Foot & Ankle - Orthobullets

Tib post insufficiency

• Obesity
• Hypertension
• Diabetes
• Increased age
• corticosteroids
• Seronegative inflammatory disorders

• Pes planus
• Hindfoot valgus
• Forefoot varus
• Forefoot abduction

• POsterior fibula/tibia/IOM
• Tibial nerve L4-5

• Anterior: inserts onto navicular tuberosity and first cuneiform
• Middle limb: seond and third cuneiform, cuboid and 2-4 metatarsals
• POsterior limb: sustentaculum tali

Posterior tibial artery: watershed area 2-6 cm proximal to navicular insertion

Isolate by placing foot in plantar flexion and eversion and test resistance

Peroneus brevis

During toe off phase: PTT fires and locks the transverse tarsal joints creating a rigid lever arm

During stance phase: adducts and supinated forefoot

• Stage 1
• Tenosynovitis
• Able to do single heel raise
• Normal x rays

• Stage 2A
• Flatfoot deformity
• flexible hindfoot
• Normal forefoot
• unable to do single heel raise
• Arch collapse on x rays

• Stage 2B
• FLatfoot deformity
• Flexible hindfoot
• Forefoot abduction >40 degrees
• Too many toes sign
• unable to do single heel raise

• Stage 3
• Flatfoot deformity
• Rigid hindfoot valgus
• RIgid forefoot abduction
• Arch collapse and subtalar arthritis

• Stage 4
• Same as 3 but with deltoid incompetence
• X ray shows lateral talar tilt

• -4 to 4: if <-4, indicates pes planus
• NOrmal btw 17 and 32 degrees

Spring ligament

• AFO with medial arch support: Stage 2-4
• Cast 3-4 months: for stage 1

Surgical

Stage 2: FDL transfer to tib post 1st TMT fusion, calc osteotomy (medial), TAL, lateral column lenghtening, PTT debridement (all if no signs of arthritis, cotton osteotomy

Stage 3: Hindfoot fusion >>typically triple

Stage 4: tibiocalcaneal arthrodesis

Stage 2 disease (flexible): transfer FDL to PT, identify it at knot of henry

Medial calc slide

Lateral calc neck lenghtening: better for correction of forefoot abduction

COtton osteotomy: dorsal opening wedge medial cuneiform osteotomy

In stage 2 PTTI if residual forefoot varus after correction of hindfoot, use this osteotomy to make a plantigrade foot by recreating the tripod effect

Triple arthodesis

• Motor weakness normal sensation
• 20-40 yeasr after infection

• 2nd and third interdigital nerves between the metatarsal heads
• Transverse intermetatarsal ligament
• Paresthesia in plantar aspect of webspace

Mulder's click: bursal click elicited by squeezing metatarsals together

Common digital nerve block: relief of pain

Neurectomy: failed non op>>>dorsal neurectomy with burial stump within intrinsics + release of transverse ligament

Equinovarus deformity

• Equinus: from overactive gastrocs
• Varus: From overactive tib ant

• Stroke
• TBI

Do split: SPLATT same as CP, put tib ant on cuboid

• Infarction and fracture of the metatarsal head
• 2nd MT: 4th and 5th rarely affected
• Upper half of articular surface
• Activity modification, NSAI's, shoes with MT bars or pads
• Partial MT resection arthroplasty and tissue interposition (EDL)

• PIP flexion
• DIP extension
• MTP neutral or extended

• Overpull of EDL and intrinsic inbalance
• Deformity should correct with ankle dorsiflexion

• Transfer FDL to EDL
• PIP resection arthroplasty +/- tenotomy and tendon transfers

• Flexion
• NOrmal
• NOrmal

• Flex
• flex
• Hyperextend

• Hyperflexion of DIP
• Flexion contracture of FDL: from shoes, often toe is longer
• Percutaneous FDL tenotomy or FDL transfer to dorsum
• DIP fusion

Hammer toe

Hyperextension of D1 leading to injury of plantar plate and sesamoid complex at the MTP

Osseous: MT and proximal phalanx articulation

Tendons: FHB, Abductor hallucis and adductor hallucis

Ligaments: MCL, LCL, intermetatarsal ligament

Plantar plate: joint capsule that attaches to adductor hallucis, flexor tendon sheath, deep transverse intermetatarasal ligament

Vertical lachman; compare to other side

• Sesamoid fracture
• Sesamoid migrated proximally

Stiff soled shoe or walking boot: as well as rest and NSAID's

Repair or excision of seamoid fracture: can use abductor hallucis transfer to reconstruct

Hallux rigidus

MTP hyperextension: leads to unnoposed flexion of DIP and PIP by FDL

Claw toes

If rigid: EDB tenotomy, EDL lenghtening, FDL flexor to extensor transfer +/- PRoximal phalanx head and neck resection

If flexible: FDL to extensor surface transfer

• at 10 years 70-90%
• Pre op ROM is best predictor of post op ROM: no significant improvement after TAA
• Significant improvement in pain and function

• Older and low demand
• Normal BMI
• Well aligned stable hindfoot
• Good soft tissues

• Active infection
• Peripheral vascular disease
• Inadequate soft tissue coverage
• Charcot arthropathy
• Insufficient bone stock
• Severe osteoporosis
• Osteonecrosis of the talus

• Prosthesis too lateral
• Prosthesis too small: subsides
• Not addressing pre op hindfoot valgus or varus

Medial malleolus

Avoid opening Tib ant tendon sheath

• Peroneal artery
• Dorsalis pedis: from anterior tibial
• POsterior tibial

• Anterior to syndesmosis: pierces IOM 5 cm above lateral malleolus
• Lateral calcaneal branch: brach that supplies flaps in clac ORIF

• POsterior medial malleolar
• COmmunicating branch
• Artery of tarsal canal: major blood supply to talar body

• Medial calcaneal branch: supply heel pad
• Branch to adductor digiti minimi
• Branch to fifth toe

• Posterolateral tubercle of talus
• Ballet dancers: extreme plantar flexion
• Sheperds fracture: fracture of posterior process of talus
• Symptomatic: if non op failed then can excise

Arthroscopic debridement

• COngenital
• Iatrogenic: overcorrection hallux valgus
• Trauma
• Inflammatory
• Neurological

• Medial deviation of hallux relative to first MTP
• Supination phalanx
• Claw toe deformity

shoe modifiactions

• Adductor hallucis reattachment to lateral sesamoid
• Transfer EHL or EDB under transverse ligament to the metatarsal neck
• 1st MTP fusion

• Medial calcaneal tuberosity
• Base 5th MT, base of 5 proximal phalanges
• Increase arch height as toes dorsiflex: major medial arch support

• TN
• CC

• Lock it with inversion
• Unlock it with eversion

Spring ligament

• Superficial and deep inferior CC ligaments
• Lateral limb of bifurcate ligament

• Medial column: 1st MTP
• Middle column: 2-3 MTP
• Lateral column: 4-5 MTP, both articulate with cuboid

• Dorsal layer
• Interosseous layer: contains lisfranc ligament from medial cuniform to base 2nd MT

• Lateral
• Middle
• Medial

Medial: usually posterior, no trauma, larger and deeper than lateral

Lateral: central or anterior, associated with trauma, tend to be smaller and more superficial

Lateral: thought to be casued by trauma

Stage 1: small area of subchondral compression

Stage 2: partial fragment detachment

Stage 3: complete detachment but undisplaced

Stage 4: displaced fragment

Short leg cast and non weight bearing for 6 weeks: only if acute symptomatic

Arthroscopic microdrilling, ORIF, osteochondral grafting

ER foot: talus pushes fibula away from tibia

• AITFL: avulsion leads to chaput fragment
• PITF: Avulsion leads to volkman fragment
• IOM
• Interosseous ligamnt
• Inferior transverse ligament

Abscence of syndesmosis tenderness

• Squeeze test: compression midcalf leads to pain
• ER stress test: pain with External rotation and dorsiflexion of foot
• Fibular translation: anterior and posterior drawar to the fibula casues pain

• Tibiofibular overlap <  6mm on AP (
• Tibiofibular overlap <1mm on mortice 
• Medial clear space < 5mm
• Increased tibiofibular clear space: >5mm (measured 1 cm abovee joint line

No eidence of ankle instability

NWB CAM for 2-3 weeks: delay weightbearing until pain free

• Older age
• DM
• fluoroquinilone
• Local steroids
• inflammatory arthritis

• Tib ant
• EHL, EDL

Steppage gait: like drop foot

• < 6 weeks: direct repair
• > 6 weeks reconstruction: EHL split or full transfer

Foot ulcers: 85%

• Serum albumin > 3 (30 in canada)
• Total lymphocyte count > 1500

• Uncontrolled hyperglycemia
• Inability to offload affected area
• Poor circulation
• Infection
• Poor nutrition

• Neuropathy
• Angiopaphy: peripheral vascular disease

0: at risk, no ulcer >>>education

1: Superficial ulceration, not infected >>>off loading total contact cast

2: Deep ulceration, exposing tendon or joint >>>surgical debridement and wound care

3: Extensive ulceration or abcess >>>debridement or amputation


A: non ischemic

B: Ischemia with no gangrene >>>refere to vascular

C: Partial foot gangrene >>>>>>vascular reconstruction or amputation

D: Complete gangrene >>>>amputation

• Transcutaneous oxygen pressures: >30-40 have good potential
• Total contact casting

• Transcutaneous oxygen pressure < 20
• ABI <45
• Albumin <3
• Total lymphocyte < 1500

• Axial load with foot in plantar flexion
• Medial cuneiform to base 2nd MT 
• Dorsal: hence dorsal displacement of 2nd MT on lateral
• Pronation and abduction: this is position of stress test

• Medial column: Medial cuneiform and 1st metatarsal
• Middle columb: Middle and lateral cuneiform + 2nd and 3rd MT
• Lateral column: 4th + 5th MT + cuboid

• On AP: Medial border of 2nd MT with medial border of middle cuneiform
• On Oblique: Medial border of 4th MT with medial border of cuboid
• On Lateral: No dorsal subluxation of MT
• Fleck sign: avulsion # off base 2nd MT
• Widening >2mm btw 1st MT/Cuneiform and 2nd MT

• AP weight bearing of both feet on one cassette
• Pronation abduction stress xray

• Medial: rigid fixation
• Lateral: Flexible temporary fixation

• Start from proximal to distal
• Continue from medial to lateral

2 INCISIONS

• Dorsal-medial:
• Btw 1st and 2nd rays
• Dorsalis pedis and Deep peroneal nerve identified and mobilized lateral
• Interval BTW EHL and EHB
• Visualize 1st TMT and medial aspect of 2nd TMT
• Protect branches of SPN in proximal part of incision

Dorsal Lateral

• Centered over 4th MT
• Visualize lateral 2nd MT + 3rd/4th TMT
• Common extensor tendons mobilized medially
• Muscle belly of EDB split in line with its fibers

Arthrodesis group had

• Improved functional outcome
• Higher return to pre injury levels
• Lower revision
• Less pain

• THIS IS THE QUOTED PAPER THATS SAYS ARTHRODESIS IS BETTER

Based on physical exam and x rays

Grade 0: stiffness, normal x ray

Grade 1: Mild pain at extremes , mild dorsal osteophyte >>> dorsal cheilectomy

Grade 2: Moderate pain with ROM, moderate dorsal osteophyte < 50% joint space narrowing >>> dorsal cheilectomy

Grade 3: Pain at extremes ROm but no mid range pain , severe dorsal osteophyte + >50% joint space narrowing >>> MTP fusion

Grade 4: Pain at midrange, x ray same as grade 3  >>>MTP FUSION

Hard soled shoe or orthotic with morton's extension

>50% joint space narrowing and dorsal osteophytes

Position

• 10-15 degrees valgus
• 15 degrees dorsiflexion relative to the floor

• Narrow shoes with heel
• Genetic predisposition
• Increased DMAA
• ligamentos laxity : 1st MTP 
• Convex metatarsal head
• 2nd toe amputation
• pes planus
• RA
• CP

• Adductor hallucis
• Abductor hallucis: after sesamoids subluxed >> forces plantarflexion and pronation of phalanx

• Often bilateral and familial
• Usually not painful
• DMAA increased
• Usually flexible flatfoot present

• Presence or absence of arthritis
• Lateral displacement of sesamoids

Hallux valgus angle: long axis 1st MT and proximal phalanx  <15 degrees


Intermetatarsal angle: < 9 degrees

DMAA: btw longitudinal axis of 1st MT and line through the base of the distal articular cap .....<10 degrees

Soft tissue (modified mcbride): HVA <25, IMA <15, DMAA not congruent

Distal osteotomy: IMA < 13, HVA <40

Proximal or combined osteotomy: IMA >13, HVA >40

1st TMT fusion (lapidus):  TMT arthritis or joint intability

MTP fusion: severe deformity or arthritis or spasticity

• Release adductor from lateral sesamoid
• Lateral capsulotomy
• Medial capsule plication

1st cuneiform osteotomy

• Recurrence: most common
• AVN: 2 incisions
• Malunion
• Hallux varus
• COck up deformity from injury to FHL

• 4-6 cm above calcaneal insertion in watershed area
• From posterior tibial artery

• Palpable gap
• Thompson test: no dorsiflexion with gastrocs contraction
• Increased resting tension lenght

Direct repair

• Gastrocs VY advancement
• FLH Transfer: find it at the knot of henry

Zone 1: pseudo jones ...enters articular surface..caused by peroneal brevis....non op >>>>Protected weight bearing in boot or hard soled shoe

Zone 2: Jones #: Meta/dia junction.inter intermetatarasal joint...vascular watershed area > increased risk of non union>>>> Non weight bearing in cast

Zone 3: Proximal diaphyseal #>>>usually stress fracture >>>Non weight bearing or operative if signs of non union/sclerosis

4.5: shown to increase rate of non union if smaller

• Elite athlete
• Return to sports prior to radiographic union
• Fracture distraction or malreduction

• Dorsomedial
• Plantar plate disrupted > LCL fails >medial structure contracted > plantar plate fails

Done for MTP dislocation

It is a shortening oblique osteotomy along with with soft tissue procedures to stabilize MTP

• Posterior fibula
• Plantarflexion of hallux and MP joint
• Btw postermedial/posterolateral tubercle of posterior talus
• Dorsal to FDS
• Distal phalanx toe
• Excessive plantar-flexion

• Rest/NSAID/arch support
• Release FHL from fibro-osseus tunnel +/- tendon repair

Compression of tibial nerve

• Ganglion cyst
• osteophyte
• tumor
• Systemic inflammatory
• Tenosynovitis

• Roof: Flexor retinaculum
• Medial: calcaneus/talus
• Inferior: abductor hallucis

• Tibial nerve
• Posterior tibial artery
• FHL
• FDL
• Tib Post

• Inferior extensor retinaculum
• Fascia over talus and navicular

• Deep peroneal nerve
• EHL
• EDL
• dorsalis pedis artery

• Medial plantar
• Lateral plantar
• Medial calcaneal

PLantar flexion and inversion of ankle

• Flexor retinaculum
• Deep investing fascia of lower leg
• Superficial and deep fascia of abductor hallucis

Tibial sesamoid (medial(: Its largerm has more weight bearing

FHL

COck up deformity of toe

Inflamation at origin of plantar fascia (calcaneous)

• Obesity
• Decreased ankle dorsiflexion

Tenderness to palpation medial calc tuberosity

NSAID's, cushioned heel pads, dorsiflexion night splint

• Plantar fascia release: release medial 1/3 to 2/3
• Distal tarsal tunnel decompression

Enlargement of posterosuperior tuberosity of calc

• Staph A
• Pseudomonas
• Tetanus + prophylactic abx

Type 1: enlarged 5th MT head or lateral exostosis

Type 2: congenital bow 5th MT, normal IMA


Type 3 (most common): increased IMA

Normal IMA6.5-8 degrees

Resection lateral third of 5th MT head

Distal metatarsal osteotomy

Onlique diaphyseal rotational osteotomy

• Plantar flexion
• Eversion and contraction of posterior tibial tendon
• Axial loading

• Cuneiforms
• Cuboid
• Calcaneous
• Talus

Type 1: transverse of dorsal fragment that involves <50% bone (no deformity)

Type 2: Oblique dorsolateral-plantarmedial..may have adduction deformity

Type 3: Central or lateral comminution...abduction deformity

• Avulsion # >25% articular surface
• Tuberosity # > 5mm diastasis
• Body # that are displaced or intra-articular

Goal of treatment is maintain lateral column lenght

• Rapid dorsiflexion of inverted foot
• Apprehension to dorsiflexion and eversion
• Peroneus brevis
• ATFL: 75%
• Superficial peroneal nerve: S1

• Longus is posterior: takes the long way
• Superior peroneal retinaculum

At the level of the peroneal tubercle of the calc, longus is inferior and brevis is superior...here it is covered by inferior peroneal retinaculum

Grade 1: SPR partially off fibula>>both tendons sublux

Grade 2: separated from cartilofibrous ridge of lateral mall>>tendons sublux btw SPR and cartilofibrous ridge

Grade 3: Cortical avulsion off fibula>>>tendons move under bony fragment

Grade 4: SPR torn from Calc

All acute injuries in non-professional athletes>cast x 6 weeks with the tendon reduces>>>outcome 50% success

• Acute: direct repair and fibular groove deepening
• Chronic:Fibular groove deepening + reconstruction with plantaris grafting

• Simple: core repair and tubularization
• Complex tear: Tendon debridement and tenodesis of proximal and distal ends of tendon to peroneous longus

Anteromedial:Medial to tib ant at the level of joint

Anterolateral: lateral to peroneous tertius and SPN

Posterolateral: 2cm proximal from tip of lateral mall, btw peroneals and achilles

Posteromedial: same levelas posterolateral but just medial to achilles tendon

• Anteromedial
• Anterolateral
• Anteromedial
• Posterolateral

• ATFL and CFL
• Drawer laxity in plantarflexion (ATFL), drawer laxity in dorsiflexion (CFL)
• Short immobilization followed by PT (neuromuscular training) with a functional brace

Gould modification of bronstrom


Anatomic shortening and reinsertion of CFL and ATFL reinfroced with extensor retinaculum

• Deltoid
• Spring ligament

• 10mm proximal to tip of fibula
• Articular cartilage of talus: 18mm from joint line
• Resist inversion whith th ankl ein plantar flexion

• 9mm proximal to tip of fibula
• calcaneous 13mm distal to ST joint
• Restraint of inversion with ankle plantarflexed

• Superficial
• Origin: anterior colliculus
• Insertion: neck of talus, sustentaculum tali, posteromedial talar tubercle
• FUnction: resist calc eversion

• Deep
• Origin: inferior and posterior aspect of medial mal
• Insertion: medial and posteromedial talus
• Function: Resist ankle Eversion

2nd MT: becasue it is the longest

• Open #
• Displaced first metatarsal#: no intermetatarsal ligament support and bears 30-50% of weight
• Central metatarsals: sagital plane deformity >10 degrees (transfer metatarsalgia) or 4 mm translation

• Stance (60%): period of time the foot is on the ground
• Swing: Period of time foot is moving forward

Peroneous longus

Obturator: At the level of hypertrophied adductors (skaters) ..can have chronic medial thigh pain

LFCN: worse with prolonged flexion or tight belts

Sciatic nerve: Ischial tuberosity or at level of piriformis (piriformis syndrome)

saphenous: Hunter(adductor cannal) from prolonged kneeling

Deep peroneal: inferior extensor retinaculum (aka anterior tarsal syndrome)

Baxter nerve: entrappedbtw abductor hallucis longus and quadratus plantae

Medial plantar: knot of henry where FDL and FHL cross

Loss of protective sensation

Type 1: Involves TMT and TN >>leads ti fixed rocker bottom

Type 2: Involves ST, TN, CC (very unstable needs prolonged immobilization)

Type 3A: Involves TT joint >>leads to valgus/varus

Type 3B: After calc#>>proximal migration of tuberosity

Type 4: Combination of areas

Type 5: Isolated forefoot

Stage 0: Joint edema, noral x rays

Stage 1 (fragmentation): Osseous fragmentation and joint dislocation

Stage 2 (coalescence): decreased local edema >>x rays show colaescence of fragments and absorption of bone debris

Stage 3 (reconstuction): No local edema..xray show consolidation and remodelling of fracture fragments

• Bone scan
• Elevates
• Total contact casting followed by CROW boot

• Resection bony prominence and TAL
• Deformity correction if cannot brace
• Amputation

Rocker bottom shoe 

• Supramalleolar osteotomy: Normal ROM, minimal talar tilt ot varus
• Medial arthritis

Arthrodesis: Elderly and less active

50% develop ST arthritis at 10 years

• Neutral dorsi, 5-10 ER< 5 degrees hindfoot valgus
• 10%
• Smoking