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EBM 2 > Achilles and Rearfoot pathology > Flashcards

Achilles and Rearfoot pathology Flashcards

1
Q

In plantar fasciitis what is the pathological process

A

Fibrofatty degeneration (not inflammation) of the plantar fascia origin with microtears and collagen nevrosis

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2
Q

Clinical presentation of plantar fasciitis

A

Poststatic dyskinesia

Pain reproduced with windlass mechanism

Deep achy pin point pain of plantar medial tubercle of calcaneus

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3
Q

Conservative treatments for plantar fasciitis (7)

A
  • Suppression: NSAIDS, steroids
  • Stretching
  • Support: Goal is to reduce GRF. deep hel cup, stiff medial arch, heel cushion.
  • Extracorpeal shock wave therapy
  • Radiofrequency coblation
  • Iontophoresis
  • Platelet rich plasma
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4
Q

Biggest side effect of plantar fasciitis surgery

A

cuboid syndrome (lateral column pain)

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5
Q

Definition of ankle equinus

A

passive ankle DF <10 degrees

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6
Q

Compensation processes that occur with ankle equinus

A
  • increased ROM at adjacent joints
  • genu recurvatum
  • Steppage gait
  • Forefoot varus
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7
Q

What accurs to the first ray with ankle equinus

A

increased achilles load–> decreased PL strength–>hypermobile 1st ray

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8
Q

How to differentiate between soleal equinus and gastroc equinus

A

Silverskiold test

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9
Q

Surgical treatment options for gastroc equinus (6)

A
  • Strayer
  • Silverskiold
  • Baumann
  • McGlamry
  • Baker
  • Vulpius
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10
Q

Describe strayer procedure

A
  • Transverse incision, suture proximal flap to soleus
  • Caution: NV bundle posterior to PT muscle

In zone 1

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11
Q

Describe the Silverskiold

A

Release gastroc heads and reinsert to proximal tibia

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12
Q

Describe the Baumann procedure

A

Recession of gastroc or soleus aponeurosis

-In zone 1

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13
Q

Describe the McGlamery proceudre

A

proximal tongue in groove procedure

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14
Q

Describe the Baker procedure

A

distal tongue in groove

in zone 2

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15
Q

Describe the Vulpius procedure

A

V pointing proximally inverted V through gastroc aponeurosis

-in zone 2

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16
Q

Surgical treatment for gastroc soleus equinus (4)

A

Hoke TAL: in zone 3
Z Plasty
Hauser- not really used
Conrad and Frost-not really used

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17
Q

What is the etiology of sinus tarsi syndrome

A

Injury of interosseus talocalcaneal ligament

Also injury of cervical ligament

Status post inversion ankle sprain

-Iatrogenic from arthroeresis implant

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18
Q

Clinical presentation of sinus tarsi syndrome

A

-Pain with palpation of sinus tarsi, and eversion of foot

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19
Q

Treatment options for sinus tarsi syndrome

A
  • steroid injection into sinus tarsi

- surgical excision of contents of sinus tarsi (remove contents of Hoke’s tonsil)

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20
Q

Etiology of cuboid syndrome (4)

A
  • ankle sprain
  • excessive lateral stress due to overuse
  • Cavus foot
  • post surgical medial band plantar fasciotomy
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21
Q

Haglund’s deformity definition

A

-painful bony prominence and bursitis of lateral posterior superior calcaneus above Achilles insertion

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22
Q

The triad of Haglund’s deformity

A

-postero-superolateral pump bump, AITC and bursitis

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23
Q

X-ray angles used to measure Haglund deformity (3)

A

Fowler Philip angle: abnormal >75

Parallel pitch line

Total angle of Ruch: abnormal is >90

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24
Q

Etiology of Haglund’s deformity

A
  • compensated RF varus
  • compensated FF valgus
  • Rigid plantarflexed 1st ray
25
Q

Conservative options for Haglund’s deformity

A

-open back shoes, heel lift, orthotics, NSAIDs, steroid injections

26
Q

Surgical options for Haglund’s deformity

A
  • Extracorporeal shock wave therapy with eccentric loading
  • Achilles lengthening
  • Remove bursa, resection of bony prominence
  • Keck and Kelly osteotomy
27
Q

Describe Keck and Kelly procedure

A
  • remove sagittal wedge in calcaneus

- Useful for structural cavus and high CIA

28
Q

Anatomy of the Achilles tendon

A
  • strongest and thickest tendon in the body
  • Tendon rotates 90 degrees as it courses distally to insert on calcaneus. Soleus inserts medially to gastroc.
  • Achilles does not have synovial sheath but instead a paratenon to allow for gliding activity
  • Sural nerve crosses tendon 11cm proximal to insertion
29
Q

Describe paratenon

A

similar to tendon sheath, majority of blood supply, preserve during surgery

30
Q

Describe mesotenon

A

tissue connection tendon to fibrous sheath

31
Q

describe the epitenon

A

outer covering of tendon within sheath

32
Q

describe the endotenon

A

tissue carrying blood vessels surrounding small collagen bundles

33
Q

Stages of tendon healing (4)

A

1) Inflammatory: neutrophil/macrophage infiltration, increased vascularity (first week)
2) Proliferative: synthesis of type 3 collagen (second week)
3) Remodeling phase: decrease in collagen, alignment of collagen fibers in direction of stress (6-10weeks)
4) Maturation phase: fibrous (10weeks-1 year)

34
Q

Major areas of blood supply for Achilles tendon

A
  • Myotendinous junction
  • Paratenon
  • At the insertion of calcaneus
35
Q

Etiology of achilles tendonitis /tendonosis

A

-mechanical overload due to :

—biomechanics- cavus foot, hyperpronation, equinus

—lifestyle- improper footwear, aging, systemic conditions

36
Q

Clinical presentation for achilles tendinitis

A
  • Noninsertional: noticeable posterior bump, thickened Achilles tendon at watershed area
  • Insertional: fist step achy pain, pain worse going up a hill/stairs, shoe irritation
37
Q

Conservative treatment options for Achilles tendinitis

A
  • activity modifications
  • Meds: NSAIDS, steroids, topical antiinflammatory
  • Orthotics: CAM walker, Heel lift
  • Stretching: eccentric and concentric
38
Q

Surgical treatment options for Achilles tendinitis

A
  • Tendoscopy
  • Release of adhesions
  • Debridement of pathologic tissue
  • Exostectomy
  • Remove retrocalcaneal bursa
  • FHL tendon transfer
39
Q

Where do Achilles tendon ruptures tend to occur

A
  • In the watershed area approximately 2-6 cm proximal to insertion of calcaneus
40
Q

Etiology of Achilles tendon rupture

A
  • Same as those causing AITC
  • Trauma
  • System: hyperlipidemia, gout, RA, CKD
41
Q

Exam findings to diagnose Achilles tendon ruptures

A
  • Mattle’s test: pt prone with knee bent
  • Simmond’s test: pt prone
  • Thompson squeeze test: patient prone, knee bent and squeeze calf
  • Hatchet strike defect
  • Palpable dell
  • Unable to PF
42
Q

Radiographic findings for Achilles tendon ruptures

A

Toygar’s angle: should be less than 150
Arner’s sign: insertion of achilles curves away from calcaneus
-Kager’s triangle will be ill defined

43
Q

What classification system is used for Achilles tendon tears

A

Kuwada classification system

  • 1: Partial tear (most common)
  • 2: Complete tear <3cm: Krackow, Bunnel, Kessler stitch
  • 3: Tear is 3-6cm displaced : Autograft, graft jacket
  • 4: Tear >6cm displaced: V-Y gastroc recession, Strayer
44
Q

What protocal claims that conservative treatment does the job

A

Willits protocol states that accelerated functional rehab and nonoperative treatment just as effective as surgical

45
Q

What are the surgical suture patterns for Achilles repair

A
  • Krackow: giftbox suture (suture tied away from rupture site
  • Bunnel: criss cross stitch to prevent shearing of suture through tendon
  • Kessler
46
Q

What are some adjunctive procedures for delayed presentation of achilles rupture(9)

A
  • V-Y gastroc lengthning
  • Silfverskiod
  • Lindholm
  • Bugg and boyd
  • Bosworth
  • FHL transfer
  • Graft Jacket
  • Pegasus
  • Lynn
47
Q

Describe the V-Y lengthening

A

Especially useful for gaps 3-5cm

48
Q

Describe silfverskoid procedure

A

1 strip of gastroc aponeurosis

49
Q

Describe the Lindholm procedure

A

multiple strips of gastroc aponeurosis used

50
Q

Describe the Bugg and Boyd procedure

A

fascia lata strips join ruptured tendon

51
Q

Describe the Bosworth procedure

A

Strip of gastroc tendon freed proximaly and flapped distally

52
Q

Describe the FHL transfer

A

Most common procedure, used in conjunction with gastroc lengthening

Stronger than the FDL with a lower muscle belly and has better vascularity

53
Q

Describe the Graft Jacket procedure

A

Used for large gaps of >10cm

54
Q

Describe the Pegasus procedure

A

Use equine pericardium

55
Q

Describe the Lynn procedure

A

use plantaris for augmentation

56
Q

Keck and Kelly: Duvries osteotomy

A

Transverse resection through medial or lateral incision

57
Q

Keck and Kelly: Fowler and Phillip

A

Transverse resection through posterior heel with a Mercedes incision

58
Q

Keck and Kelly: Miller and Vogel

A

Keck and Kelly with bumpectomy and ORIF

EBM 2 (11 decks)

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