Miller-Foot and Ankle Flashcards

Question

review PTT deficiency

Answer 1

Patients complain of medial ankle/foot pain early, progressive loss of arch, and lateral ankle pain late (subfibular impingement). □ Physical examination • Standing examination demonstrates asymmetric hindfoot valgus, depressed arch, and an abducted forefoot. • Too-many-toes sign: when the foot is viewed posteriorly, it appears to have more than five toes (Fig. 6.86) • Pain or inability to perform single-limb heel rise indicates insufficient PTT. • Whether deformity is flexible (passively correctable to a plantigrade foot) or fixed (rigid deformity that is not passively correctable) must be determined • Lateral impaction syndrome or subfibular impingement with significant valgus of the heel, such that it abuts the fibula, may be present; abutment of the lateral process of the talus and the calcaneus can occur as well. □ Radiographs (Fig. 6.87) • Pes planus indicated by negative lateral talar–first metatarsal angle (Meary angle) • Forefoot abduction indicated by TN uncoverage

Answer 2

Stage I—tenosynovitis without deformity • Nonoperative • Immobilization (cast or boot) • Orthotic after acute swelling and pain subside • Arch support with medial heel wedge • Operative • Synovectomy of PTT □ Stage II—flexible deformity is the critical feature; PTT is degenerated and functionally incompetent. • Nonoperative • AFO in conjunction with physical therapy has demonstrated the highest success rate. • Use of a full-length orthotic with an arch support, medial heel wedge, and medial forefoot support (if supination/forefoot varus present) is used after acute pain has resolved. • A lace-up ankle brace may also be used. • Operative (if conservative measures fail after 6 months or more) • Correction of all stage II deformities includes a tendon transfer (FDL or FHL) into the navicular to reconstruct the PTT. • Presence of a gastrocnemius contracture should be assessed for and if present corrected with a gastrocnemius recession. • Although reconstruction of the spring ligament has been advocated, there are limited data to demonstrate its efficacy at this time. • Stage IIA—defined by hindfoot valgus without significant forefoot abduction (\<40% uncovering of the talus) • Medial slide calcaneal osteotomy (Fig. 6.88) • To address signs of subfibular impingement • Stage IIB—defined by forefoot abduction (\>40% uncovering of the talus) in addition to hindfoot valgus • Lateral column lengthening (Fig. 6.89) • To address hindfoot valgus and improve the longitudinal arch of the foot/medial column of the foot • Additional medial slide calcaneal osteotomy may be required. • Stage IIC—defined by fixed forefoot supination/varus (first ray is elevated after correction of the hindfoot to neutral) in addition to hindfoot valgus (Fig. 6.90). Forefoot abduction may also be present. • Stable medial column—navicular is colinear with first metatarsal. • Cotton osteotomy (dorsal open-wedge osteotomy of the cuneiform) to plantar flex the first ray, to correct forefoot varus • Unstable medial column—plantar sag at NC or first TMT joint • Medial column fusion (based on point of collapse) • Isolated first TMT fusion • Isolated NC fusion • Combined NC and TMT fusion (both joints are involved radiographically) • Hindfoot treatment based on talar uncovering • Less than 40%—medial slide calcaneal osteotomy • More than 40%—lateral column lengthening and possible medial slide calcaneal osteotomy if residual hindfoot valgus • Stage II surgical summary • FDL or FHL tendon transfer for all patients • Gastrocnemius recession if contracture present • Hindfoot valgus—medial slide calcaneal osteotomy • Forefoot abduction—lateral column lengthening • Forefoot supination • Stable medial column—Cotton osteotomy • Unstable medial column—first TMT arthrodesis □ Stage III—defined by a fixed/rigid pes planovalgus deformity • Nonoperative • Accommodative rigid AFO or Arizona brace. No attempt should be made to correct the deformity—correction carries increased risk of pain and pressure points, leading to ulceration. • Operative • Triple arthrodesis • If subtalar arthrodesis (alone or as part of triple) has been malunited in valgus, with tenderness in the lateral subfibular region, arthrodesis takedown and revision arthrodesis may be required. • Severely abducted deformities may require an all-medial approach, to limit risk of wound healing issues with the sinus tarsi approach. • Some authors argue that the calcaneocuboid joint is challenging to see, but cadaveric studies have demonstrated the ability to see \>90% of each joint from the medial approach alone. • Additional medial column stabilization is occasionally needed for severe deformities (Fig. 6.91). • TAL if equinus contracture present • Stage IV—defined by incompetence of the deltoid ligament; standing AP ankle radiograph demonstrates lateral talar tilt (valgus) or ankle arthritis. • If the ankle valgus is passively correctable with minimal degenerative changes, an attempt can be made at deltoid ligament reconstruction with hindfoot reconstruction. • Rigid deformity or progressive arthritis requires TTC arthrodesis (Fig. 6.92).

Answer 3

Defined by a high-arched foot, often with associated heel varus (cavovarus) ▪ Pathology □ Neuromuscular • Unilateral—tethering of the spinal cord or spinal cord tumors must be ruled out. • Bilateral—most commonly Charcot-Marie-Tooth (see Section 11, Neurologic Disorders) • Idiopathic—usually subtle, bilateral • Traumatic—secondary to talus fracture malunion, compartment syndrome, crush injury ▪ Diagnosis □ Patients complain of painful calluses under the first metatarsal, fifth metatarsal, and medial heel. • There may be pain along the peroneal tendons as well. • These may need to be addressed as part of surgical intervention. • Secondary to the plantar-flexed first ray and varus hindfoot • Plantar flexion of the first ray is secondary to overpowering of the tibialis anterior by the peroneus longus. • Varus of the hindfoot is secondary to the overpull of the PTT. • On an adequate weight-bearing, lateral foot radiograph, visibility of the middle facet of the subtalar joint indicates varus hindfoot. □ Often associated with lateral ankle ligament instability, peroneal tendon pathology □ Coleman block test used to assess flexibility of the hindfoot (out of varus) when the first metatarsal plantar flexion (forefoot valgus) is eliminated. • Wooden block placed just lateral to the first ray; first metatarsal head then lies off the block, with remainder of block on the weight-bearing foot. • If the hindfoot passively corrects into valgus, the deformity is forefoot driven (due to plantar-flexed first ray).

Answer 4

Dwyer closed-wedge osteotomy of calcaneus for varus heel. (A) Lateral skin incision is made inferior and parallel to peroneal tendons. (B) Wedge of bone is resected with its base laterally. (C) Wedge of bone is tapered medially. (D) Calcaneus is closed after bone has been removed, and varus deformity is corrected to slight valgus. Forefoot driven treatment-often times need forefoot osteotomy

Answer 5

Cavus foot orthotic. Note the hollowed-out recess under the first metatarsal head, laterally based forefoot wedge, and lowered medial arch.

Answer 6

Compressive neuropathy of the interdigital nerve, most commonly in the third web space, followed by the second web space (Fig. 6.60) □ The pathophysiology of this condition is still poorly understood. • Theories include compression/tension around the IM ligament, repetitive microtrauma, vascular changes, excessive bursal tissue, endoneural edema, and eventual perineural fibrosis. ▪ Diagnosis □ Patients frequently report pain and burning on the plantar aspect of the web space, with more than 60% of patients noting pain radiating into the toe distally. Numbness is reported by only 40% of patients. □ Exacerbated by footwear with narrow toe boxes and high heels • Higher predilection in the female population • Likely related to shoewear, with forced plantar flexion of the metatarsal heads □ Physical examination • Palpation between and just distal to the metatarsal heads elicits plantar tenderness. • Compressing the medial and lateral aspects of the forefoot while palpating the web space structures can provoke symptoms and occasionally a bursal “click” with associated pain (Mulder sign). • Metatarsalgia and MTP synovitis often manifest similarly and should be ruled out. □ Radiographs • Plain films should be obtained to rule out bony masses or deformity. • MRI or ultrasound can be used to identify other pathologies but are not required for diagnosis. ▪ Nonoperative treatment □ Shoewear modification (avoiding high heels and narrow toe boxes) is the most important and effective intervention. □ Metatarsal pads placed proximal to the focus of pain can prevent direct pressure and widen the intermetatarsal space during weight bearing, thereby indirectly decompressing the nerve. □ Corticosteroid injections can have moderate effectiveness (≈50% of patients report positive response); repetitive injections can lead to hammer-toe deformity. □ Alcohol sclerosing injections have not proved to be effective and are not recommended. ▪ Operative treatment □ Excision of neuroma • Dorsal approach most common • Transverse intermetatarsal ligament is incised and resected. • The common digital nerve and its branches are identified and the nerve is resected 2 to 3 cm proximal to the intermetatarsal ligament (proximal to the small plantar branches), allowing the proximal stump to retract (Fig. 6.61). • Minimizes formation of stump neuroma, the most common complication • Difficult visualization results in a 4% rate of failure to excise the neuroma. • Overall success rates approach 80%. • Neuroma often causes perineural fibrosis. • Plantar approach • Decreases the rate of missed neuroma excision • Does not require incision of the transverse intermetatarsal ligament • Associated with increased risk (5%) of painful plantar scar • Typically used for revision neuroma resection

Answer 7

Definition □ Bulbous enlargement of the neural stump (or secondary glioma) □ Usually caused by inadequate proximal resection or failure of the nerve to retract after excision □ Neural stump adheres to adjacent bone and soft tissue, causing a traction neuritis. ▪ Diagnosis □ Localized pain and tenderness to palpation (Tinel sign) in web space of previous neuroma resection, at or proximal to metatarsal heads □ Recurrent neuroma is likely if symptoms are localized and reproducible. ▪ Nonoperative treatment—similar to that for primary neuroma (see earlier) ▪ Operative treatment □ Excision of the stump neuroma can be performed through another dorsal incision or through a plantar incision. □ Plantar incision allows access to a very proximal location in which to place the resected neuroma stump. • Preferred approach for revision neuroma excision □ The new stump should be transposed into muscle tissue if possible. □ Success rate after excision of a recurrent or stump neuroma is 65%–75%.

Answer 8

Definition □ Compressive neuropathy of the tibial nerve within the fibroosseous tunnel posterior and inferior to the medial malleolus □ Tarsal tunnel is bounded by the flexor retinaculum (laciniate ligament) superficially; the medial talus, medial calcaneus, and sustentaculum tali deeply; and the abductor hallucis inferiorly. □ The tarsal tunnel also contains the tibialis posterior, the FHL and FDL tendons, the posterior tibial artery, the venae comitantes, and the numerous septa that subdivide the tunnel. □ Reported causes of tarsal tunnel syndrome include tenosynovitis, engorged or varicose vessels, synovial or ganglion cysts, pigmented villonodular synovitis, nerve sheath tumors, lipomas, fracture of the sustentaculum tali or medial tubercle of the posterior process of the talus, middle facet tarsal coalition, and accessory muscles. □ Systemic diseases such as diabetes mellitus, RA, and ankylosing spondylitis may have an indirect effect by causing inflammatory edema. ▪ Diagnosis □ Symptoms of tarsal tunnel syndrome may be vague and misleading. • Include a burning sensation on the plantar surface of the foot and medial ankle and occasional sharp pains or paresthesias • “Irritable” tibial nerve must be ruled out. • Palpation should be performed along tibial nerve and branches distal to flexor retinaculum. • Prolonged standing, walking, or running can exacerbate the symptoms. □ Physical examination • Percussion of the entire course of the distal tibial nerve and its branches should be performed. • Tinel sign, radiating pain or discomfort with continuous deep compression over the nerve, or diminished two-point discrimination may be elicited. • Sensory examination is usually unpredictable. • Hindfoot alignment should be assessed—pes planus may cause increased tension on the nerve. • Prior lateral closed-wedge osteotomy of the calcaneus can increase tension on nerve as well. • Wasting of the abductor hallucis or abductor digiti quinti may be seen if the medial or lateral plantar nerve is involved, respectively. □ Diagnostic tests • Electrodiagnostic studies should be performed to help make the diagnosis or determine a different level of compression. • Sensory nerve conduction study findings are more commonly abnormal than those of motor nerve conduction studies. • Electromyography (EMG) abnormalities are less sensitive. • MRI may identify the presence of a mass-occupying lesion or middle facet subtalar coalition, which if present must be excised (Fig. 6.62). • Surgical decompression with mass excision results in more predictable symptomatic improvement compared with patients with tarsal tunnel syndrome and no associated mass. • Correlation with history and physical examination findings is essential. □ Nonoperative treatment • Management should begin with conservative measures unless there is a suspicious mass or suspected malignancy. • Medications such as NSAIDs, vitamin B6, and tricyclic antidepressants are most commonly prescribed. • SSRIs and antiseizure medications (gabapentin, pregabalin) are also used. • Physical therapy may include stretching, massage, desensitization, and iontophoresis. • Orthoses to correct hindfoot valgus (medial heel wedge) play an important role as well. • In cases of acute inflammation or severe limitation because of pain, a brief course of a controlled ankle motion (CAM) walker boot or short-leg cast may be helpful. □ Operative treatment • Space-occupying lesion should be excised, with concomitant nerve release. • If appropriate conservative management for 3 to 6 months is unsuccessful, surgical intervention is warranted. • Longitudinal incision is made over the course of the tibial nerve; it curves distally behind medial malleolus to the abductor musculature (Fig. 6.63) • The nerve is identified proximally, and the proximal investing fascia and flexor retinaculum are released. • Care must be taken to release the superficial and deep fascia of the abductor hallucis muscle. • Endoscopic tarsal tunnel release is not recommended. • Recurrence of tarsal tunnel syndrome is a challenging problem. • Incomplete release is the most common etiology; however, intrinsic nerve damage may play a role in recurrent symptoms. • Revision release may be of benefit if incomplete release is suspected, although results are often poor.

Answer 9

Lateral plantar nerve entrapment □ Nerve provides sensation to the plantar lateral aspect of the foot. □ It may be injured during surgical approaches that require a plantar incision, such as a tibiotalocalcaneal (TTC) arthrodesis with an intramedullary nail. • If no evidence of paresthesias and persistent hindfoot pain, evaluation for nonunion of the ankle or subtalar joints needed □ First branch of the lateral plantar nerve (Baxter nerve) may be a source of chronic plantar medial heel pain. • Associated with long-distance/marathon running ▪ Medial plantar nerve entrapment □ Nerve provides sensation to the plantar medial aspect of the foot. □ Entrapment occurs at the knot of Henry (junction of FDL and FHL tendons). • FDL is plantar to FHL at knot of Henry. • Most common etiology is external compression from orthotic devices. • Also called jogger’s foot • Conservative treatment is often successful and includes avoidance of orthotics and of pressure along the plantar medial hindfoot.

Answer 10

Definition □ Compressive neuropathy of the deep peroneal nerve in the fibroosseous tunnel formed by the Y-shaped inferior extensor retinaculum (Fig. 6.64) □ The nerve divides into the lateral motor and the medial sensory branches within the tunnel and is accompanied by the dorsalis pedis artery. □ Common causes of compression include tightly laced shoes, anterior osteophytes at the tibiotalar and TN articulations, a bony prominence associated with pes cavus deformity or fracture, ganglion cysts, and tendinitis of the EDL, EHL, or tibialis anterior (Fig. 6.65). ▪ Diagnosis □ Patients present with burning pain and paresthesias along the medial second toe, lateral hallux, and first web space, or even vague dorsal foot pain. □ Symptoms are often worse at night when the ankle assumes a plantar-flexed posture for sleep, and with wearing of shallow, laced shoes. □ Physical examination • Decreased two-point discrimination, presence of Tinel sign along course of the deep peroneal nerve • Pain may be worse with plantar flexion of ankle as the nerve is stretched. ▪ Nonoperative treatment □ Night splints, NSAIDs, diagnostic/therapeutic injections, shoe tongue padding, and footwear with loose lacing or alternative lacing techniques are the conservative approaches. ▪ Operative treatment □ Surgical release involves incising the distal half of the inferior extensor retinaculum, releasing both branches of the nerve, excising bone spurs, and carefully repairing the bony capsule to avoid exposing the nerve to bleeding bone while protecting the dorsalis pedis artery. □ Patients should understand that relief of the paresthesias and dysesthesias may take weeks or months.

Answer 11

Definition □ Compressive neuropathy of the superficial peroneal nerve as it exits from the lateral compartment into the anterior ankle □ The opening in the fascia is approximately 12 cm proximal to the tip of the lateral malleolus. □ Neuritis may occur after an inversion injury or with fascial defects. □ The nerve can also be damaged or entrapped in scar tissue at the anterolateral portal following an ankle arthroscopic procedure. ▪ Diagnosis □ Symptoms include burning pain and tingling over the dorsum of the foot. □ Symptoms exacerbate with plantar flexion and inversion. □ Tinel sign is frequently present over the nerve as it exits the lateral compartment. ▪ Treatment □ Nonoperative treatment includes NSAIDs, diagnostic/therapeutic injections, and other nerve modalities with physical therapy. □ Surgical release of the nerve with fasciotomy is indicated if nonoperative treatment fails.

Answer 12

Entrapment of the sural or saphenous nerves is rare, typically occurring only after surgical procedures as the nerves become entrapped in scar tissue. ▪ Conservative treatments may be successful, but neurolysis or resection of neuroma with burial of the nerve end is indicated for refractory cases. ▪ The sural nerve is prone to injury with lateral hindfoot procedures that use a sinus tarsi approach. The traditional extensile lateral calcaneus approach places the sural nerve at risk at both the proximal and distal ends of the incision. ▪ Popliteal nerve blocks do not typically include the saphenous nerve.

Answer 13

Definition □ Most commonly secondary to traumatic brain injury, stroke, and spinal cord injury □ Disruption of the upper motor neuron pathways can lead to paralysis, muscular imbalance, and acquired spasticity, which ultimately may cause deformity of the foot and ankle. □ Secondary problems include fixed contractures, calluses, pressure sores, hygiene issues, joint subluxation, shoewear difficulties, and dissatisfaction with physical appearance. □ The most common deformity of the foot and ankle is equinovarus. • The equinus component is caused by overactivity of the gastrocnemius-soleus complex. • The varus is due to relative overactivity of the tibialis anterior and the tibialis posterior tendons with lesser contributions from the FHL and FDL. • The posterior tibial tendon is balanced by the peroneus brevis. • The anterior tibial tendon is balanced by the peroneus longus. • The anterior tibial tendon is balanced by the Achilles tendon complex in the sagittal plane. ▪ Nonoperative treatment □ Early intervention with physical therapy, stretching and strengthening, and maintenance of joint ROM. □ Other modalities include splinting, serial casting, oral muscle relaxants, phenol and lidocaine nerve blocks, and botulinum type A toxin injections. • Phenol blocks have a proven history, often have longer-lasting effects, and are less expensive than botulinum toxin injections. • Advantage of botulinum is ease of delivery—requires only an injection into the muscle belly rather than a precise injection around the motor nerve. ▪ Operative treatment □ Surgery for acquired spasticity should be delayed at least 6 months after onset to allow for maximum recovery. □ Equinus deformity is addressed with either an open Z-lengthening of the Achilles tendon or a percutaneous triple hemisection technique (Fig. 6.66). □ Varus deformity is addressed with one of two procedures. • Tendon transfer to lateral cuneiform • Lateral cuneiform is center of rotation of the foot • Split anterior tibial tendon transfer (SPLATT) or total anterior tibial tendon • Posterior tibial tendon transfer is not the preferred surgical procedure in the setting of spasticity. If the varus deformity is fixed, lateral closed-wedge calcaneal osteotomy or subtalar fusion may be necessary. □ Release of the toe flexors is often required secondary to a tenodesis effect as the ankle is brought into a plantigrade position.

Answer 14

CMT disease is the most common inherited progressive peripheral neuropathy, affecting approximately 1 in every 2500 people. □ As a group, the many genetic variants of CMT disease are referred to as hereditary motor-sensory neuropathies (HMSNs). • Type I HMSN is the most common presentation of CMT. • Usually autosomal dominant with a duplication of chromosome 17 □ An abnormal myelin sheath protein (PMP 22) is the basis of CMT degenerative neuropathy. □ The earlier the onset, the more severe the neurologic findings. ▪ Diagnosis □ Deformity and awkward gait are common initial complaints, with weakness, lateral ankle instability, and lateral foot pain presenting later. ▪ Physical examination □ Bilateral symmetric pes cavovarus deformity is caused by motor imbalance. • Tibialis anterior (TA) and peroneus brevis (PB) weakness seen early • First ray is plantar flexed because of relatively unopposed pull of peroneus longus (PL \> TA) (Fig. 6.67). • This creates forefoot cavus and compensatory hindfoot varus (tripod effect). • Hindfoot is pulled farther into varus because of relatively unopposed pull of posterior tibial (PT) muscle (PT \> PB). • Plantar-flexed first ray and hindfoot varus lead to external rotation of distal tibia and fibula. • Intrinsic (EDB, EHB, interossei) wasting leads to overpull of extrinsics (EHL, EDL, FHL, FDL), which causes claw-toe deformity; • Intrinsics are affected first as they have the longest axons. • Weak TA leads to recruitment of EHL and EDL during swing phase of gait, worsening claw-toe deformity. • Prominent and tender calluses may be present beneath the metatarsal heads. □ Coleman block test (Fig. 6.68) should be used to determine whether a hindfoot varus deformity is secondary to plantar flexion of the first ray or is an independent component. • Deformity corrects with Coleman block—forefoot-driven hindfoot varus. • Surgical correction involves dorsiflexion osteotomy of the first metatarsal. • Deformity does not correct with Coleman block—hindfoot varus independent of the forefoot. • Surgical correction involves both • Dorsiflexion osteotomy of the first metatarsal (forefoot) • Lateral closed-wedge calcaneal osteotomy (hindfoot) □ Sensory deficit is variable. • Proprioception, vibration, and two-point discrimination affected first • Severe sensory loss may lead to recurrent ulceration, deep infection, and even neuropathic arthropathy. ▪ Treatment □ Flexible deformity (hindfoot can be passively manipulated) • In an adolescent with closed physes and a supple deformity, surgical treatment rather than brace management is currently recommended because of the progressive pattern of this disease. • Operative treatment • Release of the plantar fascia • Closed-wedge dorsiflexion osteotomy of first metatarsal • Always required; if deformity corrects with Coleman block test, no other bony correction is required. • Lateral calcaneal slide and/or closed-wedge osteotomy if deformity does not correct with the Coleman block (Fig. 6.69) • Transfer of peroneus longus into peroneus brevis at the level of the distal fibula • Frequently a tendon Achilles lengthening (TAL) procedure is required. • Forefoot correction is performed according to the guidelines outlined previously. • A flexible clawed hallux can be surgically treated with a Jones procedure (arthrodesis of interphalangeal joint and transfer of EHL to first metatarsal). □ Fixed deformity (hindfoot cannot be passively manipulated) • Nonoperative management can be attempted with a brace. • Locked-ankle, short-leg ankle-foot orthosis (AFO) with an outside (varus-correcting or lateral) T-strap is recommended. • Rocker sole can improve gait and decrease energy expenditure. • Operative treatment • Dorsal closing midfoot arthrodesis or triple arthrodesis is usually required for deformity correction. • PTT transfer through the interosseous membrane and TAL procedure can correct equinus contracture and dorsiflexion weakness. • Plantar fascia release and dorsiflexion osteotomy of the first metatarsal • Forefoot correction is performed according to the guidelines outlined previously.

Answer 15

Gout □ Pathology • Abnormal purine metabolism results in precipitation and deposition of monosodium urate crystals into synovium-lined joints. • Induces a severe inflammatory response • Induced by certain medications that increase serum uric acid, localized trauma, alcohol, or purine-rich foods, as well as by the postsurgical state • Men are more commonly affected than women. □ Diagnosis • Patients complain of sudden joint pain, with a characteristic history (“not even a sheet could touch it”). • Physical examination—intense signs of inflammation (redness, swelling, warmth, tenderness) and pain with ROM • The great-toe MTP joint is most often involved (50%–75% of initial attacks). • 90% of patients with chronic gouty attacks have one or more episodes involving the hallux MTP joint (podagra). • Characteristic radiographic signs • Inordinate soft tissue enlargement about the MTP joint • Bony erosions both at a distance from and within the joint articular surface • Extensive articular and periarticular destruction can occur in chronic conditions (Figs. 6.70 and 6.71). • Secondary to large soft tissue deposits of gouty residue (tophi) • Definitive diagnosis—needle aspiration of the joint • Indicated in the presence of an acute swollen painful joint; fluid sent for crystal analysis and Gram stain with culture. • Pathognomonic signs: needle-shaped monosodium urate crystals, which under polarized light are strongly negatively birefringent • Ruling out an acute septic joint—which would be determined from the aspirate Gram stain and culture—is critical. • Serum uric acid may or may not be elevated and should not be used to confirm or refute the diagnosis. □ Treatment • Acute attacks treated with indomethacin or colchicine • Colchicine inhibits microtubule formation, preventing inflammatory cell migration into the area. • Chronic attacks treated with allopurinol • Allopurinol is a xanthine oxidase inhibitor. • Joint destruction or deposition of large quantities of tophi may require arthrodesis and/or débridement of tophaceous debris.

Answer 16

Pathology • Deposition of calcium pyrophosphate dihydrate (CPPD) crystals in or about a joint may lead to severe initial inflammatory response. • Usually articular, with less periarticular soft tissue involvement than gout • Commonly affects the knee but may manifest in articulations of the foot or ankle □ Diagnosis • Analysis of joint aspirate reveals weakly positive birefringent crystals with varied shapes under polarized light microscopy. • Lesser MTP, TN, and subtalar joints can be affected. • Characteristic radiographic signs • Intraarticular calcifications commonly seen (unlike in gout) • Joint destruction can occur with recurrent attacks over a long period but is rare. □ Treatment—rest, oral NSAIDs for acute synovitis, protected weight bearing, and corticosteroid injections

Answer 17

Definition □ Inflammatory arthritides in which rheumatoid factor is absent □ Distinguished from RA clinically by a higher incidence of involvement of entheses (i.e., the interface between collagen and bone where ligament, tendon, and capsular tissue insert into bone) • Involvement of this transitional tissue is found in psoriatic arthritis, ankylosing spondylitis, Reiter syndrome, and inflammatory bowel disease. □ May destroy articular cartilage but characteristically are more destructive of collagen and fibrocartilage ▪ Diagnosis □ Often manifest in the foot as plantar fasciitis, Achilles tendinitis, or posterior tibial tendinopathy □ Psoriatic arthritis can manifest as swollen and inflamed distal joints or, more classically, as dactylitis (“sausage digit”). □ Periarticular bony erosion may occur, causing a classic pencil-in-cup sign typical of psoriatic arthritis (Fig. 6.72). □ Additional findings may include nail pitting, onycholysis, and keratosis. ▪ Treatment □ Pharmacologic agents such as NSAIDs, or occasionally salicylates or cytotoxic drugs under the direction and observation of a rheumatologist, are the mainstays of treatment. □ Intraarticular corticosteroid injections may improve symptoms, especially for acute flares. □ Surgical intervention is sometimes required for small joint erosions, recalcitrant Achilles tendinopathy, and plantar fasciitis.

Answer 18

Definition □ Chronic symmetric polyarthropathy that most commonly manifests in the third and fourth decades and is more prevalent in women. □ Synovitis causes ligament and capsular laxity and cartilage and bony erosion. □ Vasculitis and soft tissue fragility are common, requiring diligent care of the soft tissues during nonoperative and operative management. • Use of immune-mediating pharmacologic therapies in the perioperative period should be discussed with a rheumatologist because of possible complications. • Most can be continued (prednisone, methotrexate, hydroxychloroquine), but the newer biologic agents (e.g., TNF antagonists) should be discontinued. • Most significant risk factor for development of a postoperative wound infection: history of previous wound infection ▪ Diagnosis □ Foot involvement very common in RA • Forefoot more commonly involved than midfoot or hindfoot □ Patients complain of forefoot swelling, poorly defined pain, and eventually deformity. □ MTP joint pathophysiology • Chronic synovitis leads to incompetence of the joint capsules and collateral ligaments. • Toes subluxate or dislocate dorsally, deviate laterally into valgus, and develop hammering (Fig. 6.73). • Intrinsic muscles worsen the claw-toe deformity. • Plantar fat pad migrates distally and atrophies, causing metatarsalgia and painful keratoses. • As lesser toes deviate laterally, hallux valgus occurs and transfer metatarsalgia worsens. □ Midfoot and hindfoot are less commonly and less severely involved in RA. • Significant midfoot/hindfoot arthrosis (TN joint characteristic) • Often results in a pes planovalgus deformity • Underlying cause of flatfoot deformity must be carefully assessed to determine whether it is midfoot driven or hindfoot driven. • Midfoot etiology—TMT joints subluxated, with a congruent hindfoot (Fig. 6.74) • Treatment—realignment midfoot arthrodesis • Hindfoot etiology—transverse tarsal and subtalar joints are subluxated, with a normal midfoot. • Treatment—triple arthrodesis □ Tibiotalar joint also commonly involved—easily differentiated from osteoarthritis by lack of osteophyte formation, osteopenia, and symmetric joint space narrowing (Fig. 6.75) • Ankle arthrodesis is currently the treatment of choice, with ankle replacement emerging as a more reliable technique. • A tibiotalar and subtalar (tibiotalocalcaneal [TTC]) arthrodesis performed with an intramedullary nail risks a tibial stress fracture in patients with RA. • This complication is best treated conservatively with a cast. • Risks of wound complications after total ankle arthroplasty have been shown to be higher in patients with RA. ▪ Treatment □ Nonoperative treatment • Rest, NSAIDs, immune-modulating drugs under the direction of a rheumatologist, toe taping, orthoses, and careful use of corticosteroid injections may help symptoms related to synovitis. □ Operative treatment • Early (mild hallux valgus, mild claw toe without dislocation) • The new disease-modifying medication has resulted in a significant decrease in end-stage rheumatologic deformity. In patients with mild deformity without joint pain and with radiographic evidence of sparing of the joint space, joint preservation surgery as would be performed for nonautoimmune cases should be considered. Patients must be informed that the rate of recurrence may be higher and that late arthrodesis may be necessary secondary to the underlying disease process. • Late (in presence of severe deformity)—“rheumatoid forefoot reconstruction” (Hoffman procedure) (Fig. 6.76) • First MTP arthrodesis, lesser metatarsal head resection with pinning of the lesser MTP joints, and closed osteoclasis of the interphalangeal joints versus PIP arthroplasty • Silicone arthroplasty not recommended; complications are cock-up deformity, silicone synovitis, and osteolysis. • Accomplished through three well-placed longitudinal dorsal incisions (Fig. 6.77) • Extensor brevis tenotomy and Z-lengthening of the extensor longus tendons may be necessary. • Most common complication of forefoot arthroplasty is intractable plantar keratoses. • Midfoot, hindfoot, or ankle arthrodesis indicated as previously described

Answer 19

First MTP joint • Tenderness over the dorsum of the joint, limited dorsiflexion secondary to large dorsal osteophyte, and pain with grind test • Graded clinically and radiographically: • Grade 0—normal radiograph features, stiff on examination • Grade I—mild dorsal osteophyte, joint space preserved, mild pain at extremes of ROM, less than 50% loss of ROM • Grade II—moderate osteophyte formation, joint space narrowing (\<50%), moderate pain with ROM that may be more constant • Grade III—severe osteophyte formation, substantial joint space narrowing (\>50%), significant stiffness with pain at extreme ROM but not at midrange • Grade IV—same as grade III but with pain at midrange of passive motion • Subtalar, TN, CC joints • Tenderness at the sinus tarsi (subtalar joint), dorsal TN joint, and/or lateral column • Pain with passive hindfoot inversion/eversion (subtalar), midfoot ROM (TN, CC) • Radiographs show varying severity of joint space narrowing and osteophyte formation. • Rigid flatfoot without arthritis is also common presentation but is not amenable to joint preservation surgery and should be treated with a triple arthrodesis. • Tibiotalar joint • Tenderness in anterior ankle joint line • Limited ROM with pain, especially in extreme dorsiflexion • May be associated varus or valgus deformity, either at ankle or more proximally, especially with history of prior fracture or injury. • Radiographs show joint space narrowing, sclerosis and cysts, osteophytes, and possibly varus or valgus deformity. • Standing radiographs essential; long-leg alignment view may be needed for history of leg trauma • May be associated with cavovarus deformity, rigid flatfoot (valgus), or chronic lateral ankle instability (varus)

Answer 20

Initial treatment should include antiinflammatory medications, activity modification, orthotic support or bracing, and corticosteroid injections. □ Hallux rigidus—stiff footplate with an extension under the great toe (Morton extension) □ Midfoot (TMT) arthritis—stiff-soled or steel shank–modified shoe with a rocker bottom in addition to a cushioned heel. Use of a full-length rigid foot orthotic can also be beneficial. □ Hindfoot (ST, TN, CC) arthritis—AFO or rigid lace-up leather brace (Arizona type) □ Tibiotalar arthritis—NSAIDs, AFO, or rigid lace-up leather brace (Arizona type). Shoe modification consists of a single hindfoot rocker sole.

Answer 21

Midfoot arthrodesis is the treatment of choice. • In the setting of deformity (flatfoot) the joints must be reduced into anatomic position to achieve a satisfactory result (realignment arthrodesis) (Fig. 6.81). • Medial column arthrodesis refers to fusion of both the NC and first TMT joints; it is occasionally required for a flatfoot deformity to stabilize the collapsed midfoot and restore the lateral–first TMT angle. • In situ fusion in the setting of a deformity will predictably lead to a poor result.

Answer 22

Arthrodesis provides excellent pain relief but also results in some restricted function (Fig. 6.85). • Position—neutral dorsiflexion (90 degrees), 0–5 degrees hindfoot valgus, 5–10 degrees external rotation • Valgus and external rotation keep the hindfoot unlocked to allow for accommodative hindfoot motion. • Leads to radiographic arthritis in surrounding foot joints • Subtalar joint is the most common location of adjacent joint arthritis. • No evidence to show causation or progress of knee or hip arthritis. • Malunion may lead to anterior talar translation of the talus. This can elongate the lever arm of the foot and needs a revision arthrodesis of the ankle. • If fibula was taken as part of ankle fusion, total ankle replacement is not possible. • Total ankle arthroplasty outcomes are improving and are no longer considered experimental. • Can be considered in patients who have low demand in the ankle, are more than 50 years old, and have minimal deformity (\<10 degrees) • Pain relief equivalent to that for arthrodesis, function and gait are slightly better, risk of revision surgery is higher • Total ankle replacement (TAR) has shown the best outcome in patients with osteoarthritis. • Superior to that shown in patients with rheumatoid or posttraumatic etiology • Syndesmotic fusion is associated with decreased rate of failure when the Agility ankle replacement system was previously used. • Current generation of implants preserves the syndesmosis and distal fibula. • Newer-generation implants retain ligamentous and bony stabilizers and require careful anatomic balancing. • Medialization of extramedullary tibial cutting guides can lead to fracture of the medial malleolus. • Salvage of implant failure is difficult given the amount of bone loss and current lack of available revision components. The most reliable current technique is a bone-block ankle arthrodesis (femoral head) with or without additional subtalar fusion. • Wound breakdown in the acute period (3 weeks) after TAR requires débridement and polyethylene exchange; if 6 weeks or longer after TAR, removal of implant and placement of antibiotic spacer should be considered. • Contraindications include severe coronal plane deformity, AVN (talus or tibia), Charcot arthropathy, young age, and history of infection. • Distraction arthroplasty using thin-wire external fixation—limited role; may be option in younger patients with preserved ankle ROM • Bipolar osteochondral allograft transplantation—data are few and most series report high failure rates

Answer 23

Indicated for prior calcaneal fracture with loss of height • Normal calcaneal declination is ≈26 degrees • Results in anterior impingement, complaints of anterior ankle pain with ambulation in addition to hindfoot pain • Autograft or allograft bone block arthrodesis restores the height of the calcaneus. • Less successful at correcting residual hindfoot varus

Answer 24

Arthrodesis of single joints leads to significant limitation in hindfoot inversion/eversion (affects TN \> ST \> CC). • Isolated TN fusion has a high rate of nonunion, and given the significant restriction of hindfoot motion from a TN fusion, an ST fusion is commonly performed in addition to ensure union without causing any incremental functional deficit. • Triple arthrodesis is also an appropriate option. If the CC joint is unaffected, it is more common to not include the CC joint in the arthrodesis (“medial double”) for a pes planovalgus deformity. • Triple arthrodesis is usually performed to correct arthritis of the triple joint complex or rigid deformity that is not pes planovalgus

Answer 25

Most common disorders include tendinitis/tenosynovitis and tendon subluxation/dislocation, which often causes peroneus brevis degenerative tears. ▪ Diagnosis □ Acute or chronic localized swelling and tenderness over peroneal tendons □ Common cause of chronic pain following an ankle sprain or with chronic instability □ Associated with cavovarus foot deformity □ Peroneal subluxation or dislocation • Caused by forced eversion and dorsiflexion leading to disruption of superior peroneal retinaculum (SPR) • Pain and/or sensation of snapping in the retrofibular groove • Often causes peroneus brevis degenerative tears • Sudden dorsiflexion during downhill skiing is a common report. • Plain radiographs may demonstrate a rim fracture of the lateral aspect of the distal fibula. □ Acute rupture of the peroneus longus tendon at or through a fracture of the os peroneum can occur. • Radiographs show a retraction or fracture of the os peroneum. • MRI may demonstrate displacement of peroneal tendons anterolateral to the retrofibular region.

Answer 26

Nonoperative treatment • Chronic peroneal tendinosis or tenosynovitis is initially treated with activity modification, NSAIDs, lace-up ankle brace, and physical therapy. • Ultrasound or MRI can be used to aid diagnosis (Fig. 6.96). • Ultrasound useful as dynamic tool to evaluate subluxation/dislocation. • False-positive results showing longitudinal tears common with MRI. □ Operative treatment—based on the pathology • Tenosynovectomy, débridement, and repair of degenerative tears (usually peroneus brevis) • If conservative management (immobilization/physical therapy) fails • Early treatment of longitudinal splits, reduces risk of progression to full tear • Synovitis or less than 50% diseased tendon • Groove deepening if shallow fibular groove and peroneal retinacular repair if evidence of tendon subluxation • Patients may have evidence of apprehension with resistant eversion, which may be relieved with manual stabilization of the peroneal tendons • Assessment for intratendinous subluxation also needed • Excision and tenodesis • Required when there is a complete rupture or severely degenerative tendon (\>50%) that prohibits repair • For hindfoot varus • Dwyer osteotomy (lateral closed-wedge osteotomy of the calcaneus) • Limits risk of recurrent tears and continued pain • For peroneal subluxation or dislocation • Chronic • Requires repair/reconstruction of the SPR and fibular groove deepening • Acute • SPR repair/reconstruction • Tendon transfer to fifth metatarsal • More than 50% degeneration of both peroneus longus and brevis requires excision of both tendons. • Good results reported with both lateral transfer of the FHL or FDL and allograft. • Allograft may be used if peroneal muscles demonstrate adequate excursion at the time of surgery with minimal atrophic change to the muscle.

Answer 27

Stage I—tenosynovitis without deformity • Nonoperative • Immobilization (cast or boot) • Orthotic after acute swelling and pain subside • Arch support with medial heel wedge • Operative • Synovectomy of PTT □ Stage II—flexible deformity is the critical feature; PTT is degenerated and functionally incompetent. • Nonoperative • AFO in conjunction with physical therapy has demonstrated the highest success rate. • Use of a full-length orthotic with an arch support, medial heel wedge, and medial forefoot support (if supination/forefoot varus present) is used after acute pain has resolved. • A lace-up ankle brace may also be used. • Operative (if conservative measures fail after 6 months or more) • Correction of all stage II deformities includes a tendon transfer (FDL or FHL) into the navicular to reconstruct the PTT. • Presence of a gastrocnemius contracture should be assessed for and if present corrected with a gastrocnemius recession. • Although reconstruction of the spring ligament has been advocated, there are limited data to demonstrate its efficacy at this time. • Stage IIA—defined by hindfoot valgus without significant forefoot abduction (\<40% uncovering of the talus) • Medial slide calcaneal osteotomy (Fig. 6.88) • To address signs of subfibular impingement • Stage IIB—defined by forefoot abduction (\>40% uncovering of the talus) in addition to hindfoot valgus • Lateral column lengthening (Fig. 6.89) • To address hindfoot valgus and improve the longitudinal arch of the foot/medial column of the foot • Additional medial slide calcaneal osteotomy may be required. • Stage IIC—defined by fixed forefoot supination/varus (first ray is elevated after correction of the hindfoot to neutral) in addition to hindfoot valgus (Fig. 6.90). Forefoot abduction may also be present. • Stable medial column—navicular is colinear with first metatarsal. • Cotton osteotomy (dorsal open-wedge osteotomy of the cuneiform) to plantar flex the first ray, to correct forefoot varus • Unstable medial column—plantar sag at NC or first TMT joint • Medial column fusion (based on point of collapse) • Isolated first TMT fusion • Isolated NC fusion • Combined NC and TMT fusion (both joints are involved radiographically) • Hindfoot treatment based on talar uncovering • Less than 40%—medial slide calcaneal osteotomy • More than 40%—lateral column lengthening and possible medial slide calcaneal osteotomy if residual hindfoot valgus

Answer 28

Tenosynovitis uncommon but can be observed in patients with inflammatory arthritis □ NSAIDs and walking cast or boot recommended □ Corticosteroid injections may provide relief but increase the risk of tendon rupture. ▪ Complete ruptures rare—occur mainly in older patients □ Commonly missed diagnosis □ Manifests as painless anterior ankle mass □ Footdrop may be subtle because of recruitment of toe extensors. □ **Primary repair generally improves functional results regardless of age.** **□** **Tendon grafting augmentation may be warranted if there is adequate excursion of the myotendinous unit and the muscle is healthy.** **□** **Interpositional graft may be required in delayed cases.**

Answer 29

**Stenosing FHL tenosynovitis** □ Usually seen in dancers on pointe and gymnasts □ Posterior ankle pain, triggering of the hallux interphalangeal joint, and pain with resisted hallux plantar flexion □ **Stenosis occurs along course of FHL between the posterolateral and posteromedial tubercles of the talus.** □ MRI is the diagnostic modality of choice. • Fluid (high signal intensity) is noted surrounding the FHL at the level of the ankle joint (Fig. 6.97). □ Nonoperative treatment—activity modification, consideration of boot immobilization for short period of rest, NSAIDs □ Operative treatment—open (posteromedial approach) or arthroscopic FHL tenosynovectomy and release of the fascia

Answer 30

**1. Calcaneal stress fractures** Most common in the active individual or military recruit MRI typically used to aid diagnosis. Treated with rest, protected weight bearing (cast, CAM walker). **2. Periostitis** Pain and tenderness in **the central portion of the heel pad** Represents traumatic periosteal or bursal inflammation secondary to a known injury or atrophic heel pad Treated with cushioned shoe inserts or a short course in a well-padded cast. The examiner should be vigilant for other signs or symptoms suggesting inflammatory arthritis. **3. Sever disease** Also referred to as calcaneal apophysitis More common in boys; typically appears between age 10 and 14 years, prior to closure of calcaneal apophysis and just before or during a growth spurt Treatment includes activity modification, gastrocnemius stretching, and cushioned heel orthotics. No correlation between symptoms and fragmentation of apophysis.

Answer 31

**Baxter neuritis (compression of first branch of lateral plantar nerve)** □ Definition • Baxter neuritis manifests as plantar medial heel pain that can be difficult to differentiate from plantar fasciitis. • Seen in athletes involved in running sports □ Diagnosis • Pain more medial over abductor hallucis (as compared to the more plantar pain seen with plantar fasciitis) • Compression over Baxter nerve reproduces the pain and may cause radiation into the plantar lateral foot. • Diagnostic tests • EMG/nerve conduction velocity (NCV) measurement may demonstrate increased motor latency within the abductor digiti quinti. • MRI may show fatty infiltration of the abductor digiti quinti, best seen on coronal views. □ Nonoperative treatment • Heel cord stretching and cushioned heel inserts □ Operative treatment • Open release of Baxter nerve must include release of the deep fascia of the abductor hallucis.

Answer 32

Weight-bearing x-rays are an important first diagnostic step to evaluate for stress injuries, subtalar arthritis, tumor, and insertional enthesophytes. • Advanced imaging (MRI) may demonstrate thickening of the plantar fascia and surrounding inflammation. consider a gastroc recession first, if no evidence of baxter's neuritis/joggers foot.

Answer 33

The second cuneiform and second metatarsal base are shaped like a keystone in the coronal plane. The Lisfranc joint is shaped like a Roman arch. The anatomy and stabilization by the Lisfranc ligament are important for support of the arch of the foot. The second cuneiform and second metatarsal base are shaped like a keystone in the coronal plane. The Lisfranc joint is shaped like a Roman arch. The anatomy and stabilization by the Lisfranc ligament are important for support of the arch of the foot.

Answer 34

Normal anteroposterior weight-bearing radiograph demonstrating the alignment relationship between the base of the second metatarsal (arrow) and middle cuneiform (arrowhead). Any lateral deviation of the second metatarsal relative to the middle cuneiform is consistent with a Lisfranc disruption and must be treated operatively.

Answer 35

Patient with a Lisfranc injury identified by the fleck sign (arrow). In this case, the ligament itself remained intact and the injury occurred by avulsion of the ligament from the base of the second metatarsal. The function of the ligament is compromised, and operative intervention is indicated.

Answer 36

The Hawkins classification of talar neck fractures remains useful because it is relatively simple, guides treatment, and has prognostic value. ## Footnote (A) Type I fracture (minimally displaced). (B) Type II fracture, with displacement of the subtalar joint. (C) Type III fracture, with displacement of the subtalar and tibiotalar joints. (D) The type IV fracture as described by Canale includes a talar neck fracture with displacement of the subtalar, tibiotalar, and talonavicular joints.

Answer 37

Snowboarder’s ankle (fracture of the lateral process of the talus).

Answer 38

The normal (A and C) vs pathologic (G and H) radiographic anatomy of the calcaneus. The lateral (A, E, and G) and Harris axial (C and H) views of the calcaneus are useful in assessing the shape and alignment of the calcaneus. (A and E) The lateral view allows for assessment of the posterior and middle facet positions as well as of calcaneal height (Böhler angle; E). The Böhler angle is formed by drawing two lines. The first is drawn from the highest point on the anterior process to the highest point on the posterior facet. The second line is tangential to the superior edge of the tuberosity. The normal value of the Böhler angle is 25 to 40 degrees. (G) In the injured calcaneus, the Böhler angle is diminished, corresponding to the loss of height (flattening). (F) The critical angle of Gissane is the angle formed by the intersection of a line drawn along the dorsal aspect of the anterior process of the calcaneus and a line drawn along the dorsal slope of the posterior facet. The normal value of the Gissane angle is 120 to 145 degrees. (C and H) The axial view is useful for determining displacement of the tuberosity, varus angulation, fibular abutment, and displacement of the lateral wall.

Answer 39

The Sanders classification is based on the fracture pattern through the posterior facet as seen on coronal CT scan. Type 1 fractures are nondisplaced. Type 2 fractures are two-part fractures of the posterior facet. Type 3 fractures are three-part fractures of the posterior facet. Type 4 fractures are highly comminuted, with four or more fragments to the posterior facet. (A and B) Type 2 and type 3 fractures are further classified according to the location of the fracture lines (A, B, and C), as shown. (C) This fracture would therefore be a Sanders type 3AC. The prognosis for calcaneus fractures worsens as the comminution of the posterior facet worsens.

Answer 40

Constitute less than 1% of all fractures but rank second (behind calcaneus fractures) among all tarsal bone injuries ▪ Anatomy □ More than half of the surface area of the talus is covered by articular cartilage. □ The neck is angled in a medial and plantar direction relative to the axis of the body. □ There are no muscular or tendinous attachments. □ Blood supply is provided by three main vessels: the posterior tibial artery, the dorsalis pedis artery, and the perforating peroneal artery. • The arteries of the tarsal sinus (br. of perforating peroneal), the tarsal canal (br. of the posterior tibial artery), and the deltoid (br. of the artery of the tarsal canal) are important branches of the main vessels. • The artery of the tarsal canal carries the main supply to the talar body. □ The head and neck are vascularized by the artery of the tarsal sinus and the dorsalis pedis. □ A thorough understanding of the relationship between fracture displacement and the vessels that are disrupted is extremely important when operative approaches and fixation are planned.

Answer 41

Approximately 75% of all fractures of the calcaneus are posterior facet fractures, and most of them have some displacement. □ Mechanism of injury • Usually secondary to high-energy trauma such as fall from height or motor vehicle accident • Result in axial loading and shear forces to the calcaneus • One or more posterior facet fragments are impacted into the body of the calcaneus. • The lateral wall is “blown out,” causing subfibular impingement and peroneal tendon encroachment. • Heel pad crush occurs. • Results in shortened, widened calcaneus, and in varus • Collapse of the posterior facet leads to flattening of the calcaneus • Collapse of the posterior facet leads to loss of declination of the talus • Significant soft tissue disruption is common, with open fractures accounting for 17% of calcaneus fractures. • The complication rate with ORIF for disruption of the medial soft tissue is no higher than for lateral soft tissue trauma. • Evaluation for concomitant injuries such as vertebral fractures needed

Answer 42

AP, lateral, oblique, and axial os calcis radiographs performed initially □ Reduction in Böhler angle or angle of Gissane, calcaneal shortening, and varus deformity to the tuberosity are common in joint depression fractures (Fig. 6.131). □ Broden oblique view of the ankle is helpful to evaluate posterior facet displacement. • More internal rotation of leg allows anterior portion of the joint to be seen. • Less internal rotation of leg allows posterior portion of the joint to be seen. □ CT scanning in the 30-degree semicoronal (posterior and middle facets displacement), axial (CC joint involvement), and sagittal (tuberosity displacement) planes is helpful in evaluating this multiplanar injury as well as in preoperative planning.

Answer 43

Sanders type I—immobilization for 2–3 weeks, early motion, non–weight-bearing status for 6 weeks. □ Sanders types II and III • Indications for ORIF • Later literature has again demonstrated that long-term function following Sanders type II and III calcaneal fractures may not be significantly improved following ORIF. Therefore, it is very difficult to provide clear-cut guidelines on when operative intervention is advised. • Patients with severe loss of calcaneal height, varus deformity, subtalar subluxation or dislocation, or subfibular impingement are good candidates for operative intervention. If these problems are not present, nonoperative intervention should be considered. • Patients with an overall normal morphology of the hindfoot with intraarticular incongruity may not benefit from operative intervention. • Extensile lateral exposure provides access to subtalar and CC joints and allows for lateral plate placement, but has a high rate of wound complications. • Delayed wound healing can occur in 25%–30% of patients treated with an extensile approach. Risk of a deep infection is much lower (1%–4%). • Lower rate of subtalar arthrosis than for nonoperative intervention • FHL at risk during placement of screws from lateral to medial—specifically at the level of the sustentaculum (constant fragment) • Soft tissue swelling and risks of wound complications or infection make operative intervention difficult within 2 weeks of injury. Wrinkle sign (skin wrinkles present over lateral hindfoot, indicating improvement in swelling) should be sought prior to operative intervention. • Less invasive techniques (sinus tarsi incision, percutaneous screws), which have lower wound healing and infection complication rates, are increasing in popularity. • May be option within first 2 weeks following injury. More difficult to perform as time passes because of callus formation and difficulty mobilizing fracture fragments. □ Sanders type IV • Significant comminution and displacement leads to relatively poor prognosis. • ORIF with primary subtalar arthrodesis is treatment of choice (Fig. 6.133).

Answer 44

Worse outcomes correlate to higher fracture types. □ Clinical outcomes are better with operative than with nonoperative management for patients with the following characteristics: significant intraarticular displacement, flattened Böhler angle, female gender, age younger than 29, and injury not involved in workers’ compensation process. □ Posttraumatic subtalar arthritis is common; may require arthrodesis. • 50% decreased ROM of subtalar joint expected after injury, regardless of treatment • Patients complain of pain over the sinus tarsi with limited inversion/eversion. • Outcomes for arthrodesis after primary ORIF superior to those for initial treatment with nonoperative management. • Secondary to restoration of height and width of the hindfoot in operatively treated patients • In cases with significant loss of calcaneal height, horizontal talus, and resultant anterior ankle pain, bone-block distraction arthrodesis of the subtalar joint is required. • A posterolateral approach should be considered to avoid the soft tissue healing issues associated with application of bone block through the sinus tarsi approach.

Answer 45

Associated tarsal fractures in 90% ▪ Medial—dorsomedial talar head, posterior tubercles of talus, lateral navicular ▪ Lateral—cuboid, anterior process of calcaneus, lateral process of talus and lateral malleolus ▪ Medial dislocation (Fig. 6.134) □ **More common (85%) than lateral dislocation** □ Results from forceful inversion of the hindfoot, which leads to medial displacement of the calcaneus □ Reduction can usually be accomplished with use of sedation or general anesthesia. □ **Most common obstacles to reduction are the EDB, the extensor retinaculum, the peroneal tendons, and the TN capsule.** ▪ Lateral dislocation (Fig. 6.135) □ Less common (15%) than medial dislocation □ Occurs with forceful eversion of the hindfoot, which leads to lateral displacement of the calcaneus □ M**ost common obstacles to reduction are an interposed posterior tibial tendon and FHL tendon.** ▪ C**T recommended in all cases to rule out small intraarticular fragments.** ▪ Treatment □ **Immobilization in boot or cast for 6 to 12 weeks if reduction stable** □ Unstable reduction requires temporary stabilization with either Kirschner wire or external fixation. □ Intraarticular fragments should be removed surgically.

Answer 46

Stable reduction of ankle mortise must be obtained. □ One millimeter of lateral talar shift is associated with a 42% decrease in tibiotalar contact area. □ Syndesmosis instability must be addressed after fixation of fractures. □ Braking response time for vehicle driving returns (on average) 9 weeks after operative fixation of ankle fractures.

Answer 47

Frequently comminuted intraarticular fractures of distal tibial plafond ▪ High-energy mechanism of injury, often associated with fall from a height or motor vehicle collision (axial load) ▪ Most common in fourth decade of life, more common in men ▪ Poor outcomes more common in patients with lower income or education levels or preexisting medical comorbidities, in males, and injuries associated with workers’ compensation claims ▪ Continued clinical improvement may be noted for up to 2 years ▪ Diagnosis