Introduction to surgery of the foot and ankle Flashcards Preview

Module 204 Theme 2 > Introduction to surgery of the foot and ankle > Flashcards

Flashcards in Introduction to surgery of the foot and ankle Deck (32):
1

Why is the foot important?

To ensure that we have a smooth gait cycle
If foot anatomy is abnormal foot function is compromised

2

List the 3 sections of the foot

hindfoot, midfoot and forefoot

3

What does the hindfoot normally have?

Valgus

4

What are the aims of treating foot and ankle pathology?

Is always to achieve a foot which is :
- Painless
- Plantigrade
- Structurally normal
- Functionally normal

5

Describe the achilles tendon

Also known as the heel cord
The gastrocnemius, soleus and plantaris muscle unites to form a band of fibrous tissue which becomes the Achilles tendon which attaches to the calcaneal tuberosity
Largest and strongest tendon
Approximately 15 cm in length
Plantarflexor of the foot

6

Why is the achilles tendon vulnerable to pathology?

Unlike other tendons it has no tendon sheath
It is surrounded by a paratenon
It has a poor blood supply
i. Posterior tibial artery ( proximal and distal section)
ii. Peroneal artery ( supplies midsection)

Blood vascularity weakest at the bone –tendon interface
Blood supply weakest at 2 to 6 cm form the calcaneal attachment

7

When does achilles rupture occur?

Occurs after a sudden forced plantarflexion to the foot
Violent dorsiflexion in a planatar flexed foot
Usually ruptures 4 to 6 cm above the calcaneal insertion in the hypovascular region

8

How is Achilles rupture treated?

In Functional bracing
Surgery
End to end repair
VY advancement
Failure to heal- Tendon transfer

9

Which tendon is used to treat achilles tendon

FLEXOR HALLUCIS LONGUS

10

Describe the surgical approach to the achilles tendon

Patient is prone or in lazy lateral position
Landmarks: The malleoli and the Achilles tendon- which is easily palpable
Incision: Longitudinal – slightly medially based ( but can go laterally as well)
Structure to avoid : Sural nerve laterally
Avoid going medial to Flexor hallucis longus (FHL) ( easily identifiable as has muscle fibres at this level ) - NEUROVASCULAR BUNDLE MEDIALLY

11

Describe the tibialis posterior tendon

Posterior aspect of interosseous membrane, fibula and tibia and has 9 insertions in the foot
Action-
Plantarflexes the ankle joint
Principal invertor of the foot
Adducts and supinates the foot
Arterial supply form the Posterior tibial, peroneal and sural nerve
Has a watershed area around the medial malleoli

12

What is the function of tibialis posterior

Stabilise lower leg
Facilitates foot inversion
Supports the foot’s medial arch
Plays a critical role in hindfoot inversion during the gait cycle

13

How does tibialis posterior insufficiency present?

Post-malleolar pain
Arch pain + aching
Progressive flat foot deformity
Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
Rarely, tarsal tunnel syndrome
Valgus hindfoot
Aquired flatfoot
Forefoot abduction

14

Describe the treatment of tibialis posterior insufficiency

Non-surgical
-Analgesics
- Shoe wear modification
- Orthotics- medial arch supports
- Physiotherapy

Surgery
- Reconstruction (tendon transfer)
- Fusion (if secondary arthritis)

15

Describe the surgical approach to posterior tibialis anterior

Position: Supine
Landmark: Tip of medial malleoli and the base of the navicular
Incision : 10 cm longitudinal incision from tip of MM
Internervous plane : None
Dissection : Avid damage to the long saphenous vein and nerve
Divide the retinaculum and identify the tibialis posterior tendon by pulling on it
( FHL will plantart flex the great toe and FDL will plantarflex the lesser toes)
Dangers: Saphenous nerve and the tibialis posterior tendon are particularly vulnerable

16

Describe the presentation of ankle arthritis

Usually post-traumatic
Presentation:
Pain
Swelling
Deformity

17

Describe the pathology of ankle arthritis

Nasty fracture – cartilage damage
Malalignment – leads to abnormal loading
Biomechanics altered in the ankle joint
Leads to abnormal point loading
Eventual joint space narrowing and pain

18

Describe the surgical management of ankle arthritis

Failed medical / non-operative control…………

“Early” disease - joint preservation
Arthroscopy (or open procedure)
Debridement / synovectomy

“Late” disease – joint abolition or replacement
Arthrodesis (fusion)
Arthroplasty (replacement)
Excision Arthroplasty (excision joint)

19

Describe ankle arthroplasty

Indications

Pain relief

Preservation of joint mobility

Preservation of function

Polyarthropathy; Subtalar / Triple complex

20

List the indications for ankle fusion/arthrodesis

Pain relief
Severe deformity

21

Describe Anterior Approach to the Ankle for TAR

Position : Supine

Landmarks: Both the malleoli which are subcutaneous

Incision : 15 cm longitudinal incision midway between the malleoli

Internervous Plane: None

Intermuscular plane : Between EHL and EDL ( both supplied by deep peroneal but receive their supply proximal to the incision)

Dissection : Find the neurovascular bundle and mobilise laterally

Dangers: i. Superficial peroneal nerve ii. Deep peroneal nerve iii. Anterior tibial artery iv.

22

Describe Tibiotalocalcaneal Arthrodesis(TTC)

Severe deformity
Osteoporotic ankle fractures
Complex failed ankle fixation
Failed TAR

23

Describe ankle sprains

Lateral ligament
Passes form anterior margin of the fibular malleolus, to the talus bone

24

List the 3 elements of the lateral ligament

Anterior talofibular ATFL
Calcaneofibular CFL
Posterior talofibular PTFL

25

Describe ATFL/CFL

Weakest and commonly injured
Commonly gets bruised and stretched during inversion injuries
Prevents talar tilt
If weak then the ankle feels unstable
Positive anterior drawer test
Positive talar tilt test

26

Describe the treatment of ankle sprains

Majority sprains recover within 3 months

Beware the sprain that persists…..

Back to basics – clinical reassessment

27

Describe Acute lateral ligament sprain (ATFL)

RICE
Physiotherapy directed rehabilitation
Loading injured ligaments
Proprioception
Strength and return to function

28

How is chronic instability diagnosed?

Examination: Positive anterior draw
Further investigations
Stress radiographs
MRI (very useful to demonstrate related pathology)

29

Describe hallux valgus

Commonly incidental finding
Female >>> Male
Family history +/- footwear
No symptoms = No surgery

30

List the symptoms of hallux valgus

Pain
Deformity
Modification of shoe wear
Nerve irritation
Lesser toe deformity

31

Describe the treatment of hallux valgus

Non- Surgical
Surgical
Bunionectomy
Osteotomy
Proximal
Metatarsal shaft
Distal
Ist TMT joint fusion
Technique used depends on the cause and the amount of correction required

32

Describe the dorsomedial approach to the great toe

Position: Supine

Landmarks: easily palpable 1st MTP joint

Incision: Proximal to the IP joint and curve over the medial eminence staying medial to EHL

Internervous Plane : none

Dissection: divide fascia and then periosteum

Dangers: i. Dorsal cutanous nerve ii. Extensor hallucis tendon iii, Flexor hallucis longus