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Flashcards in Foot & Ankle Deck (228):
1

Name and describe 2 classifications for charcot foot

Eichenholtz:

 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

 

Brodsky

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

 

2

 

How many people get subtalar arthritis 10 years post tibiotalar arthrodesis?

 

50%

3

Syndesmosis screw technique

Be specific

2 x 3.5 or 4.5mm syndesmotic screws

Through 3-4 cortices

2-5cm above plafond

Screw material:

No difference between types of metal or bioabsorbable

Cortices:

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

Post-operative care:

Typically non-weight bearing 6-12 weeks

May prolong if screw breakage is a concern

4

Name 3 gait advantages of total ankle replacement vs. arthrodesis

Increased stride length

 Improved cadence

Increased stride velocity

5

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

6

os trigonum syndrome is associated with pathology in what structure?

FHL

7

 

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.

8

Recalcitrant forefoot plantar ulcers

What is an important aspect of treatment

TAL vs. gastrocs lengthening

Decreaes plantarflexion and decreases pressure on forefoot

9

Neuropathic joint

Technetium bone scan will be

Indium WBC scan will be

Tc: ± positive in charcot (positive for OM)

indium WBC scan: negative in charcot (+OM)

10

Sectioning of which collateral ligament leads to more instability?

Accessory

B/c it attaches directly to the plantar plate

(vs. proper collateral, attaches to the proximal aspect of the phalanx)

11

 

Three differentials for posterior ankle pain not involving the Achilles.

 

  1. Os Trigonum Syndrome
  2. Posterior impingement
  3. FHL Tendonitis

12

Describe ankle arthroscopy portals

Anteromedial

  • Primary viewing portal
  • Established 1st
  • medial to tib ant & lateral to medial malleolus
  • Danger: saphenous nerve & vein

Anterolateral:

  • Primary viewing portal
  • Lateral to peroneus tertius & superficial peroneal nerve & medial to lateral malleolus
  • Danger: Dorsal cutaneous branch of SPN

Anterocentral

  • Anterior viewing portal
  • Medial to EDC and lateral to EHL
  • Not commonly used due to risk to DP artery

Posterolateral

  • Posterior viewing portal
  • 2cm proximal to tip of lateral malleolus
  • Between peroneal tendons and achilles tendon
  • Danger: sural nerve and small saphenous vein

Posteromedial

  • posterior viewing portal
  • just medial to achilles
  • Risks: posterior tibial artery

 

13

Diagnosis & Treatment (chronic)

Ankle synovitis

Arthroscopy and synovectomy

14

What are 2 associated conditions of anterior ankle impingement?

Ankle instability (up to 35% will continue to have pain after stabilization procedure)

OCD
(Technically NOT OA, b/c this is pre-OA)

15

Best predictor of post-op ROM with TAA

Pre-op ROM

16

Differenes of Juvenile HV vs. Adult:

Juvenile is:

  • 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

17

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

18

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

19

1st step in lisfranc ORIF?

Intercuneiform reduction and fixation

20

Name & Describe classic tendon transfer for foot drop

Bridle Procedure

  • Classically PTT, TA & PL transfer & tritendon anastomosis

Tib post:

  • transferred to middle/lateral cuneiform
  • THROUGH split in tib ant

Tib Ant

  • Anastomosed to Tib post

Peroneus Longus

  • PL: cut 5cm above fibula
  • Proximal end sewn to PB
  • distal end is anastomosed to newly transferred PTT

Effect

  • As tib post pulls, it will also pull on PL and TA, causing dorsiflexion & eversion (motion lost with peroneal nerve injury)

21

Classification of Hallux Rigidus:

Coughlin & Shurnas Classification

Grade 0:

  • Stiffness with normal x-ray

Grade 1:

  • mild pain at extreme range of motion
  • X-rays show mild dorsal osteophyte and normal joint space

Grade 2:

  • Moderate pain with range of motion
  • Moderate dorsal osteotomy
  • <50% joint space narrowing

Grade 3:

  • Significant stiffness and pain at extreme ROM.  No midrange pain
  • Xrays show severe dorsal osteophyte >50% joint space nrrowing

Grade 4:

  • significant stiffness and pain at extreme ROM AND pain at mid-range
  • x-rays: same as grade 3

 

22

 

List some differentials for failed treatment of ankle sprain (i.e. missed concommitant injuries/pathology)

 

  1. injury to the anterior process of calcaneus
  2. injury to the lateral or posterior process of the talus
  3. injury to the base of the 5th metatarsal
  4. osteochondral lesion
  5. injuries to the peroneal tendons
  6. injury to the syndesmosis
  7. tarsal coalition
  8. impingement syndromes

23

Indications for 1st MTP arthrodesis in HV:

CP

Down's

Ehler-Danlos

RA

Gout

Severe DJD

 

24

What is the mechanism for injury to the superior peroneal retinaculum?

Dorsiflexion & inversion

During reflexive contraction of the peroneal muscles

 

25

4 medications you can use in Charcot Foot

bisphosphonates

neuropathic pain meds

antidepressants

topical anesthetics

26

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)

27

Name 2 anatomic risks for peroneal tendon instabiliy or rupture

Low lying peroneus brevis muscle

Presence of peroneus quartus muscle

28

Most common foot position after CVA or TBI

equinovarus

29

Risks of failure in isolated subtalar arthrodesis (5)

smoking

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

30

 

What nerve can cause a painful neruoma if damaged during medial capsular imbrication for HV?

 

Medial branch of dorsal cutaneous nerve (SPN)

31

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

32

Post talar neck fracture, patient comes back with this (see picture)

best Management

TTC

?TAR?

33

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

HO

 

34

Which 1st toe sesamoid is larger?

Tibial (medial)

35

Medial supramalleolar osteotomy done usually for what?

Usually opening wedge for

varus ankle alignment & medial joint space narrowing

36

 

What is this deformity?

 

Hammer Toe

 

(Boutiennier of the foot)

37

Patient 3 months after TBI and has equinovarus foot

Surgical plan?

WAIT

Takes:

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

38

 

What is removed with a cheilectomy?

 

Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head.

 

(Hallux rigidus)

39

Cause and deformity of Hammer toe?

Overpull of the EDL

Causes Flexion of PIP and extension of DIP

40

 

Hallux valgus obviously involves valgus. What is the secondary deformity and what causes it?

 

 

 

Pronation.

 

This is caused by abductor hallicus as it migrates plantarly and medially.

41

 

What amount of dorsiflexion is requried for normal gait?

Unknown

Ranges fro 15-90 degrees

 

(WHat joint are we talking about? Nothing dorsiflexes 90 degrees)

42

Muscle imbalance in spastic equinovarus foot

Surgical treamtent

Strong TA (major) and PT, FHL, FDL (minor)

SPLATT, TAL, ± tib post transfer to dorsum of foot

43

Classification system of Hallux Rigidis

Based on radiographic & exam findings

0:

  • exam: Stiffness
  • xrays: normal xrays

I:

  • exam: mild pain at extreme ROM
  • Xrays: mild dorsal osteophyte with normal joint space

II:

  • exam: moderate pain with ROM
  • x-rays: moderate dorsal osteophyte with

III:

  • exam: significant stiffness & pain at extreme ROM. No mid-range pain
  • x-rays: severe dorsal osteophyte with >50% joint space narrowing

IV:

  • exam: significant stiffness & pain at extreme ROM.  (+) mid-range pain
  • x-rays: same as III (severe dorsal osteophytes with >50% joint space narrowing)

 

 

44

Surgical approach for total ankle replacement?

Anterior

between EHL & TA

45

Risk of OM if a diabetic foot ulcer probes to bone?

65%

46

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

Treatment

Resection if there is adequate collateral circulation

Graft and repair if there is not adequate circulation

47

Treatment of midfoot arthritis that failed non-op management

Be specific

Outcomes?

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

48

Contraindications to TCC

Absolute: infection

Relative

marginal arterial supply to area

patients unable to comply with cast care

patient unable to tolerate case (cast claustrophobia)

49

 

Patient has viral destruction of anterior horn cells.

Clinically she has motor weakness without sensory changes.

 

Diagnosis?

 

Poliomyositis.

 

 

*** patients can get post-polio syndrome 20-30 years after initial infection which invovles further brreakdown of nerves.

50

Tib ant contracts eccentrcialyl during what phase of gait?

Heel strike

51

Diabetic foot ulcer: Describe classification and treatment by Wagner

Grade 0:

  • Skin intact
  • "Foot at risk" due to deformities
  • Treat with shoe modification & serial exam

Grade 1:

  • Superficial ulcer
  • Office debridment & TCC

Grade 2:

  • Deeper, full thickness ulcer
  • Formal operative debridement & TCC

Grade 3:

  • Deep abscess or OM
  • Formal operative debridement & TCC

Grade 4:

  • Partial gangrene of forefoot
  • Local vs. larger amputation

Grade 5:

  • Extensive gangrene
  • Amputation

52

Provocative test fo Morton's neuroma (2)

 

Mulder's click

bursal click may be elicited by squeezing MT heads together

Webspace compression test

Pain with compression of MT

 

53

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

54

 

Ottawa ankle rule criteria

 

inability to bear weight

medial or lateral malleolus point tenderness

5MT base tenderness

navicular tenderness

55

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

56

Most common complication wiht total ankle arthroplasty

2 ways to prevent it

Wound complications

Prevent by:

Long incision to prevent tension on wound

Avoid incising tib ant sheath - prevents bowstringing and wound issues

 

57

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

Retrograde drilling

  • Size >1cm with intact cartilage cap

ORIF vs. osteochondral grafting

  • Displaced >0.5cm

58

When do you operate in Charcot foot?

Once inflammation has gone down

so

Coalescence phase

59

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

60

Best shoe modifiaction for reducing risk of plantar apex deformity in Charcot foot?

Double rocker bottom

61

Normal tibi/fib overlap

>6mm (some say 10mm) on AP

>1mm on mortise

62

Stance and swing make up how much of the gait cycle?

Stance: 60%

Swing: 40%

63

Main restraint to proximal migration of the talus?

Interosseous ligament (part of distal tibiofibular syndesmosis)

64

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

65

Surgial indications in Charcot foot

Recurrent ulcers

Instability not controlled by a brace

 

66

Where does Baxter's nerve get entrapped?

Becomes compressed between;

fascia of abductor hallucis longus

&

medial side of quadratus plantae

67

Define turf toe & give 2 defining features

Hyperextesion injury to plantar plate and sesamoid complex of the 1st MTP

Characteristic features:

  • inability to push off
  • reduced agility

1st line treatment is conservative

68

During gait, when do the Quads fires concentrically ?

Midstance

69

2 options for tendon transfers in CMT?

TP to dorsum of foot

PL to brevis

70

What is the treatment for juvenile HV and how long should this be done for?

Non-operative until physes close

71

3 reconstruction options for tibialis anterior ruptures:

Sliding tendon graft

EHL tenodesis/transfer

Free tendon autograft

Allograft

72

how do you treat the bony deformity assciated with plantar ulcers?

Excise them

Helps prevent recurrence

73

 

How much ROM can TAA be expected to add?

 

None.

Expect no more than the pre-op ROM.

74

Mueller-Weiss Disease

Adult onset Navicular AVN

vs. Kohler's disease (paediatric onset)

75

In ankle fusion, what should you do with the lateral malleolus?

Retain it - leaves the option for total ankle arthroplasty in the future

76

Treatment options for bunionette

Non-op

  • works in up to 90%

Surgical

Type I:

  • lateral condelectomy

Type II/III

  • Distal MT Medializing osteotomy (if low IMA)
  • Oblique diaphyseal rotational osteotomy (if high IMA)
  • AVOID proximal osteotomy as poor healing (think Jones)

77

What clinical test differentiates between high ankle sprain and low ankle sprain?

Compression test

They will use this on the exam stem to differentiate between the two

78

Approach to foot compartment syndrome fasciotomy

3 incision

2x dorsal

one just lateral to 4th MT

one just medial to 2nd MT

1 medial

start: 4cm anterior to posterior heel & 3cm superior to plantar surface

79

Cause and deformity of Mallet Toe?

FDL contracture causing DIP hyperflexion

80

Tarlar OCD location with a traumatic hx?

3 characteristics of this lesion

Lateral talar dome

(medial has atraumtic history)

Less common

More superficial and smaller

Lower incidence of spontaneous healing

More often displaced and symptomatic

More central or anterior

81

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

82

Name the foot deformity associated the myelomeningocoele at:

L1

L2

L3

L4

L5

S1

L1-L3: equinovarus

L4: cavovarus

L5: calcaneovalgus

S1: foot deformity only (no ankle)

83

Most sensitive test for diagnosing OM

MRI

84

 

Contrast OCDs of the medial versus lateral talar dome.

 

medial talar dome

usually no history of trauma

more common

more posterior

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

85

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

Gold standard:

transcutaneous oxygen pressure >30mmHg (or 40 depending on the resource)

To heal an ulcer, you must have:

transcutaneous O2 pressure >30mmHg

ABI >0.45

86

Foot position in ankle fusion

Neutral plantar/dorsiflexion

5 degrees of hidnfoot valgus

rotation equal to contralateral foot

87

 

What is this deformity?

 

Mallet Toe

88

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

89

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

90

 

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 

91

In isolated MT fracture, what holds the MT in place leading to minimal displacement?

What happens in multiple fractures?

Intermetatarsal ligaments

Displacement b/c of inability of IMT ligaments to hold MT in place

92

What is the most common foot deformity after stroke?

Name 3 surgical options specifically for this?

equinovarus

  • 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

93

What is the main structure for load/force transfer bewteen the hindfoot and forefoot during stance?

Plantar aponeurosis

94

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

95

 

T/F: Excision of fibular sesamoid causes hallux varus.

 

True.

 

Other causes are over releasing lateral structures, over tightenign medially and overcorrecting IMA.

96

Normal medial clear space (ankle)

<5mm

97

Weil osteotomy: most common complications

What is it due to?

Floating toe

Caused by improper cut, leading to intrisics migrating dorsal to the joint and acting as MTP extensors

98

Risk factors for Hallux Valgus

Intrinsic:

  • Genetic
  • increased DMAA
  • ligamentous laxity
  • convex MT head
  • 2nd toe deformity/amputation
  • pes planus
  • RA
  • CP

Extrinsic:

  • High heeled shoes with narrow toe box

99

In achilles tendinosis, when do you perform an tendon transfer?

When >50% of the tendon is diseased/debrided

100

 

What structure is the floor of the tarsal tunnel?

 

Abductor Hallicus

101

what is the mainstay of non-operative treatment for hallux rigidis?

Orthotics: Morton's extension with stiff foot plate

102

What tendon are the 1st toe sesamoids attached to?

FHB

103

 

T/F: Excision of tibial sesamoid causes hallux varus.

 

False.

 

(It's caused by excision on fibular sesamoid)

104

 

Which sesamoid is more likely to be bipartate?

 

Tibial

 

(97% of bipartate are tibial)

105

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

106

What issue is associated with anteriro impingement with anterior tibial and talar osteophytes?

Lateral instability

35% will continue to have the problem even after arthroscopic debridement

107

Pain 10 months post op.

What's the problem?

(It's not an infection)

Syndesmotic nonunion

Below is a picture of a WELL-united syndesmosis

108

Classification for Charcot Foot (Eichenholtz)

Stage 0:

  • 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

109

When do you want to operate in a charcot foot?

What is the risk?

Coalescence/consolidation phase

wait until the inflammatory phase is over b/c there is a higher rate of:

  • nonunion
  • infection
  • wound complications
  • late deformity
  • eventual amputation

There is a debate over early stabilization (but don't say that)

110

 

COntraindications to TAA?

 

uncorrectable deformity

severe osteoporosis

talus osteonecrosis

charcot joint, ankle instability

obesity

young laborers increase the risk of failure and revision

111

 

What muscles share an origin with the plantar aponeurosis?

 

abductor hallucis, flexor digitorum brevis, and quadratus plantae

112

In DM, what is the best predictor of eventual LE amputation?

Presence of Diabetic foot ulcer

113

Bunionette classification

 

Type I: widening of lateral condyle

Type II: lateral bowing if distal 5th MT

Type III: Increased IMA of 4th/5th MT

114

What is the first line treatment of Charcot foot?

 

TCC x 2-4 months

Cast changed q2-4 weeks

± Then CROW walker

115

Indications for primary arthrodesis in lisfranc injury

purley ligamentous injury

delayed presentation

116

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

117

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%)

118

What is the most common deformity of the lesser toes?

Hammer toe

119

7 complications specific to Hallux Valgus Surgical Correction

Recurrence

AVN to metatarsal head

Dorsal malunion with transfer metatarasalgia

Hallux Varus

Cock up toe deformity

2nd MT transfer metatarsalgia

Neuropraxia

120

Complication of excision of tibial & fibular sesamoids?

Cock-up deformity

121

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)

122

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

123

 

What is the operative management of Baxters nerve compression?

 

Release of fascia of Abductor hallicus

124

At the level of the fibular groove, what peroneal tendon is posterior?

Longus

125

Name 1 contraindication and 3 complications of Keller Resection Arthroplasty

Resection arthroplasty of 1st MTP

  • Contraindication: pre-existing hyperextension deformity

Complications:

  • hyperextension deformity (cock-up deformity)
  • Push-off weakness
  • Transfer metatarsalgia: decreased with capsular interposition

126

 

What are two risks specific to sesamoidectomy procedure?

 

1. Cock-up toe (need to meticulously repair FHB)

2. Nerve injury (medial plantar nerve)

127

At heel strike, is the hindfoot in varus or valgus?

Valgus with transverse tarsal joint UNlocked

Helps dissipate up to 50% of the force

128

3 indications to emergent lisfranc operative management

What implant do you use in this case?

the presence of compartment syndrome

open injury

irreducible dislocations

  • Consider ex-fix due to soft tissue compromise

129

Classification of plantar plate injury

130

Name 5 causes of Charcot arthropathy of the foot & ankle

DM

Alcoholism

Syrinx

Syphylis

Leprosy

(This was a previous SAQ)

 

131

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)

132

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

133

Most common complication in correction of Juvenlie HV?

Recurrence: > 50%

134

What peroneal tendon is more commonly torn?

brevis

135

How many patients will get subtalar arthritis 10 years after arthrodesis?

50%

136

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

137

During gait, when is the center of gravity the highest and lowest?

Highest: during midstance

Lowest: double limb support

138

 

2 indications for MTP fusion in the treatment of hallux valgus (broadly speaking)

 

  1. Connective tissue disorders/ "Loosey-goosey" (ED, CP, DOWNS)
  2. Arthritis (OA or Gout)

139

What kind of shoe for a diabetic foot at risk?

Rocker bottom

140

Treatment algorithm for hallux valgus

141

Knot of Henry, which tendon is dorsal?

Crossing of FHL and FDL

FHL is dorsal

142

List poor prognostic indicators for tarsal tunnel release

Double crush syndrome

inadequate release

Post-op hematoma

Scarring around the nerve

Improper diagnosis

143

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

Neutral rotation

144

Treatment of Hallux Rigidus by grade:

0-1:

  • Nonoperative, Activity modification with Morton's extension

1&2:

  • Dorsal cheilectomy ± Moberg's

3&4:

  • 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

 

145

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

146

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

147

Best shoe modification for Eichenholtz stage 3

Double rocker bottom shoe

148

What is the first deforming factor in HMSN?

Plantarflexion of 1st ray

149

 

Risk factors for charcot foot.

Give 4

 

  1. diabetic neuropathy
  2. alcoholism
  3. leprosy
  4. myelomeningocele
  5. tabes dorsalis/syphilis
  6. syringomyelia

150

 

What is this deformity?

 

Claw Toe

 

(Intrinsic Minus of the foot)

151

Location of anteromedial ankle portal scope

between saphenous vein and tib ant

Just medial to tib ant

152

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

153

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

154

Name 3 surgical options for charcot foot

exostectomy + TAL

reconstruction with osteotomy and fusion

Amputation

155

Risk factors for achilles tear

episodic athletes, "weekend warrior"

flouroquinolone antibiotics

steroid injections

Male

Long distance runners

156

Cause and clinical of claw toe

MTP hyperextension

Causes PIP and DIP flexion

157

If operating on a HV patient with open physes, where can you do your osteotomy?

Cuneiform

DO NOT peform at proximal metaphysis if physis is open

158

What are the 8 phases of gait?

Weight acceptance (stance):

1. initial contact

2. limb-loading response

Single-Limb support (stance):

3. Midstance

4. Terminal stance

5. Preswing

Limb-advancement (Swing):

6. initial swing

7. midswing

8. terminal swing

 

159

Name the muscle imbalances in HMSN?

Strong tib post & weak tib ant

Strong PL & weak PB

160

4 surgical interventions for hammertoe

Flexible deformity

FDL to extensor tendon transfer

Fixed Deformity

Resection arthroplasty ± tenotomy and tendon transfer

Girdlestone procedure (flexor to extensor transfer)

Arthrodesis

161

Worse with plantarflexion (pointe position in Ballet)

Dx and treamtent/

 

Os trigonum

arthroscopic excision is symptomatic

162

Mechanism of high ankle sprain

external rotation injury

vs low ankle sprain: eversion

163

Risks of nonunion in ankle fusion

Smoking

adjacent joint fusion

Previously failed arthrodesis

Avascular necrosis

164

What are this??

What are it for?

Morton's extension with stiff foot plate

Used for hallux rigidus

165

In hallux rigidus, what happens to plantar pressure across 1st MTP?

It increases

166

 

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)

167

Gold standard care for diabetic foot ulcers

Multidisciplinary foot care

always say this

168

Complication of sesamoidectomy?

Bilateral

Tibial

Fibular

Bilateral: cock-up deformity due to weak FHB

Tibial: hallux valgus

Fibular: Hallux varus

169

What is the most common cause of hallux VARUS?

Iatrogenic from over-correction of Hallux Valgus

170

 

What injury is most likely to result in a Posttraumatic tibiofibular synostosis?

 

Weber C

171

What must you do to correct flatfoot after excising an accessory navicular?

Calcaneal osteotomy

Rerouting the Posterior tibial tendon will not correct flatfoot

172

 

How much MTP dorsiflexion is needed to run properly?

 

60 degrees.

 

For stiff MTP in rigidus, a Moberg closing dorsal wedge can be used to increase dorsiflexion.

173

In hallux rigidus, what happens to the axis of rotation?

It is altered and becomes eccentric

174

 

A patient has a bunionette with an IMA > 12.

 

WHat is the treatment?

 

Diaphyseal rotation osteotomy.

 

Not a proximal osteotomy. Poor blood supply there.

175

Contraindications to total ankle arthroplasty: (7)

uncorrectable deformity

severe osteoporosis

talar osteonecrosis

Charcot joint

ankle instability

obesity

Young laboureres (increased risk of failure/revision)

176

The Center of Mass is located anterior to which vertebra?

S2

177

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

178

Classification of accessory navicular

I: sesamoid in tib post

II: separate accessory bone attached via synchondrosis

III: complete bony enlargement

179

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

180

Type of shoe sole/shape for tibiotalar arthritis

single rocker bottom

181

Complication of excision of fibular sesamoid in HV correction?

Hallux varus

182

Goal of treatment of charcot foot (and all foot issues)

The creation of a stable, plantigrade, shoeable foot and the absence of recurrent ulceration

 

183

 

What ankle portal is established first?

 

Antero medial = primary viewing portal

 

nick and spread method

 

184

 

What are the three radiologic signs of bunionette deformity?

 

  1. increased 4-5 IMA (normal 6.5-8 degrees)
  2. increased lateral deviation angle (normal 0-7 degrees)
  3. increased width of MT head (normal <13mm)

185

muscle imbalance in equinovarus foot

Strong: TA, TP ±FHL/FDL, gastrocs

Weak: peroneus longus/brevis

Equinus: gastrocs

varus: TP, TA

186

Most common location of atraumatic talar OCD

Give 3 characteristics?

medial/posteromedial talar dome

Most common overall

more posterior

larger and deeper than lateral lesions

187

What is the effect of the windlass mechanism?

Increases arch height as toes dorsiflex during toe off

Keeps everythng taught for toe off power

188

Where do peroneus brevis tears occur? Longus?

Brevis: fiblar groove (aka retromalleolar sulcus)

Longus: peroneal tubercle/cuboid tunnel

189

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)

190

 

How much bone is removed in a Girdlestone of the toe for claw toe?

 

None.

Trick question.

 

Toe girdlestone is EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer.

Deformity must be flexible.

191

A patient has tarsal tunnel release and comes back with recalcitrant symptoms.  Plan

DO NOT do repeat surgery

It is worse than the original

192

During heel strike, the transverse tarsal (Chopart) joint axes are _____________

Parallel

193

 

What is going on here and what is management?

Posttraumatic tibiofibular synostosis

Resection reserved for persistent pain that fails to respond to nonsurgical management.

194

Most diabetic foot ulcers recur within what time frame after TCC?

4 -6 weeks (closer to 4)

195

Describe borders and contents of tarsal tunnels

Posterior:

  • Flexor retinaculum (lacinate ligament)
  • calcaneus (medial)
  • talus (medial)
  • abductor hallucis (inferior)
  • Contains
  • Tom, Dick, A Very Nervous Harry

Anterior

  • Inferior Retinaculum
  • fascia overlying the talus and navicular
  • Contents:
  • DPN, EHL, EDL, DP artery

196

Diagnosis & treatment?

(see picture)

Kohler's disease: self-limiting AVN of navicular

Treatment:

SLC (walking cast) - studies show this decreases symptom duration

SURGERY NOT INDICATED

197

5th MT fracture: increased nonunion in what zones

Zone 2 (Jones)

Zone 3: diaphysis

198

Treatment of dorsal MTP dislocation

Nonoperative: 1st line but won't correct defority

Operative

  • Weil osteotomy
  • Plantar plate repair
  • Flexor to extensor tendon transfer (Girdelstone-Taylor)
  • EDB transfer under intermetatarsal ligament

199

Muscle imbalance in cavovarus foot

Strong PL, TP

Weak: TA, PB

200

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

201

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

202

Contraindications to total ankle arthroplasty (10)

  • Unresectable osteonecrotic bone
  • peripheral vascular disease
  • neuropathy
  • 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

203

Normal tib/fib clear space

<6mm on both AP and mortise, 1cm above joint

204

Normal values for:

Hallux valgus angle

Intermetatarsal angle

Distal metatarsal articular angle

Hallux valgus interphalangeus angle

HVA:

IMA:

DMAA:

HVI:

 

205

This diagnosis recalcitrant to conservative therapy. 

Next step?

tibial sesamoidectomy

206

Risk of fixation failure in base of 5th MT IM screw

elite athletes

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)

207

dDx for medial heel pain (5)

Plantar fascitis

heel pad atrophy

Baxter's nerve entrapment

Calcaneal stress fracture

Tarsal tunnel syndrome

208

6 risk factors for Charcot Neuropathy

Diabetic neuropathy

Alcoholism

Leprosy

Myelomeningocoele

Tabes dorsalis/syphylis

Syringomyelia

209

Broadly speaking, what are 2 types of syndesmotic fixation

screws

tightrope

210

3 theories for pathophysiology of charcot foot

Neurotraumatic:

Insensate joint subjected to repetitive microtrauma

Body unable to adopt protective mechanisms to compensate for microtrauam due to abnormal sensation

Neurovascular

Autonomic dysfunction increases blood flow though AV shunting

Leads to bone resorption and weakening

Molecular Biology

Inflammatory cytokines may cause destruction

IL-1, TNF-alpha lead to increased production of transcription factor kB

RANK/RANKL/OPG triad pathway

211

 

3 indications for syndesmotic screws?

 

  1. syndesmotic sprain (without fracture) with instability on stress radiographs
  2. syndesmotic sprain refractory to conservative treatment
  3. syndesmotic injury with associated fracture that remains unstable after fixation of fracture

212

What is a Morton's extension orthotic used for?

Hallux Rigidus

213

WHat's a Lapidus procedure.  What are it's indications?

lapidus: 1st TMT arthrodesis + McBride

Indications:

  • TMT arthritis
  • instability
  • Metatarsus Primus Varus
  • Severe deformity with large IMA

214

Options for tendon transfers in foot drop: (2)

Simple tib post transfer

Bridle procedure (tri-tendon anastomosis)

215

Most common complication following this:

Initial management?

Navicular stress fracture

most common complication: nonunion

Initial mangaement; cast and NWB x 6-8 weeks

High success rate

216

3 specific options for management of Morton's Neuroma (surgical an non)

Nonop

Wide toe box shoes and MT pad: 1st line.  OK results only

Corticosteroid injection: benefit in short term RCTs

Neurectomy: dorsal approach > plantar

217

Gastrocs contraction leads to what motion?

Flexion of knee

Plantarflexion of ankle

Pronation of subtalar joint

218

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

219

Best test for syndesmosis injury?

Cotton test (intraop)

fewest false-positive results and smallest inter-observer variance

220

Name the ligaments of the ankle syndesmosis

AITFL

PITFL

Interosseous membrane

inferior transverse ligament

  • AKA inferior part of IoM

interosseous ligament

  • distal continuation of the interosseous membrane
  • main restraint to proximal migration of the talus

221

 

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

222

How many articulations are there in the lisfranc joint complex?

3:

TMT

intermetatarsal

intertarsal

223

What are the comparmtnets of the foot?

9 compartments (as per JAAOS)

Medial

  • Abductor hallucis
  • FHB

Lateral

  • Abductor digiti minimi
  • FDMB

Interossei x 4

Central

  • quadratus plantae

Superficial

  • FDB

Deep

  • Adductor hallucis
  • tib post neurovascular bundle

224

 

Which test for acute syndesmotic injury of the ankle has the fewest false-positive results and smallest inter-observer variance when used intraoperatively?

 

Cotton test

 

(Pull fibula laterally)

225

Name 3 surgical options for low grade hallux rigidus

Joint debridmenet & synovectomy

Dorsal chielectomy:

  • pain with dorsiflexion is a good predictor of good results

Moberg's extension osteotomy

  • Dorsal closing wedge osteotomy of proximal phalanx

 

226

Natural history of accessory navicular?

most become asymptomatic by skeletal maturity

227

Name 2 tests specific for the lateral ankle ligments

Anterior drawer test

Talar tilt test

228

Describe the gold standard surgical treatment for lateral ankle instability

Modified Brostrum

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)