / Triple complex
describe the presentation of ankle fusion/ arthrodesis
Pain Relief
- Severe Deformity
- TAR not appropriate (TOTAL ANKLE REPLACEMENT )
what is the anterior surgical approach to the ankle for TAR
TOTAL ANKLE REPLACEMENT
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.
describe Tibiotalocalcaneal Arthrodesis(TTC) presentation
Severe deformity
Osteoporotic ankle fractures
Complex failed ankle fixation
Failed TAR
describe ankle sprains
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
describe the incidence of Acute lateral ligament sprain 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
Describe treatment for Acute lateral ligament sprain (ATFL)
RICE
Physiotherapy directed rehabilitation
- Loading injured ligaments
- Proprioception
- Strength and return to function
how do you diagnose chronic instability
on examination - posterior anterior draw
further investigation: - stress radiographs
- MRI (very useful to demonstrate related pathology)
- > 1cm ->15cm
what are the indications for surgery
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
what are some surgery options for chronic instability
- sutures
- tendon transfers
name the 2 conditions involved in hallux valgus
- hallux valgus
- bunion
describe the pathology of hallux valgus
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.
describe the epidemiology of hallux valgus
- commonly incidental finding
- female»_space;> male
- family history + foot wear
- no symptoms - no surgery
what are the symptoms of hallux valgus
the presenting symptoms:
- pain
- deformity
- modification of shoe wear
- nerve irritation
- lesser toe deformity
what are the treatments for hallux valgus
- non-surgical
- surgical :
- Bunionectomy
- osteotomy- proximal, metatarsal shaft, distal
- 1st TMT joint fusion
how do tendons exacerbate hallux valgus
- all the tendons of the 1st metatarsophalangeal joint which normalize stabilise the articulation Sublux
what are the surgical approaches 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
Internervous plane: none
Dissection: divide fascia and then periosteum
dangers: dorsal cutaneous nerve
extensor hallicus tendon
flexor hallucis longus
