T2 L17 Intro to surgery of the foot and ankle Flashcards
What are the 3 sections of the foot?
Hindfoot
Midfoot
Forefoot
Give examples of types of tendon repair
Debridement
Tenodesis
Tendon transfer
Direct repair
Give examples of types of ligament repair
Indirect repair
Tendon transfer
What is the aim when treating foot pathology?
Painless
Plantigrade
Structurally normal
Functionally normal
What is the achilles tendon?
Heel cord
Formed when gastrocnemius, soles and planters unite
Attaches to calcaneal tuberosity
What is the function of the achilles tendon?
Plantarflexion of the foot
Why is the achilles tendon vulnerable to pathology?
Has no tendon sheath
Instead surrounded by paratenon
Poor blood supply
What is the blood supply to the achilles tendon?
Proximal and distal sections supplied by posterior tibial artery
Midsection supplied by peroneal artery
What can rupture the achilles tendon?
Sudden forced plantarflexion to foot - common in tennis players
Violent dorsiflexion in plantar flexed foot
What is the treatment for a ruptured achilles tendon?
In functional bracing Surgery - end to end repair - VY advancement - tendon transfer if other methods fail
What tendon is used in a tendon transfer to repair a ruptured achilles tendon?
Flexor hallucis longus
What is the position, landmarks and incision when surgically repairing Achilles?
Patient in prone or lazy lateral position
Landmarks: malleoli and achilles tendon
Incision: longitudinal, slightly medial to avoid rural nerve
What is the tibialis posterior tendon?
From posterior aspect of interosseous membrane, fibula and tibia
Has 9 insertions in foot
What are the actions of the tibialis posterior tendon?
Plantarflexion ankle joint
Principle invertor of foot
Adducts and supinates foot
What are the functions of the tibialis posterior tendon?
Stabilise lower leg
Facilitate foot inversion
Supports foot’s medial arch
Role in hindfoot inversion during gait cycle
What is the arterial supply to the tibialis posterior tendon?
Posterior tibial nerve
Peroneal nerve
Sural nerve
How does insufficiency of the tibialis posterior occur?
Tendonitis, stiffens up, becomes non-functional and hind foot goes into valgus
Lose arch of midfoot
What are the causes of tibialis posterior insufficiency?
Trauma
Chronic flat foot
Inflammatory arthropathy
Degenerative tendinopathy
What are the symptoms of tibialis posterior insufficiency?
Post-malleolar pain Arch pain & aching Progressive flat foot deformity Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities Tarsal tunnel syndrome (rare)
What are the signs of tibialis posterior insufficiency?
Valgus hindfoot
Acquired flatfoot
Forefoot abduction
What is the non-surgical treatment for tibialis posterior insufficiency?
Analgesics
Shoe wear modification
Orthotics – medial arch supports (stops pressure on medial side of foot)
Physiotherapy
What are the surgical treatments for tibialis posterior insufficiency?
Reconstruction (tendon transfer)
Fusion (if secondary arthritis)
What tendon is used in a tendon transfer for tibialis posterior insufficiency?
Flexor digitorum longus as functional loss is minor
Describe the surgical approach to tibialis posterior tendon
Position: supine
Landmark: tip of medial malleoli & base of navicular
Incision: 10cm longitudinal incision from tip of medial malleolus
What can be damaged during surgery to tibialis posterior tendon?
Saphenous nerve
Saphenous vein
How does ankle arthritis present?
Pain
Swelling
Deformity
What is the pathology of ankle arthritis?
Fracture – cartilage damage Malalignment – leads to abnormal loading Biomechanics altered in ankle joint Leads to abnormal point loading Eventual joint space narrowing & pain
What is the surgical management of ankle arthritis?
In early disease: - arthroscopy - debridement In late disease: - arthrodesis - arthroplasty - excision arthroplasty
When is ankle arthrodesis indicated?
Pain relief
Severe deformity
When total ankle replacement isn’t appropriate
What is the surgical approach for total ankle replacement?
Position: supine
Landmarks: both malleoli which are subcutaneous
Incision: 15cm longitudinal incision, midway between malleoli
What can be damaged in total ankle replacement?
Superficial peroneal nerve
Deep perineal nerve
Anterior tibial artery
When is a tibiotalcocalcaneal arthrodesis indicated?
Severe deformity
Osteoporotic ankle fractures
Complex failed ankle fixation
Failed total ankle replacement
What is an ankle sprain?
Damage to lateral ligament
What is the lateral ligament of the ankle?
Passes from anterior margin of fibular malleolus to tallus bone 3 elements: - anterior talofibular - calcaneofibular - posterior talofibular
What is the treatment for an acute lateral ligament sprain?
RICE Physio directed rehabilitation - loading injured ligaments - proprioception - strength and return to function
What are the examination signs of chronic instability?
Posterior ankle draw
Sulcus sign
What investigations may be done in chronic instability?
Stress radiographs
MRI
What are the indications for surgery in chronic instability?
Acute rupture
Chronic mechanical instability symptoms that aren’t responding to non-operative rehabilitation
What are the surgical options for chronic instability?
Tendon transfer using peroneal tendon
What is hallux valgus?
(Bunion)
Deformity away from midline, 1st metatarsal has drifted medially
More common in females
What are the presenting symptoms and signs of hallux valgus?
Pain Deformity Modification of shoe wear Nerve irritation Lesser toe deformity
What are the treatment options for hallux valgus?
Non-surgical Surgical - bunionectomy - osteotomy - 1st TMT joint fusion
What is the surgical approach for hallux valgus repair?
Position: supine
Landmarks: easily palpable 1st metatarsal joint
Incision: proximal to IP joint & curve over medial eminence staying medial to extensor hallucis
What can be damaged in surgical repair of hallux valgus?
Dorsal cutaneous nerve
Extensor hallucis tendon
Flexor hallucis longus
