Surgical Procedures and Techniques

Question 1

Weil osteotomy

Answer 1

The Weil osteotomy is an oblique osteotomy of the central metatarsal neck and shaft. It is performed parallel to the ground. Central metatarsal head–neck osteotomies: indications and operative techniques.

Question 2

Kalish

Answer 2

A long-arm Austin with an osteotomy angle of 55 degrees, allowing for increased screw fixation

Question 3

Mayo bunionectomy

Answer 3

A Mayo bunionectomy involves incision of the first metatarsal head

Question 4

Correction of DASA

Answer 4

Correction of an abnormal DASA (>8 degrees) would be achieved utilizing a proximal akin osteotomy

Question 5

Treatment of metatarsus adductus

Answer 5

Treatment of metatarsus adductus varies by age.
Casting should start as close to birth as possible until the age of 2.
From 2-6 years of age soft-tissue procedures are indicated and after 6 years of age osseous procedures are recommended.
Heyman, Herndon & Strong (HHS) is a soft-tissue release that utilizes 3 dorsal incisions and preserves plantar lateral ligaments and joint capsules.
Bankart, Berman & Gartland, and Lepird each are osseous procedures in the surgical management of metatarsus adductus.

Question 6

Charcot

Answer 6

If the patient has a braceable deformtiy, reconstruction is NOT indicated
If the deformity is braceable, it implies the patient would do well with a device such as CROW walker; and surgery would not yet be indicated
Indications for reconstruction include wounding, infection, joint instability

Question 7

Indication for triple arthrodesis

Answer 7

In a patient with a rigid pes planovalgus deformity with pain along the sinus tarsi and subtalar joint a triple arthrodesis would be the preferred procedure versus an isolated subtalar joint fusion.
“Triple arthrodesis of the hindfoot, a simultaneous fusion of the talonavicular, talocalcaneal, and calcaneocuboid joints, is commonly performed for pain, chronic instability and gross deformity as a result of hindfoot pathology. This pathology includes severe post-traumatic conditions, osteoarthritis (OA), neuromuscular disorders, extensive contractures and longstanding posterior tibial tendon dysfunction. The procedure appears to be effective in relieving pain and improving function.”

Question 8

V-Y plasty

Answer 8

The arms of the V should be 1.5 times the length of the tendon defect
The rule of thumb for the inverted V fascia cut is that the arms of the V cut should be 1.5 times of the measured defect distally. This allows an arithmetical approach to planning the arms of the V-Y.

Question 9

Evans calcaneal osteotomy placement

Answer 9

The Evan’s osteotomy is performed approximately 1.5 cm proximal to the CCJ. Care is taken to avoid violating the CCJ

Question 10

FHL transfer for achilles rupture

Answer 10

In phase transfer, improves blood supply to tendon, low morbidity following transfer
The FHL does NOT have 50% the strength of teh Achilles tendon
Schon et al reported significant improvement in Achilles tendon and physical function, along with reduction in pain from use of an FHL tendon transfer for older patients with tendinosis. Despite some weakness, harvest of the FHL tendon had minimal functional sequelae
While the FHL is a powerful in phase transfer, the FHL is incapable of 50% of healthy achilles plantarflexion at the ankle joint.

Question 11

Anterior tibial split transfer

Answer 11

Overactivity of the anterior tibial tendon produces inversion most prominent in the forefoot and midfoot and similarly overactivity of the posterior tibial tendon produces hindfoot varus. The deformity can be clinically unidentifiable in some cases when Achilles shortening co-exists producing foot equinus

Question 12

What foot type responds well to anterior tibial split transfer

Answer 12

Works well in dorsiflexed and inverted foot type

Question 13

Contraindications to arthroscopic STJ arthrodesis

Answer 13

Greater than 15 degrees of valgus or more than 5 degrees of varus malalignment is a contraindication to arthroscopic subtalar joint fusion

Question 14

FHL transfer for cavus foot

Answer 14

FHL transfer is traditionally used for Achilles repair as potential tendon augmentation. Alternatively, there is literature describing that if the posterior tibial tendon is not strong enough another out of phase tendon can be used such as the FHL or FDL for weak dorsiflexion/extensor weakness.

Question 15

FHL transfer for Achilles augmentation

Answer 15

“We found no differences in pain, functional outcome (as measured by the AOFAS ankle/hindfoot scale), and patient satisfaction when comparing patients treated with Achilles debridement alone versus FHL augmentation for chronic Achilles tendinopathy. Ankle plantar flexion strength appeared to be improved with FHL transfer, with no loss of hallux plantar flexion strength. Although FHL transfer was a safe adjunct to tendon debridement and partial ostectomy for insertional Achilles tendinopathy in older patients with little compromise in function, it may not be necessary for primary cases

Question 16

Post op management of calcaneal fracture

Answer 16

Utilizing a night splint or wearing a CAM boot will after the cast is removed will help prevent ankle equinus in the postoperative period.

Question 17

Procedure for transverse plane deformity in a flat foot

Answer 17

Evans is a laterally based calcaneal opening wedge osteotomy known to provide correction in the transverse plane. “Uncoverage of the talar head on a standing AP of the foot of more than 30%, and certainly at 40% in a symptomatic flatfoot, suggests the need for lateral column lengthening

Question 18

Split tibialis anterior tendon transfer (STATT)

Answer 18

The STATT is an effective procedure used in flexible and spastic pes cavus/cavovarus foot deformities. “The goal of the STATT procedure is to increase the true dorsiflexion of the foot by balancing its power laterally, somewhat like a yoke. Swing phase loading of the long extensors on the toes is relieved, and the foot no longer assumes a varus or cavovarus position that would otherwise lose its flexibility over time.”
Does NOT work for spastic calcaneovalgus deformity

Question 19

How to calculate the amount of eversion to fuse the STJ in

Answer 19

If the patient has 12 degrees of tibial varum, you have to ask how will this account for the surgeon wanting A NET 2 degrees of calcaneal eversion.
So if you place the heel in 14 degrees of eversion, and subtract the effect the tibial varum (12 degrees) has, you end up with a net 2 degrees of eversion. 14 degrees eversion (from calcaneus) MINUS 12 degrees varum (from tibia) = NET 2 degrees eversion.

Question 20

Nerve that is sacrificed during lateral approach to STJ

Answer 20

“Occasionally, a small neural communicating branch between the sural (lateral dorsal cutaneous) and intermediate dorsal cutaneous nerve is noted. In some cases, this small branch may have to be sacrificed to afford optimal exposure.”

Question 21

Indication for medial malleolar osteotomy

Answer 21

Repair of a talar body fracture
Traditionally, medial malleolar osteotomies are utilized in gaining access to posteromedial lesions of the talus, not lateral dome lesions! “Traditional surgical approaches to the talus often fail to afford adequate exposure of the talar body, especially in the case of complex talar body fractures. Preservation of the remaining blood supply to the talus is a main concern during operative repair and can be difficult to accomplish when multiple approaches and forceful manipulations are required to gain satisfactory exposure. A medial malleolar osteotomy was used to gain access to the talar body in situations in which the traditional approaches did not provide adequate exposure

Question 22

Stage III flat foot surgical treatment

Answer 22

For a fixed deformity, or stage III deformity, an Arizona brace or AFO may be necessary to decrease pain, increase support, and improve function. However, in stage III, it is common for significant deformity to be present at the subtalar joint, with the most common operation for stage 3 being a triple arthrodesis.

Question 23

Time from injury to surgery for displaced intra articular calcaneal fracture

Answer 23

Surgery should ideally be performed within 3 weeks of a displaced calcaneal fracture, before consolidation has occurred

Question 24

Surgical treatment of 5 year old with symptomatic metatarsus adductus

Answer 24

Treatment of metatarsus adductus varies by age. Casting should start as close to birth as possible until the age of 2. From 2-6 years of age soft-tissue procedures are indicated and after 6 years of age osseous procedures are recommended.

Question 25

Heyman, Herndon & Strong (HHS)

Answer 25

Soft-tissue release that utilizes 3 dorsal incisions and preserves plantar lateral ligaments and joint capsules.
Used for the treatment of metatarsus adductus

Question 26

Bankart, Berman & Gartland

Answer 26

Osseous procedure for metatarsus adductus

Question 27

Lepird

Answer 27

Osseous procedure for metatarsus adductus

Question 28

Bosworth ankle fracture

Answer 28

The “Bosworth fracture dislocation” as described by Hoblitzell, is a rare fracture dislocation in which the fibula becomes entrapped behind the tibia, thus becoming irreducible. Additionally, it may cause compartment syndrome to develop. Standard radiographs are often difficult to interpret due to the severe external rotation these injuries exhibit. The posterolateral ridge is responsbile for hindering reduction, and will require ORIF.

Question 29

Coleman block test

Answer 29

The Coleman ‘block test’ should be performed to ascertain whether hindfoot varus is correctable or not.
If the hindfoot varus remains, then the deformity is fixed.
However, if the hindfoot corrects to physiologic valgus, then the deformity is flexible and driven by the forefoot deformity.
Frequently, the hindfoot varus partially corrects, and it is important to see the magnitude of the heel correction beyond neutral or a varus position.
Some authors have suggested manoeuvres for evaluating hindfoot flexibility by placing the patient in a prone position with the knee flexed at 90°. In this position, the foot is allowed to move freely without the influence of the first ray and hindfoot manipulation is easily performed, allowing determination of rigidity.

Question 30

Indication for Dorsiflexory wedge osteotomy + Dwyer calcaneal osteotomy

Answer 30

Rigid cavus foot structure
The heel is unable to be reduced, which means the deformity has a forefoot component and a rearfoot component, and the patient would benefit from the dorsiflexion wedge osteotomy as well as a dwyer osteotomy

Question 31

Indication for pantalar arthrodesis

Answer 31

Fusion of the tibiotalar, subtalar, talonavicular and calcaneocuboid joints
The patient is presenting with a rigid, painful flat foot deformity, along with a painful arthritic valgus ankle joint. Pantalar fusion is the most appropriate treatment option here. In the abscence of ankle arthritis, triple arthrodesis with deltoid ligament reconstruction could be considered to address the deformity. All other answer choices are unreasonable given this patient’s symptoms since none address both the painful flat foot deformity and the ankle arthritis.

Question 32

Heyman procedure

Answer 32

Rarely done today, the Heyman procedure involves transferring all 5 of the long extensor tendons to their respective metatarsal heads. Hibbs: “In this procedure, the EDL is attached proximally to the cuneiform. It is indicated in the patient with a flexible anterior cavus and flexible hammertoes created by extensor overpowering. By transferring the insertion of the EDL proximally, the deforming force on the toes is removed and the forefoot will dorsiflex once the retrograde force of the digits has been eliminated. Surgery on the digits is not necessary if no static deformity exists

Question 33

Axial loads, which are can create instability in diaphyseal fibular fractures, can be best remedied by the use of which type of plate

Answer 33

Neutralization plates function as load-sharing plates that shield lag screws from the torsional forces

Question 34

What is an unacceptable treatment plan for management following a comminuted cuboid “nutcracker” fracture?

Answer 34

NWB for 6 weeks
Ohmori et al. reported a “new treatment plan” for an isolated nutcracker injury—arthroscopic elevation of depressed bone fragments and the use of a bone biopsy needle to fill in the large defect with artificial bone.
Nondisplaced fractures may be treated with a short leg cast and non-weight-bearing status.
Comminuted fractures will more likely need an operative procedure.
Smith et al. note that when a nutcracker cuboid fracture is associated with lateral column shortening, lengthening of the lateral column, open reduction internal fixation (ORIF), and bone grafting may be needed [3].
External fixation may have a role in some cases. Yu et al. recommend open treatment for cuboid fractures when there is a one millimeter or more shortening of the lateral column.

Question 35

Open fracture with complete extrusion of the talus

Answer 35

The CT shown shows complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful. Additionally, it provides the added benefit in terms of surgical flexibility with respect to future surgical reconstruction.

Question 36

How to tell if ATFL is ruptured

Answer 36

Positive anterior drawer test

Question 37

How to tell if ATFL and CFL are ruptured

Answer 37

Talar tilt test

Question 38

Common ankle sprain

Answer 38

ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected.

Question 39

Lateral ankle ligaments

Answer 39

The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments.

Question 40

Ankle sprains

Answer 40

Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management.

Question 41

Ankle sprain functional rehab

Answer 41

A non-operative ‘functional treatment’ programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle.

Question 42

Dynamization for TTC

Answer 42

Dynamization is the process of converting a static interlocking nail to a dynamic nail by removing screw of the proximal static hole. This allows for cyclical loading motion which helps in bone formation where the surgeon is trying to obtain osseus union at.

Question 43

Surgical options after failure of peroneal tendon repair (both PL and PB ruptured)

Answer 43

• Flexor digitorum longus tendon transfer to the 5th metatarsal.
• A FDL transfer will work to improve the tendon balance as well as maintain hindfoot mobility. Subtalar fusion is considered a salvage procedure. Excising both peroneal tendons could result in an imbalance which would lead to forefoot varus. A longus to brevis tendon transfer would not achieve symptom reduction given that both tendons are weak since they have reruptured.

Question 44

Ligamentotaxis

Answer 44

Ligamentotaxis is the concept of fracture reduction by applying axial traction to a fractured bone when the soft tissue attachments of that bone are still intact. During ligamentotaxis, these attachments serve to draw the fragments back into anatomical alignment once one has restored the soft tissue component to its original length.

Question 45

Surgical procedure for elongated hallux proximal phalanx

Answer 45

A central, or cylindrical, akin osteotomy is performed in the central portion of the proximal phalanx. It may be cut through and through and may remove a trapezoidal or cylindrical shape to provide shortening of the proximal phalanx. The osteotomy is not directed to an apex.

Question 46

Koutsogiannis osteotomy

Answer 46

Koutsogiannis is indicated for calcaneovalgus. It involves a medial displacement oblique osteotomy of the calcaneus. The posterior portion of the calcaneus slides medially approximately 1/3 to ½ the calcaneal width.

Question 47

Hoke arthrodesis

Answer 47

A Hoke arthrodesis is the fusion of the navicular to the medial and intermediate cuneiform for correction of flexible flatfoot, a painful navicular-cuneiform fault, or instability and arthritis.

Question 48

PT tendon transfer for drop foot

Answer 48

Surgical treatment of a foot drop includes restoration of eversion and dorsiflexion. This is best achieved through a posterior tibial tendon transfer through the interosseous membrane to the dorsum of the foot. This is an out of phase transfer that requires significant rehab and muscular re-education to begin dorsiflexing the foot.

Question 49

Logroscino

Answer 49

Logroscino is a double osteotomy that includes a CBWO (corrects for IM >15) and a reverdin (corrects for PASA >8).

Question 50

Bicorrectional Austin

Answer 50

The bicorrectional modification of the Austin osteotomy allows for correction of an abnormal proximal articular set angle, PASA. A normal PASA = 0-8 degrees.

Question 51

Anchor screw for closing based wedge osteotomy

Answer 51

Place the proximal screw (anchor screw) perpendicular to the long axis of the metatarsal, stabilizing the hinge. This should be applied with just “two finger” tightness at this time in preparation for the compression screw.

Question 52

Mini tight rope

Answer 52

Mini-Tight rope procedure for hallux valgus correction uses no osteotomy to reduce the IM angle between the 1st and 2nd metatarsals. The procedure has been around for many years and there is a well-documented history of 2nd metatarsal fractures near the tunnel site. Some suggest this may be due to tunnel placement in diaphyseal bone. A modified technique to reverse hallux varus has been described after releasing the ABH tendon.

Question 53

Ludloff and Mau osteotomies

Answer 53

The Ludloff and Mau osteotomies are oblique osteotomies performed for hallux valgus correction. The ludloff is performed from dorsal proximal to plantar distal, and the mau osteotomy is performed from dorsal distal to plantar proximal. The Ludloff and Mau are infrequently used due to poor stability.

Question 54

Coalition resection

Answer 54

Surgical treatment of the calcaneonavicular coalition in an adult with minimal or no secondary changes (arthrosis) consists of resection of the coalition. The goal is to eliminate painful motion at the coalition site while potentially increasing hindfoot motion. The block of bone and fibrous tissue removed may be as large as 2 cm by using these resection margins. After removing the coalition, the surgeon looks for additional bone fragments impinging upon the talonavicular or calcaneocuboid joint. All such fragments are removed at this time. Bone wax is applied to all cut bone surfaces

Question 55

Symptomatic osteochondroma

Answer 55

Simonson patient example

Although a small asymptomatic lesion may be observed and treated conservatively, surgical resection of a subungual exostosis or subungual osteochondroma is the most common treatment of a symptomatic lesion. A partial or complete toenail avulsion is performed. A longitudinal incision is made in the nail bed. The exostosis is resected with an osteotome or bone cutter. The base of the lesion is curetted

Question 56

Treatment of metatarsus adductus

Answer 56

Treatment of metatarsus adductus varies by age. Casting should start as close to birth as possible until the age of 2. From 2-6 years of age soft-tissue procedures are indicated and after 6 years of age osseous procedures are recommended. Heyman, Herndon & Strong (HHS) is a soft-tissue release that utilizes 3 dorsal incisions and preserves plantar lateral ligaments and joint capsules. Bankart, Berman & Gartland, and Lepird each are osseous procedures in the surgical management of metatarsus adductus.

Question 57

Watermann procedure

Answer 57

A Watermann is a procedure for hallux limitus/rigidus. A closing wedge of bone is removed from the distal first metatarsal head to dorsiflex the capital fragment.

Question 58

Hibbs tenosuspension

Answer 58

Hibbs tenosuspension is indicated in flexible deformities: anterior cavus and clawtoe deformities created by extensor overpowering. The procedure is designed to decrease buckling along the MTP joints and assist in dorsiflexion. The EDL is detached at its insertion and reattached into the midfoot. The remaining distal stumps of the EDL are then sewen to the EDB, just proximal to the MTP joints.

Question 59

Daily distraction

Answer 59

Following a latency period, the maximum daily rate of distraction is 1 mm per day. It is not recommended to exceed 1 mm per day. 5/8 mm is a frequently recommended daily rate of distraction.

Question 60

Does a proximal Akin correct PASA?

Answer 60

NO. All of the following correct for a large PASA, except a proximal akin. A proximal akin osteotomy would correct for an abnormal DASA (>8 degrees). A Reverdin and a Peabody will correct an abnormal PASA. A bicorrectional Austin will correct for an increased IM angle and an abnormal PASA.

Question 61

Kessel-Boney

Answer 61

A Kessel-Bonney, or dorsal closing wedge osteotomy of the proximal phalanx. A dorsal closing wedge osteotomy of the proximal phalanx has been shown to increase motion and decrease pain at the 1st MTP joint.
Called an enclavement at HCMC

Question 62

Indication for opening base wedge plus proximal akin

Answer 62

The opening base wedge is indicated for a short first metatarsal with a large IM angle. Correction of abnormal DASA (>8 degrees) would be achieved utilizing a proximal akin osteotomy.

Question 63

Chronic exertional compartment syndrome

Answer 63

Chronic exertional compartment syndrome (CECS) involves a painful increase in compartment pressure caused by exercise and relieved by rest, common in athletes. The most common site for CECS in the lower limbs is the anterior leg compartment.” “Minimally invasive fasciotomy is effective and safe for athletes suffering from unilateral or bilateral chronic exertional compartment syndrome of the anterior and lateral compartments of the leg with good results in the mid-term

Question 64

CBWO plus reverdin

Answer 64

The CBWO is a base procedure that allows for correction of a large IM angle and a Reverdin will correct for abnormal proximal articular set angle, PASA. A normal PASA = 0-8 degrees