Name and describe 2 classifications for charcot foot
Stage 0: joint edema, x-rays negative
Stage 1: fragmentation
- Local edema
- osseous fragmentation with joint dislocation
Stage 2: coalescence:
- decreased local edema
- x-rays show coalescence of fragments and absorption of fine bone debris
Stage 3: Reconstruction
- no local edema
- x-rays show consolidation and remodeling of fracture fragments
Type 1: (midfoot)
- TMT and naviculocuneiform joints (60%)
Type 2 (Hindfoot):
- subtalar, TN, CC joints
Type 3: Ankle of calcaneus
- A: tibiotalar joint
- B: Follows fracture of calcaneal tuberosity
Type 4: Combination of areas
Type 5: solely in forefoot
How many people get subtalar arthritis 10 years post tibiotalar arthrodesis?
Syndesmosis screw technique
2 x 3.5 or 4.5mm syndesmotic screws
Through 3-4 cortices
2-5cm above plafond
No difference between types of metal or bioabsorbable
No difference between 3-4
Number of screws:
2 is better
Position of foot
Recent studies challenge the principle of holding the ankle in maximal dorsiflexion to avoid over tightening
Typically non-weight bearing 6-12 weeks
May prolong if screw breakage is a concern
Name 3 gait advantages of total ankle replacement vs. arthrodesis
Increased stride length
Increased stride velocity
4 common technical errors in Total ankle arthroplasty
Prosthesis is too lateral
Prosthesis is too small - will subside
Failing to solve preoperative varus/valgus malalignment
Attempting to replace an ankle that is too anteriorly subluxed
os trigonum syndrome is associated with pathology in what structure?
What are Scarf and Ludloff osteotomies used for? Differentiate them in one sentence.
Promixal metatarsal osteotomies for the treatment of moderate hallux valgus, usually in combination with a modified McBride distally.
See picture for differences.
Recalcitrant forefoot plantar ulcers
What is an important aspect of treatment
TAL vs. gastrocs lengthening
Decreaes plantarflexion and decreases pressure on forefoot
Technetium bone scan will be
Indium WBC scan will be
Tc: ± positive in charcot (positive for OM)
indium WBC scan: negative in charcot (+OM)
Sectioning of which collateral ligament leads to more instability?
B/c it attaches directly to the plantar plate
(vs. proper collateral, attaches to the proximal aspect of the phalanx)
Three differentials for posterior ankle pain not involving the Achilles.
- Os Trigonum Syndrome
- Posterior impingement
- FHL Tendonitis
Describe ankle arthroscopy portals
- Primary viewing portal
- Established 1st
- medial to tib ant & lateral to medial malleolus
- Danger: saphenous nerve & vein
- Primary viewing portal
- Lateral to peroneus tertius & superficial peroneal nerve & medial to lateral malleolus
- Danger: Dorsal cutaneous branch of SPN
- Anterior viewing portal
- Medial to EDC and lateral to EHL
- Not commonly used due to risk to DP artery
- Posterior viewing portal
- 2cm proximal to tip of lateral malleolus
- Between peroneal tendons and achilles tendon
- Danger: sural nerve and small saphenous vein
- posterior viewing portal
- just medial to achilles
- Risks: posterior tibial artery
Diagnosis & Treatment (chronic)
Arthroscopy and synovectomy
What are 2 associated conditions of anterior ankle impingement?
Ankle instability (up to 35% will continue to have pain after stabilization procedure)
(Technically NOT OA, b/c this is pre-OA)
Best predictor of post-op ROM with TAA
Differenes of Juvenile HV vs. Adult:
- Often bilateral
- Often familial
- Pain is not the primary complaint
- varus 1st MT with widened IMA usually present
- DMAA usually increased
- often associated with flexible flatfoot
In os trigonum syndome, in the absence of an obvious os trigonum, what may be another cause?
scar tissue behind posterior talus (where the os should be)
Found on MRI
4 pathologic conditions secondary to cavus foot
(what does cavus foot cause, NOT what causes cavus foot)
Lateral column stress fractures
Lateral ligament injury
peroneal tendon injury
Lateral column overload
1st step in lisfranc ORIF?
Intercuneiform reduction and fixation
Name & Describe classic tendon transfer for foot drop
- Classically PTT, TA & PL transfer & tritendon anastomosis
- transferred to middle/lateral cuneiform
- THROUGH split in tib ant
- Anastomosed to Tib post
- PL: cut 5cm above fibula
- Proximal end sewn to PB
- distal end is anastomosed to newly transferred PTT
- As tib post pulls, it will also pull on PL and TA, causing dorsiflexion & eversion (motion lost with peroneal nerve injury)
Classification of Hallux Rigidus:
Coughlin & Shurnas Classification
- Stiffness with normal x-ray
- mild pain at extreme range of motion
- X-rays show mild dorsal osteophyte and normal joint space
- Moderate pain with range of motion
- Moderate dorsal osteotomy
- <50% joint space narrowing
- Significant stiffness and pain at extreme ROM. No midrange pain
- Xrays show severe dorsal osteophyte >50% joint space nrrowing
- significant stiffness and pain at extreme ROM AND pain at mid-range
- x-rays: same as grade 3
List some differentials for failed treatment of ankle sprain (i.e. missed concommitant injuries/pathology)
- injury to the anterior process of calcaneus
- injury to the lateral or posterior process of the talus
- injury to the base of the 5th metatarsal
- osteochondral lesion
- injuries to the peroneal tendons
- injury to the syndesmosis
- tarsal coalition
- impingement syndromes
Indications for 1st MTP arthrodesis in HV:
What is the mechanism for injury to the superior peroneal retinaculum?
Dorsiflexion & inversion
During reflexive contraction of the peroneal muscles
4 medications you can use in Charcot Foot
neuropathic pain meds
Isolated fusion of the calcaneocuboid, subtalar, and talonavicular joint arthrodeses result in how much limitation in motion?
limit hindfoot motion by approximately 25% (CC), 40% (ST), and 90% (TN)
Name 2 anatomic risks for peroneal tendon instabiliy or rupture
Low lying peroneus brevis muscle
Presence of peroneus quartus muscle
Most common foot position after CVA or TBI
Risks of failure in isolated subtalar arthrodesis (5)
the presence of more than two millimeters of avascular bone at the arthrodesis site
failure of a previous subtalar arthrodesis
Use of structural allograft (should use autografto)
Adjacent ankle arthrodesis
What nerve can cause a painful neruoma if damaged during medial capsular imbrication for HV?
Medial branch of dorsal cutaneous nerve (SPN)
What must you do after IM screw of 5th MT base fracture (post-op care)
wait until clinical AND radiographic healing before return to sports
Post talar neck fracture, patient comes back with this (see picture)
5 radiographic changes of charcot neuropathy
obliteration of joint spaces
fragmentation of articular surface of a joint leading to subluxation/dislocation
Scattered "chunks" of bone in fibrous tissue
Surrounding soft tissue edema
Joint distension by fluid
Which 1st toe sesamoid is larger?
Medial supramalleolar osteotomy done usually for what?
Usually opening wedge for
varus ankle alignment & medial joint space narrowing
What is this deformity?
(Boutiennier of the foot)
Patient 3 months after TBI and has equinovarus foot
6-18 months post CVA for full extent of recovery
1-2 years (or several) post TBI for full extent of recovery
wait until after these times for surgery
What is removed with a cheilectomy?
Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head.
Cause and deformity of Hammer toe?
Overpull of the EDL
Causes Flexion of PIP and extension of DIP
Hallux valgus obviously involves valgus. What is the secondary deformity and what causes it?
This is caused by abductor hallicus as it migrates plantarly and medially.
What amount of dorsiflexion is requried for normal gait?
Ranges fro 15-90 degrees
(WHat joint are we talking about? Nothing dorsiflexes 90 degrees)
Muscle imbalance in spastic equinovarus foot
Strong TA (major) and PT, FHL, FDL (minor)
SPLATT, TAL, ± tib post transfer to dorsum of foot
Classification system of Hallux Rigidis
Based on radiographic & exam findings
- exam: Stiffness
- xrays: normal xrays
- exam: mild pain at extreme ROM
- Xrays: mild dorsal osteophyte with normal joint space
- exam: moderate pain with ROM
- x-rays: moderate dorsal osteophyte with
- exam: significant stiffness & pain at extreme ROM. No mid-range pain
- x-rays: severe dorsal osteophyte with >50% joint space narrowing
- exam: significant stiffness & pain at extreme ROM. (+) mid-range pain
- x-rays: same as III (severe dorsal osteophytes with >50% joint space narrowing)
Surgical approach for total ankle replacement?
between EHL & TA
Risk of OM if a diabetic foot ulcer probes to bone?
What are this?
What do you have to do before definitive management
What's definitive manageent
Digital artery aneurysm
Must see if there is adequate collateral circulation
Resection if there is adequate collateral circulation
Graft and repair if there is not adequate circulation
Treatment of midfoot arthritis that failed non-op management
1st ray TMT arthrodesis
2nd/3rd naviculocuneiform/intercuneiform joint arthrodesis
4th/5th ray - don't fuse as it allows for accomodation of the foot during gait
Can do interpositional arthroplasties of 4th/5th in certain cases
Can fuse b/c non essential
Will lead to good outcomes with near anatomic function of the foot preserved
Contraindications to TCC
marginal arterial supply to area
patients unable to comply with cast care
patient unable to tolerate case (cast claustrophobia)
Patient has viral destruction of anterior horn cells.
Clinically she has motor weakness without sensory changes.
*** patients can get post-polio syndrome 20-30 years after initial infection which invovles further brreakdown of nerves.
Tib ant contracts eccentrcialyl during what phase of gait?
Diabetic foot ulcer: Describe classification and treatment by Wagner
- Skin intact
- "Foot at risk" due to deformities
- Treat with shoe modification & serial exam
- Superficial ulcer
- Office debridment & TCC
- Deeper, full thickness ulcer
- Formal operative debridement & TCC
- Deep abscess or OM
- Formal operative debridement & TCC
- Partial gangrene of forefoot
- Local vs. larger amputation
- Extensive gangrene
Provocative test fo Morton's neuroma (2)
bursal click may be elicited by squeezing MT heads together
Webspace compression test
Pain with compression of MT
4 technical risk factors for intraoperative fracture in total ankle arthroplasty
Overextending the plafond cut too medially or laterally
Making a cut too proximal in the tibia
Using an over-sized tibial component
Distraction of the ankle with an ex-fix
Ottawa ankle rule criteria
inability to bear weight
medial or lateral malleolus point tenderness
5MT base tenderness
Name 3 surgical options for severe hallux rigidus. Which one would you recommend?
MTP arthrodesis: gold standard
MTP arthroplasty: don't do this! Long term results lead to osteolysis & synovitis
Keller Resection Arthroplasty: for low demand patients
Most common complication wiht total ankle arthroplasty
2 ways to prevent it
Long incision to prevent tension on wound
Avoid incising tib ant sheath - prevents bowstringing and wound issues
Treatment algorithm for talar OCD
SLC + NWB x6 weeks:
- Nondisplaced, acute injury
Removal of loose fragment & Microfracture
- displaced small fragment with minimal bone on the osteochondral fragment
- Size <1cm
- Size >1cm with intact cartilage cap
ORIF vs. osteochondral grafting
- Displaced >0.5cm
When do you operate in Charcot foot?
Once inflammation has gone down
4 muscles causing deformity in hallux valgus
Valgus of 1st toe leads to:
lateralization of sesamoids and respective heads of FHB
Adductor hallucis, attached to fibular sesamoid and lateral proximal phalanx, becomes deforming force
lateral deviation of EHL worsens deformity
Plantar and lateral migration of abductor hallucis casues plantar flexion & pronation
Best shoe modifiaction for reducing risk of plantar apex deformity in Charcot foot?
Double rocker bottom
Normal tibi/fib overlap
>6mm (some say 10mm) on AP
>1mm on mortise
Stance and swing make up how much of the gait cycle?
Main restraint to proximal migration of the talus?
Interosseous ligament (part of distal tibiofibular syndesmosis)
4 things you must do in tarsal tunnel release
ID the tibial nerve proximally and trace it down
Release Flexor retinaculum
Release Deep investing fascia of lower leg
Release Superficial and deep fascia of abductor hallucis
Surgial indications in Charcot foot
Instability not controlled by a brace
Where does Baxter's nerve get entrapped?
Becomes compressed between;
fascia of abductor hallucis longus
medial side of quadratus plantae
Define turf toe & give 2 defining features
Hyperextesion injury to plantar plate and sesamoid complex of the 1st MTP
- inability to push off
- reduced agility
1st line treatment is conservative
During gait, when do the Quads fires concentrically ?
2 options for tendon transfers in CMT?
TP to dorsum of foot
PL to brevis
What is the treatment for juvenile HV and how long should this be done for?
Non-operative until physes close
3 reconstruction options for tibialis anterior ruptures:
Sliding tendon graft
Free tendon autograft
how do you treat the bony deformity assciated with plantar ulcers?
Helps prevent recurrence
How much ROM can TAA be expected to add?
Expect no more than the pre-op ROM.
Adult onset Navicular AVN
vs. Kohler's disease (paediatric onset)
In ankle fusion, what should you do with the lateral malleolus?
Retain it - leaves the option for total ankle arthroplasty in the future
Treatment options for bunionette
- works in up to 90%
- lateral condelectomy
- Distal MT Medializing osteotomy (if low IMA)
- Oblique diaphyseal rotational osteotomy (if high IMA)
- AVOID proximal osteotomy as poor healing (think Jones)
What clinical test differentiates between high ankle sprain and low ankle sprain?
They will use this on the exam stem to differentiate between the two
Approach to foot compartment syndrome fasciotomy
one just lateral to 4th MT
one just medial to 2nd MT
start: 4cm anterior to posterior heel & 3cm superior to plantar surface
Cause and deformity of Mallet Toe?
FDL contracture causing DIP hyperflexion
Tarlar OCD location with a traumatic hx?
3 characteristics of this lesion
Lateral talar dome
(medial has atraumtic history)
More superficial and smaller
Lower incidence of spontaneous healing
More often displaced and symptomatic
More central or anterior
What is the relationship of teh subtalar joint and the transverse tarsal joint?
When is this important?
Inversion of teh subtalar joint locks the transverse tarsal joint
Allows for a stable hindfoot/midfoot during toe-off
Name the foot deformity associated the myelomeningocoele at:
S1: foot deformity only (no ankle)
Most sensitive test for diagnosing OM
Contrast OCDs of the medial versus lateral talar dome.
medial talar dome
usually no history of trauma
larger and deeper than lateral lesions
lateral talar dome
usually have a traumatic history
more superficial and smaller
more central or anterior
lower incidence of spontaneous healing
more often displaced and symptomatic
What is the gold standard to determine whether a diabetic ulcer will heal?
What are 2 things that must be present for an ulcer to heal
transcutaneous oxygen pressure >30mmHg (or 40 depending on the resource)
To heal an ulcer, you must have:
transcutaneous O2 pressure >30mmHg
Foot position in ankle fusion
5 degrees of hidnfoot valgus
rotation equal to contralateral foot
What is this deformity?
List the treatment options in relation to gap present in achilles tendon
0-2 cm: reapproximation
2-5 cm: V-Y Lengthening
5-8/10 cm: Gastrocs turndown +/- FHL augment
>10 cm: allograft
Who gets os trigonum syndrome
What are the main symptoms?
Dancers and soccer players
Posterior ankle pain exacerbated by:
- dancing on pointe or demi-point
- doing pushoff maneuvers
What is the treatment for a failed silicone implant used to treat hallux rigidus?
1. Removal of implant and synovectomy
2. If there is lesser toe metatarsalgia then fuse the 1st MTP
In isolated MT fracture, what holds the MT in place leading to minimal displacement?
What happens in multiple fractures?
Displacement b/c of inability of IMT ligaments to hold MT in place
What is the most common foot deformity after stroke?
Name 3 surgical options specifically for this?
- split anterior tibial tendon transfer (SPLATT)
- flexor hallucis longus tendon transfer to the dorsum of the foot and release of the flexor digitorum longus and brevis tendons at the base of each toe
- gastrocnemius or achilles lengthening
What is the main structure for load/force transfer bewteen the hindfoot and forefoot during stance?
How does autonomic dysfunction play a role in diabetic foot ulcers?
Leads to excess dryness of skin
this combined with insensate foot leads to risk of ulceration
Increased pressure/trauma (due to lack of protective sensation) on more friable skin leads to ulceration
T/F: Excision of fibular sesamoid causes hallux varus.
Other causes are over releasing lateral structures, over tightenign medially and overcorrecting IMA.
Normal medial clear space (ankle)
Weil osteotomy: most common complications
What is it due to?
Caused by improper cut, leading to intrisics migrating dorsal to the joint and acting as MTP extensors
Risk factors for Hallux Valgus
- increased DMAA
- ligamentous laxity
- convex MT head
- 2nd toe deformity/amputation
- pes planus
- High heeled shoes with narrow toe box
In achilles tendinosis, when do you perform an tendon transfer?
When >50% of the tendon is diseased/debrided
What structure is the floor of the tarsal tunnel?
what is the mainstay of non-operative treatment for hallux rigidis?
Orthotics: Morton's extension with stiff foot plate
What tendon are the 1st toe sesamoids attached to?
T/F: Excision of tibial sesamoid causes hallux varus.
(It's caused by excision on fibular sesamoid)
Which sesamoid is more likely to be bipartate?
(97% of bipartate are tibial)
Triad of symptoms for tibialis anterior rupture
(1) a pseudotumor at the anterior part of the ankle that corresponded with the ruptured tendon end
(2) loss of the normal contour of the tendon
(3) weak dorsiflexion of the ankle accompanied by hyperextension of all of the toes
What issue is associated with anteriro impingement with anterior tibial and talar osteophytes?
35% will continue to have the problem even after arthroscopic debridement
Pain 10 months post op.
What's the problem?
(It's not an infection)
Below is a picture of a WELL-united syndesmosis
Classification for Charcot Foot (Eichenholtz)
- joint edema
- Radiographs are negative
- Bone scan may be positive in all stage
Stage 1: Fragmentation
- joint edema
- Osseous fragmentation with joint dislocation
Stage 2: Coalescence
- Decreased local edema
- X-rays show coalescence of fragments and absorption of the fine bone debris
Stage 3: Reconstruction
- No local edema
- radiographs show consolidation and remodelling of fracture fragments
When do you want to operate in a charcot foot?
What is the risk?
wait until the inflammatory phase is over b/c there is a higher rate of:
- wound complications
- late deformity
- eventual amputation
There is a debate over early stabilization (but don't say that)
COntraindications to TAA?
charcot joint, ankle instability
young laborers increase the risk of failure and revision
What muscles share an origin with the plantar aponeurosis?
abductor hallucis, flexor digitorum brevis, and quadratus plantae
In DM, what is the best predictor of eventual LE amputation?
Presence of Diabetic foot ulcer
Type I: widening of lateral condyle
Type II: lateral bowing if distal 5th MT
Type III: Increased IMA of 4th/5th MT
What is the first line treatment of Charcot foot?
TCC x 2-4 months
Cast changed q2-4 weeks
± Then CROW walker
Indications for primary arthrodesis in lisfranc injury
purley ligamentous injury
How do you differentiate erythema caused by charcot neuropathy from that of infection?
In charcot, it will decrease with elevation of foot
No change with elevation in infection
6 characteristics of juvenile hallux valgus
often bilateral and familial
pain usually not primary complaint
varus of first MT with widened IMA usually present
DMAA usually increased
often associated with flexible flatfoot
Highly recurrent (50%)
What is the most common deformity of the lesser toes?
7 complications specific to Hallux Valgus Surgical Correction
AVN to metatarsal head
Dorsal malunion with transfer metatarasalgia
Cock up toe deformity
2nd MT transfer metatarsalgia
Complication of excision of tibial & fibular sesamoids?
A major dDx for 2nd MTP synovitis is Morton's neuroma
Why is it important to make the correct diagnosis?
Injection of steroids for MTP synovitis misdiagnosed as Morton's neuroma will accelerate capsuloligamentous attenuation, leading to complications (crossed-toe, MTP dislocation etc)
Indications to fix navicular fracture
avulsion fractures involving > 25% of articular surface
tuberosity fractures with > 5mm diastasis or large intra-articular fragment
displaced or intra-articular Type I and II navicular body fractures
What is the operative management of Baxters nerve compression?
Release of fascia of Abductor hallicus
At the level of the fibular groove, what peroneal tendon is posterior?
Name 1 contraindication and 3 complications of Keller Resection Arthroplasty
Resection arthroplasty of 1st MTP
- Contraindication: pre-existing hyperextension deformity
- hyperextension deformity (cock-up deformity)
- Push-off weakness
- Transfer metatarsalgia: decreased with capsular interposition
What are two risks specific to sesamoidectomy procedure?
1. Cock-up toe (need to meticulously repair FHB)
2. Nerve injury (medial plantar nerve)
At heel strike, is the hindfoot in varus or valgus?
Valgus with transverse tarsal joint UNlocked
Helps dissipate up to 50% of the force
3 indications to emergent lisfranc operative management
What implant do you use in this case?
the presence of compartment syndrome
- Consider ex-fix due to soft tissue compromise
Classification of plantar plate injury
Name 5 causes of Charcot arthropathy of the foot & ankle
(This was a previous SAQ)
3 surgical options for Freiberg's Infraction
MTP arthrotomy for I&D and removal of loose bodies
Dorsal closing wedge osteotomy (moves plantar, intact, cartilage into articulation with joint)
DuVries arthroplasty: partial MT head resection (see picture)
Positive prognostic indicators for tarsal tunnel release (5)
Compressive anatomy structure is identified and removed
Symptoms in a distribution of the tibial nerve (or DPN)
a positive nerve compression sign
Positive electrodiagnostic study
a space occupying mass
Most common complication in correction of Juvenlie HV?
Recurrence: > 50%
What peroneal tendon is more commonly torn?
How many patients will get subtalar arthritis 10 years after arthrodesis?
What muscle imbalance causes the primary deformity in CMT?
peroneus longus overpowering TA
PL causes plantarflexion of 1st ray in the absence of TA. This drives the remaining deformities of the foot
During gait, when is the center of gravity the highest and lowest?
Highest: during midstance
Lowest: double limb support
2 indications for MTP fusion in the treatment of hallux valgus (broadly speaking)
- Connective tissue disorders/ "Loosey-goosey" (ED, CP, DOWNS)
- Arthritis (OA or Gout)
What kind of shoe for a diabetic foot at risk?
Treatment algorithm for hallux valgus
Knot of Henry, which tendon is dorsal?
Crossing of FHL and FDL
FHL is dorsal
List poor prognostic indicators for tarsal tunnel release
Double crush syndrome
Scarring around the nerve
Position of fusion of 1st MTP?
10-15 degrees of dorsiflexion relative to the floor
- (be careful, sometimes they as in relation to the metatarsal, in which case it would be 25-35 degrees relative to 1st MT)
10-15 degrees of valgus relative to MT shaft
Treatment of Hallux Rigidus by grade:
- Nonoperative, Activity modification with Morton's extension
- Dorsal cheilectomy ± Moberg's
- MTP Arthrodesis
- MTP Arthroplasty - controversial
- Poor long term results with silicone implants due to osteolysis. Capsular interpositional arthroplasty gaining popularity
Old & low demand:
- Keller resection arthroplasty
Acute osteochondral or chondral defects:
- Synovectomy & debridement
Brodksy classificaiton for charcot foot
stage 1: midfoot (60%)
Stage 2: hindfoot: (30%)
Stage 3: ankle or calcaneal tubeosity: 5-10%
Stage 4: combination
Stage 5: Forefoot only
Indications for surgery in base of 5th MT fracture
Failure of nonop
Zone 2 in elite athletes
Zone 3 with sclerosis or nonunion or in athletic individual
Best shoe modification for Eichenholtz stage 3
Double rocker bottom shoe
What is the first deforming factor in HMSN?
Plantarflexion of 1st ray
Risk factors for charcot foot.
- diabetic neuropathy
- tabes dorsalis/syphilis
What is this deformity?
(Intrinsic Minus of the foot)
Location of anteromedial ankle portal scope
between saphenous vein and tib ant
Just medial to tib ant
What s Baxter's nerve?
What does it inneravate?
Name 1 common pathology with it:
1st branch of lateral plantar nerve
Innervates abductor digiti quinti
Can be a source of medial heel pain
In infected diabetic foot ulcer, how often are temperature, WBC, ESR and CRP increased?
Only 50% of the time
do not rely on this - exam and MRi/imaging are critical
Name 3 surgical options for charcot foot
exostectomy + TAL
reconstruction with osteotomy and fusion
Risk factors for achilles tear
episodic athletes, "weekend warrior"
Long distance runners
Cause and clinical of claw toe
Causes PIP and DIP flexion
If operating on a HV patient with open physes, where can you do your osteotomy?
DO NOT peform at proximal metaphysis if physis is open
What are the 8 phases of gait?
Weight acceptance (stance):
1. initial contact
2. limb-loading response
Single-Limb support (stance):
4. Terminal stance
6. initial swing
8. terminal swing
Name the muscle imbalances in HMSN?
Strong tib post & weak tib ant
Strong PL & weak PB
4 surgical interventions for hammertoe
FDL to extensor tendon transfer
Resection arthroplasty ± tenotomy and tendon transfer
Girdlestone procedure (flexor to extensor transfer)
Worse with plantarflexion (pointe position in Ballet)
Dx and treamtent/
arthroscopic excision is symptomatic
Mechanism of high ankle sprain
external rotation injury
vs low ankle sprain: eversion
Risks of nonunion in ankle fusion
adjacent joint fusion
Previously failed arthrodesis
What are this??
What are it for?
Morton's extension with stiff foot plate
Used for hallux rigidus
In hallux rigidus, what happens to plantar pressure across 1st MTP?
Two specific tests that differentiate charcot from infection?
1) elevation of foot will decrease erythema in charcot but not infection
2) indium WBC scan - cold in charcot
(Bone scan hot in both)
Gold standard care for diabetic foot ulcers
Multidisciplinary foot care
always say this
Complication of sesamoidectomy?
Bilateral: cock-up deformity due to weak FHB
Tibial: hallux valgus
Fibular: Hallux varus
What is the most common cause of hallux VARUS?
Iatrogenic from over-correction of Hallux Valgus
What injury is most likely to result in a Posttraumatic tibiofibular synostosis?
What must you do to correct flatfoot after excising an accessory navicular?
Rerouting the Posterior tibial tendon will not correct flatfoot
How much MTP dorsiflexion is needed to run properly?
For stiff MTP in rigidus, a Moberg closing dorsal wedge can be used to increase dorsiflexion.
In hallux rigidus, what happens to the axis of rotation?
It is altered and becomes eccentric
A patient has a bunionette with an IMA > 12.
WHat is the treatment?
Diaphyseal rotation osteotomy.
Not a proximal osteotomy. Poor blood supply there.
Contraindications to total ankle arthroplasty: (7)
Young laboureres (increased risk of failure/revision)
The Center of Mass is located anterior to which vertebra?
Rate of nonunion and infeection in foot surgery/reconstruction in diabetics
10x increased risk of infection in DM, associated neuropathy or peripheral artery disease
50% risk of nonunion in complicated diabetics
Classification of accessory navicular
I: sesamoid in tib post
II: separate accessory bone attached via synchondrosis
III: complete bony enlargement
What are the 2 most common causes of an unsatisfactory Symes amputation
Migration of the posterior heel pad
(avoid by securing achilles to tibia via transosseous anchors)
sloughing due to overaggressive debridement of fishmouths
Type of shoe sole/shape for tibiotalar arthritis
single rocker bottom
Complication of excision of fibular sesamoid in HV correction?
Goal of treatment of charcot foot (and all foot issues)
The creation of a stable, plantigrade, shoeable foot and the absence of recurrent ulceration
What ankle portal is established first?
Antero medial = primary viewing portal
nick and spread method
What are the three radiologic signs of bunionette deformity?
- increased 4-5 IMA (normal 6.5-8 degrees)
- increased lateral deviation angle (normal 0-7 degrees)
- increased width of MT head (normal <13mm)
muscle imbalance in equinovarus foot
Strong: TA, TP ±FHL/FDL, gastrocs
Weak: peroneus longus/brevis
varus: TP, TA
Most common location of atraumatic talar OCD
Give 3 characteristics?
medial/posteromedial talar dome
Most common overall
larger and deeper than lateral lesions
What is the effect of the windlass mechanism?
Increases arch height as toes dorsiflex during toe off
Keeps everythng taught for toe off power
Where do peroneus brevis tears occur? Longus?
Brevis: fiblar groove (aka retromalleolar sulcus)
Longus: peroneal tubercle/cuboid tunnel
What are the branches of the tibial nerve? Where does it normally branch?
Medial and lateral plantar nerves, medial calcaneal nerve
Usually branches within the lacinate ligament (flexor retinaculum)
How much bone is removed in a Girdlestone of the toe for claw toe?
Toe girdlestone is EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer.
Deformity must be flexible.
A patient has tarsal tunnel release and comes back with recalcitrant symptoms. Plan
DO NOT do repeat surgery
It is worse than the original
During heel strike, the transverse tarsal (Chopart) joint axes are _____________
What is going on here and what is management?
Posttraumatic tibiofibular synostosis
Resection reserved for persistent pain that fails to respond to nonsurgical management.
Most diabetic foot ulcers recur within what time frame after TCC?
4 -6 weeks (closer to 4)
Describe borders and contents of tarsal tunnels
- Flexor retinaculum (lacinate ligament)
- calcaneus (medial)
- talus (medial)
- abductor hallucis (inferior)
- Tom, Dick, A Very Nervous Harry
- Inferior Retinaculum
- fascia overlying the talus and navicular
- DPN, EHL, EDL, DP artery
Diagnosis & treatment?
Kohler's disease: self-limiting AVN of navicular
SLC (walking cast) - studies show this decreases symptom duration
SURGERY NOT INDICATED
5th MT fracture: increased nonunion in what zones
Zone 2 (Jones)
Zone 3: diaphysis
Treatment of dorsal MTP dislocation
Nonoperative: 1st line but won't correct defority
- Weil osteotomy
- Plantar plate repair
- Flexor to extensor tendon transfer (Girdelstone-Taylor)
- EDB transfer under intermetatarsal ligament
Muscle imbalance in cavovarus foot
Strong PL, TP
Weak: TA, PB
What should you consider doing when doing a plantar fascia release?
Release of Baxter's nerve, as this is often confused with plantar fascitis
Remember only do partial release of plantar fascia
4 favourable patient factors for total ankle arthroplasty
Older, low demand, reasonably mobile patients with no siginificant co-morbidities
Normal or low BMI
Well-aligned and stable hindfoot
Good soft tissues
Contraindications to total ankle arthroplasty (10)
- Unresectable osteonecrotic bone
- peripheral vascular disease
- neuropathic joint disease (Charcot arthropathy)
- ankle infection
- severe joint laxity
- nonreconstructible ankle ligaments
- loss of lower leg muscular control
- severe osteopenia or osteoporosis
- Heavy labourer
Normal tib/fib clear space
<6mm on both AP and mortise, 1cm above joint
Normal values for:
Hallux valgus angle
Distal metatarsal articular angle
Hallux valgus interphalangeus angle
This diagnosis recalcitrant to conservative therapy.
Risk of fixation failure in base of 5th MT IM screw
failure to wait until radiographic healing to return to sports
fracture distraction or malreduction due to screw being too long (will straighten the curved MT shaft or perforate the medial cortex)
dDx for medial heel pain (5)
heel pad atrophy
Baxter's nerve entrapment
Calcaneal stress fracture
Tarsal tunnel syndrome
6 risk factors for Charcot Neuropathy
Broadly speaking, what are 2 types of syndesmotic fixation
3 theories for pathophysiology of charcot foot
Insensate joint subjected to repetitive microtrauma
Body unable to adopt protective mechanisms to compensate for microtrauam due to abnormal sensation
Autonomic dysfunction increases blood flow though AV shunting
Leads to bone resorption and weakening
Inflammatory cytokines may cause destruction
IL-1, TNF-alpha lead to increased production of transcription factor kB
RANK/RANKL/OPG triad pathway
3 indications for syndesmotic screws?
- syndesmotic sprain (without fracture) with instability on stress radiographs
- syndesmotic sprain refractory to conservative treatment
- syndesmotic injury with associated fracture that remains unstable after fixation of fracture
What is a Morton's extension orthotic used for?
WHat's a Lapidus procedure. What are it's indications?
lapidus: 1st TMT arthrodesis + McBride
- TMT arthritis
- Metatarsus Primus Varus
- Severe deformity with large IMA
Options for tendon transfers in foot drop: (2)
Simple tib post transfer
Bridle procedure (tri-tendon anastomosis)
Most common complication following this:
Navicular stress fracture
most common complication: nonunion
Initial mangaement; cast and NWB x 6-8 weeks
High success rate
3 specific options for management of Morton's Neuroma (surgical an non)
Wide toe box shoes and MT pad: 1st line. OK results only
Corticosteroid injection: benefit in short term RCTs
Neurectomy: dorsal approach > plantar
Gastrocs contraction leads to what motion?
Flexion of knee
Plantarflexion of ankle
Pronation of subtalar joint
What is Morton's neuroma
What causes it?
Compression neuropathy of the interdigital nerve
Most commonly involves 2nd/3rd interdigital nerves
Cause unknown but likely compression around transverse intermetatarsal ligament
Best test for syndesmosis injury?
Cotton test (intraop)
fewest false-positive results and smallest inter-observer variance
Name the ligaments of the ankle syndesmosis
inferior transverse ligament
- AKA inferior part of IoM
- distal continuation of the interosseous membrane
- main restraint to proximal migration of the talus
2 reasons to include a Weil osteotomy in the treatment of claw toe?
1. Multiple toes involved (i.e. treatment of multiple flexible claw toes = girdlestone and Weils)
2. Fixed deformities = resection arthroplasty, capsulotomy and Weil
How many articulations are there in the lisfranc joint complex?
What are the comparmtnets of the foot?
9 compartments (as per JAAOS)
- Abductor hallucis
- Abductor digiti minimi
Interossei x 4
- quadratus plantae
- Adductor hallucis
- tib post neurovascular bundle
Which test for acute syndesmotic injury of the ankle has the fewest false-positive results and smallest inter-observer variance when used intraoperatively?
(Pull fibula laterally)
Name 3 surgical options for low grade hallux rigidus
Joint debridmenet & synovectomy
- pain with dorsiflexion is a good predictor of good results
Moberg's extension osteotomy
- Dorsal closing wedge osteotomy of proximal phalanx
Natural history of accessory navicular?
most become asymptomatic by skeletal maturity
Name 2 tests specific for the lateral ankle ligments
Anterior drawer test
Talar tilt test
Describe the gold standard surgical treatment for lateral ankle instability
Lateral approach to ankle
Dissect out remnants of ATFL & CFL (often torn off fibula)
Dissect out extensor retinaculum
With suture anchors or trans-osseous tunnels, anatomically repair the ATFL & CFL ligaments to their origins along with a bite of the extensor retinaculum
±tendon transfer & tenodesis (ie Evans split peroneus brevis)