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Flashcards in Foot and Ankle Deck (137)
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Where is the watershed area of the PTT?

2-6 cm proximal to the navicular


Obese patient comes in with feet that look like this?  How can you stage this?

  • Stage I - Tenosynovitis
    • No deformity
    • (+) single-leg toe raise 
  • Stage IIA - Flatfoot deformity
    • Exam
      • Flexible hindfoot
      • (-) single-leg heel raise
      •  Mild sinus tarsi pain
    • Imaging
      • Arch collapse deformity on imaging
  • Stage IIB - Flatfoot deformity
    • Exam
      • Flexible hindfoot
      • Forefoot abduction ("too many toes") 
    • Imaging
      • >40% talonavicular uncoverage
  • Stage III
    • Exam
      • Flatfoot deformity
      • Rigid forefoot abduction
      • Rigid hindfoot valgus
    • ​Imaging
      • Arch collapse deformity
      • Subtalar arthritis
  • Stage IV
    • ​Exam
      • Flatfoot deformity
      • Rigid forefoot abduction
      • Rigid hindfoot valgus
      • Deltoid ligament compromise
      • Ankle pain
    • Imaging
      • Arch collapse deformity
      • Subtalar arthritis
      • Talar tilt in ankle mortise 



Difference between adult and juvinile 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
  • complications
    • recurrence is most common complication (>50%)
    • overcorrection
    • hallux varus


Risk factors for hallux valgus

  • intrinsic
    • genetic predisposition
    • ligamentous laxity
    • convex metatarsal head
    • pes planus
    • rheumatoid arthritis
    • cerebral palsy
  • extrinsic
    • shoes with high heel and narrow toe box


Pathoanatomy of hallux valgus

  • valgus deviation promotes varus position of metatarsal
  • sesamoid complex becomes lateral to the metatarsal head, which moves medially
  • medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
  • adductor tendon becomes deforming force
  • inserts on fibular sesamoid
  • lateral deviation of EHL
  • plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx
  • windlass mechanism becomes less effective
  • leads to transfer metatarsalgia 


Radiographs for hallux valgus

  • views
    • weight bearing AP and Lat
    • sesamoid view can be useful
      • displacement of sesamoids
      • often displaced laterally
    • joint congruency and degenerative changes can be evaluated
  • radiographic parameters (see below) guide treatment
    • Hallux valgus (HVA)        
      • Long axis of 1st MT and prox. phal.
      • Identifies MTP deformity        
      • Normal = < 15°        
    • Intermetatarsal angle (IMA)        
      • Between long axis of 1st and 2nd MT                 
      • Normal = < 9°        
    • Distal metatarsal articular (DMAA)        
      • Between 1st MT long. axis and line through base of of distal articular cap        
      • Identifies MTP joint incongruity
      • Normal = < 15°        
    • Hallux valgus interphalangeus (HVI)        
      • Between long. axis of distal phalanx and proximal phalanx                 
      • Normal = < 10 °         


Approach to adolescent bunions

  • best to wait until skeletal maturity to operate
  • can not perform metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
  • surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
  • severe deformity with a DMAA > 20 perform a double MT osteotomy
  • technique
    • soft tissue procedure alone not successful
    • similar to adults if physis is closed (except in severe deformity)


Options for treatment of hallux valgus

  • Nonoperative
    • shoe modification/ pads/ orthoses
    • silastic spacer
      • orthoses more helpful in patients with pes planus or metatarsalgia
  • Soft Tissue Procedure - modified McBride
    • never appropriate in isolation
    • in conjunction with medial eminence resection osteotomy
    • release medial capsule of 2nd MTP; can be sutured to lateral capsule of 1st
    • adductor hallucis is released and interposed
      • Can be left to scar down
    • Transverse intertarsal ligament is releases which attaches to the fibular sesamoid
    • Don't resect the fibular sesamoid as was done with the original McBride or you will get hallux varus
  • distal metatarsal osteotomy
    • mild disease (HVA 20-40, IMA 10-13)
    • distal metatarsal osteotomies include
      • Chevron   
      • biplanar Chevron
      • Mitchell
    • may be combined with proximal phalanx osteotomy
  • proximal metatarsal osteotomy  
    • moderate disease (HVA >40°, IMA >13°)
    • proximal metatarsal osteotomies include
      • crescentric osteotomy
      • Broomstick osteotomy
      • Ludloff
      • Scarf
  • double (proximal and distal) osteotomy
    • severe disease (HVA 41-50°, IMA 16-20°)
    • DMAA > 15
    • Scarf + chevron
    • Lapidus + Akin
  • first cuneiform osteotomy
    • severe deformity in young patient with open physis
  • Lapidus procedure (1st metatarsocuneiform arthrodesis)
    • severe deformity
    • Metatarsus primus varus
    • hypermobile 1st tarsometatarsal joint
  • MTP Arthrodesis
    • Gout
    • Rheumatoid arthritis
    • Down's syndrome
    • cerebral palsy
    • Severe DJD
    • Ehler-Danlos
    • Resection arthroplasty
  • proximal phalanx (Keller) resection arthroplasty
    • largely abandoned
    • still indicated in some elderly patient with reduced function demands


Complications associated with HV

  • Recurrence
    • most common cause of failure is insufficient preoperative assessment and failure to follow indications
      • e.g., failure to recognize DMAA > 15°
      • e.g., failure to do adequate distal soft tissue realignment
    • more common in juvenile/adolescent population
    • noncompliant patient that bears weight
  • Avascular necrosis
    • medial capsulotomy is primary insult to blood flow to metatarsal head
    • distal metatarsal oseotomy and lateral soft tissue release inconjuction do not increase risk for AVN
  • Dorsal malunion with transfer metatarsalgia
    • due to overload of lesser metatarsal heads
    • risk associated with
      • Lapidus
      • proximal crescentric osteotomies
  • Hallux Varus
    • caused by
      • overcorrection of 1st IMA
      • excessive lateral capsular release with overtightening of medial capsule
      • overresection of medial first metatarsal head
      • lateral sesamoidectomy
  • Cock up toe deformity
    • due to injury of FHL
    • most severe complication with Keller resection
  • 2nd MT transfer metatarsalgia
    • often seen concomitant with hallux valgus
    • shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
  • Neuropraxia
    • Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve.
    • This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.


Iatrogenic causes of this deformity

  • overcorrection of 1st IMA
  • excessive lateral capsular release with overtightening of medial capsule
  • overresection of medial first metatarsal head
  • lateral sesamoidectomy



  • Nonoperative
    • shoe modifications to accommodate the deformity
    • extra depth and wider more flexible toe box
    • placing pads over prominent areas
    • taping or splinting the deformity
  • Abductor hallucis release and transfer of EHL or EHB to proximal phalanx
    • indications
      •  flexible deformities
    • technique
      • transfer portion of EHL or EHB under the transverse intermetatarsal ligament to the distal metatarsal neck (from lateral to medial) distal portion of tendon left intact, creating static stabilizer
  • First MTP arthrodesis
    • indications
      • fixed deformity
      • significant arthrosis


Classification of Hallux Rigidus

Cougling and Shurnas

  • Grade 0        
    • Stiffness with normal XR
  • Grade 1
    • mild pain at extremes of motion
    • mild dorsal osteophyte, normal joint space
  • Grade 2        
    • moderate pain with range of motion increasingly more constant        
    • moderate dorsal osteophyte,
  • Grade 3        
    • significant stiffness, pain at extreme ROM, no pain at mid-range
    • severe dorsal osteophyte, >50% joint space narrowing          
  • Grade 4
    • significant stiffness, pain at extreme ROM, pain at mid-range of motion
    • same as grade III        


Options for treatment

Hallus Rigidus

  • *Steroid injections are often ineffective and can adversely affect the cartilage and is not recommended
  • NSAIDS, activity modification & orthotics   
    • grade 0 and 1 disease
    • activity modifications
      • avoid activities that lead to excessive great toe dorsiflexion
    • types of orthotics
      • Morton's extension with stiff foot plate is the mainstay of treatment
    • stiff sole shoe and shoe box stretching may also be used
  • Joint debridement and synovectomy
    • patients with acute osteochondral or chondral defects
  • Dorsal cheilectomy - common first approach, high success rates
    • grade 1 and 2 disease (with reports of treating even up to grade 4)
    • pain with dorsiflexion is an indicator of good results with dorsal cheilectomy
    • shoe wear irritation from dorsal prominence and pain (ideal candidate)
    • contraindication
      •  pain mid-range of the joint during passive motion (grade IV)
    • technique
      • remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection
      • the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively
  • Moberg procedure (dorsal closing wedge osteotomy of the proximal phalanx)
    • Sometimes done in conjunction with cheilectomy
    • runners with reduced dorsiflexion (60° is needed to run)
      • Alternatively a proximal MT osteotomy can be used to improve dorsiflexion as a joint salvage procedure, however is not recommended and is associated with metatarsalgia
    • failure of cheilectomy to provide at least 30 to 40 degrees of motion
    • technique
      • increases dorsiflexion by decreasing the plantar flexion arc of motion
  • Keller Procedure (resection arthroplasty)
    • elderly, low demand patients with significant joint degeneration and loss of motion (>70)
    • contraindicated in patients with pre-existing rigid hyperextension deformity of 1st MTP joint
    • technique
      • involves removing the base of the first proximal phalanx
    • Complications
      • requires appropirate patient selection and minimal resection
      • risk of hyperextension (cock-up deformity)
      • weakness with push-off
      • transfer metatarsalgia (decreased with capsular interposition)
      • IP arthroplasty has poor results and currently not recommended until further explored
        • Seems to do better with intact plantar plate and FDB transfer
  • MTP arthroplasty 
    • indications controversial
    • technique
      • capsular interpositonal arthroplasty gaining popularity
      • silicone implants are not recommended due to poor long-term results
      • Cobalt chrome with titanium plasma spray total joint and hemi arthroplasty are available but often loosen and are unreliable
    • outcomes
      • silicone implants may have a good short term satisfaction rate but are currently not recommended
      • osteolysis and synovitis cause mid to long term pain and joint destruction
      • Total joint components have increased loosening and also are currently controversial and not often used
  • MTP joint arthrodesis   - best definative option for failed chilectomy, in some patients with more severe disease can go straight to this
    • grade 3 and 4 disease (significant joint arthritis)
    • most common procedure for hallux rigidus
    • outcomes
      • 70% to 100% fusion rate
      • 15% of patients experience degeneration of IP joint after surgery (mostly asymptomatic)


Strongest construct for first MTP arthrodesis

dorsal plate with compression screw is biomechanically strongest construct


Risk factors for achilles rupture

Eccentric muscle contraction


Treatment options for acute achilles rupture

  • Epidemiology
    • men
    • 30-40
    • 4-6 cm above calcaneal insertion

  • Nonoperative
    • functional bracing/casting in resting equinus (20 deg plantar flexion) with protected early functional rehab
    • indications
      • sedentary patients
      • elderly patients
      • medically frail patients
      • patient desires to avoid surgery
      • increased risk of rerupture 
    • outcomes
      • patient will have decreased plantar flexion strength
      • Increased risk of re-rupture
  • End-to-end Achilles tendon repair 
    • acute rupture (< 3 months)
    • technique
      • Posteromedial incision
      • Avoid or beware sural nerve
      • Carefully incise periotenon
      • Find each end, debride and perform and end to end repair using krochow technique and nonabsorbable suture
      • Oversew the peritenon with 4-0 absorbable sutures
    • outcomes
      • decreased re-rupture rate
      • increase plantar flexion strength 
    • disadvantages
      • skin complications including infection, sloughing (5-10%)
      • risk factors for wound complications included  
        • tobacco abuse 
        • steroid use
        • diabetes mellitus
        • female sex
        • sural nerve injury
  • rehab
    • initially immobilize in 20° of plantar flexion to decrease tension on skin and protect tendon repair
    • functional rehabilitation during treatment improves range of motion and outcome
  • percutaneous repair 
    • weaker and not recommended
    • sural nerve at highest risk for injury


Indications for non-operative treatment of achilles rupture

sedentary patients
elderly patients
medically frail patients
patient desires to avoid surgery
increased risk of rerupture 


Increased risk of wound complications of achilles repair

tobacco abuse 
steroid use
diabetes mellitus
female sex
sural nerve injury



Options for treatment of chronic achilles tear or re-rupture

  • Nonoperative
    • physical therapy - toe strengthening, gait training
    • AFO
  • Primary repair < 3 cm
  • Reconstruction with VY advancement
    • defects 3-5 cm
    • Posteomedial incision extended proxiamlly to MC junction
    • Debride tendon edges
    • Fashion two flaps 1cm wide and 7-8cm long
    • Advance the tendon to allow end-end repair and close the proximal incision of the tendon
  • FHL transfer    
    • defects > 5 cm
    • Prone position with tourniquette
    • Posterio-medial incision protecting NV bundle
    • Separate medial incision to relesae the tendon at the knot of henry
      • Some will harvest from the level of the joint
    • excise degenerative tendon edges
    • transfer FHL through osseous tunnels in the calcaneus, weave FHL to native achilles tendon
  • >10cm = Allograft
  • Gastroc turndown
    • another option but a large procedure


Complications associated with treatment of achilles

  • Dehisence/Infection
    • ESR, CRP, WBC
    • Consult ID and Plastics
    • OR - I&D, deep cultures, VAC or free flap
    • Directed IV abx until normal ESR/CRP
  • Re-rupture
  • Sural nerve palsy


Differential for Chronic Achilles inflammation

  • Paratenonitis 
    • Inflammation of the peritendinous structures, including the paratenon and septum
  • Tendinosis
    • Asymptomatic degeneration of tendon without inflammation, with regional focal loss of tendon structure
  • Paratenonitis with tendinosis
    • Inflammation of the peritendinous structures along with intratendinous degeneration
  • Retrocalcaneal bursitis
    • Mechanical irritation of the retrocalcaneal bursa
    • Younger patient, shoe wear
    • haglund
  • Insertional tendinosis
    • Inflammatory process within the tendinous insertion of the Achilles tendon 
    • middle age, boney enlargement
    • tendon calcification


Middle aged woman with chronic heel pain.  Differential? Likely Diagnosis?  Helpful imaging?

Insertional Tendonitis

  • Differential
    • insertional tendonitis
    • tendonosis
    • retrocalcaneal bursitis
  • Pain and tendon thickening at insertion of Achilles tendon
    • repetitive trauma leads to inflammation followed by cartilaginous then bony metaplasia
  • History
    • Take a complete and AMPLE history
    • occurs in middle-aged and elderly patients with a tight heel cord
    • symptoms
      • posterior heel pain, swelling, burning, and stiffness
      • shoe wear pain due to direct pressure - pump bump
    • progressive bony enlargement of calcaneus at insertion site
  • Physical exam
    • Examine - boney enlargement at insertion
    • Palpate - midline tenderness at insertion site of Achilles tendon
    • Move - reduced passive and active ROM
  • AP, lateral and oblique views of the foot
    • lateral foot shows bone spur and intratendinous calcification
  • MRI and ultrasound
    • can demonstrate amount of degeneration
    • Early - fluid around the tendon
    • Late - intratendonous calcification, degeneration of the tendon


Treatment of Insertional Achilles Tendonitis

  • activity modification, shoe wear modification, therapy
    • first line of treatment
    • techniques
      • physical therapy with eccentric training
        • Challenges muscle, to strengthen, promote repair and increase metabolic activity
      • gastrocnemius-soleus stretching
      • shoe wear
        • heel sleeves and pads (mainstay of nonoperative treatment)
      • small heel lift
      • locked ankle AFO for 6-9 months (if other nonoperative modalities fail)
  • retrocalcaneal bursa excision, debridement of diseased tendon, calcaneal bony prominence resection 
    • indications
      • failure of nonoperative management
    • technique
      • midline, lateral, or medial J-shaped incisions
  • tendon augmentation or transfer (FDL, FHL, or PB) vs. suture anchor repair 
    • indications
      • when > 50% of Achilles tendon insertion must be removed


Young patient with chronic heel pain.  Differential?  Likely diagnosis?  Helpful imaging?

Retrocalcaneal bursitis

  • Differential
    • insertional tendonitis
    • retrocalcaneal bursitis
    • tendosis
  • History
    • Take a complete and ample history (social, sports, smoking, PMhx, meds, allergies)
    • more common in young patients
    • Due to rubbing on shoes
  • Physical exam
    • Examine
    • Palpate
      • Two finger squeeze = pain localized to anterior and 2 to 3 cm proximal to the Achilles tendon insertion
      • fullness and tenderness medial and lateral to tendon
      • Pump bump = bony prominence at Achilles insertion
    • Move
      • pain with dorsiflexion (compresses the space)
    • Silverskiold
  • AP, lateral, oblique of the foot
    • lateral of foot demonstrates Haglund deformity
    • Loss of kager triangle due to bursitis
    • Swelling of tendon >9mm
    • 2cm above the joint line
  • MRI
    • rarely needed


Treatment of retrocalcaneal bursitis

  • activity modification, shoe wear modification, therapy, NSAIDs 
    • first line of treatment
    • techniques
      • ice
      • shoewear - external padding of Achilles tendon
      • PT
      • no injections
  • Retrocalcaneal bursa excision and resection of Haglund deformity
    • disease refractory to nonoperative management 
    • technique
      • midline, lateral, or medial J-shaped incision


Mechanism of Achilles Tendonosis

  • overuse - common in soccer players
  • imbalance of dorsiflexors and plantar flexors
    • poor technique
  • poor tendon blood supply - watershed area
    • 2-6cm proximal to insertion
  • genetic predisposition
  • fluoroquinolone antibiotics
  • inflammatory arthropathy


Classification of achilles TENDONOSIS

  • Achilles tendinosis
    • tendon thickening
    • thought to be caused by anaerobic degeneration in portion of tendon with poor blood supply 
    • Get a mucoid degeneration of the tendon due to age or reduced vascularity
    • Inability to heal with repetative microtrauma, often seen after rupture and can be painless
    • Especially middle age men who increase their activity
  • Achilles paratenonitis
    • involves inflammation of tendon sheath
    • Younger, due to repetative injury with inflammation around the tendon
    • Runners, shoe wear issues, young athletes who overtrain
  • Tendinosis with paratenonitis
    • Progression of disease = paratenonosis < paratenonosis with tendonitis < tendonitis alone
    • Usually stranding within the tendon shows starting to develop tendonitis
    • The further along the progression, the less likely to respond to therapy


Younger patient with chronic heel pain.  Differential?  Likely diagnosis?  Helpful imaging?

Achilles Tendonosis

  • Differnetial
    • insertional tendonitis
    • retrocalcaneal bursitis
    • achilles tendonosis
      • peritenonitis
      • tendonosis
      • combined
  • History
    • Take a complete and AMPLE history
    • Age - Young (paratenonosis), old (tendinosis)
    • symptoms - gradual onset
      • Pain with activity, pain with ADL (will gradually become more painful as process continues)
    • Pain more proximal with increasing severity as time goes on
    • pain, swelling, warmth
    • worse symptoms with activity
      • difficulty running
    • Minimal pain - think tendonitis
    • PMHx - obesity, HTN, diabetes associated with tendionsis
  • Physical exam
    • Examine, Palpate - tendon thickening and tenderness 2 to 6 cm proximal to Achilles insertion
    • Move - pain throughout entire range of motion
      • Paratenonitis
        • Limited ROM
        • Pain is fixed through all ROM
    • Positive silverskiold test
  • US - fluid around the tendon with hypoechoic regions
  • MRI 
    • disorganized tissue will show up as intrasubstance intermediate signal intensity
    • thickened tendon
    • paratendinosis
      • Fusiform swelling and high intesity with-in tendon (reflective of mucoid degeneration of tendinosis)
    • chronic rupture will show a hypoechoic region between tendon ends


Options for treatment of achilles tendonosis

  • activity modification, shoe wear modification, physiotherapy, NSAIDs
    • first line of treatment
    • techniques
      • Retraining
      • physical therapy with eccentric training
        • Gastroc stretching
      • shoewear
      • heel lifts or shock absorber
      • cast or removable boot (severe disease)
      • Orthoses to correct pronation (tendonitis)
    • outcomes
      • nonoperative management is 65% to 90% successful
  • glyceryl trinitrate patches, prolotherapy, and aprotinin injections
    • Theory is injections to break down fibrous tissue - NOT appropriate for tenodonitis, only paratenonitis
    • indications
      • evolving indications due to lack of evidence at this time
  • **Risks for failing non-op
    • Age
    • Duration of symptoms
    • Degree of degeneration
  • Percutaneous tenotomies
    • longitudinal tenotomy made in the degenerative area
    • strip the anterior Achilles tendon with a large suture to free any adhesions
  • open excision of degenerative tendon with tubularization
    • moderate to severe disease that is refractory to non-op treatment
    • Technique
      • Posterior incision with development of full thickness flaps
      • Incise paratenon and debride posterior, medial and lateral portion of the tendon
    • outcomes
      • 70% to 100% successful
  • tendon transfer (FHL, FDL, or PB)
    • This is not used for paratenonosis, only for tendonitis
    • indications
      • degeneration of >50% of the Achilles tendon
      • >55 years of age
      • MRI evidence of diffuse tendon thickening without a focal area of disease


Risk of failing non-operative treatment for achilles tendonosis

Duration of symptoms
Degree of degeneration