* Wheaton Pimp Questions Flashcards

Question

genicular anastomoses

Answer 1

1. descending genicular (femoral) --\> medial superior genicular 2. descending branch of the lateral femoreal circumflex --\> lateral superior genicular 3. circumflex fibular 4. medial/lateral superior geniculars 5. medial/lateral inferior geniculars 6. anterior and posterior tibial recurrent arteries

Answer 2

gastroc, soleus and plantaris

Answer 3

1. circumflex fibular (40%) 2. posterior tibial recurrent 3. anterior tibial recurrent 4. anterior medial malleolar 5. anterior lateral malleolar 6. muscular branches to anterior and lateral compartment

Answer 4

1. circumflex fibular (32%) 2. muscular branches supplying FHL, PL, PB, TP, and soleus 3. peroneal a 4. nutrient a to tibia 5. posteior medial malleolar a 6. communicating branch with peroneal 7. medial calcaneal 8. medial plantar 9. lateral plantar

Answer 5

1. perforating branch 2. nutrient a to fibula 3. communicating with posterior tibial a 4. posteriro branch terminates by giving off psoterior lateral malleolar and lateral calcaneal a

Answer 6

1. superficial epigastric 2. superficial circumflex iliac 3. superficial external pudendal 4. profundus femoris 5. descending genicular

Answer 7

superficial epigastric a and inferior epigastric a

Answer 8

deep circumflex iliac superior gluteal lateral femoral circumflex

Answer 9

internal pudendal

Answer 10

1. lateral femoral circumflex 2. medial femoral circumflex 3. perforating

Answer 11

1. ascending branch ... anastomosis with deep circumflex iliac and superior gluteal 2. transverse branch ... to cruciate anastomosis 3. descending branch ... to vastus lateralis and anastomosis with superior lateral genicular

Answer 12

* transverse branch lateral femoral circumflex * medial femoral circumflex * inferior gluteal * 1st perforating a off profundis femoris

Answer 13

medial femoral circumflex

Answer 14

* 1st ... superiro to adductor brevis * 2nd ... anterior to brevis, gives off nutrient a to femus * 3rd ... distal to adductor brevis * 4th ... terminal branch of profundus femoris

Answer 15

femur: 2nd perforating a of profundus femoris tibia: off posterior tibia a fibula: off peroneal a

Answer 16

* saphenous branch to medial thigh * articular branch .... anastomosis with medial superior genicular and anterior tibial recurrent

Answer 17

* lateral tarsal * medial tarsal * arcuate artery * 1st dorsal metatarsal artery * deep plantar artery

Answer 18

anterior and posterior medial malleolar a

Answer 19

tibial: anterior division L4-S3 common peroneal : posterior division L4-S2

Answer 20

1. iliohypogastric n (T12/L1) 2. ilioinguinal n (L1) 3. genitofemoral n (L1/2) 4. lateral femoral cutaneous n (L2/3 post) 5. obturator n (L2-4 ant) 6. accessory obturatory n (L3/4 ant) 7. femoral n (L2-4 post

Answer 21

* posterior division * common peroneal L4-S2 * n to piriformis S1/2 * inferior gluteal n (L5-S2) * superior gluteal n (L4-S1) * anterior division * tibial n (L4-S3) * n to quad femoris/inf gemellus (L4-S1) * n to obturator internus/sup gemellus (L5-S2)

Answer 22

The normal lateral talocalcaneal angle is 35-50 degrees. If it is less that 35 degrees then there is a cavus deformity

Answer 23

* The goal of the procedure is to move the attachment of the EDL more proximally to eliminate a deforming force, most often on hammertoes. As the EDL moves more proximal, it increases in dorsiflexory power. Several modifications of the procedure have been described. Grambart recommends transferring the EDL _into the peroneus tertius or the lateral cuneiform_ for cavus charcot marie tooth deformities. * Grambart ST. Hibbs Tenosuspension. Clinics in Podiatric Medicine and Surgery (2016) 33: 63-69.

Answer 24

* Boffeli argues that the frontal plane alignment of the calcaneus is rarely fixed in position because of the inherent flexibility of the foot and ankle. For this reason positioning of the foot is critical in imaging. The tibia should be aligned with the long axis of the foot (second metatarsal). * Boffeli TJ, Waverly BJ. Angle and Base of Gait Long Leg Axial and Intraoperative Simulated Weightbearing Long Leg Axial Imaging to Capture True Frontal Plane Tibia to Calcaneus Alignment in Valgus and Varus Deformities of the Rearfoot and Ankle. J Foot Ankle Surg (2106) 55: 1043-51.

Answer 25

* Type 1A is the most common type. It is caused by a duplication of the peripheral myelin protein 22 gene on chromosome 17p11.2-p1. * the mode of inheritance for this type is autosomal dominant * X-linked CMT Type 1 is caused by mutations in the gap junctions of the connexion 32 gene on chromosome Xq13.1 * (UpToDate Charcot Marie Tooth)

Answer 26

An IPJ fusion must be performed in conjunction with a Jones Suspension. Without a fusion, the FHL is able to gain mechanical advantage and overpower the EHL, leading to a flexion deformity at the IPJ.

Answer 27

* Sural nerve is at risk of iatrogenic damage with repairs to the achilles tendon. * Blackmon et al found that the _sural nerves crosses the lateral border of the Achilles tendon 8-10 cm proximal to the superior border of the calcaneal tuberosity_. * Kammar et al used ultrasound to identify the sural nerve in a health population. They found the mean distance between the nerve and tendon was 2.1, 1.5, 0.6, and 0.08 cm lateral to the achilles measure at the insertion and 4. 8, and 11 cm proximally. * Of note, kammar also found that older patients may be at increased risk of injury iatrogenically because the nerve courses closer to the tendon than in younger populations.

Answer 28

Posterior leg can be divided into five anatomical levels. See picture to the left for anatomical division and procedure names. Endoscopic recession is a growing trend. It is commonly performed just distal to the level of the musculotendinous junction

Answer 29

* _Fowler_: pathology indicated above 75 degrees . normal 44-69 degrees. * _Parallel pitch lines_: a positive result is defined as the bursal projection extending beyond the parallel lines * Cheng et al 2007 compared fowler angles and parallel pitch lines in symptomatic and control patients. They did not find any statistically significant differences indicating that the fowler angle and parallel pitch lines were of little predictive value for Haglund syndrome.

Answer 30

* _The four stages of tendon healing are (1) impact, (2) inflammatory, (3) proliferative and (4) remodeling._ * Inflammatory: erythrocytes and neutrophils enter site of injury, monocytes and macrophages predominate with phagocytosis of necrotic materials, initiation of angiogenesis and tenocyte proliferation, and Type III collagen synthesis initiated. * After a few days, remodeling: peak type III collagen synthesis, water and gylcosaminoglycan concentrations remain high. * After approximately 6 weeks, remodeling. Can be broken into consolidation and maturation. * Consolidation: weeks 6-10: cellular to fibrous tissue, Tenocytes and collagen fibers become aligned in direction of stress, and Type I collagen proliferation. * Maturation: 10+ weeks: gradual change to scar-like tendon tissue over the course of one year.

Answer 31

* Lack of congruency in _Shenton’s line_ of the ankle (distal anteromedial border of the fibula involved in the tibiofibular joint)

Answer 32

* Huang review allergy textbooks as far back as 1954 and was unable to track the origin of the _myth_ that seafood allergies are related to iodine content in shellfish. Fish and shellfish allergies are the result of sensitivity to proteins in the meats (parvalbumin in fish, tropomyosin in shrimp), not to iodine. Iodine is an essential trace mineral, required for the synthesis of thyroid hormones.

Answer 33

christopher

Answer 34

* attinger described 6 total * Posterior tibial artery supplies medial ankle and planar foot: * Calcaneal branch of the posterior tibial supplies medial heel * Medial plantar artery supplies the medial plantar foot and hallux * Lateral plantar artery supplies the lateral foot and plantar toes * Anterior tibial supplies dorsum of the foot * Peroneal artery supplies anterolateral ankle and lateral rear foot: * Anterior perforating branch supplies anterolateral ankle * Calcaneal branch of the peroneal artery supplies lateral heel * The angiosomes have vessels with small diameters called ‘choke vessels’ which allow for anastomosis between angiosomes. This allows for one angiosome to provide blood to another adjacent angiosome. * In cases of patients with blood supply to an angiosome is provided via the choke vessels, the knowledge of which angiosomes are in which location allows for better selection of flaps by ensuring blood flow is not disrupted. It also aids in the placement of incisions over areas where both sides of the incision will have sufficient blood supply for healing. Incisions closer to one angiosome might not heal as the choke vessels from the adjacent angiosome are too distant to provide enough blood to the area now disconnected from its original blood supply.

Answer 35

* Dr. Richard Ferkel’s 21-point examination system for visually inspecting the ankle joint using an arthroscope. * This 21-point exam is done to be certain that all pathology is visualized, and this method is useful because it is reproducible. * the 8 anterior points, as seen from the anterior portals * 1. deltoid ligament * 2. medial gutter * 3. medial talus * 4. central talus * 5. lateral talus * 6. talofibular articulation * 7. lateral gutter * 8. anterior gutter * the 6 central and posterior points as seen from anteromedial portal * 9. medial talus * 10. central talus * 11. lateral talus * 12. posterior inferior tibfib lig. * 13. transverse tibfib lig. * 14. capsular reflection of flexor hallucinating longus * the 7 posterior points, as seen from the posterior portals * 15. medial gutter * 16. medial talus * 17. central talus * 18. lateral talus * 19. talofibular articulation * 20. lateral gutter * 21. posterior gutter

Answer 36

* make triangular wedges in teh areas of puckering aka **burow's wedges** * avoid dog ears: fish-shaped incision, y closure, tear drop incision, L-scar technique, liposuction

Answer 37

* In a cadaveric study by VanDijk et al in 2016, blood was mainly supplied to the peroneal tendons by the peroneal artery through a posterolateral **vincula** connecting both tendons. Branches were found to bifurcate at an average of every 3.9 cm starting 24 cm proximal to the tip of the fibula. Interestingly, 8/10 cadavers had poorly vascularized zones in the peroneus longus but no avascular zones were found in the peroneus brevis. * Van Dijk PA, Madirolas FX, Carrera A, Kerkhoffs GM, Reina F. Peroneal tendons well vascularized: results from a cadaveric study. Knee Surg Sports Traumatol Arthrosc (2016) 24: 1140.

Answer 38

* Stravix is cryopreserved, viable human tissue designed for soft tissue repair released by Osiris in 2015. It is composed of umbilical amnion and wharton’s jelly. Osiris claims it retains the extracellular matrix, growth factors, neonatal mesenchymal stem cells, fibroblasts and epithelial cells. I was unable to find any research published on Stravix on pubmed. It was used in our case today to wrap the diseased peroneal tendons with the goal of providing an anti-adhesion and anti-inflammatory barrier.

Answer 39

* Trade Name: Naropin * Generic Name: Ropivacaine * Metabolism: Liver – CYP450 (it is an amide) * Half Life: 4.2 hours * less chondrotoxicity, less cardiotoxicity, and less motor block

Answer 40

* In 1977, via a cadaveric study of bimalleolar fractures, Yablon observed that the talus could be anatomically repositioned only when the lateral malleolus was accurately reduced. A case study of 53 patients with bimalleolar fractures and lateral fixation found anatomic reduction of talus and medial malleolus in each case, without degenerative arthritis. They therefore concluded that the lateral malleolus is the key to anatomic reduction of bimalleolar fractures, because the displacement of the talus followed that of the lateral malleolus. * Yablon IG, Heller FG, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. Journal of Bone & Joint Surgery 1977.

Answer 41

* The perforating artery is at risk when screws are placed across the syndesmosis. It is pertinent to know the location of the peroneal artery perforating through the syndesmosis. Penera et al analyzed the position of the perforating branch of the peroneal artery in 37 cadavers and the artery was found 3.42 +/- 0.6 cm proximal to the tibial plafond. It was closer to the screw placed 4 cm proximal to the ankle joint, they therefore concluded that a second screw placed more proximal in the 4 cm area increased the likelihood of injuring the artery. * Penera K, Manji K, Wedel M, Shofler D, Labovitz J. Ankle Syndesmotic Fixation Using Two Screws: Risk of Injury to the Perforating Branch of the Peroneal Artery. J Foot Ankle Surg 53 (2014) 534-8.

Answer 42

* “Two-finger tightness” refers to the technique of using just two fingers to grasp screwdriver instead of entire hand when tightening screws, especially those in osteoporotic or comminuted bone. Wilkofsky analyzed torque produced by different level orthopedic residents (n=24) tightening bone screws into polyurethane foam blocks. Wilkosfsky found the average torque to be **0.247 N-m** with a range from 0.11 to 0.32. Peak torque applied by 5^th year residents, attendings, and fellows was statistically greater. Acker repeated a similar study and found considerable variability in torque production, especially in junior residents.

Answer 43

* K wire sizes: 0.028 \ 0.035 \ 0.045 \ 0.062 * Width (mm) 0.6 \ 0.9 \ 1.2 \ 1.6 * Cap color Yellow \ Blue \ White \ Green “Young boys wear green” * 0.062 can be used as an underdrill for 2.0 screws and the 0.045 can be used as an underdrill for 1.5 screw.

Answer 44

* There is a 2016 case report of an entrapment of the PT within a posterior malleolar fragment. This article also references entrapment of the PT within the syndesmosis and within a medial malleolar fracture. I did not find an eponym associated with these case reports, however, Bosworth fractures are also notable in the literature as irreducible. In a Bosworth fracture, the proximal fibular fragment is posterior to the lateral ridge of the tibia. This type of fracture dislocation was first described by Bosworth in 1947.

Answer 45

* Bending forces create a tension and compression side of a bone. A tension band converts tensile force into compression force at the opposite cortex. This is achieved by applying a device on the convex side of a curved bone. When applied to a bone fragment avulsed at insertion of ligament or tendon, the tension band can reattach the avulsed fragment and convert tensile force into compression. This can allow immediate motion of the joint. * Dynamic vs. Static: A tension band that produces compression at the time of application is called a static tension band, as the forces at the fracture site remain fairly constant during movement. If the compression forces increase with motion, the tension band is dynamic.

Answer 46

1. E extra-articular fx at met-diaphseal junction (true jones) 2. I intra-articular avulsion fx of 5th met base 3. E extra-articular fx of styloid process 5th met base 4. I intra-articular comminuted fx of 5th met base 5. O avulsion fx of epiphysis in children, extra-articular ## Footnote **"EIEIO"**

Answer 47

* myotendinous junction * osseoutendinous junction * mesotenon (anterior to tendon)

Answer 48

at metaphyseal-epiphyseal junction

Answer 49

up to 40% original length

Answer 50

* Haro et al describes the surgical steps of a Hoke TAL procedure. The incision placement depends on the deformity and orientation of the achilles tendon rotating 90 degrees with the gastric fibers attaching laterally and posteriorly and the soleus attaching medially and anteriorly: * For calcaneal valgus: distal lateral to central medial to proximal lateral * For calcaneal varus: distal medial to central lateral to proximal medial

Answer 51

* Apostolakos et al defines an enthesis as an area where tendon, ligament, or joint capsule inserts into bone and acts to transmit tensile load from soft tissues to bone. * Entheses can be divided into two categories, based on their composition at their insertion site: fibrous and fibrocartilagenous. * The type of enthesis most relevant to podiatry is the fibrocartilagenous type, which includes the Achilles Tendon. * An enthesopathy is the term for a disorder involving the attachment of the tendon or ligament to bone. * Enthesopathies are very commonly associated with seronegative spondyloarthropathies (ankylosing spondylitis, reactive arthritis, psoriatic arthritis, etc).

Answer 52

* 2-6 degrees higher in the affected foot * Fatma Bilge Ergen, MD, Saziye Eser Sanverdi, MD, and Ali Oznur, MD. Charcot foot in diabetes and an update on imaging. Diabet Foot Ankle; 2013.

Answer 53

* Eichenholtz * Sanders and Frykberg * Brodsky and Rouse

Answer 54

* Wong et al describes the technique as a two-stage process that involves filling a large bone defect with temporary cement, followed by application of bone graft several weeks later. * This technique can be used on bone defects of up to 25 cm. * The first stage involves debriding the area and filling it with temporary cement. The cement is left in place for 8 weeks to allow for an induction membrane to form. At 8 weeks the temporary spacer is removed and bone graft is placed in the defect. The induction membrane is actually closed over the graft and functions to protect the bone graft from resorption and is a source for important growth factors. * Wong T, Lau T, Li X, Fang C, Yeung K, Leung F. Masqulet Technique for Treatment of Posttraumatic Bone Defects. Scientific World J. 2014.

Answer 55

Kaleta 2001

Answer 56

* In the original 1952 paper, Eagle found a limited bactericidal response to penicillin in mice inoculated with older (time) strep infections. He theorized that penicillin was ineffective once the bacteria reached a stabilized population and were no longer actively replicating (stationary growth phase). Increasing dosage of penicillin does not negate this effect. Adjunctive treatment with an antibiotic that kills cells even when they are not replicating is indicated. Stevens et al found that clindamycin was a successful adjunct in mouse models. Wargo e al found in 2015 that clindamycin + vancomycin was not significantly different in comparison to just vancomycin treatment for skin infections, but clinda + vanc was more effective in treatment when an abscess was involved with the skin soft tissue infections. * Eagle H. Experimental approach to the problem of treatment failure with penicillin: Group A streptococcal Infection in Mice. Am J Med (1952) 13:4:389-99. * Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis (1988) 158:1:23-8. * Wargo KA, McCreary EK, English TM. Vancomycin combined with clindamycin for the treatment of acute bacterial skin and skin-structure infections. Clin Infect Dis. (2015) 61:7:1148-54.

Answer 57

* Pinzur et al looked at **serum albumin level (minimum level = 3.0 g/dL, blood total-lymphocyte count (1500), and the Doppler ischemic index (0.45 or 0.5 w/DM)**. When a minimum level was achieved in 1 or 2/3 markers, amputation healing rate was 38.5% in comparison to patients with above minimum levels in 3/3 factors with a healing rate of 92.2%. * Pinzur M, Kaminsky M Sage R, Cronin R, Osterman H. Amputations at the middle level of the foot. A retrospective and prospective review. J Bone Joint Surg Am (1986) 68:7:1061-4.

Answer 58

* They are associated with tuberous sclerosis. Tuberous sclerosis is a Neurocutaneous syndrome of dominant autosomal inheritance in which the brain, eyes, skin, heart, kidneys, lungs, and bones may be affected. It is classically defined by a triad of seizures, mental retardation, and a variety of skin lesions * However, they are most commonly caused from trauma, infection, or chronic irritation. Also, they can easily be confused with a subungual osteochondroma. * **Source:** Mann’s Surgery of the Foot and Ankle

Answer 59

* _Medial cuneiform:_ distal surface is kidney-shaped with hilum on lateral margin. PI reports upper and lower facets partially completely separated 50% of the time. The plantar border of the joint is more proximal than the dorsal border. The surface is minimally convex. _1^st metatarsal base_: also kidney/renifrom shaped with hilum on lateral margin. Slighlty concave. May also be one or two facets. Lateral plantar prominence located proximal to or including the peroneus longus tubercle (Mason). The average depth of the first metatarsal-cueniform joint, according to cadaver studies by Ryan et al, was **_32.3 mm_**_._ Correlations between length of the foot and depth of joint were statistically significant. * Remember to keep in mind the four principles of arthrodesis when fusing the joint: 1) cartilage removal 2)accurate approximation of joint surfaces 3)optimal joint position and 4)fixation. (Glissan) * Ryan JD, Timpano ED, Brosky TA. Average depth of tarsometatarsal joint for trephine arthrodesis. J Foot Ankle Surg (2012) 51:2:168-171. * Mason LW, Tanaka H. The first tarsometatarsal joint and its association with hallux valgus. Bone Joint Res (2012) 1:6:99-103.

Answer 60

**_“Paprika sign”_** which is characterized by punctuate cortical or cancellous bleeding

Answer 61

_0.062 k wire = **1.6 mm in size, this means it can be used as an underdrill for 2.0 screws**_**.** It should be capped in green.

Answer 62

* Besse et al described bone tendon graft for Achilles pathology as a new technique, using patellar tendon with a piece of tibial tuberosity bone, in a small case study in 1999. Fibers from the chosen donor tendon are sutured to the residual Achilles tendon and the bone plug is inserted into calcaneus. Philippot used a bone-quadriceps tendon graft in 25 procedures and found excellent results (98.4 AOFAS), but physical activity was still limited at last follow-up (52 mo). Hansen et al reported a similar procedure technique, but used achilles tendon allograft instead. Hansen also augmented the technique with FHL transfer. * Besse Jl, Lerat Jl, Moyen B, Brunet-Guedj E. Achilles tendon repair using a bone-tendon graft harvested from the knee extensor system: three cases. J foot Ankle Surg (1999) 38:1:70-4. * Philippot R, Wegrezyn J, Frosclaude S, Besse JL. Repair of insertional achilles tendinosis with a bone-quadriceps tendon graft. Foot Ankle Int (2010) 31:9:802-6. * Hansen U, Moniz M, Zubak J, Zambrano J, Bear T. Achilles tendon reconstruction after sural fasciocutaneous flap using Achilles tendon allograft with a ttached calcaneal bone block. J Foot Ankle Surg 92010) 49:1:5-10.

Answer 63

* V-Y lengthening was first described by Abraham and Pankovich in 1975. _When the gap is more than 5cm_, v-y advancement is hypothesized to result in increased weakness of the muscle unit. Elias et al found good outcomes (94.1 AOFAS) combining the v-y lengthening with FHL tendon transfer for large lesions. Elisa et al also recommended that the limbs of the V should be at least twice as long as the rupture gap. * Abraham E, Pankovich AM. Neglected Rupture of the Achilles Tendon: Treatment by v-Y tendinous flap. The Journal of Bone and Joint Surgery (1975) 57:2:253-255. * Elias I, Besser M, Nazarian LN, Raikin SM. Reconstruction for Missed or Neglected Achilles Tendon Rupture with V-Y Lenghtening and Flexor Hallucis Longus Tendon Transfer through One Incision. Foot & Ankle International (2007) 28:12:1238-48.

Answer 64

* In a study by Younger et al (2005), the authors noted that pressures of 1000-1400 mmHg can be generated beneath an elastic bandage in a lab when stretching and wrapping the bandage 3-5 times. Multiuser testing revealed an elastic bandages had pressures of 321-423 mmHg. * In a study by Biehl et al (1993), the authors cited that Esmarch pressures varied based on size and number of times it was wrapped. Maximum pressures observed: * -3 inches, 3 wraps: ~321 mmHg * -3 inches, 4 wraps: ~413 mmHg * -4 inches, 3 wraps: ~328 mmHg * -4 inches, 4 wraps: ~380 mmHg