Surgical Principles

Question 1

Distal tibial osteotomies/supramalleolar osteotomies

Answer 1

Indicated for distal tibial torsional deformities

Question 2

Proximal tibial osteotomies

Answer 2

High complication rate and are usually reserved for correction of genu valgum and genu varum

Question 3

Major factors causing dorsal bunion deformity following clubfoot releases

Answer 3

Weak Achilles tendon
Overpowering of flexor hallucis longus
Strong anterior tibial tendon
Weak peroneus longus tendon

Question 4

Neutralization plate

Answer 4

Neutralization plates are commonly used in comminuted fractures, and often used in combination with lag screws

Question 5

Bridge plate

Answer 5

Bridge plating is fixed to only the two fracture fragments, leaving the fracture zone untouched; maximizing the blood supply to the area.

Question 6

Antiglide plate

Answer 6

Antiglide plates are a method of fixation functioning similar to a buttress plate but produces compression when a lag screw passes through the plate. This is often seen in distal 1/3 fibular fractures where a 1/3 tubular plate is applied posterolaterally on the fibula to act as a buttress to resist posterior-proximal displacement with an additional lag screw applied through the plate.

Question 7

Gastroc equinus

Answer 7

If there is less dorsiflexion when the knee is extended (but INCREASED when the knee is flexed), this indicates a gastroc equinus

Question 8

Gastrocsoleus equinus

Answer 8

If dorsiflexion is equally limited with the knee flexed and extended, this points to a soleal equinus – which would subsequently require an achilles tendon lengthening.

Question 9

Biomechanical reasoning for lateral column lengthening in pes planus

Answer 9

Analysis shows that a 10mm lateral column lengthening calcaneal osteotomy reduces the excess force on the medial arch in an adult flat foot and adds biomechanical rationale to this clinical procedure. Load on the first metatarsal increases to 37% body weight in the flat foot compared to 12% for the normal foot and the moment about the talo-navicular joint increases from 5.6 N m to 21.6 N m. Lateral column lengthening shifts the load toward the lateral column, decreasing load on the first metatarsal to 10% and decreasing the moment about the talo-navicular joint to 8.1 N m

Question 10

Pilon fracture

Answer 10

First step in surgical repair of a pilon fracture is fixation of the fibula

Question 11

Relative contraindications for TAR

Answer 11

Severe osteoporosis, history of osteomyelitis, diffuse osteonecrosis, or significant bone defect on the tibial and/or talar site.
Previous long-term therapy with steroids or immunosuppressive substances may also reduce bone quality, resulting in compromised osteointegration of prosthesis components.
Also,heavy physical work, medium level of sports activities (eg, tennis, jogging, and downhill ski), high body mass index, diabetes, and smoking.
Significant preoperative varus or valgus deformity (>10°) has also been seen as a contraindication for TAR.

Question 12

Absolute contraindications for TAR

Answer 12

Neuroarthropathy (Charcot foot), Non-manageable hindfoot malalignment, Massive joint laxity (eg, patients with Marfan disease), Highly compromised periarticular soft tissues (eg, in patients with posttraumatic OA who underwent several previous surgeries), Severe sensomotoric dysfunction of foot/ankle, Active soft-tissue or bony infection
TAR should not be considered as the first-choice therapy in patients with a high level of functional demand (eg, contact sports)

Question 13

Oblique versus vertical talus

Answer 13

• The presence of hindfoot equinus will allow differentiation between an oblique talus (reducible deformity) versus a more rigid deformity (vertical talus).

Question 14

Fixed joint in a vertical talus

Answer 14

While equinus still may need to be addressed in cases of oblique talus, fixed hindfoot equinus and an irreducible talonavicular joint are hallmark of congenital vertical talus. Hindfoot/talocalcaneal parallelism is characteristic of a club foot deformity.

Question 15

Dislocated joints in a vertical talus

Answer 15

Dorsal dislocation of the cuboid and navicular are both present in congenital vertical talus, but are not THE distinguishing factors in making a diagnosis of vertical talus versus oblique talus. When testing equinus in a suspected oblique talus, the talonavicular joint should reduce with plantarflexion.

Question 16

Clinical test for oblique versus vertical talus

Answer 16

An easy way to distinguish between the two is to remember the congenital vertical talus is a FIXED deformity, whereas oblique talus is reducible. To differentiate, place the foot through range of motion evaluating for equinus. In oblique talus, you will note that the talonavicular joint should reduce with forced plantarflexion

Question 17

Watson Jones Navicular fracture classificaiton system

Answer 17

Type I
Type II
Type IIIa
Type IIIb

Question 18

Watson Jones Type I

Answer 18

Avulsion fx of tuberosity by PT tendon

Question 19

Watson Jones Type II

Answer 19

Dorsal lip fx, may resemble os supranaviculare

Question 20

Watson Jones Type IIIa

Answer 20

Transverse fx, non-displaced

Question 21

Watson Jones Type IIIb

Answer 21

Transverse fx, displaced Type IV - Stress fx

Question 22

Subtalar joint dislocation

Answer 22

Typically the bifurcate and spring ligaments remain intact, as they have no attachments to the talus

Question 23

Buttress plate

Answer 23

Following fracture reduction and realignment of the articular surface, a buttress plate is seen along the medial surface of the distal tibia. Most pilons fail in varus and are often stabilized with a medial buttress plate. Contouring the plates prior to placement improves fit. Buttress plates function opposite to tension band. The plate is always under compression and is helpful around thin bone and around joints.

Question 24

Antiglide plate

Answer 24

Antiglide plates are a method of fixation functioning similar to a buttress plate but produces compression when a lag screw passes through the plate. This is often seen in distal fibular fractures where a 1/3 tubular plate is applied posterolaterally on the fibula to act as a buttress to resist posterior-proximal displacement with an additional lag screw applied through the plate.

Question 25

Neutralization plates

Answer 25

Neutralization plates are commonly used in comminuted fractures. The plate is attached to two primary fracture fragments. Force is then transmitted from proximal to distal, passing over the fracture site neutralizing torsional forces. Bridge plates provide stability to allow for callus formation. The plate is fixed only to two fracture fragments leaving the fracture zone untouched maximizing the blood supply to the area.

Question 26

Nerve damage during TTC arthrodesis

Answer 26

Damage to the lateral plantar nerve is a risk present during intramedullary nailing/TCC fusion. The cadaveric study performed on 10 cadaveric legs listed below showed: “The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve.

Question 27

Positioning of STJ for fusion

Answer 27

Sliding the calcaneus anteriorly on the talus results in dorsiflexion of the forefoot on the rearfoot (decreasing arch height)
Conversely, sliding the calcaneus posteriorly on the talus results in plantarflexion of the forefoot on the rearfoot (increasing arch height).

Question 28

Fragments in ankle fractures

Answer 28

The Chaput fragment is the anterolateral fragment of the distal tibia (the anterior inferior tib fib ligament stays attached to the fracture fragment.

A pilon fracture is often splint into 3 fragments:

1. Chaput (anterolateral)
2. Volkmann (posterolateral)
3. Medial fragment.

The Wagstaff fragment is the fibular equivalent to the Chaput fragment. Wagstaff fragment serves as the other attachment point of the anterior inferior tibiofibular ligament.

Question 29

Fractures of the neck of the talus based on the Hawkins classification are as follows:

Answer 29

(A) Type I fracture is a talar neck fracture,
(B) Type II is a talar neck fracture with subtalar dislocation,
(C) Type III is a talar neck fracture with subtalar and tibiotalar dislocations, and
(D) Type IV is a talar neck fracture with subtalar, tibiotalar, and talonavicular dislocations.

Question 30

Incision for navicular fracture repair

Answer 30

The dorsomedial approach to the navicular is made between the tibialis anterior tendon and extensor hallucis longus (EHL) tendon. The approach should be made straight down from skin to periosteum without raising flaps or any unnecessary dissection

Question 31

Meniscoid bodies and fibrous bands in ankle arthroscopy

Answer 31

Meniscoid lesions and fibrous bands are unique lesions, most likely of differing origin. Although they are similar in clinical presentation, their appearance at arthroscopy is clearly different. The meniscoid lesion is attached only at its origin at the inferolateral gutter on the anterior talofibular ligament. Fibrous bands are attached at two ends and may be found anywhere in the joint but are most common extending dramatically over the anterior joint line. Unexpected encountering of a fibrous band should alert the surgeon to carefully inspect the joint for other associated (occult) pathology. Because of the frequent association of bands with antecedent fracture, the observation of this lesion should lead the clinician to consider antecedent intra-articular fracture (transchondral fracture, malleolar fracture, and tibial pilon fracture) as a likely co-pathology. Careful examination of the ankle and review of the radiographs and other available images may be helpful in assessing the joint for these injuries when fibrous bands are encountered. The association of meniscoid lesion with prior soft tissue injury (sprain) is also important to understanding this lesion. Excision of both these abnormal lesions in concert with repair of coexistent pathology is associated with improvement of symptoms. Finally, both fibrous bands and meniscoid lesions are associated with symptoms that warrant closer inspection and observation. Whether the operative intervention is open or closed, the reader can benefit from the information presented.

Question 32

Tendon balancing in Chopart amputation

Answer 32

Choparts amputation is a partial foot amputation through the talonavicular and calcaneocuboid joints and its primary complication is equinus deformity . This can be mitigated by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck.

Question 33

Tibial torsion

Answer 33

The presence of tibial torsion can be suspected from lateral position of the patella causing patella maltracking and patellofemoral joint pain.” “Normally, lateral rotation of the tibia increases from approximately 5º at birth to approximately 15º at maturity. Whereas medial torsion improves with time, lateral torsion often worsens because the natural progression is toward increasing external torsion. The ability to compensate for tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot, externally rotating at the hip, or both. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hips.

Question 34

Relative contraindications to TAR

Answer 34

evere osteoporosis, history of osteomyelitis, diffuse osteonecrosis, or significant bone defect on the tibial and/or talar site. Previous long-term therapy with steroids or immunosuppressive substances may also reduce bone quality, resulting in compromised osteo integration of prosthesis components. Further relative contraindications for TAR include heavy physical work, medium level of sports activities (eg, tennis, jogging, and downhill ski), high body mass index, diabetes, and smoking. Significant preoperative varus or valgus deformity (>10°) has also been seen as a contraindication for TAR

Question 35

Latency period for brachymetatarsia

Answer 35

Latency period is subjective and typically ranges from 4-14 days for foot and ankle procedures.
If performed within metaphyseal bone, distraction can begin in 7-10 days, whereas a latency of 2 weeks is suggested for the procedure in diaphyseal bone.
It should be noted that there is no consensus on this topic. Considerations should be made for bone mineralization, overall health, osteopenia, osteoporosis, diabetes, weight, etc. In generally a longer latency period is considered in adults as younger individuals have a thicker periosteum and quicker revascularization that allows for earlier callus distraction. BoardWizards note: There is controversy regarding this topic. Review of this topic has been recommended by several of our writers. We strongly recommend referencing McGlamry’s textbook because, in our opinion; questions regarding latency (and most controversial subjects) will most likely be sourced from there.

Question 36

Position of 1st MTPJ for fusion

Answer 36

Ideal position of the 1st MTP joint after arthrodesis should be 10 - 15 degrees of dorsiflexion and 10 - 20 degrees of valgus. In the operating room, the hallux should sit loaded just slightly off of a flat plate, and position parallel to the 2nd toe.

Question 37

Jones tenosuspension

Answer 37

During a jones tenosuspension, the extensor hallucis longus tendon is transected and then rerouted through a medial to lateral drill hole in the 1st met head and then sutured back to itself dorsally. This procedure is recommended for the following circumstances: flexible cavus foot, flexible plantarflexed first ray, cock-up hallux, prophylaxis when both hallucal sesamoid bones are removed, and to relieve lesser metatarslgia.

Question 38

Last stage of correction for clubfoot

Answer 38

Equinus. As part of the Ponseti technique, a percutaneous tendo-Achilles tenotomy (TAT) is performed on feet that are unable to obtain 15° of dorsiflexion once the forefoot adduction and hindfoot varus have been corrected. It has been reported that TAT is required in approximately 80% of cases

Question 39

Size of countersink

Answer 39

The appropriate size countersink for a fully threaded 6.5 mm and a partially threaded 6.5 mm screw is 6.5mm. Synthes large frag.

Question 40

Most common reason for failure of reverse sural skin flap

Answer 40

Venous congestion is a well-known complication of the RSSAF because of the presence of valves in the deep venous system that prevent uninterrupted retrograde venous flow. The true incidence of congestion is difficult to interpret from the literature as most data are derived from small case series and not every reconstructive surgeon performs the same technique. Proposed explanations for the wide variation in outcomes include differences in patient comorbidities, pedicle widths, whether the pedicle is tunneled or exteriorized, or if the flap is supercharged”

Question 41

Purpose of capsule tendon balancing procedure in hallux valgus correction

Answer 41

Relocate sesamoids

Question 42

Antibiotic added for open fracture in the setting of a farm injury

Answer 42

Farm injuries are considered inherently dirty/contaminated wounds, and therefore are automatically considered Type III Gustilo Anderson wounds, regardless of their size. The recommended antibiotics for Type III Gustilo Anderson injuries include a first or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries.

Question 43

Mechanism of injury for peroneal subluxation

Answer 43

The mechanism of injury involves a dorsiflexed foot and sudden, substantial inversion contraction of the peroneal muscles.

Question 44

Purpose of surgical shoe post op

Answer 44

A surgical shoe will limit the ability of the hallux to “toe-off” and activate the windlass mechanism; inhibiting the propulsive phase of gait.

Question 45

Angle of weil osteotomy

Answer 45

The Weil osteotomy is made in an orientation from dorsal distal to plantar proximal, angulated 30 degrees, parallel to the weightbearing surface of the 2nd metatarsal.

Question 46

Average onset of juvenile hallux valgus

Answer 46

12 years

Question 47

Mechanism of injury of Lisfranc dislocation

Answer 47

Lisfranc joint injuries occur from 2 basic mechanisms:

1. Direct force injuries occur with a crushing mechanism (ie, crushe by vehicle, weight, large object).
2. Indirect injuries are most common and occur from forefoot abduction and plantarflexion forces to the TMT joint.

Question 48

Orientation of Z skin plasty

Answer 48

The initial incision which will become the diagonal line of the Z, is made longitudinally along the length of the scar or along the direction to be lengthened. The other two incisions are then made off this central line at 45-60 degree angles and should parallel to the RSTL

Question 49

Tracking vs track bound

Answer 49

During range of motion exercises a hallux that drifts laterally after being placed in neutral position is track-bound, unable to stay completely in a corrected position. Hallux that drifts immediately back to abnormal position during motion is tracking.

Question 50

FHL transfer for achilles rupture

Answer 50

The tendon utilized for the tendon transfer is the Flexor Hallucis Longus tendon, which can be utilized in repair of the achilles. It is innervated by the tibial nerve and inserts into the distal phalanx of the first digit/hallux.
A possible outcome of sacrificing the Flexor Hallucis Longus for a tendon transfer is weakness with plantarflexion of the hallux.

Question 51

Benefit of base osteotomy over distal osteotomy for bunion

Answer 51

Larger IM correction is a significant advantage in using first metatarsal base osteotomies and procedures. Simple fixation, early-weight bearing, and less shortening are often associated with distal 1st metatarsal osteotomies.

Question 52

Calculating TRUE IM angle in med adductus

Answer 52

The True, calculated intermetatarsal angle = the intermetatarsal angle plus (metatarsus adductus angle – 15 degrees). In this example 12 + (20 – 15) = 17 degrees.
Just remember than metadductus angle over 15 is abnormal, therefore only include any deformity over normal in your calculation

Question 53

Why add penicillin for farm open fracture

Answer 53

Clostridium is an anaerobe, and would be covered by Penicillin as this is a dirty, contaminated injury.

Question 54

Hammer toe etiology (3)

Answer 54

• Flexor stabilization
• Flexor substitution
• Extensor substitution

Question 55

Flexor stabilization

Answer 55

Flexor stabilization: most common, occur in a pronated foot and involves the flexors tendons that overpower the interossei. Recognized by excessive “gripping,” hammering/clawing, and adductovarus deformity to the fourth and fifth toes

Question 56

Flexor substitution

Answer 56

Flexor substitution, the least common of the three groupings responsible for digital deformity. The deep compartment flexors overpower the interossei when they attempt to substitute for a weak triceps surae muscle. This may be seen after excessive lengthening of the Achilles tendon.

Question 57

Extensor substitution

Answer 57

Extensor substitution: occurs when the extensors overpower the lumbricals, often seen in anterior cavus, anterior compartment muscle weakness, and equinus. Clinically this type is recognizable by as the extensor tendons begin to contract prior to heel off with marked bowstringing. The toes appear clawed with no varus rotation.

Question 58

Treatment of vertical talus

Answer 58

Serial casting should be the initial treatment, though before the article by Dobbs et al, it was usually thought to be unsuccessful. Serial casting should be used to stretch the foot in plantarflexion and inversion while counterpressure is applied to the medial aspect of the talus. Elongating and stretching the talonavicular joint in order to facilitate its reduction is important in avoiding compression of the dorsally displaced navicular into the talus. A long leg cast is then applied, with the knee flexed 90° to prevent the cast from slipping. The cast should be changed frequently (about every 1-2 weeks) in order to maximize its effectiveness. Whereas preoperative casting may be useful for stretching out the dorsal structures, casting rarely is associated with permanent correction.” “In the Dobbs technique, if the navicular can be manipulated into the correct alignment relative to the talus, it can then be pinned with a Kirschner wire (K-wire) to maintain the reduction. A small incision can be made over the talonavicular joint, and the joint can be reduced via an open technique if there is any difficulty with the reduction. A percutaneous heel-cord tenotomy is always performed. The K-wire is left in place for a total of 5 weeks, and the position is held with a long leg cast, which is changed 2 weeks after surgery. A postoperative brace is worn 23 hours per day until walking age, and it is then worn for walking until age 2 years. A single-stage surgical correction is another option and can be accomplished via either the Cincinnati approach or the dorsal approach

Question 59

PTTD Stages

Answer 59

Stage 1
Stage 2 A/B
Stage 3
Stage 4

Question 60

PTTD stage 1

Answer 60

Normal radiographs, able to perform single-heel raise, and mild tenosynovitis.

Question 61

PTTD stage 2A

Answer 61

Arch collapse on a radiograph, unable to perform single-heel raise, and a flexible flatfoot deformity.

Question 62

PTTD stage 2B

Answer 62

Arch collapse and talonavicular uncoverage (over 40%) on a radiograph, unable to perform single heel raise, flexible flatfoot deformity, and characteristic forefoot abduction or “too many toes” sign.

Question 63

PTTD stage 3

Answer 63

Subtalar arthritis on a radiograph, unable to perform single heel raise, flatfoot deformity with rigid forefoot abduction and hind foot valgus

Question 64

PTTD stage 4

Answer 64

Valgus deformity of talus in the ankle mortise visualized on AP radiograph of the ankle - talar tilt due to deltoid ligament compromise, subtalar arthritis on radiographs, unable to perform single heel raise, flatfoot deformity with rigid forefoot abduction and hind foot valgus.

Question 65

Equinus and PF

Answer 65

There is evidence to demonstrate that 83% of patients with plantar fasciitis have an equinus contracture.

Question 66

Complication of anterior translation of talus in TTC fusion

Answer 66

Anterior translation of the talus will increase the lever arm of the foot and place extra mechanical stress across the midtarsal joint complex, leading to premature wear over time.

Question 67

Buttress plate

Answer 67

Buttress plates function opposite to tension band. The plate is always under compression and is helpful around thin bone and around joints, and are used to support bone that is unstable in axial loading.

Question 68

Antiglide plate

Answer 68

Antiglide plates are a method of fixation functioning similar to a buttress plate but produces compression when a lag screw passes through the plate. This is often seen in distal 1/3 fibular fractures where a 1/3 tubular plate is applied posterolaterally on the fibula to act as a buttress to resist posterior-proximal displacement with an additional lag screw applied through the plate.

Question 69

Neutralization plate

Answer 69

Neutralization plates are commonly used in comminuted fractures, and often used in combination with lag screws.

Question 70

Bridge plate

Answer 70

Bridge plating is fixed to only the two fracture fragments, leaving the fracture zone untouched; maximizing the blood supply to the area.

Question 71

Chondral death after intra articular ankle fracture

Answer 71

Post-traumatic arthritis typically will take hold after an intra articular fracture. Chondrocytes which are affected can die via necrosis or apoptosis. Initial cell death at the superficial cartilage zones will occur via necrosis at the fracture margins, while apoptosis will occur in a delayed manner.

Question 72

TIllaux fracture

Answer 72

Patients between 12 and 15 years of age with closing physes are susceptible to specific distal tibial fracture patterns. The Tillaux fracture is a variant of SH-III fractures and represents avulsion of anterolateral distal tibia epiphysis at the insertion site of anterior inferior tibiofibular ligament. This accounts for less than 5% of pediatric ankle fractures, and may present together with a distal fibula fracture. Triplane fractures are complex, three-dimensional SH-IV fractures, occurring in younger children than the Tillaux fractures

Question 73

Posterior ankle scope

Answer 73

A surgical pen is used to mark the Achilles tendon and the lateral malleolus. With the foot in neutral position (90°), a straight line parallel to the foot sole is drawn from the tip of the lateral malleolus to the Achilles tendon. 
The posterolateral portal (PL) is made just proximal to this line and tangential to the Achilles tendon. 
The posteromedial (PM) portal is located at the same level on the medial side of the Achilles tendon . 
Ten ml of saline are injected into the ankle or subtalar joint with a syringe. Then, the vertical skin incision of the PL portal is made. Dissection of the subcutaneous tissue and deeper layers is performed bluntly with a mosquito clamp, which is oriented towards the first interdigital space. 
A 2.7 or 4.0-mm arthroscope is then inserted into the joint. The posterior talar process can be palpated and used as a landmark between ankle and subtalar joints. The PM portal skin incision is then made at the same level and parallel with respect to the PL portal. Deep dissection is performed with a mosquito clamp as previously described. The clamp is directed toward the arthroscope shaft at a 90° angle, then it is moved along the shaft and opened in front of the tip of the arthroscope in order to create space and improve visualization. 
A 2.9 full-radius mm shaver is then inserted into the PM portal, and initial synovectomy is performed. The FHL tendon is an important landmark and should always be identified, debrided from its sheath, and kept in view medially in order to avoid damage to the neurovascular bundle during the whole procedure. Passive motion of the great toe will assist in the identification of the FHL

Question 74

Talus lateral process fracture

Answer 74

Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.” “Fractures of the posterolateral process can potentially be mistaken as os trigonum, which is the posterior process arising from a secondary ossification that failed to fuse with the body of the talus. An os trigonum appears rounded, corticated and is found in 7% to 10% of the normal population. It can also fracture and cause difficulty in diagnosis, but a CT or MRI scan can aid in differentiating the two conditions. Fractures of the lateral tubercle of the posterior process are known as Shepherd’s fracture and may be similar to ankle sprains in presentation but may demonstrate posterolateral tenderness with pain both on movement of the subtalar joint and on passive movement of the flexor hallucis longus (FHL) tendon.

Question 75

Syndesmotic injuries typically occur with what type of injury

Answer 75

External rotation
Pathologic forces to the ankle syndesmosis typically result from excessive external rotation of the ankle at the end-range of dorsiflexion or some combination of ankle dorsiflexion associated with adduction or abduction of the foot. These forces can produce widening of the fibula relative to the tibia at the ankle mortise, disrupting the syndesmotic ligaments and resulting in secondary talar instability . With high pathologic forces rotating a fixed foot (i.e., from body weight or impact with another player or object), the talus rotates laterally, resulting in injury to the AITFL. With continued force, the fibula moves further away from the tibia, producing a shearing force that can be transferred axially between the bones, causing injury to the interosseous membrane. With continued high forces, the PITFL and deltoid can fail, and/or the fibula, posterior malleolus, or medial malleolus can fracture

Question 76

Treatment of purely ligamentous Lisfranc injuries

Answer 76

Open reduction and internal fixation is currently the accepted treatment for displaced Lisfranc joint injuries. However, even with anatomic reduction and stable internal fixation, treatment of these injuries does not have uniformly excellent outcomes. A primary stable arthrodesis of the medial two or three rays appears to have a better short and medium- term outcome than open reduction and internal fixation of ligamentous Lisfranc joint injuries

Question 77

Distance of posterior ankle scope portals from vital neural structures

Answer 77

6 to 7 mm from the tibial nerve & 3 to 4 mm from the sural nerve

Question 78

Indication for posterior tibial tendon transfer

Answer 78

The posterior tibial tendon (PTT) can be subjected to anterior transfer, a surgical procedure performed to repair foot drop caused by several conditions, such as irreversible lesions in the peroneal nerve or the dorsiflexor muscles of the foot and the ankle , supinated equinovarus foot deformity secondary to club deformity , Charcot-Marie-Tooth disease , leprosy , mononeuropathy, trauma to the common peroneal nerve ,cerebrovascular accident, and Duchenne’s muscular dystrophy

Question 79

Age range for posterior medial release for club foot

Answer 79

The best age for this procedure is one to two years, and the upper age limit should be approximately six years

Question 80

Which fracture to fix first in pilon

Answer 80

In previous studies, most authors agree that the distal fibula plays the key role in the stability of the ankles because 1 mm lateral displacement of the talus decreases the tibiotalar contact surface by 42%. As we know, ankle instability increases the risk of tibiotalar arthrosis. . .We concluded that rigid fixation of the fractured fibula in the pilon fracture provided strong ankle stability and should decrease the ankle arthrosis

Question 81

Antibiotic prophylaxis for dental procedures following TAR

Answer 81

Deep infection is a potential complication of any joint implant. Ankle arthroplasty is no exception. The American Academy of Orthopaedic Surgeons has a position statement on the use of prophylactic antibiotics after joint arthroplasty. The authors follow the same recommendations. All patients undergoing dental, genitourinary, or gastrointestinal manipulations who are within 2 years of their arthroplasty surgery are given 2 g amoxicillin 2 hours before the procedure, or 600 mg clindamycin 1 hour before, if allergic to penicillin. After 2 years, only patients at high-risk (patients with diabetes, patients with hemophilia, or patients who are immunosuppressed) are given prophylaxis antibiotics. The authors also consider patients with rheumatoid arthritis who are taking medication for their disease to be in this high-risk category