Foot & Ankle Flashcards
(246 cards)
1
Q
What physcial exam finding do you expect after plantar fasciitis rupture that was not their prior?
A
Pes planus deformity from loss of the medial longitudinal arch.
2
Q
What percent of infected total ankle arthrolasties that require explantation and abx spacer succesfully undergo component reimplantation?
A
Myerson et al reported only 16%.
This was because of extrensive bone loss from debridement, persistent infection, and risk of recurrent infection.
4 weeks defines as the turning pint for aute vs chronic.
3
Q
How long should non-operative treatment be given for a zone 2 metatarsal base fracture before considereing operative treatment in a non-elite athlete?
A
6-8 weeks.
4
Q
What is the most common complication of a Weil osteotomy?
A
Floating toe or MTP dorsiflexion contracture.
Resultes from altered mechanics where interossei go from plantarflexors to dorsiflexors.
5
Q
What is ideal dorsiflexion after a 1st MTP fusion?
A
10-15 degrees.
6
Q
What hindfoot deformity is seen after calcaneus fracture?
A
hindfoot varus.
7
Q
How may calcaneonavicular tarsal coalitions be inherited?
What syndromes may the be present in?
A
Autosomal dominant
Apert syndrome or FGFR-associated craniosynostosis
8
Q
What is the optimal positing for an ankle arthrodesis?
A
Plantigrade
10 degrees of external rotation
5 degrees valgus
5mm of posterior positioning of the talus on the tibial plafond. This decreases the lever arm of the foot during gait
9
Q
How does your treatment change for an adult with a cavovarus foot that does not correct with Coleman block test vs when it does correct?
A
Corrects= flexible. 1st metatarsal dorsiflexion osteotomy.
Doesn’t correct= stiff. Triple arthrodesis, lateral calcaneal slide or closed wedge osteotomy.
10
Q
How do you test the competency of the ATFL?
A
Anterior drawer in 20 degress of plantar flexion.
Compare to uninjured side.
Forward shift of more than 8 mm on a lateral radiograph is considered diagnostic for an ATFL tear.
11
Q
What ligament is injured when the ankle is inverted in neutral dorsiflexion?
A
Calcaneal Fibular Ligament
12
Q
How do you perfrom a talar tilt test?
What does it test for?
A
On AP of ankle measure the angle formed by tibial plafond & talar dome while an inversion force is applied to hindfoot.
< 5 degrees is normal for most ankles.
Useful to evaluate for combined injury of both ATFL and CFL ligament
Inversion test with ankle in slight dorsiflexion is best for CFL ligament alone.
13
Q
What are the differences between the superficial and deep layers of the deltoid ligament?
A
SUPERFICIAL- Crosses both ankle and subtalar joints.
Originates from anterior colliculus and fans out to insert into the navicular neck of the talus, sustenaculum tali, and posteromedial talar tubercle.
DEEP- Corsses only ankle joint.
Functions as the primary stabilizer of the medial ankle.
Originates from inferior & posterior aspects of medial malleolus and inserts on medial nad posteromedial aspects of the talus.
14
Q
What is another name for the calcaneonavicular ligament?
A
Spring ligament
attaches from the sustentaculum tali to the inferior aspect of the navicular.
Injury leads to flattening of the medila longitudinal arch.
15
Q
What motion leads to locking of the transverse tarsal joint?
A
Inversion of the subtalar joint. Allows for a stable hindfoot/midfoot for toe-off.
Eversion of the subtalar joint unlocks the transverse tarsal joint. Allows for a supple foot to accommodate ground just after heel strike.
16
Q
What are the three layers of the tarsometatarsal joint?
A
Interosseus layer- contains the lisfranc ligament. Strongest layer.
Plantar layer. Next strongest
Dorsal layer. Weakest layer
17
Q
What is the first nerve the lateral plantar nerve?
What does it innervate?
A
Baxter’s nerve
Abductor digiti minimus
18
Q
What nerves provide sensation to plantar foot?
A
19
Q
Where is the most reliable location to test sensation from the sural nerve?
A
4th web space.
Provided by sural nerve 70-80% of the time.
Sural nerve at risk with extensile lateral approach to calcaneus, screw palcement for 5th metatarsal stress fracture, and achilles tendon repair especially percutaneous.
20
Q
Injury to the deep peroneal nerve which can happen in trauma or charcot marie tooth will lead to weakness where?
A
Weak or absent EDB and EHB.
21
Q
What nerve is at risk with bunion surgery?
A
Medial branch of superficial peroneal nerve.
Vulnerable on dorsomedial aspect of hallux.
22
Q
Where does the lateral cutaneous branch of the superficial peroneal nerve exit the deep fascia?
A
12-15cm proximal to the tip of the lateral malleolus.
23
Q
What is another name for an accessory navicular?
A
Os tibiale externum
Second most common ossicle in the foot/ankle after os trigonum
24
Q
What is the most common sesamoid in the foot besides the hallux sesamoids?
A
os peroneum
located in the peroneus longus tendon.
25
Where is the os trigonum in relation to local anatomy?
Lateral to FHL, tibial nerve, PTT, and posterior tibial artery.
26
What is the etiology of a os trigonum?
This secondary ossification center forms posterior to the talus between 8-13 yrs.
Normally fuses with talus within 1 yr of froming.
If the ossicle fails to fuse it articulates with the talus through a synchondrosis.
27
What is a shepherds fracture?
Fracture of the posterior process of the talus.
28
What is an os vesalianum?
secondary ossicle at lateral base of 5th metatarsal
29
What should you be concerned about if there is a large amount of diastatis between an os peroneum and pain?
Peroneus longus rupture along with os peroneum fracture.
30
Where is the center of gravity in the body?
In standing position it is 5cm anterior to the S2 vertebral body.
31
What is a hopkins test used for in foot and ankle injuries?
Also known as the squeeze test.
Compression of tibia and fibula at midcalf level causes pain at syndesmosis.
32
What is the incidence of posttraumatic tibiofibular synostosis after Weber C ankle fractures?
10%
Surgical excision should only occur after long perior of failure to respond to non-surgical management and ossification must be "cold" on bone scintigraphy.
33
Describe the classifications of low ankle sprains.
34
Anterior drawer of the anlkle in plantar flexion tests what?
In dorsiflexion?
ATFL
CFL
35
Describe the Ottawa Ankle Rules?
36
What treatment is recommended after a grade III low ankle sprain?
Grade 3 = Complete tear of ankle ligament. Severe pain with weight bearing. Significant ecchymosis and swelling.
May benefit from a period of immobilization and non-weight bearing but should not last for longer than 10 days. Early motion leads to better recovery.
Once swelling has subsided and patient have full ROM they should begin neuromuscular training with a focus on peroneal muscles strength and proprioception training.
Functional brace to be used during strengthening phase of recovery.
37
What is the Gould modification?
Shortening and reinsertion of the ATFL and CFL are r**einforced with inferior extensor retinaculum and distal fibular periosteum**.
38
Most common cause of chronic pain after an ankle sprain is?
Missed injury, can include:
Missed fractures
Osteochondral lesion
Peroneal tendon injury
Syndesmosis injury
Tarsal coalition
Impingement syndromes
39
What is return to play after Grade 1-3 Ankle sprains?
High ankle sprain?
40
What is the usual mechanism of forces that cause a lisfranc injury?
Indirect rotational forces and axial load through hyperplantar flexed forefoot.
Hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation.
Metatarsals displaced in dorsal/lateral direction.
41
What ligaments have to be disrupted for their to be transverse midfoot instability?
interosseous first cuneiform-second metatarsal ligament (lisfranc's ligament) and plantar ligament between the first cuneiform and the second and third meatarsals.
42
What should you be concerned for when you see medial plantar brusing?
Lisfranc injury.
43
What lisfranc injuries can be treated non-operatively?
Sprains with no displacement on weight bearing or stress radiographs.
No evidence of bony injury on CT.
These are usually dorsal sprains.
8 weeks of cast immobilization.
44
Where do you make an incision to expose the 1st TMT joint?
inbetween 1st and 2nd metatarsal fro skin incision.
Joint exposed between EHL and EHB tendons.
45
What is the recommended postoperative care after ORIF of Lisfranc injury?
NWB for 6 weeks at least.
Gradually advance to full weight bearing at 10-12 weeks.
Early midfoot ROM
Not able to return to competitive sports for 9-12 months.
46
Where is a common stress fracture in ballet dancers?
base of 2nd metatarsal.
47
What other things should be evaluated in a healthy individual who has a foot stress fracture?
Look for associated foot deformity
Consider metabolic evaluation
48
What is implicated in the formation of interdigital neuromas?
distal intermetatarsal ligaments
Condition otherwise known as a Morton's neuroma
49
When do you consider operative fixation of metatarsal fractures that have no TMT joint involvement?
Any displacement of the first metatarsal as there is no intermetatarsal support and it bears 30-50% of the weight.
CENTRAL METATARSALS: Sagittal plane deformity more than 10 degrees. \>4mm translation. Multiple fractures
50
What is the risk of malunion in metatarsal fractures?
transfer metatarsalgia.
plantar keratosis.
Treat with osteotomy to correct deformity.
51
What inserts on the tuberosity of the 5th metatarsal?
Peroneus brevis and lateral band of plantar fascia insertion
Peroneus terius inserts on dorsal metadiaphysis
52
What is the blood supply to the base of the 5th metatarsal?
What zone is most prone to nonunion?
Zone 2 (true jones fracture) represents a vascular watershed area making these fractures prone to nonunion.
53
What mechanism typically lead to fractures in each of the 5th metatarsal base fractures?
Zone 1- plantarflexion and hindfoot inversion
Zone 2- Forefoot adduction
Zone 3- Repetitive microtrauma
54
Zone 3 metatarsal fractres are associated with?
cavovarus foot deformities.
Sensory neuropathies.
Stress fractures in athletes.
55
What should be evaluated on physical exam in patients with 5th metatarsal base fracture?
Lateral ligamentous instability
Whether there is any hindfoot varus and whether the hindfoot is correctable.
Peroneal tendon weakness
56
What are the union rates after IM screw for 5th metatarsal base fractures?
Approaching 100%
57
How long should zone 2 and 3 fractures be NWB in non-athletic individuals?
Use of extracorpeal shock wave?
Until signs of radiogrpahic callus.
More than 6 weeks for Zone 3 fractures.
Has not been show to improve or speed up union rates.
58
What is the post-operative protocol after IM screw fixation of 5th metatarsal fractures?
3 weeks NWB.
3 weeks of PWB with therapy focused on ROM.
Running and impact activites can begin to commence at 6 weeks if surgicla stie pain free and signs of radiographic callus.
59
Rate on nonunions in zone 2 5th metatarsal fractures?
15-30%
33% risk of refracture in those treated non-operatively
60
What is the mechanism for:
navicular tuberosity fracture?
Naviuclar body fractures?
Eversion with simultaneous contraction of PTT
May represent an acute widening/diastasis of an accessory navicular
Axial load
61
What is Mueller-Weiss syndrome?
Spontaneous navicular AVN
Rare
Seen in middle aged adults with chronic midfoot pain
62
Describe the Sangeorzan Classification of Navicular Body Fractures?
63
What are indications for ORIF of navicular fractures?
Avulsion fractures invovling \> 25% of articular surface
tuberosity fractures with \> 5mm diastais or large intra-articular fragment
Displaced or inta-articular Type I and II body fractures.
**Type 3 body fractures (comminution) treated with ORIF then followed by ex-fix or primary fusion**
64
How do you treat end stage AVN of the navicular?
Fusion of talonavicular and naviculocuneiform joints
Need to maintain or restor lateral column length.
65
Where is the arcuate artery?
Vascular arch that runs in the dorsal midfoot deep to the extensor tendons.
gives off dorsal metatarsal arteries that run in the 2nd, 3rd, and 4th intermetatarsal spaces.
66
What is the blood supply to the heel pad?
Posterior tibial artery -\> Lateral plantar arterires -\> medial calcaneal branch
67
Describe the muscle deforming forces for the following deformities.
Also describe the muscles that is weak.
68
What is the most common foot deformity following a stroke?
Equinovarus foot.
Use AFO and physical therapy for at least 6 months to await neuro recovery.
Overactivity of the tibialis anterior, with contributions from the FHL, FDL, and tibialis posterior.
69
What is the surgical treatment for a equinovarus foot?
Split anterior tibial tendon transfer (SPLATT).
Flexor hallucis longus tendon transfer to the dorsum of the foot and rleease of the flexor digitorum longus and brevis tendons at the base of each toe.
Gastrocnemius or achilles lengthening.
70
What treatment is recommended for a chronic foot drop?
Posterior tibial tendon transfer to lateral cuneiform +/- gastroc or Achilles tendon lengthening.
71
Where does an achilled tendon rupture most commonly occur?
In the hypovascular region 4-6cm above the clacaneal insertion.
72
What are the outcomes for the following when comparing achilles tendon ruptures treated with fuctionla bracing/casting in resting aquinus vs Operative repair:
Plantar flexion strength?
Risk of re-rupture?
Complication rate?
equivalent strength.
Generally thought to be increased risk of rerupture but this has not been found to be significant if functional rehabilitation is used.
Fewer complications than operative treatment.
73
When should VY advancement be considered for achilles tendon ruptures?
FHL transfer?
Chronic ruptures with defect \< 3cm.
Chronic ruptures with a defect \> 3cm. Requires a functioning tibial nerve.
74
Where is the sural nerve relative to the achilles tendon?
Lateral
So make incision just medial to achilles tendon for repairs.
Sural nerve injury higher with percutaneous repair.
75
What is the incidence of wound healing problems in achilles tendon repairs?
Risk factors? Which is most common?
5-10%
Smoking most common. Female gender, steroid use, and open technique.
76
Why may there be a delay in dianosis after an anterior tibial tendon rupture?
Because a patient my have intact dorsiflexion due to function of the EHL and EDL muscles.
Should compare strengh to contralateral side.
77
What is a steppage gait?
Where the hip is flexed more than normal in the swing phase to prevent toes and foot from catching due to a drop foot.
78
For how long should a direct repar as oppossed to a reconstruction be attempted for a tibialis anterior rupture?
\< 6 weeks
Can be attempted up to 3 months but usually will require reconstruction after 6 weeks.
Some residual weakness is expected.
79
What other surgical procedure may need to be done to protect the repair of a tibialis tedon and optimize motion at the ankle?
Gastrocnemius recession
If less than 5 degrees of ankle dorsiflexion with the knee extended.
80
What are the options for a tibialis tendon reconstruction?
Sliding tendon graft- where one half of the tibialis anterior tendon is turned down to span the gap. Secured to medial cuneiform or dorsal navicular.
Interposition of autograft (hamstring or plantaris) or allograft.
EHL tenodesis or transfer- distal EHL tenodesed to EHB. Proximal EHL used as tendon graft to repair tibialis anterior insertion
81
What mechanism usually leads to peroneal tendon subluxation or dislocation?
Rapid dorsiflexion of an inverted foot leading to rapid reflexive contraction of PL and PB tendons.
82
Which peroneal tendon is usually involved in degenerative tears?
peroneus brevis
At the level of the fibular groove.
Brevis is anterior and medial to peroneus longus at the level of the lateral malleolus.
83
What is the primary restraint for the peroneal tendons within the retromalleolar sulcus?
Superior peroneal retinaculum.
Originates from the posterolateral ridge of the fibular and inserts onto the lateral calcaneus (peroneal tubercle)
84
In what patients are operative repairs indicated for peroneal tendon dislocations?
Athletes who desire a quick return to sport or presence of a longitudinal tear. -\> repair of SPR and deepening of the fibular groove.
Chronic/recurrent dislocations -\> In addition to groove deepening soft tissue transfer and/or osteotomy likely to be requried. Not able to repair SPR. May have hindfoot varus that needs to be corrected with osteotomy.
85
Treatment for simple peroneal brevis tear?
Complex tear?
Complex tear of both brevis and longus?
Core repair and tubularization of the tendon.
Debridement of the tendon with tenodesis of distal and proximal ends of the brevis tedon to the peroneus longus.
Debridement of both tendons with interposition allograft **if they have preserved muscle excursion.**
Debridement of both tendons with FHL transfer **if they have no muscle excursion.**
86
What is an option for a patient with chronic peroneal tendon pathology and varus hindfoot alignment besides a calcaneal osteotomy?
Subtalar arthrodesis.
87
What is the most common cause of osteomyelitis after foot puncture wounds?
Pseudomonas.
Staph aureus is the most common cause of infection.
10% of foot puncture wounds will develop infection.
88
Recommended abx for foot puncture wounds?
Ciprofloxacin or levofloxacin.
Want to cover for pseudomonas.
Alternative abx ceftaxidime or cefepime.
89
What foot deformity is found in adult acquired flatfoot deformity?
Pes planus
Hindfoot valgus
Forefoot varus
Forefoot abduction
90
In late posterior tibial tendon insufficiency what is failing?
Static hindfoot stabilizers and collapse of the medial longitudinal arch:
Spring ligament complex
Plantar fascia
Plantar ligaments
Early disease is loss of medial longitudinal arch dynamic stabilization
91
What motions within the foot and ankle does the posterior tibial tendon contribute to?
Acts as a hindfoot invertor.
Adducts and supinates the forefoot during the stance phase of gait.
Acts as a secondary plantar flexor of the ankle.
92
Describe the classification of PTTI?
93
What should be on your differential for causes of adult pes planus?
PTTI
Midfoot pathology- Osteoarthritis or chronic lisfranc injury.
Incompetent spring ligament- primary static stabilizer of the talonavicular joint.
94
Non-operative treatment for PTTI?
AFO initial treatment for stages II-IV
Walking cast/boot for 3-4 months in stage I disease
For stage I and II custom molded in shoe orthosis. **Medial heel lift and longitudinal arch support.** Medial forefoot post indicated if fixed forefoot varus is present.
95
Operative intervention for Stage I PTTI that has failed non-op treatment?
Tenosynovectomy.
96
Operative intervention for Stage II PTTI?
Contraindications?
FDL transfer. Calcaneal osteotomy. TAL. +/- forefoot correction osteotomy. +/- spring ligament repair. +/- PTT debridement.
Lateral column lengthening for talonavicular uncoverage.
Medial column arthrodesis if deformity is at naviculocuneiform joint.
**Contraindications: Hypermobility, neuromuscular conditions, severe subtalar arthritis, obesity (relative), and age \> 60-70 (relative).**
97
Operative treatment for Stage II PTTI with 1st TMT hypermobility?
Need to include a first TMT joint arthrodesis along with the usual calcaneal osteotomy and TAL.
+/- lateral column lengthening and PTT debridement.
98
What is a contraindication for isolated subtalar arthrodesis to treat PTTI?
Any fixed forefoot supination/varus.
Doing this without addressing the forefoot witll overload the lateral border of the foot.
99
What tendon is synergistic with tibialis posterior?
FDL
100
How do you differentiate the FDL from the FHL when harvesting it for surgery in PTTI?
Find FDL and FHL at knot of henry.
FHL runs deep (dorsal) to FDL.
For the transfer FDL is inserted into the navicular near the insertion of the tibialis posterior.
101
Contraindications to a FDL transfer in PTTI surgical treatment?
Rigidity of subtalar joint- \<15 degrees of motion
Fixed forefoot varus deformity- \> 10-12 degrees
102
What osteotomy is used to treat forefoot abduction in Stage IIB PTTI?
**Evans** lateral column lengthening osteotomy.
103
What techniques are used to correct fixed forefoot supination/varus in stage IIC PTTI?
**Plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy**:
Used with a stable medial column (navicular is colinear with first MT)
Corrects residual forefoot varus after hindfoot correction is made surgically
**Medial column fusion (isolated first TMT fusion, isolated navicular fusion, or combined TMT and navicular fusions):**
Used with an unstable medial column (plantar sag at first TMT and/or naviculocuneiform joint).
104
When should tendon augmentation or transfer be performed after achilles tendon insertional debridement?
When \> 50% of Achilles tendon insertion must be removed during thorough debridement.
Heavier patients with more severe disease.
105
When is a percutaneous tenotomy acceptable for achilles tendonopathy?
Mild to moderate disease.
Longitudinal tenotomy made in the degenerative area.
Strip the anterior achilles tendon with a large stuture to free any adhensions.
Open excision of degenerative tendon with tubulariation. for moderate to severe disease. 70-100% succesful.
106
What are risk factors for plantar fasciitis?
Obesity.
Decreased ankle dorsiflexion in a non-athletic population.
Weight bearing endurance activity such as dancing and running.
107
What structures share the origin on the medial calcaneal tubercle with the plantar fascia and may be inflamed as well in fasciitis?
abductor hallucis
flexor digitorum brevis
quadratus plantae
108
What are the classic symptoms of plantar fasciitis?
"start up" pain when first getting out of bed that improves with ambulation.
Pain increaes with increased activity and is bad by the end of the day.
109
For plantar fasciitis answer the following treatment related questions:
Pre-fabricated shoe inserts or custom orthotics?
Type of stretching?
when stretching and orthotics aren't working what is another option?
pre-fabricated have been shown to work better.
Plantar fascia specific stretches such as dorsiflexing foot by grabbing toes, not just achilles stretching.
dorsiflexion night splint.
110
When do you consider operative treatment for plantar fasciitis?
Persistent pain after 9 months of failed conservative measures
Complications common and recovery protracted
Consider associated distal tarsal tunnel decompression. Success rates are 70-90% for dual plantar fascial release and distal tarsal tunnel decompression.
has to be open if both procedures are being done.
Only release medial 1/3 to 2/3.
111
What complications are associated with plantar fasciitis and plantar fascia releases?
Plantar fascia rupture- risk factors are athletes, minimalist runners, and corticosteroid injections. Treat with cast immobilization.
Lateral plantar nerve injury.
Too much release leading to destabilization of medial longitudinal arch.
Increased stress on dorsolateral midfoot
Chronic pain.
112
Is there a genetic predispostion with hallux valgus?
Yest, 70% of patients with hallux valgus have a positive family history.
113
What risk factors are associated with hallux valgus?
INTRINSIC: Genetic predisposition.
Increased distal metaphyseal articular angle (DMAA)
Ligamentous laxity (1st tarso-metatarsal joint instability)
Convex metatarsal head
2nd toe deformity/amputation
pes planus
Rheumatoid arthritis
Cerebral palsy
EXTRINSIC: Shoes with a high heel and a narrow toe box.
114
What tendons become a deforming froce in hallux valgus?
Adductor tendon becomes deforming force- inserts on fibular sesamoid and lateral aspect of proximal phalanx.
Lateral deviation of EHL further contributes to deformity.
Plantar and lateral migration of abductor hallucis causes muscle to plantar flex and pronate phalanx.
115
What is the most common complication after surgery for hallux valgus?
Recurrence
\> 50%
116
Describe the four radiographic measurements used in evaluation of hallux valgus?
What are normal values for each?
117
When is surgery indicated for juvenile and adolescent hallux valgus?
Best to wait until skeletal maturity to operate.
Can not perform proximal metatarsal osteotomies if physis is open (**cuneiform osteotomy ok**).
**Surgery indicated in symptomatic patients with an IMA \> 10 degrees and HVA of \> 20 degrees.**
Consider double MT osteotomy in adolescent patients with increased DMAA
118
For Hallux valgus categories of Mild, Moderate, and Severe describe the radiographic indications and the recommended procedure?
119
When would you consider a biplanar chevron osteotomy over a simple chevron osteotomy?
If there is a DMAA \> 10 degrees use a biplanar checron osteotomy as this also corrects DMAA which a simple chevron osteotomy does not.
120
What are the indications for an Akin osteotomy?
Halux valgus interphalangeus \> 10 degrees
Congruent joint with DMAA \< 10 degrees
Done as a secndary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) did not provide sufficient correction due to a large DMAA or HVI.
121
What is a lapidus procedure?
When is it indicated?
1st metatarsocuneiform arthrodesis with modified McBride.
Severe defromity (Very large IMA).
arthritis at 1st TMT.
metatarsus primus varus.
Hypermobile 1st TMT joint.
Concomitant pes planus.
122
What are the surgical indications for the specific conditions as they relate to hallux valgus?
123
What kind of osteotomies are Scarf, Ludloff, and Mau?
Metatarsal shaft osteotomies.
Used in moderate to severe hallux valgus: IMA 14-18 and DMAA is normal or increased.
Complications- dorsal malunion with transfer metatarsalgia. Recurrence.
124
When is a proximal crescentric or broomstick osteotomy utilized for hallux valgus?
Severe deformity: IMA \> 20 and HVA \> 50 degrees.
125
What is the most common cause of surgical failure for hallux valgus surgery?
Insufficient preoperative assessment and failure to follow indications.
Failure to recognize DMAA \> 10 degrees.
Inadequate correction of IMA.
Failure to do adequate distal soft tissue realignment.
Other causes: noncompliance (patient bears wait to early). Rounded shape to metatarsal head. Failure to perform a lateral release of the adductor hallucis tendon.
126
What leads to avascular necrosis after surgery for hallux valgus?
Medial capsulotomy is primary insult to blood flow to metatarsal head.
Chevron plus lateral soft tissue release thought to be a risk in the past but has been shown to not increase AVN.
127
What can cause hallux varus after surgery for hallux valgus?
Overcorrection of 1st IMA.
Excessive lateral capsular release with overtightening of medial capsule.
Overresection of medial first metatarsal head.
Lateral sesamoidectomy.
128
What is a surgical treatment option for 2nd MT transfer metatarsalgia?
Shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release.
Often seen concomitant with hallux valgus.
129
What leads to a neuroma after surgery for hallux valgus?
Most often the neuroma invovles the medial dorsal cutaneous nerve (a terminal branch of the superfiial peroneal nerve).
It is most commonly injured during the medial approach for capsular imbrication or metatarsal osteotomy.
130
Turf toe is an injury to what structes of the foot?
plantar plate and sesamoid complex
tear to capsular-ligamentous-seasmoid complex
tear occurs off the proximal phalanx, not the metatarsal
131
Abduction and adduction of the the big toe is in relation to what axis?
In relation to the 2nd metatarsal and toe.
Abductor hallucis attaches to medial sesamoid.
Adductor hallucis attaches to lateral sesamoid.
132
What is the plantar plate and what does it attach to?
Composed of the joint capsule.
Attaches to the transverse head of adductor hallucis, flexor tendon sheath, and deep transverse intermetatarsal ligament.
133
What may you see on radiorgraphs with a turf toe?
Medial sesamoid may be displaced proximally.
There may be a sesamoid fracture.
Usually not a dislocation of the great toe MTP joint.
134
What is an associated condition with a turf toe?
Stess fracture of the proximal phalanx.
135
Treatment for a turf toe?
Rest, NSAIDs, stiff-sole shoe or walking boot for all grades of injuries.
Do not tape in the acute pahse.
Progresive motion once the injury is stable.
136
When is surgical repair indicated for a turf toe?
Failed conservative treatment.
Retraction or fracture of sesamoids with diastasis.
Loose fragments in joint.
Hallux toe deformity.
Traumatic bunions.
137
Surgical technique for turf toe?
Rehab and return to sport?
Repair or excision of sesamoid. Can use headless screw or surture.
Joint synovitis or osteochondral defect often requires debridement or cheilectomy
Abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored.
Immediate post-op non-weight bearing for at least 6 weeks.
Progressive ROM and physotherapy.
Return to sport 3-4 months after surgery.
138
What is the mainstay of treatment for hallux rigidus?
Morton's extension with stiff foot plates.
Stiff sole shoe and shoe box stretching may also be used.
NSAIDs
Activity modification.
139
What is a Moberg procedure and when is it indicated?
Dorsal closing wedge osteotomy of the proximal phalanx of the great toe.
Runners with reduced dorsiflexion. 60 degrees is needed to run.
Failure of cheilectomy to provide at least 30 to 40 degrees of motion.
140
When is a dorsal cheilectomy utilized for hallux rigidus?
Paients with no pain in the mid range of motion.
Pain with terminal dorsifelxion is an indicator of good results.
Shoe wear irritation from dorsal prominence and pain are ideal candidates.
TECHNIQUE: Remove 25-30% of the dorsal aspet of the metatarsal head along with dorsal osteophyte resection.
The goal of surgery is to obtain 70-90% of dorsiflexion intraoperatively.
141
What is the preferred surgical alignment for a 1st MTP joint arthrodesis?
10-15 degrees of valgus in relation to metatarsal shaft.
15 degrees of dorsiflexion.
Best way to assess this intraoperatively is with a foot plate to simulate weight bearing with 4-8mm of clearnace of toe from plate.
142
What is one of the most common complications after 1st MTP joint arthrodesis?
IP joint degeneration. 15% of patients exerpience this and it is mostly asymptomatic.
90% go on to fuse without any issue.
143
What is the slavage for a failed MTP arthroplasty?
MTP joint arthrodesis with structural bone graft.
Usually shortening \> 5mm require structural bone graft.
1st MTP shortening leads to loss of medial support of the 2nd toe. This predisposes it to 2nd MTP joint varus.
144
Which sesamoid of the foot is more commonly injured?
Tibial sesamoid
Larger than lateral sesamoid.
Has greater weight bearing status.
145
What should bilateral sesamoiditis raise concern for?
Reiter's disease (urethritis, conjunctivits/iritis, inflammatory bowel disease).
Psoriatic arthritis.
Seronegative RA.
146
What are the attachments to the tibial and fibular sesamoids?
FHB attaches to both tibial and fibular sesamoid.
Sesamoids are connected to each other by intersesamoid ligament and plantar plate.
Abductor hallucis is connected to tibial sesamoid
Adductor hallucis is connected to fibular sesamoid.
147
When is a sesamoidectomy indicated?
Failure of non-op treatment for 3 months.
Goes for both fractures and synovitis.
148
What is a complication of complete foot sesamoidectomy?
Tbial sesamoid excision?
Fibular sesamoid excision?
Removal of both is associated with a high incidence of cock-up deformity. Caused by weakness of FHB which should be meticulously repaired.
Should avoid excision of both.
Hallux valgus.
Hallux varus.
149
What are som causes of Hallux Varus that are not iatrogenic?
CONGENITAL: Metatarsal physeal bracket.
ACQUIRED: trauma, inflammatroy (rheumatoid, ankylosing spondylitis), neurologic (Charcot-Marie-Tooth, post polio)
150
What are the three possible components of hallux varus?
Medial deviation of the hallux relative to first MTP joint.
Supination of the phalanx.
Claw toe deformity.
151
What should be done with a patient who had hallux valgus correction surgery a week ago and now has developed a hallux that is "too straight"
"too straight" common complaint of patients who have developed hallux varus.
Early post-op varus deformities can benefit from frequent taping and follow-up. Duration should be maintained for up to 3 months or until soft-tissues have healed.
May correct deformity if initiated within the first few weeks from surgery.
152
Operative indications and treatments for hallux varus?
Overcorrection of proximla/distal metatarsal osteotomy or proximal phalangeal osteotomy -\> lateral closing wedge osteotomy.
Flexible first MTP joint deformities -\> tendon transfer with medial release.
Fixed not passively correctable first MTP joint with significant deformity and non-functioning hallux or painful joint arthritis -\> First MTP arthrodesis.
153
What ar ethe usual characteristics of medial talar dome OCD lesions?
Usually no history of trauma.
More posterior
Larger and deeper than lateral lesions.
154
What are the usual characteristics of lateral talar dome OCD lesions?
Usually have a traumatic history
More superficial and smaller
More central or anterior
Lower incidence of spontaneous healing
More often displaced and symptomatic
155
What is the main blood supply to the talar body and dome?
Deltoid artery.
Extra-0sseous blood supply.
156
What treatment would be recommended for a chronic talus osteochondral lesion that is \> 1cm with a intact cartilage cap?
Retrograde drilling and/or bone grafting.
Chronic lesions smaller than 1cm -\> arthroscopy with removal of loose fragment if one is there with debridement and marrow stimulation.
For lesions that do not have an intact cartilage cap and are greater than 1cm or shoulder lesions -\> Osteochondral grafting. This is also what is done for failed marrow stimulation or drilling.
157
How should marrow stimulation be done for a osteochondral lesion of the talus?
All unstable cartilage flaps need to be removed to create a stable and contianed defect.
microfracture awl tapped into subchondral bone 2-4mm deep. Holes spaced 2-3mm from each other.
Stop inflow to allow fat or blood to emanate from holes indicated adequate penetration.
85% pain improvement. 65-90% improvement in patient reported outcomes.
Fibrocartilage formation at site of lesions in 60% of patients on second-llo arthroscopy, no correlation noted with patient outcomes.
158
What will you see on x-ray of a talar osteochondral defect that has been fixed with OATs harvested from the knee?
prominent graft despite the cartilage surface being flush because the knee has a cartilage thickness less than the native talus.
159
What percentage of ankle arthritis is primary osteoarthritis?
Accounts for less than 10% of all ankle arthritis.
Greater than 2/3 of all ankle arthritis is post-traumatic arthrits.
160
What is normal ROM of the ankle joint?
20 degrees of dorsiflexion and 50 degrees of plantar flexion.
161
In what patients can a supramalleolar osteotomy be considered for ankle arthritis?
near normal ROM
Minimal talar-tilt or varus heel alingment.
Medially focused ankle arthritis. Stage 2 or 3a according to the Takakura-Tanaka classification for varus-type osteoarthritis.
162
What is the most common complication after tibiotalar arthrodesis?
50% of patients deomstrated subtalar arthrosis 10 years following ankle arthordesis.
163
What are contraindications for ankle arthroplasty?
Uncorrectable deformity, severe osteoporosis, talus osteonecrosis, charcot joint, ankle instability, obesity, and young laborers.
All of these have increased risk of failure and revision.
164
What is improved in terms of gait with ankle arthroplasty vs arthrodesis?
Increased gait speed and stride length.
165
What are the more recent 5-10 year outcomes with ankle arthroplasty?
90% good to excellent results with newest generation of ankle arthroplasty.
Sill need long-term studies.
166
which athletes most commonly have tibiotalar impingement?
Athletes who play on turf or grass most commonly.
167
What is an option for tibiotalar impingement before arthroscopic excision when NSAIDS, therapy, and activity modifications have failed?
Corticosteroid injections
168
What joints are included in midfoot arthritis?
naviculocuneiform joint
Intercuneiform joint
metatarsal cuneiform
169
What is the most common etiology for midfoot arthrits?
Primary osteoarthritis
Posttraumatic is second. This differs from ankle arthritis.
170
What are some of the deformity characteristics of midfoot arthritis?
Longitudinal arch collapse with weight bearing.
Midfoot collapse (Look like PTTI).
Forefoot abduction.
Hindfoot valgus.
Equinuus contracture of achilles tendon.
Hallux Valgus.
171
True or false an inflammatory etiology of midfoot arthritis will lead to consistent symmetric degeneration across the midfoot?
True
172
What orthotics should be recommended for midfoot arthritis?
Cushioned heel
Longtidunal arch supports
Stiff sole with a rocker bottom
173
What operative intervention is recommended for midfoot arthritis that has failed conservative measures?
Midfoot arthrodesis, +/- TAL, +/- hindfoot realignment
Arthrodesis results in close to normal foot function as midfoot joints are non-essential joints.
Do not fuse the 4th/5th tarsometatarsal joints. In select cases interpositional arthroplasties can be performed.
174
Between TTC fusion with retrograde nail vs plate and screw constructs. Which has better bending stiffness?
Rotational stability?
Retrograde nail
Also retrograde nail
175
What is the advantage of using a lateral transfibular approach over and anterior approach for a TTC?
Able to prepare both tibiotalar and sub-talar joints through one approach.
Provides a source of local autograft.
176
What is the greatest risk factor for persistent nonunion with revision ankle arthrodesis for nonunion?
Neuropathy is the greatest risk factor.
Tobacco users have a 2.7x risk of nonunion.
177
Contrainidications to ankle arthrodesis?
Active infection.
Profound vascular disease.
Severe tibia malalignment.
178
In what area is function thought to be better with a total ankle arthroplasty over an ankle arthrodesis?
Walking on uneven ground.
179
What are the contraindications to total ankle arthroplasty?
Active infection
Peripheral vascular disease
Inadequate soft-tissue envelope
Charcot arthropathy
Insufficient bone stock
Severe osteoporosis
Osteonecrosis of the talus
180
What are favorable patient factors for a total ankle arthroplasty?
Older, low demand, reasonably mobile patient with no significant co-morbidities.
Normal or low body mass index.
Well-aligned and stable hindfoot.
Good soft tissue conditions.
181
What are common technical errors in implant placement of a total ankle arthroplasty?
Placing the prosthesis too lateral.
Using too small a prosthesis, which subsides.
Failing to solve preoperative varus or valgus malalignment and attempting to replace an ankle that is too anterior subluxated.
182
What is imperative to restore when performing total ankle arthroplasty and how is it obtained?
Restore mechanical alignment to the ankle.
Imperative to achieve a stable, neutrally aligned, plantigrade, weight-bearing position of the ankle and hindfoot.
Ligament reconstruction, tendon transfers, osteotomies, heel cord lengthening, and arthrodesis may be necessary.
183
What is the most common complication after total ankle arthroplasty?
Delayed wound healing.
Reported in 4-17% of cases in the literature.
Sensory deficits are also very common due to anterior incision and proximit to superficial and deep peroneal nerves.
Deep wound infection rates rane .5-3.5% in the literature.
184
What component of a total ankle arthroplasty most commonly fails?
Talar component fails more commonly than the tibial component.
185
What is a complication in total ankle arthroplasty that occurs more often medially than laterally?
Intraoperative fracture. Medial malleolus \> Lateral malleolus.
Can be prevented with prophylactic screws or k-wire.
Caused by overxtending the plafond cut or making a cut too proximal. Also higher risk with oversized tibial component.
Subsidens is another risk that may require coversion to a fusion where allograft bone block needs to be used if there is \> than 2cm of bone loss.
186
A claw toes deformity is characterized by?
MTP hyperextension with PIP and DIP flexion.
Analogous to intrinsic minus deformity in the hand.
MTP plantar plate becomes insufficient over time and translates dorsally.
Most common etioloty is synovitis. Also caused by trauma or missed compartemnt syndrome.
187
What conditions are associated with claw toes?
Cavus deformity
Neuromuscular disease
Inflammatory arthropathies
188
First line of treatment for claw toes.
Taping and shoe modification.
Provide adequare plantar padding using metatarsal and/or crest pads or orthotics to offload plantarly-subluxed metatarsal heads.
Wear a shoe with a high toe box
use a sling to hodl the proximal phalanx parallel to the ground.
189
What is the most comon complication of a Weil osteotomy?
Floating toe.
Caused by intrinsics migrating dorsal to the joint and acting as MTP Extensors
190
Operative options for Claw toes?
FLEXIBLE: Girdlestone (FDL flexor-to-extensor transfer), EDB tenotomy, and EDL lengthening.
FIXED CONTRACTURES: Girdlestone, MTP capsulectomy, and proximal phalanx head and neck resection.
CLAW TOE DEFORMITY IN ALL FOUR LESSER TOES: Girdlestone and distal MT shortening osteotomy (Weil lesser MT osteotomy)
191
Hammer toe deformity is characterized by?
PIP Flexion, DIP Extension, MTP Neutral or extended.
Deformity can be rigid or flexible.
Most common deformity of lesser toes. More common in older women.
192
What does a push up test tell you regarding a hammer toe?
Tells you whether it is flexible or not.
Dorsal directed pressure on the plantar aspect of the involved metatarsal. Flexible deformity is reducible. Effect of over active extrinsics is removed.
193
What treatment is recommended for a flexible hammer toe that has failed non-operative measures?
FDL to EDL tendon transfer (Girdlestone)
194
What treatment is recommended for a rigid hammer toe that has failed non-operative treatment?
PIP resection arhtroplasty +/- tenotomy and tendon transfers.
EDL Z-lengthening, tenotomy, and dorsal capsular release depending on severity of MTP hyperextension.
PIPJ arthrodesis is an option.
195
What is a Morton Foot?
Elongated second metatarsal relative to the first metatarsal.
Risk factor for synovitis of the 2nd MTP joint.
Another risk factor for synovitis is hallux valgus deformity.
196
Synovitis of the 2nd MTP joint lead to attenuation of what structure?
Associated with what toe deformity?
If the MTP instability leads to dislcoation what direction is it in and what other toe deformity does it lead to?
plantar plate
cross-over toe deformity
Dorsal dislocation that has a predisposition to hammer toe deformity.
197
Which webspace is more comon for a mortons neuroma?
Which is more painful barefoot synovitis of interdigital neuroma?
3rd webspace
2nd webspace pain more commonly from 2nd MTP synovitis.
Pain with synovitis is worse when barefoot.
Pain is less severe when barefoot in neuromas.
**Importatnt to distinguish MTP synovitis from interdigitial neuroma becase a steroid injection will help a neuroma but worsen MTP synovitis because of weakening of capsuloligamentous structures that leads to progressive deformity.**
198
What operative treatment is recommended for 2nd MTP synovitis?
Failure of non-op and no deformity -\> synovectomy
Fixed deformity with long second metatarsal -\> distal oblique shortening MT osteotomy (Weil procedure)
Fixed deformity with NO long 2nd metatarsal -\> FDL to EDL tendon transfer or MTP capsular release with extensor tendon lengthening.
199
What is another name for a Bunionette Deformity?
Tailor's bunion
2-4x more common in women.
Often bilateral
200
What are characteristic findings of a bunionette of radiographs?
Increased 4-5 IMA ( Normal 6.5-8 degrees)
Increased lateral deviation angle (Normal 0-7 degrees)
Increased width of MT head (Normal \<13mm)
201
What type of bunionette deformities can you perform a simple condylectomy?
Symptomatic, not cosmetic Type I (large 5th metatarsal heads)
resection of lateral third of the 5th MT head. Combine with lateral MTP joint capsule tightening.
Advantage is it does not require a extended period of immobilization.
202
How do you decide whether to perform a distal metatarsal osteotomy vs a oblizue diaphyseal rotational osteotomy?
4-5 IMA \< 12 degrees then distal metatarsal osteotomy. Can be combined with condylectomy. Chevron medializing osteotomy is most common and most stable.
4-5 IMA \> 12 degrees then oblique diaphyseal rotational osteotomy. Shave plantar aspect of 5th MT head if callosity present. May produce 5th MT shortening.
**Proximal osteotomy should be avoided due to poor blood supply in this region of the metatarsal.**
203
What are the pathoanatomic stages of a crossover toe?
**Plantar plate disrupted**- most common cause is chronic inflammation.
**Lateral collateral ligament fails**- leads to medial deviation of the second toe.
**Medial structures become contracted-** Lumbrical and interosseous tendons, MCL, and medial capsule become tight and contracted creating addction force.
**Plantar plate subsequently fails-** Hyperextension forces on the proximal phalanx result in dorsal instability.
204
What lab values are associated with increased healing potential for diabetic foot ulcers?
Serum albumin \> 3.0 g/dL
total lymphocyte count \> 1,500/mm3
205
What percent of diabetics have foot ulcers?
What percent of of lower extremity amputations are due to foot ulcers?
12%
85%
206
What other than sensory dysfunction occurs in diabetics what other neuropathic change makes them more prone to ulcer development?
Autonomic dysfunction leads to drying of skin due to lacke of normal glandular function. This along with sensation leads to a net effect of increased mechanical and axial stress on skin that is more prone to injury due to drying.
Another separate
207
What are two major classification systems for diabetic foot ulcers?
Wagner
Brodsky Depth-Ischemia Classification
208
What is the gold standard study to determine wound healing potential of a lower extremity ulcer/amputation?
TcpO2- \> 30mm Hg or 40mm Hg depending on review source is a good sing of healing potential.
For ABI's index \> .45 and toe pressure \>45mm Hg are needed to heal amputation and \>60mm Hg to heal an ulcer.
209
What are absolute and relative contraindications to total contact casting (TCC)?
ABSOLUTE: Infection
RELATIVE: Marginal arterial supply to affected area. Patients unable to comply with cast care or cannot tolerate a cast.
If culers are going to recur it is typically 3-4 weeks after cast removal.
total contac tcasting often necessary for up to 4 months.
210
What percentage of patients with diabetes and neuropathy develop charcot arthropathy?
7.5%
Can be foot, ankle, shoulder, elbow, and knee.
211
What are the theories on the pathophysiology of Charcot Arthropathy?
Neurotraumatic- insensate joints subjected to repetitive microtrauma.
Neurovascular- Autonomic dysfunction increases blood flow through AV shunting. Leads to bone resorption and weakening.
212
Are charcot joints painful or painless?
Both
50% are painful
50% are painless
213
How do you differentiate erythema from charcot arthropathy vs infecion?
Erythema will decrease with elevation in Charcot arthropathy, but is unchanged in infection.
214
What are late changes on radiographs consistent with charcot arthropathy?
Obliteration of joint space.
Fragmentation of both articular surfaces of a joint leading to subluxation or dislocation.
Scattered "chunks" of bone in fibrous tissue.
Surrounding soft tissue edema.
Joint distension by fluid.
Heterotopic ossification.
215
What is the best imaging test to determine osteomyelitis from charcot arthropathy?
MRI is most sensitive.
There are still limitations in differentiating charcot from osteo.
May add a bone scan to help.
Technetium bone scan may be positive for a neuropathic joint and osteomyelitis.
**Indium WBC scan will be negative (cold) for neuropathic joints and positive (hot) for osteomyelitis.**
216
What is detritic synovitis
Cartilage and bone distributed in synovium
217
What is the initial treatment for charcot arthropathy?
Total contact casting.
Casts changed every 2-4 weeks for 2-4 months.
CROW boot can be used after contact casting.
Also utilize other shoe modifications and medications.
Outcomes are 75% successful.
218
What shoe modifications and medications can be used for charcot arthropathy?
In feet that are in the reconstruction stage of charcot arthropathy (Eichenholtz stage 3) a double rocker shoe can be used to reduce the risk of ulceration at the plantar apex of the deformity.
MEDICATIONS: Bisphosphonates, neuropathic pain medications, antidepressants, and topical anesthetics.
219
What are the operative interventions for charcot foot/ankle?
What are the specific indications?
Braceable foot with equinus deformity and focal bony promineneces causing skin breakdown -\> Resection of bony prominences (exostectomy) and TAL.
Severe deformity that is not braceable -\> Deformity correction, arthrodesis +/- osteotomies. **Very high complication rate 70%.**
Failed previous surgery or recurrent infection -\> Amputation. Goal is for a partial or limited amputation if vascularity allows.
220
Describe the anatomy of the interdigital nerve of the foot?
Lies plantar to the transverse intermetatarsal ligament between the metatarsal heads.
Composed of the confluence of the branches of the lateral and medial plantar nerves.
Morton's Neuroma most commonly involves the 2nd and 3rd interdigital nerve between the metatarsal heads.
221
What will worsen symptoms of a Morton's neuroma and what will make them better?
Wearing shoes, especially with narrow toe boxes and weight bearing.
Relief of symptoms by removing shoes and massaging foot.
222
What are provocative exam tests used to diagnose a interdigital neuroma?
Positive web space compression test.
On some occassions the neuroma may be palpable.
**Mulder's Click-** bursal click may be elicited by squeezing metatarsals together.
**Drawer test-** assess for MTPJ instability
223
What will a Morton's neuroma look like on Ultrasound?
Oval hypoechoic mass oriented parallel to the metatarsal bones.
224
What is a confirmatory test that can be done for a Morton's neuroma?
Corticosteroid injection.
If no relief of pain consider MTP joint synovitis.
225
What operative intervention is recommended for Morton's Neuroma?
Dorsal approach most common.
Neurectomy with nerve burial (bury proximal stump within intrinsic muscles)
Transverse intermetatarsal ligament release.
Need to identify nerve bost proximal and distal to the nerve bifurcation.
**Resect the nerve at least 3cm proximal to intermetatarsal ligament.**
reapproxiamte and repair the transverse intermetatarsal ligament to avoid intermetatarsal head instability.
226
What complications are associated with neurectomy for Morton's neuroma?
**Stump neuroma-** inadequate retraction. caused by tehtering of plantar neural branches that prevent retraction following resection.
Also can be caused by inadequate resection (not proximal enough) **Most common**
Painful scar- 5% increased risk with plantar incision.
227
What are the anatomic structures that define the posterior tarsal tunnel?
Flexor retinaculum (laciniate ligament)
Calcaneus (medial)
Talus (medial)
Abductor hallucis (inferior)
CONTENTS INCLUDE: tibial nerve, posterior tibial artery, FHL tendon, FDL tendon tibialis posterior tendon
228
What anatomic structures define the anterior tarsal tunnel?
What are the contents of the anterior tarsal tunnel?
Inferior extensor retinaculum and fascia overlying the talus and navicular.
CONTENTS INCLUDE: Deep peroneal nerve and branches. EHL. EDL. Dorsalis pedis artery.
229
What is the heel pain triad?
Posterior tibial tendon deficiency (adult acquired flatfoot)
Plantar fasciitis.
Tarsal tunnel syndrome.
Believed to be due to loss of static and dynamic stabilizers of the medial arch and subsequent traction neuropathy on the tibial nerve.
230
What are the symptoms of tarsal tunnel syndrome?
Pain with prolonged standing or walking.
Often vague and misleading medial foot pain.
Sharp, burning pains in the foot.
intermittent pareshtesias and numbness in the plantar foot.
231
What physical exam findings are consistent with tarsal tunnel syndrome?
Tinel's over tibial nerve
Muscle wasting of foot intrinsicis- abductor digiti quinti or abductor hallucis
Compression test. Digital pressure over tarsal tunnel.
232
What EMG findings are consistent with tarsal tunnel syndrome?
Distal motor latencies of 7.0 msec or more
Prolonged sensory latencies of more than 2.3 msec- **sensory (SAP) more likely to be abnormal than motor.**
Decreased amplitude of motor action potentials of abductor hallucis or abductor digiti minimi.
233
Treatment for tarsal tunnel syndrome?
3-6 months of nonoperative treatment which infludes: NSAIDs, SSRIs, bracing, and activity modifications.
IF that fails and the following are found can proceed with surgical release. Compressive mass, positive EMG, and reproducible physical findings.
**Best surgical results are when a compressing anatomic structure such as a ganglion cyst is identifited and removed.**
234
What must be released for a tarsal tunnel surgical release?
Flexor retinaculum
Deep investing fascia of lower leg
Superficial and deep fascia of abductor hallucis
**repeat tarsal tunnel release not recommended.**
235
Is there such a thing as surgical release of ilioinguinal nerve?
Yes, entrapment can occur from hypertrophied abdominal muscles as a result of intensive training.
Hyperestheisa is common
Pain worse with hyperextension of hip.
236
What is surfer's neuropathy?
Compression of the saphenous nerve, usually at Hunter's canal.
Caused by kneeling for long periods of time.
Symptoms- pain inferior and medial to knee.
Treatment- non-operative, use knee pads. Activity modification.
237
What is the most common cause of medial plantar nerve compression?
Also known as jogger's foot.
Most common cause of compression is foot orthotics.
238
Where does the superficial peroneal nerve exit the fascia?
12cm proximal to lateral malleolus.
Can get entrapment symptoms from inversion injury of fascial defects.
Observation if the preferred method of treatment.
Can be released in refractory cases or for elite athletes.
239
What causes compression of Baxter's nerve?
Baxter nerve = first branch of the lateral plantar nerve.
Compressed between fascia of abductor hallucis longus and medial side of quadratus plantae.
Common nerve entrapment in the running athlete.
Operative treatment in most cases which is surgical release of abductor hallucis fascia.
240
A disrupted spring ligament causes what deformity?
Flatfoot deformity.
241
What subtle foot deformity does this image most likley indicate?
The figure demostrates a right sided "peak-a-book sign" where you can see the medial border of the heel. This indicates hindfoot varus.
This patient likely has a subtle cavovarus foot (SCF) and would benefit from an orthotic with lateral hindfoot posting and first metatarsal head recess.
242
What is the structure labeled in A in the photo?
What is the clinical relevance?
Peroneus quartus
Supernumary muscle arising most commonly from the peroneus brevis. The presence is not uncommon, up to 21% of the time and is associated with lateral ankle pain and peroneal tendon symptoms.
243
What does a high DMAA within the halux suggest about the joint?
Congruent joint.
If the joint is congruent does not need a distal osteotomy. In general can be treated with just a proximal osteotomy for hallux valgus.
244
A low DMAA suggests what about the MTP joint?
What value is considered low?
What procedure is likely indicated?
Low DMAA suggests a incongruent 1st MTP joint.
Low DMAA is \< 10 degrees
No procedure distally. When there is a high DMAA and a congruent joint with moderate to severe hallux valgus is when a distally- based medially clsoing wedge osteotomy is indicated to correct the DMAA.
245
What kind of distal metatarsal osteotomy is indicated for high DMAA in hallux valgus?
Biplaner distal chevron osteotomy.
246
varus alignment of the talar neck causes a decrease in what kind of motion?
subtalar eversion
