T2 L17 Intro to surgery of the foot and ankle

Question 1

What are the 3 sections of the foot?

Answer 1

Hindfoot
Midfoot
Forefoot

Question 2

Give examples of types of tendon repair

Answer 2

Debridement
Tenodesis
Tendon transfer
Direct repair

Question 3

Give examples of types of ligament repair

Answer 3

Indirect repair

Tendon transfer

Question 4

What is the aim when treating foot pathology?

Answer 4

Painless
Plantigrade
Structurally normal
Functionally normal

Question 5

What is the achilles tendon?

Answer 5

Heel cord
Formed when gastrocnemius, soles and planters unite
Attaches to calcaneal tuberosity

Question 6

What is the function of the achilles tendon?

Answer 6

Plantarflexion of the foot

Question 7

Why is the achilles tendon vulnerable to pathology?

Answer 7

Has no tendon sheath
Instead surrounded by paratenon
Poor blood supply

Question 8

What is the blood supply to the achilles tendon?

Answer 8

Proximal and distal sections supplied by posterior tibial artery
Midsection supplied by peroneal artery

Question 9

What can rupture the achilles tendon?

Answer 9

Sudden forced plantarflexion to foot - common in tennis players
Violent dorsiflexion in plantar flexed foot

Question 10

What is the treatment for a ruptured achilles tendon?

Answer 10

In functional bracing
Surgery
 - end to end repair
 - VY advancement
 - tendon transfer if other methods fail

Question 11

What tendon is used in a tendon transfer to repair a ruptured achilles tendon?

Answer 11

Flexor hallucis longus

Question 12

What is the position, landmarks and incision when surgically repairing Achilles?

Answer 12

Patient in prone or lazy lateral position
Landmarks: malleoli and achilles tendon
Incision: longitudinal, slightly medial to avoid rural nerve

Question 13

What is the tibialis posterior tendon?

Answer 13

From posterior aspect of interosseous membrane, fibula and tibia
Has 9 insertions in foot

Question 14

What are the actions of the tibialis posterior tendon?

Answer 14

Plantarflexion ankle joint
Principle invertor of foot
Adducts and supinates foot

Question 15

What are the functions of the tibialis posterior tendon?

Answer 15

Stabilise lower leg
Facilitate foot inversion
Supports foot’s medial arch
Role in hindfoot inversion during gait cycle

Question 16

What is the arterial supply to the tibialis posterior tendon?

Answer 16

Posterior tibial nerve
Peroneal nerve
Sural nerve

Question 17

How does insufficiency of the tibialis posterior occur?

Answer 17

Tendonitis, stiffens up, becomes non-functional and hind foot goes into valgus
Lose arch of midfoot

Question 18

What are the causes of tibialis posterior insufficiency?

Answer 18

Trauma
Chronic flat foot
Inflammatory arthropathy
Degenerative tendinopathy

Question 19

What are the symptoms of tibialis posterior insufficiency?

Answer 19

Post-malleolar pain 
Arch pain & aching
Progressive flat foot deformity
Forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
Tarsal tunnel syndrome (rare)

Question 20

What are the signs of tibialis posterior insufficiency?

Answer 20

Valgus hindfoot
Acquired flatfoot
Forefoot abduction

Question 21

What is the non-surgical treatment for tibialis posterior insufficiency?

Answer 21

Analgesics
Shoe wear modification
Orthotics – medial arch supports (stops pressure on medial side of foot)
Physiotherapy

Question 22

What are the surgical treatments for tibialis posterior insufficiency?

Answer 22

Reconstruction (tendon transfer)

Fusion (if secondary arthritis)

Question 23

What tendon is used in a tendon transfer for tibialis posterior insufficiency?

Answer 23

Flexor digitorum longus as functional loss is minor

Question 24

Describe the surgical approach to tibialis posterior tendon

Answer 24

Position: supine
Landmark: tip of medial malleoli & base of navicular
Incision: 10cm longitudinal incision from tip of medial malleolus

Question 25

What can be damaged during surgery to tibialis posterior tendon?

Answer 25

Saphenous nerve | Saphenous vein

Question 26

How does ankle arthritis present?

Answer 26

Pain Swelling Deformity

Question 27

What is the pathology of ankle arthritis?

Answer 27

``` Fracture – cartilage damage Malalignment – leads to abnormal loading Biomechanics altered in ankle joint Leads to abnormal point loading Eventual joint space narrowing & pain ```

Question 28

What is the surgical management of ankle arthritis?

Answer 28

``` In early disease: - arthroscopy - debridement In late disease: - arthrodesis - arthroplasty - excision arthroplasty ```

Question 29

When is ankle arthrodesis indicated?

Answer 29

Pain relief Severe deformity When total ankle replacement isn't appropriate

Question 30

What is the surgical approach for total ankle replacement?

Answer 30

Position: supine Landmarks: both malleoli which are subcutaneous Incision: 15cm longitudinal incision, midway between malleoli

Question 31

What can be damaged in total ankle replacement?

Answer 31

Superficial peroneal nerve Deep perineal nerve Anterior tibial artery

Question 32

When is a tibiotalcocalcaneal arthrodesis indicated?

Answer 32

Severe deformity Osteoporotic ankle fractures Complex failed ankle fixation Failed total ankle replacement

Question 33

What is an ankle sprain?

Answer 33

Damage to lateral ligament

Question 34

What is the lateral ligament of the ankle?

Answer 34

``` Passes from anterior margin of fibular malleolus to tallus bone 3 elements: - anterior talofibular - calcaneofibular - posterior talofibular ```

Question 35

What is the treatment for an acute lateral ligament sprain?

Answer 35

``` RICE Physio directed rehabilitation - loading injured ligaments - proprioception - strength and return to function ```

Question 36

What are the examination signs of chronic instability?

Answer 36

Posterior ankle draw | Sulcus sign

Question 37

What investigations may be done in chronic instability?

Answer 37

Stress radiographs | MRI

Question 38

What are the indications for surgery in chronic instability?

Answer 38

Acute rupture | Chronic mechanical instability symptoms that aren't responding to non-operative rehabilitation

Question 39

What are the surgical options for chronic instability?

Answer 39

Tendon transfer using peroneal tendon

Question 40

What is hallux valgus?

Answer 40

(Bunion) Deformity away from midline, 1st metatarsal has drifted medially More common in females

Question 41

What are the presenting symptoms and signs of hallux valgus?

Answer 41

``` Pain Deformity Modification of shoe wear Nerve irritation Lesser toe deformity ```

Question 42

What are the treatment options for hallux valgus?

Answer 42

``` Non-surgical Surgical - bunionectomy - osteotomy - 1st TMT joint fusion ```

Question 43

What is the surgical approach for hallux valgus repair?

Answer 43

Position: supine Landmarks: easily palpable 1st metatarsal joint Incision: proximal to IP joint & curve over medial eminence staying medial to extensor hallucis

Question 44

What can be damaged in surgical repair of hallux valgus?

Answer 44

Dorsal cutaneous nerve Extensor hallucis tendon Flexor hallucis longus