foot and ankle

neuropathy- loose protective mechanism

vascular

67%

• lymphocyte count over 1500/mm3
• serum albumin over 3.0 g/dl

ABI:

index of > 0.45 and toe pressure >40mm Hg are needed to heal ulcer

transcutaneous oxygen pressures: over 40mHg good for healing

rocker bottom soles

• provide moist environment
• absorb exudate
• act as a barrier
• off-load pressure at ulcer

grade 3 or more need decridementan abx before casting

test silverskjold- may need tal

• obesity
• hypertension
• diabetes
• increased age
• corticosteroid use
• seronegative inflammatory disorders

origin: fibula, tibia, IOM

• insertion:
• ant limb- navicular tuberosity + 1st cuneifrom
• middle limb_ 2 + 3rd cuneiform + MT 2-4
• posterior limb-sustentaculum tali

• hindfoot inverter, adducts supinate forefoot
• plantar flex the ankle

• stage 1- tenosynovitis
• stage 2a- single heel -ve, arch collapse- flexible deformity/hindfoot

stage 2b- flatfoot, flexible hind, forefoot abduction, ? 40% talonavicular uncoverage

stage 3- rigid hindfoot valgus, forefoot abduction ( sinus tasi pain), subtalar arthritis

stage 4-deltoid compromise, ankle pain, talar tilt

• AP foot
• increased simmon angle- talo- first MT angle
• talonavic uncoverage

• lateral wb-
• meary angle- over 4 is pes planus
• calcaneal pitch- 17-32 degrees
• decreased medial cuneiform floor height
• subtalar arthritis

ankle mortise- talar tilt

• synergistic with PT- 
• rigidity of subtalar less than 15%, fixe forefoot varus over 12

• 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

• often bilateral and familial
• pain usually not primary complaint
• varus of first MT with widened IMA usually present
• DMAA usually increased
• often associated with flexible flatfoot

HVA- long axis 1st mt and prx valgus - wnl if less than 15

IMA- long axis 1st and 2nd MT- WNL less than 9

DMAA- long axis of toe-- then perp to that and / line articular cap  wnl less than 10

HVI- long axi of proximal phalynz and distal phalynx wnl less than 10

13 degrees and 40 degrees

• IMA over 10
• HVA over 20

DMAA over 20 consider double osteotomy

medial closing wedge proximal phalynx

mcbride- capsule plication medially

lapidus- 1st mt cuneiform fusion ( do for large IMA or OA)

mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot

lisfranc ligament-medial cuneiform to base of 2n MT- plantar side- tightens with pronaton and abduction

plantar tarometatarsal ligaments- medial cuneiform - 2n + 3rd MT

dorsal tarsometatarsal- weaker

intermetatarsal btwn 2nd-5th

disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform

widening of the interval between the first and second ray

medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view

metatarsal base dorsal subluxation on lateral view

disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)

fleck sign

• most common
• ATFL- caused by plantar flexion and inversion
• P/E- drawer laxity in plantar flexion

• 2nd most common
• CFL-dorsiflexion and inversion

• injury to the anterior process of calcaneus
• injury to the lateral or posterior process of the talus
• injury to the base of the 5th metatarsal
• osteochondral lesion
• injuries to the peroneal tendons
• injury to the syndesmosis
• tarsal coalition
• impingement syndromes

• grade1- mild pain extrmes, dorsal soteophyte
• 2- mod pain, <50%  joint space narrowing
• 3-severe dorsal osteophyte >50%, STIFFNESS
• 4- pain at mid range

• 10-15 of valgus  in relation to metatarsal shaft
• 15 degree dorsiflexion

dorsiflexion and inversion- quick firing PL PB

longitudonal tears - peroneous brevis in fibular groove

see atfl/ cfl injuries in up to 75% of people

BP- s1 nerve root superficial peroneal, evert the foot

PL -plantar flor

superior peroneal retinaculum is the roof of the peroneal tendons

• .1-1.4% of patients with diabetes
• 7.5 % with neuropathy

• diabetic neuropathy
• alcoholism
• leprosy
• myelomeningocele
• tabes dorsalis/syphilis
• syringomyelia

Il-1/ TNF-alpha

increased TFkB and RANK/RANKL/OPG

• 0- joint edema/ radiographs negative
• 1- fragmentation
• 2-coalesence
• 3- reconstruction

• 3.3  higher temp
• erythema that decreases with elevation
• rocker bottom
• collapse medial arch

cold for neuropathic joints and positive for osteomyelitis

full contact casting 2-4 months change every 2-4 weeks.

then at stage III double rocker bottom shoe

meds:

• bisphosphonates
• neuropathic pain medications
• antidepressants
• topical anesthetic

• neutral dorsiflexion
• 5-10° of external rotation
• 5° of hindfoot valgus

indications:

• End-stage ankle and subtalar arthritis
• Charcot neuroarthropathy
• Significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis)
• Osteonecrosis of the talus
• Severe acute trauma

• 20 degrees dorsiflexion
• ankle plantat flexion 50

• uncorrectable deformity,
• severe osteoporosis
• , talus osteonecrosis,
• charcot joint,
• ankle instability,
• obesity,
• and young laborers increase the risk of failure and revision

• 4-6 cm above calcaneoul insertion
• post tib artery is the blood supply

• 1- stretching/ heel pads/ dorefle night splint
• 2- shockwave treatment
• 3) surgery after 9 months of non
• -surgical release and distal tarsal tunnel decompression

• zone 1: hindfoot inversion
• zone 2: forefoot adduction- JONES watershed ( 15-30% non-union)
• zone 3: repetitive microtrauma- assoc with sensory neuropathy
• 

• smaller diamter screw < 4.5
• too long which straightes the toe

always fix- as carries 30-50% of weight

• sagittal plane deformity more than 10 degrees
• >4mm translation
• multiple fractures

most common posterior medial talar dome

lateral- traumatic history, smaller and central ) less likely to spontaneously heal

• 1- small subchondral compression
• 2-partial fragment detachment
• 3- complete fragment detachement
• 4- displaced fragment

forced external rotation

• OCD- 15-25%
• peroneal tendon injury up to 25%
• weber c/ weber b

• AITFL- chaput to fibula
• PITFL- volkman to lat malleolus
• IOM
• IOL
• ITL

• hopkins- squeeze midcalf
• external rotation test- knee an hip flexed and ext rotate foot
• cotton
• fibular translation

• Anterolateral portal
• risks superficial peroneal nerve    
• most common neurovascular injury
• specifically, the dorsal intermediate cutaneous branch

• Anteromedial portal
• risks saphenous nerve and vein

• Anterocentral portal
• risks dorsalis pedis artery

• Posterolateral portal
• risks sural nerve and short saphenous vein

• Posteromedial portal
• risks posterior tibial artery

• worry about reiters( urethritis/ conjuctivitis/iritis/ IBD
• seronegative ra
• psoriatic disease

• absorb weight
• reduce friction MT head
• protect FHL tendon
• fulcrum for FHB

for claw toe

FDL transfer

• boney prominence +/- bursitis over lateral aspect of 5th metatarsal head
• increased 4-5 intermetatarsal angle  (normal 6.5-8 degrees)  
• increased lateral deviation angle (normal 0-7 degrees)  
• increased width of MT head (normal <13mm)
• lateral bowing of the 5th metatarsal bone

• 1- enlarged 5th mt head or lateral exostosis
• 2- congenital bow of 5th mt
• 3- increased IMA btw 4-5th ( most common)

• oblique diahyseal rotational osteotomy
• - symptomatic 2 and 3 and IMA over 12

if less do distal chevron

• Lumbar radiculopathy (L4)
• can be differentiated from TA rupture by
• intact tendon palpable
• no ankle mass
• may have dermatomal sensory abnormality
• positive lumbar spine MRI

• plantaris/ hamstring graft
• harvest half of tib ant and attach distally
• EHL tenodises to EHB and use proxima EHL to repair

10 yearr- 70-90%

FHL - posteromedial

os trigonum- posterolateral

os lies lateral to FHL, tibial nerve, PTT, and posterior tibial artery

• 10% get infection
• 1-2% osteomyelitis

S. aureou most common/ osteo is pseuodomonas

• mtp straight
• pip flex
• dip ext

due to overpull of edl

• fdl to edl trasnfer
• edl lengthething
• fusion etc

CVA

• 25% regain normal ambulation
• 75% regain some level of ambulation

• SPLATT
• split anterior tibialis tendon transfer ( to cuboid)

TBI

• an anatomic structure defined by
• 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

• flattened space defined by
• inferior extensor retinaculum
• fascia overlying the talus and navicular 
• contents include
• deep peroneal nerve and branches
• EHL
• EDL
• dorsalis pedis artery

• positive finding include
• 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