Foot & Ankle (2008-2019) Flashcards

Question

25. List 4 causes for hallux varus deformity after correction of hallux valgus. (2014)

Answer 1

AAOS Core Review: Over-correction of IMA through osteotomy \<0 Excessive medial eminence resection Excessive medial capsular tightening Excessive lateral release Excision fibular sesamoid

Answer 2

2010, 2015 JAAOS 2007 - Bunionette Deformity Metatarsal head translated dorso-medial (relieve callosities) Lateral eminence resection Medial soft-tissue release of 5th MTP

Answer 3

ANSWER: B 2008, 2013, 2016 JAAOS 2006 – The Hallucal Sesamoids * Sesamoid complex transmits as much as 50% of body weight * The larger tibial sesamoid lies within the medial head of the flexor halluces brevis, the smaller fibular sesamoid lies within the lateral head * Usually a single artery per sesamoid, but up to 2-3 per sesamoid have been described

Answer 4

ANSWER: A 2008 * Hughes J (JBJS Br 1990) The importance of the toes in walking * They concluded that the toes are in contact for about 3/4 of the walking cycle and exert pressures similar to those from the metatarsal heads * The great toe takes the highest pressures (30% of total toe pressure), with the second taking 25%, the third 20%, the fourth 15% and the fifth 10%.   * While the extremes of the foot (heel and hallux) are in contact with the ground for only 54% to 64% of stance phase the forefoot, speciﬁcally the middle forefoot, contacts the ground for 86% of stance phase.

Answer 5

ANSWER: C 2012 * Belthur MV (JPO 2011) The Spectrum of Preaxial polydactyly of the Foot * 20/28 feet with polydactyly had hallux varus * Lovell and Winter's Pediatric Orthopedics: * Often associated with short first metatarsal, bracket epiphysis of the first MT, pre and post-axial polydactyly and fibrous band that acts as a tether along medial side of great toe * "mild forms of hallux varus with a flexible deformity generally resolve spontaneously, but that condition should be differentiated from congenital hallux varus" * Treatment: * There is no role for conservative management * McElvenny --\> soft tissue release and resection * Resection and grafting of physeal bridge * Opening wedge osteotomy * Amputation

Answer 6

ANSWER: B 2012 * Coughlin MJ (FAI 1995) Juvenile Hallux Valgus: etiology and treatment * Retrospective study of 45 patients with 60 feet * Early onset was characterized by increased deformity and an increased DMAA * 72% had maternal transmission * "an increased DMAA may be the defining characteristics of juvenile hallux valgus"

Answer 7

ANSWER: C 2008, 2014 * Lapidus (first TMT fusion + distal soft tissue procedure) would likely be the best option, however, a TMT fusion alone is not ideal. A first MTP fusion is an appropriate treatment option for a severe bunion – especially in an elderly patient.   * Disorders of the first metatarsal phalangeal joint. Mann. JAAOS. 1995. * Incongruent deformities are classified as mild (hallux valgus angle less than 30 degrees and IM angle less than 13 degrees), moderate (hallux valgus angle less than 40 degrees and IM angle greater than 13 degrees), and severe (hallux valgus angle greater than 40 degrees and IM angle greater than 20 degrees). * For advanced moderate and severe deformities, a distal soft-tissue procedure with a proximal osteotomy will give a reproducible satisfactory result in most cases, although it is technically demanding. The MTP arthrodesis is an excellent procedure for treating a severe hallux valgus deformity, particularly in older patients and those with rheumatoid arthritis, spasticity, or arthrosis. arthrodesis is used along with the complete distal soft-tissue procedure.

Answer 8

ANSWER: A (old answer D) 2011, 2015 * Group discussion - argument that since it is incongruent, would need a distal soft tissue procedure with your proximal osteotomy, controversial * Charles:Too young for MTP fusion, better correction with proximal base osteotomy and ST release * Miller’s = IMA \> 13 OR HVA \> 40 = proximal MT osteotomy * IMA \<13 AND HVA \< 40 = dital MT osteotomy (chevron)

Answer 9

ANSWER - A 2008, 2014 * Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint (J Bone Joint Surg Am, 1998 Jun; 80 (6): 898 -908)  * Kinematic analysis of the first metatarsophalangeal joint in patients who have hallux rigidus reveals a decrease in the total arc of motion, with relatively normal plantar flexion but markedly restricted dorsiflexion. * Motion analysis reveals instant centers of rotation that are displaced and located eccentrically about the metatarsal head. * Patients who have symptomatic hallux rigidus have been found to have higher-than-normal dynamic plantar pressures of the first ray. * Decreased plantar pressures of the first ray have been reported after resection arthroplasty and implant arthroplasty. * The minimum physiological dorsiflexion of the first metatarsophalangeal joint that is necessary for a normal gait is unknown; however, the values that have been reported in the literature have ranged from 15 to approximately 90 degrees

Answer 10

ANSWER: B 2011, 2014, 2016 * JAAOS 2012 - Surgical Management of Hallux Rigidus * Shoe modifications, such as a Morton extension orthosis * Often poorly tolerated * Cheilectomy and Proximal Phalanx Osteotomy * Arthrodesis * Favorable and time-tested procedure for managing late and end stage hallux rigidus * Keller Resection Arthroplasty * Better choice for patients \> 70 years, less active

Answer 11

ANSWER: D 2008, 2010, 2011, 2012 JAAOS 2000- Ankle Arthrodesis The foot should be externally rotated 20-30o relative to the tibia The ankle joint in neutral flexion, 5-10o external rotation and slight valgus (5o)

Answer 12

ANSWER: A 2011

Answer 13

ANSWER: D (old answer A... A is associated but D is straight from article) 2015 * JAAOS 2014 - Anterior Ankle Impingement: Diagnosis and Treatment * 14-26% of patients undergoing modified Brostrom procedures have anterior ankle impingement * Described "tram track lesions" cartilage lesions on the talus, but didn’t comment on thickness * Tibial spurs are lateral on CT, so PM OCD doesn't make sense --\> AL OCD is possible but not mentioned in the article * Kim SH (Arthroscopy 1999) Tram track lesion of the talar dome: * Describes 6 lesions in talar dome * Full thickness lesions in the anterior half of the medial aspect of the talar dome, * longitudinal defects of variable width * No patients had ankle instability * Moon JS (Arthroscopy 2010): * 57 patients treated arthroscopically * 26% had chronic ankle instability * No correlation between instability and spur severity * 80% of ankles had cartilage lesions * Mainly in anterior half of talar dome, corresponding to the mediolateral location of tibial spurs * 61% of those with tram-track lesions had lesions on both tibia and talus * Presence of instability didn’t correlate with cartilage lesions

Answer 14

ANSWER: C 2012, 2016 Discussed with LaMothe: If POSTERIOR to middle facet then FHL If ANTERIOR to middle facet the FDL as FHL under sustentaculum

Answer 15

ANSWER: B 2016 JAAOS 2015 – Evaluation of the Painful TAA Haddad (JBJS 2007) Component loosening and/or subsidence (28%) were the primary reasons for revision Reported rates of infection after TAA range from 1-3.5% Glazebrook:

Answer 16

ANSWER: A 2016 * JAAOS 2014 - Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management * "CLO (calc length osteo) produced significantly better correction of the subluxed navicular on the head of the talus, but the procedure was associated with a marginally higher rate of complications. Most of these complications were related to subluxation of the calcaneocuboid joint and can be avoided with proper stabilization of the joint, as described in the literature * Comparison of the Calcaneo-Cuboid-Cuneiform * Osteotomies and the Calcaneal Lengthening Osteotomy in the Surgical Treatment of Symptomatic Flexible Flatfoot * Rathjen and Mubarak11 modiﬁed this procedure, per- forming a sliding-closing medial calcaneal osteotomy, aplantar-closing wedge osteotomy of the medial cunei-form, and an opening wedge osteotomy of the cuboid (triple C osteotomy). The other osteotomy, described byEvans,12 consists of an opening wedge calcaneal osteot-omy to lengthen the lateral column. Mosca13 modiﬁed Evans’ procedure and added a plantar-medial closing wedge osteotomy of the medial cuneiform to correct the supination of the forefoot

Answer 17

ANSWER: A  2014, 2016 JAAOS - Adult Acquired Flatfoot * Lateral column lengthening provides correction to the abducted talonavicular joint and raises the arch * It also decreases eversion and increases the pressure along the plantar lateral border of the foot * Lengthening may result in lateral foot overload, fifth metatarsal stress fracture and significant stiffness *   * Roche and Calder. Foot Ankle Clin N Am. 2012. * Evans suggested preserving the joint through his osteotomy; however, studies have shown that the contact pressure generated across the calcaneocuboid joint after lengthening may actually rise, raising concerns that this may predispose to early degenerative change…They found that joint contact pressures were increased from baseline levels after Evans procedures by 111%. The addition of a medializing calcaneal osteotomy reduced this pressure increase to 93%. * Lots of biomechanical evidence for CC arthritis, little clinical evidence *   * Neufeld SK (Foot and Ankle Clin 2001) * Calcaneal lengthening osteotomies can results in over correction and result in excessive and fixed SUPINATION, thought to be a cause of lateral foot pain * Overlengthening can cause metatarsocuboid arthritis or instability *   * Moseir-LaClair S, Pomeroy G, Manoli II A. Intermediate follow-up on the double osteotomy and tendon transfer for stage II posterior tibial tendon insufficiency. Foot Ankle Int 22:283-291, 2001 * 14% CC arthritis (but 50% of cases had pre-existing arthritis) 

Answer 18

ANSWER: B 2011 JAAOS 2008 - Shoe Wear and Orthoses Heel to toe orthoses reduce need for ankle motion Other Options: Double Rocks accommodate for midfoot pathology Toe only rocker --\> increase weightbearing proximal to MT heads (forefoot problems) Negative Rocker --\> foot in fixed dorsiflexion

Answer 19

ANSWER: B 2009 Coester (JBJS 2001) Long-term results following ankle arthrodesis for post-traumatic arthritis More OA of ipsilateral subtalar, talonavicular, CC, NC, TMT and fist MTP joints No worse knee OA

Answer 20

ANSWER: B 2012 JAAOS 2010 - Osteochondral Lesions of the Talus Retrograde drilling if cartilage cap is intact MM osteotomy not needed for microfracture, only needed if placing grafts/need appropriate angle for plugs OATS generally only if \> 1-1.5cm

Answer 21

ANSWER: A 2015 JAAOS 2008 - Plantar Fasciitis * Plantar fasciotomy, either partial or complete, is the common surgical procedure chosen for treating recalcitrant cases * Biomechanical and finite-elements studies have shown that release of \>40% of the plantar fascia has detrimental effects on other ligamentous and bony structures in the foot; therefore, releases should be limited * Release of tarsal tunnel only indicated if tarsal tunnel symptoms present

Answer 22

ANSWER: B 2011

Answer 23

ANSWER: C 2015 Uquilas CA (JBJS 2015) Everything Achilles The Achilles tendon is part of a musculotendinous unit that spans three joints, praducing knee flexion, tibiotalar flexion, and subtalar inversion

Answer 24

ANSWER: D 2014 JAAOS 2013 – Triceps Surae Contracture * “Strong association with metatarsalgia, neuropathic ulceration, plantar fasciitis, Charcot midfoot breakdown” * “Lesser degree PTTD, Achilles tendinopathy, ankle sprain and fracture, MTP synovitis, hallux valgus, claw toes and toe walking” * Coughlin MJ (FAI 2003) Hallux Rigidus * Case series of 114 patients * “there was no evidence of an Achilles or gastrocnemius tendon contracture”

Answer 25

ANSWER: B 2012

Answer 26

Answer: A 2013 D: You should reestablish the cascade C: should be distal dorsal to plantar proximal JAAOS 1994 – Rheumatoid Arthritis of the Foot and Ankle B: Advanced deformity often requires extensor brevis tenotomy (little toe = no EDB), EDL tendon Z-lengthening and resection of the base of the proximal phalanx. * ®Dorsal Approach to Lesser MT Head Resection in RA Foot: * -Modified technique involves metatarsal head trimming or resection thru a dorsal incision with or w/o excision of all or part of the proximal phalanx may resolve the symptoms * -Two longitudinal incisions are made in the 2nd and 4th interspaces * -Collateral ligaments, the dorsal aspect of the capsule, the plantar plate, and the interossei are released in a circumferential fashion around the base of the proximal phalanx and the head and metaphysis of the metatarsal * -Long extensor tendon is left intact (EDB is released) * -Metatarsal head resection: * -Improve exposure of metatarsal head by clearing the base of the proximal phalanx and by distracting on the phalanx * -Bone cutter is used to transect the second metatarsal in the region of the distal metaphysis * -It is essential that the metatarsal heads be transected in a distal-dorsal to plantar proximal direction * -Larger amount of bone needs to be resected with more severe overlap of proximal phalanx on the metatarsal head * -Goal is to create about 1 cm of space between the metatarsal neck and base of proximal phalanx * -After resection of the second metatarsal, remaining metatarsals should be progressively shorter by several mm (from 2nd to the 5th) * -Failure to achieve a nice cascading of the metatarsal, may result in metatarsalgia * -Attempt to preserve the base of the proximal phalanx at the MP joint (preserves the alignment and relocation of the lesser MP joints) * -Subsequent in the operative procedure the hammertoe deformities are fixed with a K wire that is also driven across the relocated MTP joint, which provides stability * -Another technique involves longitudinal "Y" incisions between the 2nd and 3rd and between the 4th and 5th metatarsal heads, so that a Webbing procedure can be performed on the lesser toes * -With more severe deformity, (with dislocation of the metatarsal heads) it may be necessary to resect the proximal bases of the lesser toes * -With more severe deformity, a more extensive Webbing procedure may have to be performed, usually past the region of phalangeal resection, to prevent drifting of the digits * ®Wheeless: * ®Position of 1st MTP Arthrodesis: * -Toe is placed in approx 25 to 30° of dorsiflexion in relation to first metatarsal and approximately 10-15° of valgus in a first MP joint arthrodesis * -First toe should end up resting comfortably against the second toe * -Toe should be in 15° of dorsiflexion from the floor (although during surgery it is not possible to make this determination) * -This places the least amount of stress on the interphalangeal joint of great toe & provides patient w/ smoother gait pattern. * -Remember the angle of inclination to the floor helps fine tune the dorsiflexion; angle of MTP arthrodesis * -A flat foot will need less dorsiflexion while a high arched foot will need more dorsiflexion * -Following arthrodesis, reduction of intermetatarsal angle will occur in proportion to the preoperative intermetatarsal angle * - Abdo et al. Rheumatoid Arthritis of the Foot and Ankle. JAAOS November 1994 ; 2:326-332. * The forefoot is commonly the most painful area and it is usually the first to be operated upon, but if the forefoot and hindfoot are equally involved the hindfoot should be corrected first. * The typical rheumatoid forefoot has hallux valgus, plantar displacement of the metatarsal heads and a varus position of the little toe. Subluxation or dislocation of the proximal phalanges dorsally on the metatarsal heads is common. * MTP Fusion, resection arthroplasty MT heads, PIP fusion * Retrospective study of 43 consecutive patients; average F/U 74 months * High percentage of successful results at 6 years * fusion of the first ray maintained alignment and protected the hallux and the lesser metatarsophalangeal joints from recurrent deformity and subsequent metatarsalgia * Avoid excessive shortening * Position of the hallux is assessed fluoroscopically and clinically with a flat surface to simulate weight bearing. * Proper positioning includes valgus of 10 to 15 degrees, dorsiflexion of 25 to 30 degrees relative to the metatarsal shaft (or 15 degrees relative to the sole of the foot), and neutral rotation. * Clinically, the hallux should not impinge on the second toe and the nail plate should be aligned with the same plane as the lesser toes.

Answer 27

ANSWER: B or C 2008 * B better but described as Tn and CC fusion in young active * C is better for early disease * JAAOS 1994 - Rheumatoid foot and ankle * "Occasionally, isolated involvement of the talonavicular joint will occur without deformity. Formation of cysts and joint destruction can sometimes be extensive. In these circumstances, isolated TN arthrodesis has been recommended. However, progression of arthritis destruction in adjacent joint is possible. We have found SPECT useful before proceeding with TN arthrodesis….some authors advocate double arthrodesis or TN and CC joints for younger more active patients"

Answer 28

ANSWER: A 2008 JAAOS 2005 - Nerve and tendon lacerations about the foot and ankle Acute repair of a tibialis posterior tendon laceration can lead to a good result Small case series of these

Answer 29

* Hypertrophic Scar * Sural nerve injury * Infection * Wound breakdown * Tethering of Achilles to skin

Answer 30

JAAOS 2010 - Diagnosis and Treatment of Acute Achilles Tendon Rupture "….although surgical treatment is an option, it should be approached more cautiously in patients with: * Diabetes * Neuropathy * Immunocompromised states * Age \> 65 * Use Tobacco * Sedentary life * Obese (BMI \> 30) * Peripheral vascular disease"

Answer 31

ANSWER: A 2010, 2013, 2016 FHL tendon transfer --\> FHL is stronger than FDL and peroneals Similar axis of force to Achilles In phase transfer

Answer 32

ANSWER: C 2012 * Willits K (JBJS 2010) Operative versus Non-operative Treatment of Acute Achilles Tendon Ruptures * Mohtadi Study * 144 patients randomized to operative vs non-operative * Both groups had early WB and ROM * No difference in re-rupture rates, higher soft tissue complications in operative group * Wong (AJSM 2002) * Wound complications: 14.6% vs 0.5% * Re-rupture: 10.7% casting, 1.4% open, 1.5% functional brace * Overall complication rates: * 6.7% in open repair with early mobilization * 15.6% perc repair and early mobilization * Khan (JBJS 2005) * 12 studies with 800 patients * Once again higher rate of re-rupture with non-op and higher rate of complications with OR * Functional brace had re-rupture rate of 2.4% vs 12.6% in casting group * Soroceanu A (JBJS 2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials * 10 studies * Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included * Surgery had 15.8% increased risk for complications other than re-rupture

Answer 33

ANSWER: A 2012 JBJS 2015 - Everything Achilles: Knowledge update and current concepts Chiodo CP (FAI 2006) Current Concepts Review: Acute Ruptures of the Achilles Tendon V-Y turndown --\> gaps of 3-5 cm (because need twice the length of the turn down of the gap, so for 5cm would need 10cm length) FHL tendon transfer Synthetic grafts described but no long term evidence (Lamothe says remove synthetic from your algorithm).

Answer 34

ANSWER: B 2009, 2016 * JBJS 2014 - Current Concepts: Injuries to the Ankle Syndesmosis * Three radiographic parameters have been defined for the diagnosis of syndesmotic injury including: * Tibiofibular overlap: \> 6mm in the AP radiograph, \>1mm in mortise * Tibiofibular clear space \<6mm in both AP and mortise at 1cm proximal to plafond * Medial clear space: should be less than or equal to the clear space between the talar dome and tibial plafond * (C also true in older other source – but Millers’s, Sagars, orthobullets, etc...all say \> 6 not \>10)

Answer 35

ANSWER: B (old answer A – wrong... Charles) 2016 * Hastie (FAI 2015) WB radiographs facilitate functional treatment of ankle fractures of uncertain stability * Gravity stress test - ipsilateral side down (foot externally rotates with gravity) --\> therefore C incorrect * JAAOS 2009 Stress Radiographs in Orthopedic Surgery * Manual stress tests should be done with ankle in neutral DF and 10o ER * Femino JE (FAI 2013) Varus ER stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption * Conclusions: Varus external rotation stress was more effective than valgus external rotation stress in demonstrating displacement of markers at the medial gutter and on AP and mortise radiographs for both DDL and DDL with syndesmotic instability * Left lateral decubitus position (LLDP) would mean that the patient is lying on his or her left side. * This is fucking stupid....no evidence of abduct and ER, just that varus ER is better to detect deltoid AND syndesmosis injury, most important is dorsiflexing and ER *

Answer 36

ANSWER: B 2019 * JAAOS 2010 – Treatment of Lisfranc Joint Injury: Current Concepts * Nearly 20% of these injuries are misdiagnosed or missed on initial radiographic assessment * Anatomic variances frequently predispose to injury. Peicha et al14 showed that persons with Lisfranc injury had a shallower medial mortise depth compared with control subjects. They suggested that adequate mortise depth provides for greater stability by allowing for a stronger Lisfranc ligament. * For more obvious Lisfranc fracture-dislocation, screw fixation has been shown to have lower rates of redisplacement7,27,34 and faster return to weight bearing27,34 postoperatively compared with Kirschner wire (K-wire) fixation. Small-fragment (3.5 mm) cortical screw fixation is recommended for the first, second, and third TMT joints. The fourth and fifth joints may be pinned with K-wires.  * We consider using dorsal plating for bridging fixation of comminuted fractures with bony fragments in the TMT joints (Figure 6) and total ligamentous injuries (Figure 7), and as an alternative surgical treatment in certain cases, such as joint damage and loss of fixation. We use dorsal plating in approximately 10% of patients with comminuted joint injuries * 25% OA even after fixation * JBJS 2018 - Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes. * Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique * In fact, a shallow second TMT joint mortise is considered a risk factor for suffering a Lisfranc injury - Lisfranc fracture-dislocations: current management EFFORT reviews 2019 * Edmonton: * Lisfranc fractures.  All true except  * Decreased length of 2nd metatarsal and keystone shallower leads to higher risk of injury  * 25% go on to arthritis despite good reduction  * Plates have better outcomes than screws  * 20% commonly missed injuries * Answer:C? * A is true, B is true, C questionable, D is true (Sask picked C) * * JAAOS 2017 article-sites cadaver model that no difference between dorsal plating and screws---paper below states differently. * Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes. * Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. * Two randomized studies directly compared the results of primary arthrodesis with those of ORIF for TMT joint complex injuries. Ly and Coetzee6 randomly assigned 41 patients to either open reduction or primary arthrodesis for ligamentous injury patterns. The arthrodesis group had substantially improved functional outcomes, higher returns to preinjury activity levels, lower rates of revision surgery, and less pain at final follow-up. In the group that underwent open reduction, 25% of patients required conversion to arthrodesis for symptomatic posttraumatic arthritis * Abbasian et al40 found no substantial difference in functional outcome, pain, return to activity, or rates of posttraumatic arthritis following ORIF in matched cohorts of 29 patients each with ligamentous injuries or osseous injury patterns. Radiographic arthritis was seen in 27% of ligamentous injuries compared with 31% of osseous injuries; however, only one patient in each treatment group (3%) required conversion to arthrodesis during the study period. * Keystone: the importance of this osseous configuration has been emphasized in a study that reported that subjects with a shallower recess are more prone to injuries at this articulation

Answer 37

ANSWER: D 2019 * calcaneal nerve always at risk, but provides reliable clearance of the medial plantar, lateral plantar, and sural nerves. The medial and lateral calcaneal nerves were always at risk regardless of the location of the osteotomy. * Low risk to sural & plantar nerves, but not calcaneal nerves ??? * Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy: A Cadaveric and Radiographic Investigation - 2013 * Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction? – 2018 * SAFE ZONE: On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the "landmark line." A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique. * In a recent cadaveric article, Talusan et al11 attempted to identify the ideal osteotomy location and define a “safe zone” for calcaneal osteotomies that may be referenced to decrease the risk of iatrogenic neurologic injury. * The authors define their “safe zone” as an area on the lateral foot radiograph extending 11.2 mm anterior from a line connecting the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia.11  * They conclude that their safe zone would reliably spare the medial plantar, lateral plantar, and sural nerves during a calcaneal osteotomy.11 * The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line. * The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy

Answer 38

ANSWER: A 2019 Saltzman (aka hindfoot alignment view) but they say axial view is better Canale – Talar neck view Broden – subtalar view Mortise – no

Answer 39

ANSWER: A 2019 * https://www.podiatrytoday.com/article/7485 * JAAOS 2014 - Anterior Ankle Impingement: Diagnosis and Treatment * At the time of surgery, the authors found that a distal portion of the AITFL was impinging on the anterolateral talus. * talar spur lies medial to the midline, whereas the tibial spur lies lateral to the midline; typically, the spurs do not overlap. Neither were the spurs found to overlap in the cadaver study by Tol and van Dijk.13 Soft-tissue inflam- mation and cartilage lesions may cause pain.3,13,14,18-22 A triangular- shaped area of soft tissue consisting of synovium, collagen, blood vessels, and adipose is located in the anterior * joint space between the talus and tibia; in a normal ankle, these tissues are compressed between the talus and tibia on 15 of dorsiflexion.13 In pa- tients with AAI syndrome, pain may be secondary to impingement of this soft tissue3,18,20 (Figure 1).

Answer 40

ANSWER: B 2019 Edmonton * arthrodesis has long been an option for this condition, but leads to noticeably altered gait mechanics and velocity, decreased range of motion, and resultant osteoarthritis of the adjacent joints. * Patients who had undergone arthroplasty, when compared with patients who had undergone arthrodesis, demonstrated greater postoperative total sagittal plane motion (18.1° versus 13.7°; p \< 0.05), dorsiflexion (11.9° versus 6.8°; p \< 0.05), and range of tibial tilt (23.1° versus 19.1°; p \< 0.05). Plantar flexion motion was not equivalent to normal in either group. Ankle moments and power in both treatment groups remained significantly lower compared with the control group (p \< 0.05 between each treatment group and the control group for both variables). Gait patterns in both treatment groups were not completely normalized. Improvements in patient-reported Ankle Osteoarthritis Scale and Short Form-36 scores were similar for both treatment groups.

Answer 41

ANSWER: A (newest evidence favors ER stress test over Cotton) (B old answer) Intraoperative Assessment of the Stability of the Distal Tibiofibular Joint in Supination-External Rotation Injuries of the Ankle Sensitivity, Specificity, and Reliability of Two Clinical Tests Harri Pakarinen, MD, Tapio Flinkkila, MD, PhD, Pasi Ohtonen, MSc, Pekka Hyv ¨ onen, MD, PhD, ¨ Martti Lakovaara, MD, Juhana Leppilahti, MD, PhD, and Jukka Ristiniemi, MD, PhD The hook test had a sensitivity of 0.25 (95% confidence interval, 0.12 to 0.45) and a specificity of 0.98 (95% confidence interval, 0.94 to 1.0) for the detection of the same instabilities. The external rotation stress test had a sensitivity of 0.58 (95% confidence interval, 0.39 to 0.76) and a specificity of 0.96 (95% confidence interval, 0.90 to 0.98). **Matuszewski PE, Dombroski D, Lawrence JTR, Esterhai JL, Mehta S. Prospective Intraoperative Syndesmotic Evaluation During Ankle Fracture Fixation: Stress External Rotation Versus Lateral Fibular Stress. J Orthop Trauma. 2015;29(4):4.** The difference in widening with stress external rotation was significantly greater than lateral fibular stress and appreciable on standard fluoroscopic views. Stress external rotation radiographs are a more reliable indicator of mortise instability than traditional lateral fibular stress. 2019 * http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.904.9905&rep=rep1&type=pdf * JAAOS management of ankle fractures – can create wider medial space widening with cotton test * JWO - Diagnosing syndesmotic instability in ankle fracture – cotton better * Pre-op – best is ER or gravity * On the basis of a biomechanical cadaveric study, Stoffel et al[28] concluded that use of the lateral (bone hook) stress test or Cotton test[32] and examination of the tibio fibular clear space on stress radiographs intra-operatively is more reliable, because of the greater displacement when per- forming this test, than the exorotation stress test. * The “Hook” or “Cotton” test is more reliable than the exorotation stress test

Answer 42

ANSWER: B 2019 Charles – Miller's says IMA \< 0 causes hallux varus and the Modified part of McBride is that they dont do lateral sesamoidectomy Risk Factors for Iatrogenic Hallux Varus (after Hallux valgus surgery) * 2-10% incidence following HV surgery * Over tightening of medial capsule * Excessive resection of medial eminence * Overcorrection of IMA / HVA * Excessive lateral capsular release (McBride) – taking down the collateral ligament * Excision of fibular sesamoid

Answer 43

ANSWER: B 2019 In a systematic review of 49 primary studies that evaluated TAA and ankle arthrodesis, Haddad et al27 reported implant survival rates of 78% and 77% at 5 years and 10 years, respectively. The revision rate for TAA was 7%. Component loosening and/or subsidence (28%) were the primary reasons for revision (Figure 1).

Answer 44

* ANSWER: B 2019 Risk factors for failure of transmetatarsal amputation in diabetic patients: a cohort study. CANADIAN study * Blood glucose control as measured by HbA1c was the most important single factor predicting the success of TMA. Need for debridement after TMA was also found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups. * *  primary factor determining the success of a TMA was the quality of glucose control. As a result of this study we currently do not perform any elective, trauma or emergency surgery on diabetic patients with an HbA1c of over 8 unless the need for surgery is to save life or limb.

Answer 45

ANSWER: B 2019 * The Stieda process is an elongation of the lateral tubercle of the posterior process of the talus (Fig 1). It is larger than the medial tubercle and is considered the most variable aspect of hindfoot anatomy. This process is the insertion point of the posterior talofibular ligament. * A would def be wrong, fracture of stieda process looks like os trigonum but IS NOT (os trigonum is failure a a secondary ossification centre to fuse) like all the other os in the body. - prob not well remembered * Os trigonum syndrome often coexists with FHL tenosynovitis in thes ame patient population. JAAOS 2019 Ankle injuries in Dancers - Pain with hyperplantar flexion, doesnt mention decrease plantar flexion - Associated with FHL tenditinitis - mention one study suggesting surgery after 4 months nonop but no clear guidelines

Answer 46

Answer: C (2017) – Would be lateralizing. JAAOS 2016 – Supramalleolar Osteotomies for the treatment of ankle arthritis

Answer 47

Answer: B (2017) A - yes B – prob no C - yes D – OCD can def cause it * Aside ankle sprains: most common reason for missed athletic participation. Associated injuries: OCD, peroneal tendon injuries, subtle cavovarus foot, deltoid ligament injury, 5th MT fracture, anterior process of calcaneus, lateral process of talus. ATFL is most commonly injured. After treatment, the most common cause of chronic pain is a missed injury.

Answer 48

Answer: C 2017 * Tim Daniel’s paper 2014 * Same gait speed * Same cadence * Same stance phase * TAR – BETTER total sagittal ROM (mostlydorsiflexion) * Same plantar flexion * TAR – more tibial tilt at heel-off * Same power/ heel rise * \*\*\* compared to normal ankle: worst plantar flexion (TAR and fusion), worst power (TAR and fusion), coronal plane motion same in all groups, gait speed SAME in all groups * * The gait patterns of patients following three-component, mobile-bearing total ankle arthroplasty more closely resembled normal gait when compared with the gait patterns of patients following arthrodesis.  * Ankle arthroplasty and ankle arthrodesis: gait analysis compared with normal controls. * Singer S1, Klejman S2, Pinsker E1, Houck J3, Daniels T1. * * Comparison of gait after total ankle arthroplasty and ankle arthrodesis * Robert Flavin 1, Scott C Coleman, Shay Tenenbaum, James W Brodsky * . 2013 Oct;34(10):1340-8. * doi: 10.1177/1071100713490675. Epub 2013 May 13. * * Baseline parameters showed comparability among the treatment and control groups. Temporospatial analysis, using time as the main effect, showed that compared with ankle arthrodesis, patients with total ankle arthroplasty had higher walking velocity attributable to both increases in stride length and cadence as well as more normalized first and second rockers of the gait cycle * * Conclusions: Patients in both the arthrodesis and arthroplasty groups had significant improvements in various parameters of gait when compared with their own preoperative function. Neither group functioned as well as the normal control subjects. Neither group was superior in every parameter of gait at 1 year postoperatively. However, the data suggest that the major parameters of gait after ankle arthrodesis in deformed ankle arthritis are comparable to gait function after total ankle arthroplasty in nondeformed ankle arthritis.

Answer 49

Answer: B (2017) – joint space narrowing * The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally

Answer 50

Answer: C (2017) A – yes. Rigid flatfoot. Tx takedown vs subtalar fusion B – yes JAAOS C- not likely. D – yes recurrent sprains with cavovarus foot is a common presentation. Get Peroneal tendon pathology

Answer 51

Answer: C (2017) - Shit question but sounds like he has charcot joint thus no total ankle. Remembered different in other exams where it’s clear patient has charcot joint.

Answer 52

Answer: D (2017) – high risk only. * Prophylaxis Overview * prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is most important factor in decreasing morbidity and mortality * prophylaxis treatment should be determined by weighing risk of bleeding vs risk of pulmonary embolus * AAOS risk factors for major bleeding * bleeding disorders * history of a recent gastrointestinal bleed * history of a recent hemorrhagic stroke * AAOS risk factors for pulmonary embolus * hypercoagulable state * previous documented pulmonary embolism * DVT prophylaxis is recommended for all arthroplasty patients; for standard patients, not recommended for upper extremity procedures, arthroscopic, and isolated fractures at knee and below * the use of pharmacologic prophylaxis and mechanical compression received a moderate strength recommendation from the AAOS * * F&A Surgery Prophylaxis * the risk of VTE was not found to be lowered by thromboprophylaxis in a study of 20,043 adult patients * * Note: no increase in DVT has been associated with the use of tranexamic acid (TXA)

Answer 53

Answer: D (2017) A – no needs specific rehab for Achilles protocal. B – no needs early ROM C – No, plantar flexion but not for 6 weeks D – you could. Assume its chronic. * Fowler protocol for accelerated achilles rehab * 0-6 w * Air cast WBAT WITH 2 CM lift (plantar flex) * At 2 weeks start physio, ROM to 0 degrees of dorsi * 6-8 w * Remove lift * 8-12 w * Transition out of boot I don't really like this question/answer – If he’s completing physiotherapy with only pain being his complaint – perhaps it’s just a partial tear. Don’t think I’d jump in with a chronic tear reconstruction. Would start non-op tx protocol.

Answer 54

ANSWER: D 2018 * States pristine subtalar joint so no triple also doesn’t involve CC jt, too old for ORIF, failed observation * Based on a high percentage of good results, retrospective studies strongly suggest that isolated talonavicular arthrodesis provides efficient pain relief and functional improvement in case of talonavicular arthritis in rheumatoid arthritis, primary or posttraumatic arthritis, flexible acquired flatfoot deformity, residual dorsolateral subluxation of the talonavicular joint after surgical treatment of clubfoot, and some neurologic disorders. * Depends on the actual question * Better chance of fusion of TN if double or triple

Answer 55

ANSWER: C 2018

Answer 56

ANSWER: A 2018

Answer 57

ANSWER: B 2018 PM = atraumatic AL = traumatic

Answer 58

ANSWER: C * 2018 * Tricky question * Associated conditions: * calcaneal apophysitis * gastrocnemius-soleus contracture * heel pain triad * plantar fasciitis * posterior tibial tendon dysfunction * tarsal tunnel syndrome * anatomic variations * femoral anteversion * pes cavus * pes planus * * Plantar fasciitis can lead to calcaneal spur * * Usually non op or ESWT * * Surgical release with plantar fasciotomy * approach * can be done open or arthroscopically * open procedure is indicated if tarsal tunnel syndrome is present as well * release * release medial one-third to two-thirds * avoid complete release as it may lead to * destabilization of the longitudinal arch * overload of the lateral column * dorsolateral foot pain * consider simultaneous release of Baxter's nerve * release the deep fascia of abductor hallucis * may improve outcomes

Answer 59

ANSWER: B 2018

Answer 60

ANSWER: A /C 2018 OITE = C Can do non op first. Depends on question, if cavus and clear achilles tight then perc lengthening

Foot & Ankle (2008-2019) Flashcards

(84 cards)