Foot And Ankle

Achilles Tendon

Achilles Tendon Rupture

AnatomyAchilles tendon anatomy

 

Gastrocnemius tendon 10-25 cm long

- soleus 3-10 cm

- inserts superior calcaneal tuberosity

- fibres spiral 90°

- fibres that lie medially in proximal portion become posterior distally

- allows elastic recoil & energy storage

 

Plantaris present in 90% population

- medial to T Achilles

 

Poor blood supply midportion

- mesotenal vessels

- fewest at 2-6 cm

- other blood supply from osseous insertion

 

Epidemiology

 

Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports

 

Aetiology

 

Calf contraction with forced dorsiflexion in setting of tendon degeneration

 

Combination of

 

1.  Repetitive microtrauma

2.  Hypovascularity

- occurs at watershed of vascular supply 

- an area of hypovascularity 5 cm proximal to tendon insertion

 

Factors

- corticosteroids - oral or injected

- anabolic steroids

- flouroquinolone / ciprofloxacin (especially elderly)

- gout

- hyperthyroidism

- tendinitis (10% ruptures have preexisting achilles tendon disorder)

- cavovarus OR planovalgus foot

 

Mechanical Overload

- footwear (low heel, inadequate shock absorption)

- sudden training increase

- cross training

 

Classification of Tendon Inflammation

 

1. Paratenonitis 

- inflammation of paratenon

- swelling, pain, crepitation, tenderness, warmth

 

2. Paratenonitis with tendinosis

 

3. Tendinosis 

- intratendinous degeneration due to atrophy

- aging, microtrauma, vascular compromise

- swelling absent

- +/- palpable nodule

 

Rupture Site

 

1.  Watershed area

- 5 cm proximal to insertion

- most common

 

2.  Insertion

- common with insertional tendonitis

 

3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness

 

Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2

 

NHx (if neglected)

 

Weakness / wasting

- difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals

 

Calf Wasting Left Leg

 

History

 

Sudden pain in calf

- with audible snap

- on unaccustomed exercise

- especially tennis / squash

 

Examination

 

MAJOR SIGNS (AAOS Clinical Practice Guidelines 2010)

Positive Thompson Test (90% sensitivity and specificity)

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle

 

Thompson Sign Normal PreThompson Sign Normal Post 

Palpable gap (70% Sensitivity and Specificity)

 

Achilles Tendon Rupture 1Achilles Tendon Rupture 1

 

MINOR SIGNS (more difficult to elicit acutely) 

Weak PF

- unable to perform single heel raise 

 

Increased DF comparted to contralateral side

 

Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side

 

TA rupture increased DF

 

Xray

Only indicated if associated bony tenderness 

 

Ultrasound

 

Cheap, dynamic, fast

- operator dependant

- check reduction of tendon ends with plantarflexion

 

Acute Achilles Tendon Rupture UltrasoundAcute Achilles Tendon Rupture Reduced with Plantarflexion

 

MRI

 

Indication

- incomplete rupture 

- signs of degeneration

- clinical uncertainty (two major signs not present) 

- measurement of gap in chronic cases / preoperative planning for reconstruction

 

MRI TA rupture chronic

 

Operative v Non-operative Management

 

Issues

 

1.  Complications 

- infection & skin necrosis with operative

- ? re-rupture with non operative

 

2.  Function

- strength & patient return to activity / sports

- ? better function with non operative

 

Meta-analysis 

 

Khan et al JBJS Am 2005

- 12 trials involving 800 patients

- operative treatment associated with lower RR (.27; CI .11 - .64) of rerupture

- higher risk of complications (RR 10.6; CI 4.82 – 23.2) 

 

 

Willits et al JBJS Am 2010 

- 144 patients randomised trial operative v non operative

- concept of accelerated functional rehabilitation in both groups

- 2 weeks NWB

- weight bear in aircast with 2 cm heel raise up to 8 weeks

- able to actively DF / PF below neutral

- no significant difference in rerupture rate or loss of motion / power at all time indices

- 13 complications in operative versus

 

Non-operative

 

Indications

- elderly, DM, PVD, smokers

- non athlete

 

Technique

 

Equinus front slab 

- need to do within 24 hours

- try to close gap before haematoma forms

- change to full cast at 1 week

- debatable if need long leg cast v short leg

- 2 weeks

 

Functional Rehabilition

- heel raise 2 cm and air cast

- FWB for further 6 weeks

- active ROM below neutral

 

Achilles Tendon Boot and heel raise

 

Results

 

Rerupture

- rate unknown

- likely in order of 5%

- likely some minimal loss of plantarflexion strength

 

No risk of infection / wound breakdown

 

Operative

 

Achilles tendon ruptureAchilles tendon repairKrackow suture

 

Indication

- young, active

- athlete 

 

Technique

 

Timing

- ? delay for one week to allow swelling to reduce

 

Position

- prone

- prep both feet to check tension

 

Posteromedial approach

- avoids sural nerve and short saphenous vein

- don’t place scar directly posteriorly / less scar discomfort

- full thickness skin to paratenon

 

Open paratenon and dissect off tendon

- want to repair at end of case on dorsum of tendon

- this reduces skin adhesions

- incise paratenon in the midline anteriorly / increases tissue available for closure

 

Tendon repair

- Bunnell Suture  / Krackow suture x 2 with high strength suture / fibre wire

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- augment with circumferential 4.0 prolene to minimise bunching

 

Augmentation

- not usually needed acutely

 

Paratenon repair

- closure posteriorly to aid glide

- prevents adherence to scar

- use 3.0 vicryl

 

Careful skin closure

- LA with adrenalin

- front slab short leg

 

Post operative

- accelerated rehab as above

- jog at 3/12

- sports at 6/12

 

Complications

 

Wound breakdown

 

Debride, manage infection

- vac dressing

- free muscle flap (usually gracilis) + SSG

- fasciocutanous flap (radial or lateral thigh) has better wear characteristics

 

Rerupture

 

Case 1

 

Previously non operative management / new onset severe pain with bump

- intrasubstance / incomplete tear

 

Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002

  

Case 2

 

Acute pain 8 weeks post non operative management rupture

- ultrasound demonstrates scar tissue

- no reduction with plantarflexion

 

Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion

 

Reconstruction / Augmentation

 

Indication

 

Unable to primary repair / chronic setting

 

Algorithm

 

< 3cm 

- turndown

 

Achilles Tendon Turndown

 

3 - 5 cm 

- VY lengthening

 

Achilles Tendon VY Turndown

 

VY Advancement

 

> 5 cm 

- FHL / FDL / peroneal transfer

- free gracilis graft

- allograft

 

Chronic TA rupture reconstruction with graft

 

Large gaps

- turndown + FHL

- FHL is most accessible / directly medial to T achilles

 

Techniques

 

VY advancement

 

Turndown / Bosworth technique

 

Harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself

 

Can reinforce with plantaris / FHL / FDL / PB

 

Turndown and FHL Harvest

 

FDL / FHL transfer

 

Medial foot incision

- harvest tendon

- suture distal FDL stump to FHL

 

Medial calf incision

- pull tendon through

- through drill hole in calcaneum

- pass tendon through and suture to itself

 

FHL Transfer 2FHL Transfer 3

 

Peroneus brevis transfer

 

Lateral incision

- divide tendon

 

Standard Posteromedial calf incision

- pass through calcaneal drill hole

 

Augment with plantaris if needed

 

Free Gracilis tendon transfer

Achilles Tendonitis

Definition

 

Inflammation of achilles tendon; insertional or noninsertional

 

Spectrum

 

Tendonitis / Tendonosis / Rupture

 

Anatomy

 

Triceps surae

- medial and lateral gastrocnemius

- soleus

- surrounded by paratenon which allows gliding and supplies nutrition

 

Inserts middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally

 

Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin

 

Aetiology

 

1.  Non-insertional form 

 

Younger / fitter / more active patients

- overuse and over training

 

Occurs in area of hypo-vascularity & fibre rotation

- 3-5 cm from insertion

- due to repetitive loading associated with jumping

- Angiofibrotic Dysplasia

 

Risk Factors

 

A.  Pronated foot 

- mid-foot pronation is coupled with IR force on tibia 

- opposite to the normal ER in knee extension

- forces are concentrated at the hypovascular area of TA producing high tensile stresses

 

B.  Heel cord tightness

 

C.  Changes in activity level 

 

2.  Insertional form 

 

Occurs at site of insertion

- more common in the overweight / middle aged / comorbidities

- have combination of tendonitis / retrocalcaneal bursitis / spur

- also occurs in athletes 30s - 40s

 

Risk factors

 

A. Poor women's shoe-wear

 

B. Bony protuberance of Os Calcis 

- Haglund's Deformity / Pump bump

- Patrick Haglund, 1928, Swedish orthopaedic surgeon

- prominence of posterosuperior & lateral calcaneus

- causes impingement & mechanical abrasion of T achilles at insertion

 

Pump Bump Clinical Photo

 

C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed

 

Ankle Retrocalcaneal Bursa

 

DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia

- DISH

 

Pathology

 

Peritendinitis

- inflammation limited to paratenon

 

Tendinosis

- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear

 

Clinical Features

 

Non Insertional

 

Presentation

- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture

 

Findings

- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited

 

Insertional

 

Presentation

- pain at bone-tendon interface

- worse after exercise

 

Findings

- localised tenderness & thickening

- bony lump

- DF may be limited

 

Note:

Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear

 

X-ray

 

Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle

 

Achilles Insertional Tendonitis XrayTendoachilles insertional calcification

 

Pavlov 

- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)

 

Achilles Haglund's and Pavlov linesPavlov's Lines

 

Fowler's angle  

 

Normal < 70°

Abnormal > 80°

 

Fowler's Angle

 

MRI

 

Thickening of the tendon with some intra-substance degeneration

 

Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI

 

Non-Insertional Management

 

Non-operative (ELMPOPI) 

 

1) Education 

 

2) Lifestyle modification - Rest 

 

3) Physiotherapy - Alfredson protocol 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#ref35

- Eccentric exercise program originally devised by Curwi

- Duration extended and scientifically validated by Alfredson 

- 90% success rate if adhered to 

 

4) Orthotics - Heel cups ; raises ; medial arch supports 

 

5) Pharmacologics - NSAIDs

 

6) Injectables - Steroids contraindicated ; alternatives PRP , Autologous blood , sclerosing agents 

Limited evidence for any injectable currently

Gross et al FAI 2013 

http://www.ncbi.nlm.nih.gov/pubmed/23637232

 

Operative

 

Indication

- failure non operative > 12 months

 

Technique

 

Para-tenon resected

- tendon debrided

- tears in tendon repaired

 

Percutaneous vertical tenotomies

- may stimulate revascularisation

 

> 50% tendon degenerative

- may need augmentation

- FDL / FHL

 

Results

 

Rompe Am J Sports Med 2009

- RCT of eccentric v eccentric + ECSW

- improved results with combined treatment

 

Kearney 2012 Foot Ankle Int

- systematic review

- some evidence for eccentric loading and ECSW

- minimal evidence for surgery / case series only

 

Insertional

 

Non-operative

 

As for non-insertional

 

Operative

 

Indication

- if fails to settle in one year

- high risk

- these patients have poor tendon and skin

 

Open / Arthroscopic Technique

 

Supine positioning

 

Sandbags & rolled towel under knee on operative side

 

Tilt bed away from operative side (increases ER)

 

Lateral approach

- preserve sural nerve (blunt dissection superficially)

- open plane between lateral achilles tendon & deep fascia

- usually need release portion of achilles tendon

 

Retrocalcaneal bursa excised

 

Osteotome resection Haglund's if present

 

Resection of bone spur if present

 

Tendon debrided 

- remove inflammed paratenon

- vertical tenotomies

- reattach tendon with anchors

- if tendon severely compromised, transfer required

 

Ankle Arthrodesis

Results 

 

90% fusion rates

 

Lose70% sagittal plane ROM

 

Disadvantages of Arthrodesis 

 

Non union rates up to 12%

Decreased gait speed

Poor mobility over uneven surfaces

Need for shoe modification

Arthritic degeneration in STJ of up to 100%

 

Types

 

Tibiotalar arthrodesis

 

1.  Intra-articular

 

A. Open

- gold standard

- especially significant deformity / mal-alignment

- screws from tibia into talus

 

B. Arthroscopic

- 8 Vs 14 weeks for fusion time

- minimal deformity only

 

2.  Extra-articular / Frame

- children

- sepsis

- osteopenia

 

Tibiotalocalcaneal (TTC)  Intramedullary Nail

- commonly needed in RA

 

Blair Fusion

- refer to talar fracture complications

 

Position

 

1.  5° Valgus

- excess varus causes cavovarus

 

2.  Neutral Dorsiflexion

- if fused in plantar flexion develop genu recurvatum to put foot on floor

 

3.  5-10° ER

 

4.  Tibia anterior on talus

- preserves heel

- decreases lever arm = less energy required for toe-off

 

5.  Subtalar Joint 5°Valgus

- for TTC hindfoot fusion nails 

 

Surgical Techniques 

 

1. Intraarticular Technique 

Dual incision reciprocal flat-cut technique

 

Ankle Fusion APAnkle Fusion Lateral

 

Incision

- over distal fibular, curved forward over ST joint

- inter nervous plane between sural and superficial peroneal nerves

- full thickness down to bone

 

Superficial dissection

- subperiosteally expose distal fibula

- protect peroneal tendons posteriorly

 

Fibula osteotomy / excise distal fibula

- oblique cut ending 1.5 cm proximal to joint

 

Fibula Osteotomy Ankle FusionFibula Osteotomy and Reflected Posteriorly

 

Deep dissection

- expose talar neck anteriorly

- expose tibia posteriorly

- protect anterior tendons and NV bundles with retractors

- protect posterior peroneal tendons with retractors

- open the tibio-talar joint with lamina spreaders

 

Distal tibial cut

- oscillating saw

- perpendicular to tibial axis

- just above subchondral bone / 2-3 mm

- care not to take off medial malleolus

- if cut is too thick, will enter medial malleolus

 

Make a separate antero-medial incision

- medial to T anterior, protect saphenous nerve and vein

- use osteotome to complete tibial cut and protect medial malleolus

- denude medial malleolus of articular cartilage

- also clear medial talus

- note that the deltoid ligament carries the primary blood supply to the talus, and should be preserved

 

Talar dome cut

- place foot in desired position

- 5o valgus and neutral DF

- make a parallel cut to distal tibia

- again only 2-3 mm

- ensure two cuts appose

 

Stimulate bleeding bony surfaces

- drill holes in distal tibia and talar dome / sharp osteotome

- especially if sclerotic bone

 

Position foot

- ER 5 – 10o depending on other foot position

- with respect to patella

- hold with wires for 6.5 mm cannulated screws

 

Fixation

 

Option 1

- medial tibia down to talus

- one into dome & one into neck / parallel

 

Option 2

- lateral talus up to medial tibia

- region sinus tarsus / lateral process

- parallel

 

Supplement

- medial malleolar screw

- fibular to talus screw

 

Check II 

 

Options for fibular 

- discard 

- reattach to tibia and talus as onlay graft 

- morcellize with reamer and insert 

 

Postop 

NWB 6/52 in cast

PWB in moon boot further 6/52

Double time if diabetic

 

2.  External Fixation

 

2 circular rings distal tibia

- 4 half pins

 

2 wires metatarsals

- connect to half ring

 

2 x wires calcaneum

- foot plate

- connect to half ring

 

Rods between and compress

 

3.  Tibiotalocalcaneal (TTC) Fusion 

 

Pantalar Fusion APPantalar Fusion Lateral

 

Technique

- prepare ankle arthrodesis site as per compression arthrodesis

- approach and prepare subtalar joint between peroneus brevis and tertius

- elevate EDB

- stabilize both joints with K wires placed to not interfere with nail insertion 

 

Insertion site

- line from 2nd toe through centre of heel pad

- line in coronal plane / junction anterior & middle 1/3 of heel pad

- should pass through anterior part of posterior facet of calcaneum

- posterior to lateral plantar artery and nerve

- screw fixation in calcaneum and talus (lateral to medial ; possible posterior to anterior calcaneal screw)  

- compression (distally locking and tapping on inserter or company specific jig) 

- 2 x proximal screws medial to lateral 

 

Complications

 

Intraoperative 

-NV Damage 

-Metalwork Breakage 

 

Postoperative 

- Immediate - Infection ; compartment syndrome 

- Medium Term - Delayed or nonunion ; painful malunion 

- Long Term - Stiffness and Gait Changes ; Arthrosis in adjacent joints 

 

Nonunion

 

Arthrodesis nonunionArthrodesis nonunion lateral

Ankle Arthroplasty

Ankle OA Pre ArthroplastyAnkle Arthroplasty APAnkle Arthroplasty Lateral

 

History

 

First generation (late 70s early 80s) 

 

Results

- 80-85% Good / excellent in  short term

- severe osteolysis, aseptic loosening 90% 

 

Problems

- cemented 

- highly constrained

- considerable bone resection

- subsequent revision technically challenging

 

Second Generation (mid 80s onwards) 

 

Design

- semiconstrained

- uncemented

- mobile and fixed bearing options

- bone preserving 

  

Indications

 

1.  Older patient with low demand

 

2.  Other joints arthritic

- degenerative SJT / midtarsal joint

- contra-lateral AKJ AO 

- previous triple arthrodesis

 

Absolute Contraindication

 

Infection (Acute or Chronic) 

Neuroarthropathies i.e Charcot 

PVD

Poor soft tissue envelope

Severe malalignment or instability that cant be corrected intraoperatively 

Major AVN affecting >1/3 of talus 

 

Relative Contra-indication

 

Dx - Posttraumatic worse outcomes than RA which has worse outcomes OA  

 

Age - Younger (worse outcomes in < 50 years) 

 

Ankle OA Post ORIF Ankle OA Arthroplasty APAnkle Arthroplasty post ORIF lateral

 

Minor Malalignment (>10 degrees of varus or valgus as compromises ligament stability) 

 

Instability

 

Stiffness (preoperative ROM = Postoperative ROM) 

 

Minor AVN talus

 

Second Generation Implants

 

STAR

 

Design

- cobalt chrome tibia and talus

- titanium porous coating

- talus single keel

- tibial component two rounded keels

- mobile bearing poly

 

Anderson et al JBJS Am 2004

- 51 STAR

- 12 revisions

- 5 year survival 70%

 

Depuy Agility

 

Design

- fusion of the distal tibio-fibular syndesmosis to support tibial component

- titanium tibial component with cobalt chrome talar resurfacing

- uncemented

- modular poly inserts into tibial component

 

Knecht et al JBJS Am 2004

- 69 followed clinically with 90% reporting decreased pain and satisfactory outcome

- 11% revision rate

- 76% demonstrated peri-implant radiolucency

- 20% progressive subtalar OA and 15% progressive TNJ OA

 

Techique

 

Anterior approach

- protect SPN

- between T ant and NV bundle

- remove anterior osteophytes

 

Tibial cut

- distal alignment jig

- resect few mm above eroded bone

- neutral cut

- must not cut medial or lateral malleolus

 

Talar dome

- resurfaced

- 3-4 mm removed

 

Results

 

Haddad et al JBJS Am 2011

- systemic review

- similar satisfaction rates and and ankle scores in arthroplasty and arthrodesis groups

- 5 and 10 year survival of arthroplasty 77%

- 7% revision rate in arthroplasty (loosening and subsidence)

- 9% revision rate in arthrodesis (non union)

 

Is ankle replacement cost effective compared with arthrodesis?

 

Complications

 

Loosening

 

TAR LooseLoose TAR AP

 

Revision

 

Revision TAR APRevision TAR Lateral

 

Ankle Arthroscopy

IndicationAnkle Arthroscopy

 

Diagnostic

 

Pain / Stiffness / Locking

Instability

- exclude OCD

Assess syndesmosis

 

Therapeutic

 

Synovitis

Osseous lesions / Tibiotalar impingement spurs

Osteochondral defects

Anterolateral impingement lesions (soft tissue)

Loose bodies

 

Ankle Scope Loose BodyAnkle Scope Loose Body 2

 

 

Technique

 

Set up

 

Position

- supine on table

- tourniquet

 

Traction

A.  Assistant provide traction

B.  Foot traction halter

C.  Skeletal distracter

 

Ankle Arthroscopy Traction

 

Instrumentations

- standard knee scope or

- 2.7mm 30° scope

- small scope better for getting across joint line without chondral damage

 

Portals

 

Ankle distended first

- 20 ml syringe, normal saline

- anteromedial

- insert needle, move ankle

- if on bone and needle moves, on talus and need to redirect proximally

- if on bone and needle doesn't move, on tibia and need to redirect inferiorly

- insufflate with 15 mls to create anterior space

 

Portals

- usually want instrumentation on side of pathology

- exception is anterior spurs

- usually large osteophyte laterally so first portal insert medially

 

Ankle Scope Medial and Lateral PortalsAnkle Superficial Peroneal Nerve

 

Anterolateral

- lateral to peroneus tertius

- can then transilluminate and avoid saphenous nerve on AM portal

- structure at risk is branches SPN

- Just proximal to joint line

- incision in skin only

- blunt dissect down to capsule

- insert blunt trochar

- aim anterior to joint to create space

 

Anteromedial

- second portal

- medial to tibialis anterior

- structure at risk is G saphenous vein and saphenous nerve

- use transillumination to avoid

- insert and visualise needle

- skin incision, blunt dissection

- insert shaver, again anteriorly

- clear soft tisse until can visualise joint line

- beware anterior tendons and nerves

 

Technique

 

1.  Inspect anterior talus

- plantarflex foot

- look for chondral lesions

 

2.  Inspect distal tibia

- look for osteophytes

 

3.  Inspect gutters

 

A.  Medial

 

Ankle Arthroscopy Medial GutterAnkle Scope Medial GutterAnkle Scope Medial Gutter

 

B.  Lateral

- exclude meniscoid lesions

 

Ankle scope lateral gutterAnkle Scope Lateral Gutter

 

4.  Look across joint

- distract

- insert probe or shaver and use as level

- look at tibial plafond and syndesmosis

 

Ankle Arthroscopy Lateral GutterAnkle Scope Talar Dome

 

5.  Inspect syndesmosis

- probe and assess stability

 

Ankle scope syndesmosisAnkle scope syndesmosis 2

 

6.  Inspect posterior joint line

 

Ankle Scope Posteromedial CapsuleAnkle scope posterior capsule laterally

 

Posterior Ankle Arthroscopy

 

Posterior ankle arthroscopy

 

Posterolateral

- just lateral to tendo achilles

- medial to fibular

- 1.2-1.5cm above tip of fibula

- sural nerve & vein anterior

- remember joint 1cm higher at back

 

Subtalar Arthroscopy

 

Subtalar arthroscopy

 

Complications

 

Nerve Injury

 

Specific

 

Anterolateral portal - SPN

Anteromedial portal - Saphenous

Posterolateral portal - Sural

Anterocentral - Deep Peroneal

Posteromedial - Posterior Tibial

 

Minimise by

1.  Marking of skin prior to arthroscopy

2.  Transillumination to visualise nerves

3.  Feel nerve 

4.  Use of blunt dissection

 

Mechanism injury

- penetration

- neural structures close to capsule

- anterior penetration by chondrotome may injure DPN

- traction device

- pins in talus and calcaneus may injure sural nerve

 

Other

 

Compartment syndrome

- From extravasation of fluid into calf

 

Articular cartilage damage

 

Infection

 

Pseudoaneurysm

 

Pseudoaneurysm AngiographyPseudoaneurysm MRI

 

Ankle Injuries

Ankle Fracture

AnatomyDislocated Ankle

 

Bony

- 90% load through plafond to talus

- 10% load through lateral talofibular articulation

 

Ligaments

 

A.  Lateral Ligament Complex

 

ATFL (Anterior Talo-Fibular Ligament) 

- tight in plantar flexion

 

CFL (Calcaneo-fibular ligament)

- slopes down & back

- tight in dorsiflexion

 

PTFL (Posterior Talofibular Ligament)

- scissors with Posterior Tibiofibular Ligament

 

B.  Medial Ligaments

 

Superficial Deltoid (SDL)

- origin medial tibia

- broad insertion talus / calcaneum / navicular

- resists hindfoot eversion

 

Deep Deltoid (DDL) 

- tibiotalar

- key to stability / primary stabiliser of ankle

- resists talus ER

- if divided get abnormal ER of talus in plantar flexion

 

C.  Syndesmosis

 

Interosseous Ligament

- between AITFL and PITFL (anterior inferior and posterior inferior tibio-fibular ligament)

 

Biomechanics

  

ROM

- DF = 30°

- PF = 45°

- Rolls & slides to produce DF/PF

 

Plantarflexion

- deltoid ligament acts as a checkrein

- prevents ER of talus

- causes 5° IR talus

 

Dorsiflexion

- talus wider anteriorly 2.5 mm

- fibula moves laterally & ER to accommodate

 

Ramsey 1976

- 1mm talus shift = Contact area decreased by 40%

- non-physiological study

- jammed wedges in intact ankle

 

Ankle Fracture Classification 

 

No system prognostic

 

1.  Weber ABC

 

A.  Fracture distal to syndesmosis

- stable / avulsion type fracture

- FWB

 

Weber A

 

B.  Fracture at level of syndesmosis

- syndesmosis intact

- ORIF if medial structures not intact

- xray below demonstrates Weber B with rupture deltoid ligament

- ankle unstable

 

Ankle Weber B Fracture

 

C.  Fracture above level syndesmosis

- syndesmosis at risk / must assume is torn

- medial structures often torn

 

Ankle Weber C Fracture

 

2.  Lauge-Hansen 1950

 

Two part 

 

1.  Position of talus

- supination tenses lateral structures

- pronation tenses medial structures

 

2.  Direction of force

- rotation or translational injury

 

A. Supination-Adduction

Stage 1: Transverse fracture of lateral malleolus at or below the level of anterior talo-fibular ligament (Weber B) 

Stage 2: Vertical fracture of medial malleolus (often a marginal impaction at medial edge of plafond)

 

Ankle Fracture Supination Adduction

 

B.  Supination-External Rotation (Most common - up to 85% all injuries)

Stage 1: Rupture of AITFL

Stage 2: Short oblique fracture of the lateral malleolus (Weber B) (stable)

Stage 3: Rupture of PITFL / fracture of posterior malleolus of tibia

Stage 4: Transverse fracture of medial malleolus (unstable) 

 

Ankle Fracture Supination ER

 

C. Pronation-Abduction (Less than 5% of ankle fractures)

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior and posterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Proximal fibula fracture (often butterfly)

 

Ankle Pronation Abduction

 

D. Pronation-External Rotation

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Spiral/Oblique fracture of the fibula above the level of the syndesmosis        

Stage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus

 

Ankle Fracture Pronation External Rotation

 

X-ray assessment

 

3 standard views

 

AP, lateral and mortise

 

Ankle AP XrayAnkle Mortise View

 

Mortise

 

Technique

- foot internally rotated

- AP projection

- should be symmetrical clear space around talus

 

Ankle Mortise View

 

1.  Lateral talar shift / increased medial clear space

- medial clear space > superior clear space

- should be < 4mm

- indicates injury to medial structures

- instability

 

Ankle Fracture Increased Medial Clear SpaceAnkle Fracture Increased Medial Clear Space 2

 

2.  Tibia / fibular overlap < 1mm / syndesmotic injury

 

Ankle Fracture Syndesmosis WidenedAnkle Diastasis

 

Incidence

 

Unimalleolar 70%

Bimalleolar 25%

Trimalleolar 7%

Open 2%

 

Management

 

Principles

 

Reduction

- protects skin medially

- conscious sedation in emergency department

- well moulded POP

- unstable ankles need monitoring for loss of reduction

- can need external fixation to maintain position

 

Ankle Fracture Severely Dislocated Dislocated Ankle Lateral

 

Timing

- operate when swelling reduced

- usually < 6 hours or 6 days

- higher risk with bimalleolar / 2 incision operations

- risk not being able to close wounds / infection

 

Long term results rely on

- reduction of talus under tibia

- mechanical stability

- degree of chondral damage

 

Medial ligament injury is the key to management

 

1.  Isolated Lateral Malleolar / Weber B Fracture

 

Ankle Fracture Isolated Weber BIsolated Fibula Fracture 3 mm displaced

 

Definition

- no medial fracture / no complete deep deltoid injury

- no increased medial clear space

- no instability on stress ER views

- no syndesmotic injury

 

Pathology

 

85% have no medial injury

- by definition have no talar shift 

 

LM displacement not important if medial side not injured

- Biomechanical studies show Talus doesn't follow LM when axially loaded if medial ligament  intact 

- Doesn't lead to altered biomechanics

 

There is no external rotation of the distal fragment 

- its relationship to the talus is fixed

- the proximal fragment is internally rotated

- again, this does not alter the biomechanics

 

Diagnostic Dilemma / Is the deltoid ligament intact?

 

Examination

 

A.  Non tender / no bruising

- is intact

- non operative management

 

B.  Tender / bruising

- may be partially injury sprained / or completely ruptured and unstable

- inconclusive

 

Lateral BruisingMedial bruising

 

Xray

 

1.  Mortise view

- any increased clear space

- ORIF

 

2.  Stress views

 

Option A:  Gravity Stress View

- Patient lies injured side down, cross table xray

- see if medial clear space opens

 

Option B:  Valgus view

- lead gloves

- can be painful as patient has acute injury

 

Option C:  EUA

 

Results of Isolated Weber B Fibular Fracture

 

Results of surgical and non surgical management equally good

- Talus is stable if medial ligament is intact

- If  < 3mm fibula displacement, nil poor outcome

 

Non operative

- Kristensen and Hansen etal

- 95% good outcome non operatively

- no salvage operations required for post-traumatic arthritis

 

Operative

- 1-3% chance of serious infection

- more long term swelling

 

Management

 

Cast in Internal Rotation to reduce the deformity

 

2.  Bi Malleolar Injury

 

Types

 

A.  Medial Malleolus and Lateral Malleolus Fractured

 

Ankle Fracture Bimalleolar

 

B.  Deltoid tear + Lateral Malleolus Fractured

 

Ankle Fracture Weber B + Deltoid Ligament

 

If have talar shift, then by definition bi-malleolar injury

- must be an interruption to medial structures

 

Results

 

Superior results with operative management

- able to obtain and maintain anatomical reduction

- 90% good results

 

Closed treatment

- for elderly or medically unfit

- acceptable reduction / ankle internally rotated

- 60% good results

 

Surgery

 

1.  Weber B + Medial Malleolus fracture

 

Fibula

- interfragmentary lag screw

- derotation 1/3 tubular plate

 

Medial malleolus (dependant on fragment size)

- 2 partially threaded lag screws

- 1 screw and one k wire

- TBW

 

Screen syndesmosis

- should be stable with Weber B

- stress view (ER and dorsiflexion)

- cotton test (clamp on fibula and attempt to open syndesmosis under II)

 

Ankle Fracture Bimalleolar ORIFAnkle Fracture Bimalleolar ORIF

 

2.  Weber B + Deltoid Ligament

 

Ankle Weber B Deltoid Ligament InjuryAnkle Weber B Deltoid Ligament ORIF

 

A.  Manage Fibula as above

- ensure joint fully reduced

 

Ankle Fracture Fibula ORIF Increased Medial Clear Space

 

B.  Medial clear space remains open

- ensure fibular out to length and anatomical

- assess syndesmosis intact / reduce and fix

- if remains open, must be suspicious of OCD fragment or deltoid ligament blocking medial reduction

- may need to open medially

 

No evidence that repair of medial ligament improves results

 

3.  Tri-Malleolar Fracture

 

Posterior malleolus

 

Anatomy

- avulsion of PITFL

 

Ankle Fracture Small Posterior Malleolus Xray

 

Ankle instability results if

- > 1/3 articular surface (>30%)

- displacement of > 2mm 

- risk posterior subluxation of the tibio-talar joint

 

Issue

- these can be highly unstable and require external fixation

 

Trimalleolar UnstableTrimalleolar Unstable

 

Ankle External Fixator APAnkle External Fixator Lateral

 

Indications to ORIF posterior malleolus

- usually get anatomical reduction after plating of LM

- ORIF if > 30% and > 2mm displaced

 

 Ankle Fracture Large Posterior Malleolus XrayAnkle Fracture Large Posterior Malleolus CT

 

Surgical Options

 

1.  Posterolateral approach to fibula

- enable AP clamp to reduce and hold fracture

- anterolateral approach

- front to back screws

 

2.  Formal posterolateral approach

- patient lateral or prone

- PA screws or buttress plate

 

Posterior Malleolus LargePosterior tibial buttress plate

 

Ankle Fracture Trimalleolar ORIFAnkle Fracture Trimalleolar ORIF Lateral

 

4.  Syndesmosis Injury

 

Ankle Fracture Clear Syndesmotic Injury

 

Definition

 

Disruption of syndesmosis between level of fracture and plafond

- distal tibia and fibular not connected and stable

 

Situations

 

A.  Weber C fracture

- extremely high risk

- almost always safer to ORIF

 

Ankle Weber C Syndesmotic InjuryAnkle Weber C Syndesmotic Screw

 

B.  Weber B fracture + medial column injury

- occasionally syndesmotic injury

- check intraoperatively

 

C.  Maisonnerve injury

- high fibula fracture

- medial clear space opening / deltoid injury

- need diastasis screw

 

Ankle Fracture Maisonnerve InjuryAnkle Fracture Maisonnerve Proximal Fibula

 

D.  Isolated Injury

 

Ankle DiastasisORIF Diastasis

 

Intraoperative tests

 

Cotton test

Stress test

 

Management

 

Reduction technique

- foot in neutral, clamp across medial and lateral malleolus

- don't reduce in plantarflexion as posterior talus is more narrow

- don't over reduce the joint

- check symmetrical joint space on mortise view

 

Diastasis Screw Fixation technique

 

1.  With other LM / MM fracture

- 1 or 2 screws

- 3 or 4 cortices

- 3.5 or 4.5 mm

- at level of epiphyseal scar

 

Ankle Fracture Diastasis Screw

 

2.  High Weber C fibula / Maisonnerve

- don't have to plate fibula

- ensure fibula out to length

- usually 2 screws
 

Post op

 

Need screw in for 8 - 10 weeks

- need to await ligament healing

- NWB

- usually remove screw as will break

 

Ankle Broken Diastasis Screws

 

5.  Medial Malleolar Fractures

 

Medial Malleolus Fracture

 

Management

 

Displaced

- ORIF

- 20% risk of non union

 

Undisplaced

- can usually manage in cast

- still small risk of non union

 

Fixation

 

A.  Large fragment

- 2 x screws

 

Ankle Fracture Medial Malleolus 2 Screws

 

B.  Small fragment

- screw + K wire

- TBW

 

Ankle Fracture Medial Malleolus TBW

 

C.  Plate

- vertical fractures

 

Medial Malleolus Plate

 

6.  Open Ankle Fractures

 

Presentations

 

Compound Ankle Fracture

 

Clean & Closeable wound

- wound usually medial

- washout / ORIF / close

 

Dirty wound / wounds need skin cover

- external fixation

- wound management

- ORIF later

 

7.  DM

 

Risks

- amputation (6% open, 40% closed)

- infection

- malunion / non union / delayed union

 

Increased in patient with neuropathy and PVD

 

Management

- increase fixation

- double NWB times

- leave sutures in for twice as long

 

8.  Elderly / Osteoporotic

 

Issue

- bone very poor

- good fixation difficult

 

Ankle Fracture OsteoporoticAnkle Osteoporotic Fixation

 

Complication

 

Non-union 

- uncommon

- Improve for up to 9 yrs

 

Medial Malleolus Non union

 

Swelling 

- worse after ORIF 

- continues > 3/12

 

Fibula malunion 

- decreases tibiotalar contact by 30%

- correction <4 years = Good results

 

Infection 1-4%

 

Missed fractures

- plafond fractures

- chondral lesions (50%)

- anterior process calcaneum

 

RSD

 

Stiffness

 

OA

 

Ankle OA Post ORIF

 

Complex Ankle Sprain

Definition

 

Simple sprain 

- injury to ATFL

- will almost always get better in 6-8/52

 

Complex sprain 

- associated injury

- suspect if patient slow to recover 

- diagnose most things on MRI

 

Symptoms

 

Instability

- clinical diagnosis 

- most will get better with appropriate physio

 

Pain

- if pain is present as well then consider other pathology

- isolated instability isn't usually painful

 

Causes

 

1.  Soft tissue

- lateral gutter fibrosis

- Bassett's ligament (thicknened AITFL)

- meniscoid / ferkel lesion

 

2.  Bony Injury

- OCD / loose body

- bone bruise

- fracture anterior calcaneum / lateral process / sustenaculum tali

 

3.  Tendon / ligament

- deltoid

- peroneal dislocation / tears

- high ankle sprain / syndesmotic injury

- sinus tarsi syndrome

- Achilles tendonitis

 

DDx

 

Soft Tissue

 

1.  Lateral gutter fibrosis

 

Ligament healing thicker than normal 

- associated scar tissue

- initial injury seemed to get better 

- ongoing pain and swelling over lateral ankle

 

Management

- arthroscopy and debride

- most will get better

 

2. Bassett's Lesion

 

Pathology

 

Primary injury to AITFL

- tear may produce laxity

- talar dome may extrude anteriorly in DF

 

AITFL

- normally thin and above level of ankle joint

- may become thickened and scarred causing lateral ankle pain and swelling

 

Diagnosis

 

Difficult to diagnose

- tender in syndesmosis & interosseous membrane

- positive squeeze test

 

Management

- arthroscopy and debride

- most will get better

 

3.  Meniscoid Lesion

 

Definition

 

Scar tissue beginning in the lateral gutter

- extending across between tibia and talus

- looks like a meniscus

 

Management

- arthroscopy and debride

- most get better

 

Bony Injury

 

1.  Fracture Anterior process of calcaneum

 

Pathology

 

Avulsion of the origin of the bifurcate ligament

- often missed if x-ray is in the wrong plane

 

Calcaneum Anterior Process Fracture

 

Diagnosis

 

Suspect if tender over anterior calcaneus

- CT or more plain films

 

Calcaneum Anterior Process Non Union

 

Management

- non-op for 6/12 

- most will unite or get a painless fibrous nonunion

 

2.  Fracture Lateral Process

 

Pathology

 

Eversion injury leading to lateral ankle pain

- tends to be larger than appears on plain x-ray

- often cause stiffness as involves STJ

 

Diagnosis

 

CT / MRI

 

Management

 

ORIF 

- > 1cm

- displaced > 2mm

 

Small and comminuted 

- excise

 

3.  Fracture Sustenaculum Tali

 

Caused by impaction on medial malleolus as the talus internally rotates

 

Management

- usually treat non-operatively

 

4.  Fractured Os peroneum 

 

Pain distally over the CCJ

 

Management

- non-operative initially

- late excise 

 

5.  Bone bruise

 

Pathology

 

Oedema in bone usually medial talar body and medial malleolus

- initial injury settles 

- get pain with resumption of activity

 

Diagnosis

 

MRI 

 

Management

 

Usually settles in 6/12

 

5.  Osteochondral fracture

 

Mechanism

- occur as the talus is inverted within the mortise

 

Pathology

 

Anterolateral 

- caused by shear stresses as the lateral talus abuts the lateral malleolus 

- tend to be smaller and generally do better

 

Posteromedial 

- caused with medial ridge impacting the roof

- more significant injury

- tends to be larger with underlying necrotic bone

 

6.  Loose Body

 

Tendon / Ligament

 

1.  Deltoid Tear

 

Pathology

- severe injury / almost an ankle dislocation

- gross inversion of talus with distraction 

- complete tear of lateral structures and tear of deltoid

- medial pain with lateral sprain

 

Management

 

Initially treat non-operatively

- may need debridement / repair

 

2.  High Ankle Sprain

 

Pathology

 

Injury to AITFL

- point tenderness and swelling

 

Management

 

Exclude diastasis

 

Treat non-operatively

- will take 12 weeks

 

Can benefit from late debridement

 

3.  Peroneal Dislocation

 

Pathology

 

Occurs with inversion while plantar flexed (strong contraction of peroneals)

- more common in cavus type feet 

- usually not diagnosed at the time

 

Symptoms

 

Patient complaining of painful snapping or clicking on lateral ankle

- after ~ 1/12 get synovial lined pouch anterior to malleolus from chronic subluxation

- won't heal

 

Management

 

Operative

- surgery with repair &/or deepening of groove

- repair and augment with periosteal flap or slip of Tendo achilles

 

4.  Peroneal Tear

 

Single or multiple longitudinal split

- associate with subluxation / dislocation

- associated with cavus feet

 

5.  Sinus Tarsi Syndrome

 

Lateral ankle pain

- injury to interosseous ligament

- residual synovitis

 

Management

- HCLA

- excision of contents of sinus

 

6.  Achilles tendonitis

 

Insertional tendonitis

Retrocalcaneal bursitis

Haglund' s deformity

 

 

 

 

Deltoid Ligament

 

Epidemiology

 

Incidence isolated deltoid ligament injury 2.5%

 

Anatomy

 

Strong fan-shaped structure 

- composed of a deep and superficial layer

 

Superficial layer 

- inserts as one continuous structure 

- navicular anteriorly, spring ligament (calcaneonavicular), sustentaculum, and calcaneum 

- measures 10 mm wide at its origin and 2 to 3 mm thick

- length varies from 20 to 30 mm

 

Deep layer

- inserts onto the nonarticular medial wall of the talus 

- most of the fibers concentrated on the posterior medial aspect of the talus

 

Management

 

Isolated deltoid injuries are extremely rare 

- need proximal fibular xrays to exclude maisonneuve injury & / or syndesmotic injury

- treated in a cast or brace

 

 

 

Lateral Ligament Complex

Acute Injury

Definition

 

Partial or complete rupture of one or parts of lateral ligaments of ankle

- common ankle sprain

 

Epidemiology

 

Lateral ligaments sprains are the most common ligamentous injuries of the human body

- account for approximately 15% of all athletic injuries

- it is estimated that there is one ankle inversion injury per day per 10,000 people

 

Most common young males

- average age 27

- M:F 2.5 : 1

- common injury in sport 

- basketball & soccer

- 10% emergency consults

 

NHx

 

Up to 20% to 40% of ankle sprains treated conservatively have some residual symptoms

- undertreatment is more common than overtreatment

- inadequate treatment can result in chronic ankle instability with recurrent sprains and early degenerative arthritis

- 10% of lateral ligament injuries will have subtalar instability also

 

Aetiology

 

Inversion injury

- jumping sports

- land plantarflexed and inverted

 

Associations

 

Peroneal muscle weakness

Pes Cavus

Tarsal Coalition

 

Anatomy

 

The ankle is a uniaxial joint that resembles a mortise and tenon

 

It is very stable when loaded in the neutral position

- bony contact and stability decrease with plantar flexion

 

1.  ATFL 

 

The most frequently injured ligament in the human body

 

Dimension

- 15 to 20 mm long, 6 to 10 mm wide, and 2 mm thick on average

 

Anatomy

- arises anterior aspect fibula, 1 cm above tip, 2 cm long, attaches 8 mm above STJ

 

Action

- primary restraint to anterior displacement, internal rotation, and inversion of the talus at all flexion angles

- in cadaveric studies, the ATFL always failed first

 

2.  CFL 

 

Cylindrical structure

- lies deep to the peroneal tendons

- 2.5 times stronger than the ATFL

 

Dimension

- 20 to 30 mm long, 3 to 5 mm thick, and 4 to 8 mm wide

 

Anatomy

- arises tip fibular, 2 cm long

- subtends angle 130 degrees from fibula

- attaches 13 mm below STJ

 

Action

- crosses two joints and acts as a subtalar joint stabilizer

- isolated CFL ruptures rare

- the ATFL and the CFL function together at all positions of ankle flexion to provide lateral ankle stability  

 

3.  PTFL 

 

The strongest of the lateral ligaments

- least often injured

 

Dimensions

- 30 mm long, 5 mm wide, and 5 to 8 mm thick

 

Anatomy

- medial surface of lateral malleolus to posterior lip talus

 

Ankle MRI PTFLMRI Ankle Intact PTFL

 

Pathology

 

Most are mid-substance tears

- avulsion injuries occur in about 14%

 

Findings

- isolated ATFL tear is most common injury(60% to 70%)

- combined ATFL / CFL tear (20%)

- isolated CFL, PTFL, & subtalar ligament ruptures all very rare

 

Examination

 

Tenderness

 

Fingertip palpation of all structures 

- shown to be almost as accurate and more cost-effective than the tests available

 

Instability testing

 

Controversial & unreliable without anaesthesia in acute setting  (LA or GA)

 

1.  Anterior drawer 

 

Most important & best predictor ATFL

- 10° plantarflexion neutral rotation

- CFL plays no role

 

> 3mm is positive

 

Ankle Anterior Drawer

 

2.  Talar tilt 

 

CFL test / subtalar instability

- 10% of patients with lateral ligament instability also have subtalar instability

 

Patient seated / foot unsupported

- 10-20° PF

- stabilise tibia /  gentle inversion

- compare to other side

 

> 20o abnormal

 

Talar Tilt

 

Investigations

 

X-rays

 

Advisable with significant ankle injuries / unable to weight bear

- AP, Mortise & Lateral views

- +/- AP Foot

 

Look for OCD / Weber A fibula

 

High resolution CT & MRI

 

Exclude OCD if needed

Not required acutely

Define injury in chronic situation

 

Grading Acute Injury

 

Grade I 

 

Mild injury with minimal swelling and tenderness and slight or no functional loss

- ankle is stable 

- negative drawer and talar tilt tests

 

Considered to be a partial tear

- patient can perform normal activities but with pain

 

Grade II 

 

Moderate injury with diffuse swelling and tenderness

- moderate functional loss with difficulty with toe walking

- partial stability is lost 

- mildly positive anterior drawer  (ATFL complete tear) 

- negative talar tilt (CFL partial tear only)

 

Partial to possibly complete tear of the ATFL and a possible partial tear of the CFL

- patient cannot perform normal activities and can bear weight but with increased pain

 

Grade III 

 

Severe injury

- significant functional loss and marked tenderness, swelling, and pain

- lateral ankle stability is lost 

- positive drawer and talar tilt tests

 

Considered to signify a double ligament injury with complete rupture of the ATFL and CFL

- weight bearing is usually not tolerated

 

Acute Management

 

Grade I & II Injuries 

 

Mechanically stable 

 

Benefit from protection 

- stirrup-type brace or high boot

- until nonprotected weight bearing is relatively pain-free

 

Ankle Orthosis

 

During the protected period 

- non-weightbearing ROM exercises are performed

 

Progressing to proprioceptive & ultimately agility training

- shown to shorten the period of disability

- Grade I ankle sprain should be near full recovery at 1-2 weeks

- Grade II ankle sprain at 2-3 weeks (may take a lot longer)

 

Grade III Injuries

 

Mechanically unstable by definition

 

Previously thought to all require surgery but now shown to be successfully treated non-operatively

 

1.  Casting for 4-6 weeks 

- in slight dorsiflexion & eversion to approximate ligament ends

- then functional rehabilitation

 

2.  Functional Bracing

- removable brace

- progressive weightbearing

- ROM, proprioception & strengthening exercises

- success demonstrated with MRI studies

 

Moonboot

 

Rehabilitation

 

Kannus Meta-analysis

 

Functional treatment superior in

- time to return to work

- physical activity

- ROM

- less wasting

- complications

 

No difference in

- instability 

- pain, swelling & stiffness

- re-injury

 

Protocols

 

Strapping

- figure 8 weave

- in neutral DF & slight ER

- shortens ATFL & helps proprioception

 

Physiotherapy

- peronei rehab is the key

- proprioception exercises

 

Return to Sport 

- successful performance of simple tests provide adequate guidelines

- ability to run, cut and jump 10 times on the single injured foot

- to stand on one foot with eyes closed for one minute 

- all without excessive pain

- athletes can return to sports when they are able to run and pivot without pain while the ankle is braced

- bracing or taping for sports is continued for 6 months after injury

 

Outcome

 

Most return to work by 8/52

20% have pain that limits activity

20 - 40% will have recurrent sprains

 

 

Chronic Ankle Instability

Definition

 

Chronic instability due to rupture of one or more parts of the lateral ligament

 

Anatomy

 

Progressive injury

1. Anterolateral capsule

2. ATFL

3. CFL

 

NHx

 

Can lead to ankle OA over time

 

Ankle OA Post Lateral Ligament Instability

 

History

 

Swelling over anterolateral ankle

 

Giving way with inversion

- occurs with activity & walking on uneven ground

- stiffness, locking, crepitation

 

Chronic pain is unusual with isolated chronic instability

 

Examination

 

Tender & swelling over involved ligaments

- anterior to lateral malleolus for ATFL 

- inferior to lateral malleolus for CFL

 

Limited dorsiflexion

 

Calf atrophy (especially peroneal)

 

Instability

- depends on ligaments involved

 

ATFL Instability

 

1.   Positive Anterior Drawer

- anterior subluxation on anterior drawer of talus on tibia

- ankle in 10° PF

 

Ankle Anterior Draw

 

2.  Increased inversion on varus stress with AJ in PF 

 

CFL Instability

 

1.  Increased inversion on varus stress with AJ in DF

 

2.  Positive Talar Tilt

 

Talar TIlt

 

ATFL & CFL instability

 

1.  Increased inversion on varus stress in all positions of AJ

 

2.  Positive Anterior Drawer and Talar Tilt

 

Stress Xrays

 

Plain xray usually normal

- look for OCD

- medial aspect of talus

 

1.  Talar Tilt 

 

Best to supervise personally, use lead gloves

- mortise view

- AJ 10o PF

- > 10° side to side difference

 

2.  Anterior Drawer

 

AJ 10° PF knee flexed

- side to side diff 3mm

- > 10mm on single film

 

MRI

 

Will demonstrate tears of ATFL / CFL

 

MRI Torn ATFL Axial VewAnkle MRI CFL

 

DDx

 

Bone

- tibiofibular synostosis

- stress fractures (calcaneum)

- intra-articular fracture / OCD

- lateral talar process

 

Ligament 

- syndesmosis strain

 

Tendon

- peroneal tendonitis / subluxation / dislocation

 

Nerve / RSD

 

Sinus tarsi syndrome

- pain & tenderness over lateral opening sinus tarsi

- inversion injury

- tear of interosseous talocalcaneal ligament

- usually heals but can get synovitis

 

Mechanical Instability vs Functional Instability

 

Mechanical 

- beyond physiologic range

- >10mm anterior drawer / >10° talar tilt

 

Functional 

- ankle giving way during ADL's

 

Classification O'Donoghue

 

Grade 1

 

Partial Tear ATFL or CFL

- incomplete injury

- negative Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray

 

Grade 2

 

Torn ATFL +/- partial CFL

- positive Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray

 

Grade 3

 

Torn ATFL & CFL

- positive Anterior Draw clinically and on xray

- positive Talar Tilt clinically and on xray

 

Management

 

Non-operative  (90%)

 

Rehabilitation programme

- strengthen of peronei

- proprioception (wobble board)

 

Shoe-wear modification with lateral flared heel

 

Operative Management

 

Indication

 

Instability with failure of non-operative treatment

Patient not willing to accept the discomfort 

 

Options

 

1.  Anatomic repair / modified brostrom

2.  Advancement

3.  Augmentation of repairs

 

1.  Anatomic Repair / Modified Brostrom

 

Procedure

- mid substance repair

- often attenuated 

 

Advantages

- restore normal anatomy & mechanics

- no donor site morbidity or weakening

 

Gould Modification

 

Technique

- suturing extensor retinaculum over ATFL repair

 

Advantages of modification

- reinforces repair

- limits inversion

- correct STJ part of instability (present in 10%)

 

Inferior extensor retinaculum anatomy

- laterally arises from anterior surface calcaneum

- medially has 2 limbs - med malleolus & plantar aponeurosis

 

Results

 

85% G/E without Gould modification

95% G/E with Gould modification

 

Poor outcome

1.  Generalised ligamentous laxity

2.  >10 yrs instability

3.  Previous operations

4.  Ankle osteoarthrosis

 

2.  Fibular advancement of ATFL / CFL

 

Technique

 

EUA
- confirm talar tilt / anterior draw

 

Longitudinal incision anterior to lateral malleolus

- protect branches of SPN

- expose tissue of ATFL / CFL

- can often feel them

- tissue is broad and diffuse

 

Lateral Ligament Repair IncisionLateral Ligament Repair Flap Incisions

 

Dissect out two flaps

- anterior incision between ATFL and CFL to talus

- begins at tip of fibula to talus

- superior flap is ATFL

- take off fibula as broad / thick flap

- inferior flap is CFL

- need to protect peroneals with inferior portion of dissection

 

First Transverse IncisionATFL FlapInferior CFL Flap

 

Inspect talar dome for OCD

- place retractor across talar dome

- ensure no loose bodies

- can remove anterior ankle osteophyte if necessary

 

Place foot in eversion and AJ neutral

 

Inferior AnchorAnterior Anchor

 

2 x 3.5 mm anchors in fibula

- ensure not in joint and not prominent

- 4 sutures through ATFL

- 2 through CFL

- 2 sutures either side of interval of ATFL and CFL so can close this

 

4 Sutures ATFL2 Sutures Inferior Flap2 Sutures to Close Interval

 

Make sure FROM & anterior drawer is negative at end

 

Extensor retinaculum is sutured over the site

- over ATFL

- over anterior aspect of fibula

 

Post op

- weight bear in moon boot for 6/52

- sport 3/12

 

Ankle Ligament Reconstruction APAnkle Lateral Ligament Reconstruction Lateral

 

3.  Augmented Repairs

 

Technique

- most use peroneus brevis (PB)

 

Indications

- poor tissue for anatomic repair

- long standing instability

- hypermobile STJ / ligamentous laxity

- previous surgery / revision

 

A. Chrisman & Snook

 

Reconstructs ATFL + CFL

- stabilizes the STJ

- preserves 1/2 PB

- most widely used non-anatomic reconstruction

 

Good results in 90%

- restricted inversion (100%) and dorsiflexion (20%)

 

Technique

- split PB in 2 leaving 1/2 attached to 5th MT base

- drill fibula transversely in AP direction

- drill calcaneus with small tunnel inferior to fibula

- thread tendon from fibula anterior to posterior & then into calcaneus 

- then back onto PB / PL or to PB anterior to fibula

 

B.  Evans

 

Tenodesis of PB

- divide proximally

- re-route through drill hole from anteroinferior tip to postero-superior

- pass PB through & suture to proximal end

- will also limit SJ motion

 

Baltopoulis et al. CORR 2004

- 27 patients, average AOFAS score 91

- 1/3 restricted hindfoot movement

 

C. Watson-Jones

 

Attempt to recreate ATFL with PB tenodesis

- detach PB tendon as proximally as possible

- drill hole through fibula transversely 1 inch from tip

- drill second hole through talar neck

- thread tendon through fibular posterior to anterior

- then through talus superior to inferior

- suture back to itself over LM

- limits STJ motion

 

D. Colville

 

Anatomic reconstruction CFL and ATFL

- 1/2 PB left attached distally

- through calcaneal tunnel

- to tip fibula tunnel to anterior fibula 8mm proximally

- to talar neck tunnel and back to anterior tibia

- idea is not to restrict STJ movement

Os Trigonum FHL Impingement

Posterior Ankle Impingement

 

Epidemiology

 

Repetitive plantar flexion

- soccer players, ballet dancers

 

Cause

 

Os trigonum

FHL stenosing tenosynovitis

Soft tissue mass

 

Os Trigonum

 

Secondary centre of ossification of talus

- lateral to groove for FHL

- 2-7% of normal feet

- impinges against plafond with forced PF

- can cause FHL tenosynovitis

 

Os TrigonumOs TrigonumOs Trigonum

 

Examination

 

Pain with forced plantarflexion

Pain with resisted FHL

 

MRI

 

Classically

- synovitis over posterolateral process talus

- fluid in sheath about FHL

 

May also see

- posterior tibia bone oedema

- thickened posterior capsule

- os trigonum

 

Management

 

Non Operative

 

US guided HCLA

- good results reported

 

Operative

 

Options

 

1.  Lateral approach

 

Indication

- resection of os trigonum only

 

2.  Medial approach

 

Indication

- also release of FHL

 

Technique

- incision between medial malleolus and T achilles

- T post, FDL and neurovascular bundle anterior

- release FHL compartment, look for accessory muscle or nodule

- open capsule over os trigonum

- excise

- need to ensure don't damage posterior talus articular cartilage

 

Os Trigonum Skin MarkingOs Trigonum Skin IncisionOs Trigonum Superfical Dissection

 

Os Trigonum FHLOs Trigonum FHL Accessory MuscleOs Trigonum Capsule

 

Os Trigonum ExposedOs Trigonum ExcisedOs Trigonum Posterior Talus Cartilage

 

FHL Tenosynovitis

 

Clinical

 

Pain behind medial malleolus

Pain with stressing FHL

 

Xray

 

No os trigonum

 

Arthroscopic release

 

FHL Arthroscopic Release 1FHL Arthroscopic Release 2

 

Subtalar Dislocation

Epidemiology

 

Rare

 

Types

 

Medial

- 80%

- calcaneum dislocated medially

 

Lateral

- 20%

- higher energy injury

 

Subtalar Dislocation Xray 1Subtalar Dislocation Xray 2

 

Anterior / Posterior

- extremely rare

 

Pathology

 

Tearing of strong interosseous ligament

 

Dislocation of

- talonavicular joint

- talo-calcaneal

 

Reduction

 

Subtalar dislocationSubtalar dislocation 2

 

Conscious sedation

- flex knee to relax gastrocnemius

- increase deformity

- reduce calcaneum whilst holding talus

 

Blocks to reduction

- medially - talar head buttonholes through capsule / EDB

- laterally - tibialis posterior

 

Post reduction

 

CT

- exclude intra-articular fragments

- ensure congruent reduction

 

CT post subtalar dislocationCT post subtalar dislocation 2

 

Results

 

Main risk is restricted ROM

- very difficult to treat surgically

- usually stable after reduction

- don't immobilize for long or subtalar joint will stiffen

 

Risk of osteochondral injury and later OA


 

 

 

 

Syndesmotic Injuries

Definition

 

High ankle sprain

 

Epidemiology

 

Uncommon

- often unrecognised or misdiagnosed as lateral ligament injuries

- seen in ice hockey

 

1-15% of ankle sprains involve the syndesmosis

 

Mechanism Injury

 

Hyperdorsiflexion and forced external rotation

 

Anatomy

 

Structures

- anterior inferior tibiofibular ligament (AITFL)

- posterior inferior tibiofibular ligament (PITFL)

- interosseous ligament (provides only 10% of strength)

 

Ankle MRI AITFL PITFLSyndesmosis MRI Normal

 

Examination

 

High Ankle Sprain Clinical

 

1.  Tenderness over the AITFL

 

2.  Positive squeeze test 

- pain at ankle with squeezing the tibia & fibula at mid-calf

 

3.  Painful ER

- probably most reliable test

- neutral ankle with knee flexed 90o

- hold tibia in neutral

- externally rotate foot

 

Xray

 

Usually is no evidence of syndesmotic widening

 

Ankle AP Xray Syndesmotic MeasurementsAnkle Mortice Xray Syndesmotic Measurements

 

3 reliable indicators of syndesmotic widening

 

1.  Clear space 

- between the medial border of the fibula and the lateral border of the posterior tibia (incisura fibularis)

- measured 1 cm above the plafond

- distance should be approximately 5 mm or less on both the AP and mortise views in the normal ankle 

 

2.  Overlap of the fibula and the anterior tibial tubercle

- greater than 6 mm on the AP views

- greater than 1 mm on the mortise view

 

3.  Stress films for syndesmotic instability

- application of an external rotation and abduction force

- anesthesia is often required because of the painful nature of this examination

 

Syndesmosis stress view

 

Chronic

 

May see HO / MO interosseous ligament

 

Ankle Interosseous HO

 

CT

 

Normal

 

CT Syndesmosis normal

 

MRI

 

Highly accurate

- see disruption of ligament

- bone contusions posteromedial talus and posteromedial tibia

 

High Ankle Sprain MRI 1High Ankle Sprain MRI 2

 

Syndesmosis Injury T1Syndesmosis injury T2

 

Arthroscopy

 

Inspect the syndesmosis under external rotation stress test

- see widening > 2mm between tibia and fibula

- can also visualise AITFL and PITFL

- often a tibial chondral injury

 

Management

 

1.  Xray evidence of widening

 

Syndesmosis InjurySyndesmosis TightropeSyndesmosis Tightrope 2

 

Management

- diastasis screw / tightrope

 

2.  Syndesmotic injury with no widening

 

Takes 6 - 12 weeks to resolve

- impossible to strap

- WBAT but no impact sports 6 weeks

 

3.  Chronic injury / pain

 

Ogilvie-Harris Arthroscopy 1994

- arthroscopic debridement of sydesmosis and chondral injuries in 19 patients

- good results reported

- elimination of external rotation test

 

Ankle MRI

Deltoid Ligament

 

Deep Deltoid Ligament

 

Ankle Coronal MRI

 

Superficial Deltoid Ligament

 

Ankle MRI Superficial Deltoid LigamentSuperficial Deltoid MRI

 

Lateral Ligament Complex

 

PTFL

 

Ankle MRI PTFL

 

PTFL / CFL

 

Lateral Ligaments

 

Syndesmosis

 

MRI AITFL PITFL

 

Peroneal Tendons

 

Ankle Sagittal MRI

 

 

 

 

Ankle OA

AetiologyAnkle OA

 

Trauma

 

A. Ankle Fracture
 

Types

- Weber A 4%
- Weber C 33%
- Displaced large posterior malleolar

 

Any OA develops in first 2 years

 

Causes

- articular damage at time of injury
- non anatomical reconstruction
- complications i.e. infection

 

B. Plafond Fracture

 

C. Talus Injury

 

Talar Dome OCD

Talus AVN

Talar neck malunion

 

Other

 

Inflammatory OA

Infection

Hemochromatosis

Hemophilia

Charcot

 

Incidence

 

Ankle OA much lower than hip or knee

 

Anatomy

 

Thin cartilage 1 mm

 

Joint highly congruent

 

Tibio-talar contact stresses
- 1mm shift causes 40% decrease in contact area
- medial instability more important than lateral instability

 

Clinically

 

Pain

- with weight bearing

- nightime

 

Stiff Ankle Joint

 

Xray

 

Ranges from

- anterior spurring

- severe OA

 

Ankle Xray Anterior Tibial OsteophyteAnkle OA Kissing Spurs

 

Ankle OA AP XrayAnkle OA Lateral Xray

 

CT

 

Useful to define small anterior osteophytes

- may be causing pain with excessive dorsiflexion

 

Ankle CT Anterior Osteophyte

 

MRI

 

Ankle OA MRI

 

Ankle OA Coronal MRIAnkle OA Sagittal MRI

 

Management

 

Non Operative

 

Solid Ankle Foot Cushion (SACH) + rocker bottom sole

Analgesia

HCLA / Hyaluronic acid Injections

 

Operative Options

 

1.  Arthroscopic debridement

 

Technique 1

- debride chondral lesions
- microfracture / abrasion

 

Ankle Scope Medial OA

 

Technique 2

- removing kissing osteophytes

- anterior tibial and talar neck osteophytes

 

Ankle Spurs with Anterior ImpingementAnkle Scope Anterior Tibial OsteophyteAnkle Scope Osteophyte Debridement

 

2. Articular distraction with external fixator

 

Technique

- apply for 4/12
- distracted 5 mm
- reasonable results reported
- up to 3 years improvement
- delays arthrodesis

 

3.  Ankle Arthrodesis

 

4.  Ankle Replacement

 

 

 

 

Calcaneal Fractures

Background

Anatomy

 

3 facets

 

1.  Posterior facet (STJ)

2.  Middle facet (sustenaculum tali)

3.  Anterior facet (on distal medial aspect)

 

Anterior process 

- forms calcaneocuboid (CCJ) articulation

 

Thalamic portion 

- under lateral process talus

 

Tuberosities

 

Posterior tuberosity 

- posterior process / T Achilles attachment

 

Medial tuberosity 

- ABDH, FDB, plantar fascia, ADM, Flex Acc

 

Lateral tuberosity

- ADM, long plantar ligament, Flex Acc

 

Aetiology

 

Usually fall from height

- heel in valgus

 

Lateral process talus strikes Crucial Angle Guisanne 

- primary fracture line

- calcaneus driven up against talus

 

MVA

 

Direct blow

 

Essex-Lopresti Classification

 

A.  Extra-Articular  (25%) 

 

Anterior Process fracture

Avulsion of Posterior Tuberosity

Medial & lateral Tuberosity

Sustentaculum Tali

Extra-articular body fractures

 

B.  Intra-Articular (75%) 

 

Epidemiology

- 10% bilateral

- 10% associated with lumbar spine fracture

 

Primary Fracture Line of Palmer

- lateral process of talus driven into crucial angle

- starts at lateral wall near tarsal sinus at crucial angle (in coronal plane)

- passes obliquely across posterior facet

- position of line within the posterior facet variable

- may be medial towards S Tali, middle or lateral towards wall   

- exits at medial wall posterior to sustentaculum tali

 

Produces 2 main fragments

 

1.  Tuberosity / Lateral wall / Variable amount posterior facet

- usually comminuted

- usually displaces superiorly & laterally

 

2.  Sustentaculum / Anterior / Middle facet

- usually undisplaced

 

Sub-classified

- based on appearance of secondary fracture line on lateral X-ray

 

1.  Tongue type (20%)

- secondary fracture line passes posteriorly along calcaneal body to exit laterally below T Ach          

- tuberosity fragment attached to articular fragment (thalamic fragment)

 

Calcaneal Fracture Tongue TypeCalcaneal Fracture Intra-articular

 

2.  Joint Depression (80%)

- secondary fracture line also exits posteriorly

- passes immediately behind the posterior facet of the subtalar joint              

- exits posterior to posterior facet & anterior to T Ach insertion

- creates thalamic portion containing posterior facet

 

Calcaneal Fracture Joint Depression

 

Fracture Anatomy

 

1. Sustenacular Fragment

- constant

- supero-medial 

- attached to talus by deltoid lig

 

2. Superolateral fragment

- thalamic fragment

- lateral fragment of posterior facet

 

3. Lateral wall fragment

 

4. Tuberosity fragment

- posterior heel

 

Examination

 

EMST

 

Lumbar spine

- log roll

- injury in 10%

 

Other heel

- 10% bilateral

 

Foot

- compartment syndrome

 

Effects

- loss heel height

- increased heel width

- varus heel

 

X-ray Views

 

Lateral

- Bohler's angle

- crucial angle Guisane

 

Calcaneal Fracture Lateral

 

Harris axial views

- 45o axial of heel

- normally hindfoot 10o of valgus

- view varus malalignment & heel width

 

Calcaneal Fracture Harris Axial ViewCalcaneal Fracture Harris Axial View

 

Oblique view

- CCJ

 

Calcaneal Fracture Oblique Xray

 

Broden's view

- visualise posterior facet

- IR foot 45 degrees with ankle neutral initially

- plantar flex the foot 10° increments from 10° to 40

- alternatively angle beam cephalad in 10 degree increments

- replaced by CT

- useful intra-op to assess congruency of STJ

 

Xray Angles

 

1.  Bohler's angle  (20-40°)

 

Highest point on anterior process to highest point on posterior facet to highest point on tuberosity

- represents the height of the calcaneus

- angle of </=0° is associated with a poor outcome

 

Indicates

- the posterior facet/ STJ  has collapsed

- proximal displacement of tuberosity

 

Calcaneum Normal Bohlers AngleCalcaneal Fracture Reduced Bohlers Angle

 

2.  Crucial Angle Guisane 120-140°

- lies inferior to lat process of the talus

- where the primary fracture line starts

- disrupted in joint depression fracture

 

Formed by 2 cortical struts

a) lateral border of posterior facet

b) anterior to beak of calcaneus

 

Thus see

- decrease in Bohlers angle

- increase in Gissanes angle 

 

CT scan

 

3 mm cuts

- foot flat on table

- transverse and coronal

- sagittal reconstruction

 

1. Axial

- parallel to bottom of foot

- information regarding CCJ & sustentaculum

 

Calcaneal Fracture Axial CT

 

2. Coronal plane

- perpendicular to posterior facet

- information regarding posterior facet and number of fragments +

- sustentaculum / heel shape / position peroneal & FHL tendons

 

Calcaneal Fracture Coronal CT

 

3.  Sagittal

- Bohlers angle / depression of posterior facet

 

Calcaneal Fracture Lateral CTCalcaneal Fracture Lateral CT

 

Sanders Coronal CT Classification

 

Summary

- calcaneum divided into 3 columns by 2 lines

- based on lateral, central & middle columns of posterior facet

- number of longitudinal fracture lines on coronal CT through post facet

 

Position

- patient positioned supine in scanner with hips & knees flexed 45°

 

Type I 

- undisplaced, irrespective of number of parts

- cast

 

Type II 

- 2 parts of the posterior facet

- > 2mm displacement

- subgroups A,B,C based on primary fracture line

- more medial the fracture line (C), the more difficult to ORIF

 

Calcaneal Fracture Sanders 2

 

Type III 

- 3 part (AB, AC, BC)

- ORIF / fusion

 

Calcaneal Fracture Sanders 3 CT

 

Type IV 

- highly comminuted

- primary fusion

Complications

Early

 

Wound necrosis

 

Superficial infection 17%

 

Sural nerve neuroma

 

Intra-articular hardware penetration

 

Compartment Syndrome 10%

 

Deep infection

- Debridement and removal of metalwork

- Free flap over Abx beads, IV ABx

- Late grafting and STJ OA

 

Late

 

RSD

 

Non union

 

Heel pad problems

 

OA 

- STJ & CCJ

- may require arthrodesis

 

Malunion

 

Calcaneal Malunion

 

Stephens and Sander's classification

 

Issues

- varus hindfoot locks Midfoot

- shortened foot / shortened lever arm

- peroneal impingement

- shoewear problems

 

Options

 

1.  Lateral wall exostectomy and peroneal tenolysis

 

2.  Above + STJ arthrodesis

 

3.  Above + calcaneal osteotomy

- this may not allow the wound to be closed

- may need to do so gradually with frame

 

 

 

 

Management Extra-articular Fractures

1.  Anterior process

 

Part of complex sprain / easily missed

- non operative if small

- ORIF if large and displaced

 

2.  Tuberosity fractures

 

Need ORIF if displaced

- have T Achilles attached and can put skin under threat

- ORIF (usually closed reduction and screw)

 

Calcaneum Tuberosity Fracture

 

3.  Body fractures

 

Non operative treatment

 

4.  Sustentacular fractures

 

Sustenaculum Fracture CT 1Sustenaculum Fracture CT 2

 

ORIF if displaced

- medial approach with buttress plate

 

 

 

Management Intra-articular Fractures

Operative v Nonoperative Literature

 

1.  Buckley etal JBJS Am 2002

 

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

 

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

 

Improved Operative Outcome if

- not workers compensation

- women

- < 29

- bohler's angle 0 - 14 initially (not -56 to -1)

- light workload (not heavy manual worker)

- anatomical reduction < 2mm (CT of post facet)

- type 2 sanders (types 3 and 4 did not)

 

Note:

Any patient who required a subtalar arthrodesis to relieve pain was removed from the study.  

A non operatively treated patient was 5.5 x more likely to need this operation!

 

Complications  

- 5% deep infection

- 17% superficial infection

- STJ arthrodesis: non operative 17%, operative 3%

 

2.  Sanders 1993

 

Heel shape restored in 98+%

- Type II - 85% reduction and 75% good results

- Type III - 60% reduction and 70% good results

- Type IV - no anatomical reduction and 10% good results

 

Conclusion:

Sanders classification gives guide of prognosis

Once posterior facet is in more than 3 parts, good outcome decreases drastically

 

3.  Stulik etal JBJS Br 2006

 

287 displaced intra-articular fractures

- 1 year follow up

- Sanders 2, 3, 4

 

Any patient excluded from ORIF but amenable to OT

- DM / smokers / vascular insufficiency / compound wound / severe fracture blisters

 

Treatment

- MUA & Gissane spike percutanous reduction

- additional K wires

 

Results

- 16.5% excellent, 55.7% good

- 14.8% fair and 13% poor

- Sanders 2 > 4

 

Complications

- 1.7% deep infection

- 7% superficial infection

- nil amputation

 

Conclusion:  

There are intermediate options between ORIF and non operative

- with the ability to somewhat restore heel height and width

- in high risk patients who cannot have ORIF

- probably makes subsequent fusion easier

 

4.  Poeze et al JBJS Am 2008

 

Calcaneal volume load v outcome

- centres with higher volume load

- reduced rates of deep infection and subsequent subtalar arthrodesis

 

5.  Heller JBJS Am 2003

 

43 compound calcaneal fractures

- wound usually medial

 

Type I ORIF

- no infections in 7/7

 

Type II 

- 3/8 infection

 

Type IIIA

- 3/12 infection

 

Type IIIB

- 10 /13 infection 

- 6 /13 became deep osteomyelitis

- 3 required amputation

 

Conclusion

- very dangerous to ORIF anything other than Type I compound fracture

- a quarter to a third of type II and IIIA will get a deep infection

- absolutely not in any patient who will need a flap

 

6.  Folk et al JOT 1999

 

If patient had DM + PVD + smoker, wound problem rates > 90%

 

5. Rodger Atkins AOA 2000

 

Salvage arthrodesis very difficult

- Always better to attempt reconstruction initially even if just to make arthrodesis easier

- Alternative is Primary Arthrodesis

 

Management

 

Aims

 

Pain free functional foot that can fit in a shoe

 

Goals

 

1.  Restore heel shape (height, length and width)

2.  Reduce joint surface

 

Options

 

1. Non-operative

2. ORIF

3. Primary STJ arthrodesis

4. Salvage / STJ arthrodesis

 

Issues

 

1.  Patient factors

 

Smoking 

- higher incidence infection

- try to get them to stop

 

DM, PVD

- high risk of infection

 

Heavy manual workers 

- will find it difficult to return to work

 

Bilateral fractures

- do worse

 

Gender

- women do better

 

Age

- younger do best

 

2.  Soft tissue envelope

 

Compound fractures

- wound medial

- operative for Type 1

 

3.  Fracture type

 

Bohler's angle

- if less than 0o initially, do poorly however managed

 

Sander's

- prognostic (type I do well, type IV high rates fusion)

- lateral wall fragments easier to fix (2A)

- very medial fractures (2C) very difficult

 

Assess

- Bohler's angle

- Posterior facet / Sanders

- CCJ joint

- lateral wall fragment

- sustentaculum fragment

- tuberosity / heel in valgus

 

4.  Surgeons experience

 

Non Operative Management

 

Indications

- non displaced

- Bohler's > 20

- Sanders IV

- DM, PVD

- compound fracture Type 2 & 3 

 

Technique

- elevate +++

- POP

- NWB 6/52

- Then progressive WB

 

Complications

- STJ OA

- peroneal impingement or subluxation

- calcaneocuboid arthritis

- malunion of hindfoot

- posterior tibial nerve entrapment

- difficulty with show wear

 

Operative

 

Indications

- healthy patient

- ? smoking

- Saunders II / III

- Bohler's < 20o

- displaced tongue type fractures

 

Contra-Indications

- severely comminuted sustentaculum tali

- type IV

 

Needs to be an individualised approach with risk stratification

 

Initial

- Bed rest, elevation, ice & compression till skin wrinkles evident

- between 1 week and 4 weeks

 

Blisters

- clear fluid (some epidermis attached to dermis)

- bloody fluid (no epidermis attached to dermis)

- shown that there is some increased risk of wound problems if incision passes through blisters

 

1.  ORIF  

 

Calcaneal ORIFCalcaneal ORIF LateralCalcaneal ORIF Axial

 

Technique

 

Position

- patient on side, blankets under foot

- operated foot up

- radiolucent table, II available

- GA, IV Abx, tourniquet

 

Incision

- extensile lateral approach

- behind posterior edge of fibula

- anterior to T Achilles

- sural nerve posteriorly in flap

- along borders of calcaneum (Abd H below)

- keep distal cut along inferior margin calcaneum

- angle up towards CCJ

 

Superficial dissection

- elevate full thickness flap with peroneal tendons

- down to bone

- divide CFL

- K wires to retract skin flap

- 2 in talus / 1 in fibula

- expose CCJ

 

Bleeding

- calcaneal artery

- branch of peroneal artery

 

Steinmann pin to tuberosity 

- through heel skin

- can elevate and pull out of varus

 

Hinge lateral wall fragment 

- opens on posterior / inferior periosteum

- gives access to subtalar joint

- if type 2C may need lateral wall osteotomy

- divide interosseous ligament 

- homan or lamina spreader to expose STJ

 

ORIF

- Reduce medial fragments and work laterally

 

1. Restore posterior facet with screws

2. Restore calcaneum height and Bohler's by reducing tuberosity fragment

3. Pull out of varus

4.  Reduce posterior facet & lateral joint fragment onto sustentaculum fragment

- golden screw

- 3.5 mm screw

- aimed anteriorly, medially and slightly upwards

5.  Elevate anterior process fragment

6.  Locking contoured plate

 

Intra-operative II

- lateral

- Broden's view

 

Closure

- careful haemostasis

- closure over drain

- elevate +++ for one week

 

Post op

- NWB 12 weeks

- early ROM exercises once wound healed (2-4 weeks)

 

2.  Essex-Lopresti closed reduction and percutaneous pinning 

 

Indications

- tongue type fractures 

- joint depression fractures not suitable for ORIF

- compound fractures

 

A.  Technique 1 for IA Fractures

 

Position

- patient prone with knee flexed

 

1st steinmann pin (if comminuted IA)

- from medial to lateral through body

- traction to restore height

- correct varus

- manually compress heel to reduce lateral wall displacement

 

2nd steinmann pin

- Posteromedial corner of posterior tuberosity

- aim towards sole and towards CCJ

- under thalamic portion, then lever pin dorsally

- aiming to correct Bohler's

- then aim towards CCJ and can even pass through

 

Incorporate 2 pins into plaster

- remove after 6 weeks

 

B.  Technique 2 Stulik et al JBJS Br 2006 for IA Fractures

 

Calcaneal Fracture Percutaneous Pinning

 

Transverse Steinmann as above

- disimpact fragments

- pull out of varus

 

Plantar stab incision

- posterior facet elevated with bone punch

 

Longitudinal Steinmann pins x 2

- elevate and hold thalamic portion

 

Transverse K wires under posterior facet

 

Results

- 1.7% deep infection

- 7% superficial infection

 

C.  Technique 3 for IA fractures

 

Percutaneous screws + Ilizarov

 

D.  Technique 4 Stulik et al for tongue type

 

Reduce tongue with longitudinal Steinmann

 

Fix with 2 mm K wire / screws

 

Calcaneal Fracture Tongue TypeCalcaneum Fracture Tongue Type ORIF

 

3.  STJ Arthrodesis

 

Indications

- type IV Sanders

- late STJ OA

 

Early

- ORIF with lateral plate

- 2 x 6.5 mm screws

 

Late

- In setting on previous fracture very difficult

- Still have to restore anatomy

- restore heel height & width 

- may have skin problems if have very planovalgus foot

- may need lateral bone block

- need lateral wall ostectomy

 

Calcaneal Fracture OA FusionCalcaneal Fracture OA Post Fusion

 

 

 

 

Charcot

Charcot Joint

Charcot Foot AP Charcot Foot Lateral

 

Definition

 

Neuropathic Arthropathy

 

Progressive destructive arthropathy 2° to neurological condition

- usually minimal to no trauma

 

Aetiology

 

DM

- western world

 

Leprosy / syphilis

- third world

 

Other

- polio

- paraplegia

- syringomyelia

 

Pathophysiology

 

Likely combination of :

 

1.  Neuro-traumatic theory

- cumulative trauma in insensate foot unrecognised

- results in progressive joint destruction

 

2.  Neurovascular theory

- neurally stimulated vascular reflex

- stimulates bone resorption

 

Newer theory: due to inflammatory cytokines

(TNF Alpha & IL-1) = stimulates osteoclast resorption  

 

Classification Temporal - Eichenholtz

 

Sidney N Eichenholtz, American surgeon, 1966

 

Stage 0

 

- added by Shibata et al 1990

- clinical signs (swelling/ erythema) precede XRay changes

- NWB during this period may prevent XRay changes

 

Stage 1 Dissolution

 

Findings

- acute inflammation (swollen, red, warm)

- DDx infection

- erythema reduces with elevation 10 minutes

 

Charcot FootCharcot Foot Elevated

 

X-ray

- demineralisation of regional bone

- periarticular fragmentation

- joint dislocation

- hyperaemia precedes fragmentation by hours to weeks

 

Charcot Foot Stage 1 Fragmentation

  

Treatment

- TCC remains gold standard

- WBAT ; no evidence that better outcomes with NWB

- applied weekly until clinical progression to stage II

- frequency of application may decrease as progress

 

Stage 2 Coalescence

 

Findings

- inflammation decreases / less swelling

- reduced temperature

 

X-ray

- absorption of osseous debris

- organization and early healing of fracture fragments

- periosteal new bone formation

 

Charcot Foot Stage 2 Resolution

 

Treatment

- TCC or transition to CROW (Charcot Resistant Orthotic Walker)i.e bivalved AFO

- may need to modify CROW a number of times before stage III

 

CROW

 

Stage 3 Reconstruction

 

Findings

- normal temperature

- swelling reduced

- clinically stable

 

X-ray

- smoothing of edges

- sclerosis, osseous or fibrous ankylosis

- complete bone healing 

- resolution of osteopenia

 

Charcot Foot Stage 3 Consolidation

 

Treatment

- accommodative shoes with custom moulded orthotic

- CROW or AFO if ongoing ankle instability

 

Px

- 30% will relapse between stages

- 7% risk of BKA without ulcer

- 28% risk of BKA with ulceration

 

Classification Anatomical - Brodsky

 

James Brodsky; Orthopaedic F&A Surgeon; Dallas Tx ; 1993

 

Type 1 Midfoot (60%)

- metatarsocuneiform and naviculocuneiform

- collapse of the medial longitudinal arch with rocker bottom foot

- progress through Eichenholtz stages quicker

- may present stage III with bony prominences & DFU

 

Charcot Midfoot

 

Type 2 - Hindfoot (30%)

- any / all subtalar joint i.e TNJ; subtalar; calcaneocuboid

- more instability than type 1

- require longer periods immobilisation

- varus or valgus

 

Charcot Hindfoot

 

Type 3 (10%) 

3a

- tibiotalar joint

- usually post ankle fracture

- most unstable pattern

 

3b

- pathologic fracture calcaneal tubercle

- weak push-off and ulceration

 

Investigation

 

DDx infection

- MRI

- combination labelled WCC + Bone Scan if MRI CI

 

Management

 

Goal 

 

Stable plantigrade foot that is shoe-able or braceable

 

Few require operative surgery

- control with casts and braces

 

Indications For Surgery 

 

1.  Severe deformity unable to brace

 

2.  Marked instability (usually type II or IIIa)

 

3.  Ulcers

- common type 1

- aim to try and heal ulcer first

- may be caused by fixed bony deformity i.e. midfoot collapse

 

4.  Soft tissues at risk

 

Contra-Indications

 

Uncontrolled diabetes

PVD

Medically unwell

Stage 1 disease

 

Goals of Operative Management

 

Restore alignment & stability so brace &/or shoe can be worn

- prevent alternative which is amputation

 

Timing of Surgery

 

Operating in stage 1 or 2 remains very controversial

 

Correct deformity in resolution / consolidation stage III 

- after cast / brace, shoe failed

 

Acute Fractures

 

Issue

- is it charcot or non charcot?

 

1.  Likely Charcot

 

Patient

- fracture a week or 2 old / red & swollen

- peripheral neuropathy & displaced fracture

- mimimal trauma

 

Eichenholtz I

- treat non-operatively

 

2.  Non Charcot 

 

Truly acute fracture

- reasonable trauma

- patient has peripheral neuropathy / DM

- treat as per usual, but accept higher complication rate

 

Management

- ORIF early before acute (dissolution) phase sets in

- if delayed be wary of ORIF as bone stock very poor

- need very strong and augmented ORIF

- must warn of risk of Charcot in acute fracture

- with peripheral neuropathy double period of immobilisation

- NWB 3/12 then further 3-4 month in TCC

 

Surgical procedures

 

1.  Midfoot ostectomy

 

Charcot Midfoot CollapseNeuropathic Ulcers from midfoot collapse

 

Midfoot most common site for neuropathic destruction

- mid foot collapse 

- apex of rocker-bottom common site for recurrent ulceration

 

Technique Ostectomy

 

1.  Attempt to heal ulcer first

- TCC

- debridement +/- IV ABs if OM

 

2.  Remove bony prominence causing ulcer

- medial or lateral incision

- avoid areas of ulceration

- full thickness soft tissue dissection to expose exostosis

- remove with osteotome / saw

- smooth edges with rasp

- haemostasis

- closure over drain; compressive dressing

- postoperative TCC for 6/52

 

2.  Hindfoot Realignment & Arthrodesis

 

Indications

- hindfoot Charcot not amenable to bracing 

- severe deformity or instability following failed bracing

- amputation is only alternative

 

Amputation v Arthrodesis

 

May develop bilateral issues

- try to avoid bilateral amputations

 

Contraindications to Arthrodesis

1. Disease Factors

 - Active infection (consider staged)

 - Stage I Eichenholtz

 - Insufficient soft tissue coverage

 - Insufficient bone stock

2. Patient Factors

 - Uncontrolled DM or malnutrition

 - Nonreconstructable PVD 

 - Non-compliant  

 

Technique

 

Preoperative

- cast / TCC till Stage III

- optimise HBA1c and nutrition

 

Intraoperative

- longitudinal incisions with full thickness flaps under no tension

- meticulous soft tissue handling

- resect bone to correct deformity

- strongest fixation device possible ; often augmented

- if using hindfoot nail ensure >200mm length

(risk of tibial stress fractures with shorter nail)

- often need percutaneous T Achilles lengthening

- alternative: fine wire fixation if active infection

 

Postoperative

- TCC - 3/12 NWB ; 1/12 PWB; 1/12 WBAT

- Lifelong AFO

- Periodic 6/12 follow-up

 

Results

- Lowery FAI 2012 - 76% bony fusion; 22% fibrous ; 1.2% amputation

- fibrous union can still result in good function

Total Contact Cast

Total Contact Cast 1Total Contact Cast

 

Mechanism

 

TCC’s heal ulcers by reducing pressure

- 1/3 of load is taken by wall of cast & transmitted to the leg

- 45% reduction in forefoot pressure but not heel pressure

 

Works best if closely applied & moulded to leg

 

Goals

 

Protection from trauma

Immobilize

Reduce oedema

Reduce pressure over ulcers

Redistributes pressure over a greater weight bearing surface

 

Indications

 

1.  Superficial forefoot and midfoot plantar ulceration

 

Neuropathic Midfoot Ulcers

 

Deeper ulcers with exposed tendon & bone

- require surgical debridement to convert them to superficial ulcers prior to TCC

 

2.  Eichenholtz stage I or II neuroarthropathic fractures

 

3.  Post operative neuropathic foot surgery

- post-op immobilisation after ORIF of acute fractures

- after reconstruction of deformity

 

Contraindications

 

1.  Heel ulcers

- not effective

- heel ulcers typically have ischaemic component & osteomyelitis

- TCCs don’t reduce heel pressure

 

2.  Deep infection

- abscess, osteomyelitis, gangrene

- beware of ulcer with drainage

 

Treat infection with rest in bed / NWB / Antibiotics

 

If ulcer is deeper than wide

- surgically debride to open ulcer

- allow deeper layers to heal & convert to superficial ulcer

 

3.  Poor skin quality

- especially if on steroids or have stasis ulcers

 

4.  Severe arterial insufficiency (pre-gangrenous feet)

- ABI < 0.45

- Doppler toe pressure < 30mmHg

- TcPO2 < 30

 

5.  Poor patient compliance

- must attend follow up & follow cast precautians

 

TCC Application

 

Technique

 

TCC Toe PaddingTCC Padding Bony Prominences

 

Meticulous

- absorbent gauze on ulcer

- enclose the toes with gauze between toes to reduce moisture

- seamless stocking

- felt over bony prominences

- avoid overpadding the cast / increases shear forces

- well moulded POP / fibre glass

 

Post Application Protocol

 

First 6 weeks

- change weekly

- because oedema subsides quickly

- photos of ulcer at each change

 

Then 2 weekly

- until ulcer healed / Stage 2 Charcot

 

6 months / orthosis

- CROW (Charcot restraint orthotic walker)

 

 

 

Compartment Syndrome Foot

Incidence

 

10% of calcaneus fractures 

40% of crush injuries

 

Diagnosis

 

High index of suspicion / classic signs less reliable

 

Pain & pain with passive stretch remain the cardinal signs

- pallor, paresthesia, pulselessness, & paralysis occur later or sometimes not at all

- low threshold calcaneal compartment pressures & surgical exploration

 

Anatomy

 

Nerve supply sole of foot

 

1.  Medial calcaneal 

- posterior weight bearing surface

 

2.  Medial plantar

- medial 3 & 1/2 sensation

- AbdH, FHB, 1st lumbrical

 

3.  Lateral plantar

- lateral 1 & 1/2 

 

4 muscle layers of the foot

 

Layer 1 (3)

- 3 short muscles that cover the sole

- AbdDM, FDB, AbdH

 

Layer 2 (3)

- long tendons to the digits

- FDL, Flexor accessorius, FHL

 

Layer 3 (3)

- short muscles of the digits

- FHB, AddH, FDMB

 

Layer 4 (3)

- plantar / dorsal interossei and tendons

- P longus, T posterior & interossei

 

4 Compartments

 

Septae from the plantar fascia

- insert 1st and 5th metatarsals

- separate medial / calcaneal and lateral compartments

 

1. Medial 

- ABDH & FHB 

 

2. Central / Calcaneal compartment

- superficial: FDB

- deep: ADDH / F accessorius

 

3. Lateral 

- FDM & AbDDM

 

4. Interosseous 

- interossei

 

The calcaneal compartment communicateswith the deep post compartment of the leg through the medial retro-malleolar space

 

Management

 

3 incision emergent decompression

 

Two dorsal longitudinal incisions

- medial aspect of the 2nd MT

- lateral aspect of the 4th MT 

- release interossei compartments

 

One 6-cm medial incision

- begins at the post margin of MM

- distally along the sole 

- open ABDH & 1st MT interval

- release medial / calcaneal / lateral compartments

- DPC or split-thickness skin grafting at 5 days

 

Non Treated Compartment Syndrome

 

Deformities

- claw toes

- cavus

- FDL tethering

 

DDx / Posterior leg compartment syndrome / FDL involvement

- if the deformity decreases with PF of ankle

- FDL muscle & deep post compartment of leg are involved

 

Diabetic Foot

Background

Diabetic Foot Pathophysiology 

 

1. Neuropathy

2. Arteriopathy

3. Immunopathy

 

Neuropathy 

 

Most important aetiologic factor in foot disease. Due to : 

- metabolic (glycosylation of nerves)

- ischaemic factors 

 

A.  Sensory Neuropathy

 

Definition

- loss of protective sensation - level of sensory loss allows damage to occur without being “painful”

 

Distribution

- stocking i.e. affects longest fibers first

 

Diagnosis

1) Semmes Weinstein 5.07 monofilament

- applies 10gm of force

- defines the presence & severity of neuropathy 

- tip pressed against skin until starts to bend; patient asked if they can feel it

- no standardized number of testing sites

- 90% of patients who are able to feel won’t ulcerate

 

2) 128 Hz Tuning Fork

- Less predictive of ulceration

 

B.  Autonomic Neuropathy

 

20 – 40% of Diabetics

- skin dry / scaly / Cracked  

- easier access for bacteria

 

C.  Motor Neuropathy

 

Loss of intrinsic muscle balance = claw & hammer toes

- Achilles tendon contraction = MT head pressure 

- Results in IPJ dorsal & MT head plantar ulcers

 

Arteriopathy 

 

50% of diabetic foot ulcers (DFU) have arteriopathy 

- large and small vessel disease 

 

Vascular Foot

 

A.   Large Vessel Disease

 

Different disease pattern to non-DM population:

- younger onset

- more rapidly progressive

- above and below knee (non-DM below knee rare)

- typical location at or just distal to popliteal vessels

- more diffuse with longer occlusions       

           

Symptoms

- vascular claudication

- rest pain

- nonhealing or hindfoot ulcer

  

B.  Small Vessel Disease

 

Microangiopathy

- primarily responsible for retinopathy / nephropathy

- may contribute to delayed ulcer healing

 

Immunopathy

 

Good BSL control improves healing  (less microbial growth;

no impaired chemotaxis)

 

Nutrition affects wound healing; predictive indices 

- total protein > 6 g/dl or 60 g/L

- albumin > 3.5 g/dL or 35 g/L

- lymphocyte count > 1500 /mm3

- transferrin < 200mg/dl

 

Diabetic Foot Complications

1)   Diabetic Foot Ulcers (DFU)

2)   Diabetic Foot Infections

3)   Charcot Arthropathy (refer to separate section)

 

1. Diabetic Foot Ulceration (DFU)

 

Rule of 50s -

50% DM admissions 

50% of all leg amputations

50% involve major level (BKA or AKA)

50% coexisting vascular disease

50% contralateral amputation 5 years

50% mortality 5 years (higher than breast and prostate ca)

 

85% of diabetic amputations involve DFU

 

2. Diabetic Foot Infection

 

Microbiology

 

1) Acute & Mild Infections

- usually monomicrobial

- commonly S Aureus, Strep

- Up to 30% of DFU hospitalized patients MRSA  

 

2) Chronic & Severe

- more likely polymicrobial

- G + Cocci (Staph; Group B Strep)

- G - (E Coli; Pseudomonas)

- Anaerobes –in ischaemic Limbs; Eg Bacteriodes Fragilis

 

Workup of Diabetic Foot 

 

Diabetic Foot History

 

Ulceration 

- duration 

- episodes of infection

- mobility level 

- prior treatments (wound care; shoe-wear) 

 

Diabetic Control

- HbA1c

- end organ disease (vascular; cardiac; retinopathy; neuropathy; nephropathy)  

 

Examination

 

Look 

- shoes – fit, material, wear-pattern

- bony prominences / deformity

- ulcers

   size, depth, granulation tissue, deep structures, cellulitis

- toenails - ingrown, thickened (vascular/ fungal)

 

Feel 

- pulses / capillary refill

- temperature (Charcot)

 

Move 

- anterior and lateral compartment mm power (for balancing transfers)  

 

Special Tests 

- Silfverskiold Test (need for TAL) 

Diabetic Amputations

Risk FactorsToe gangrene

- DM > 10 years

- chronic hyperglycaemia

- impaired vision or joint mobility

- lack education

- increasing age

- previous amputation

 

Considerations

- blood flow

- soft tissue envelope

- deformities / Charcot collapse

- sensation

- contractures - Achilles tendon, knee, toe

- rehab goals

 

Selection of Level

 

Aim is to preserve foot

- BKA leads to contralateral BKA in 1/2 in 5 years

 

'Biologic Amputation Level'

- most distal functional amputation level with reasonable potential for wound healing

 

Technique

 

No tourniquet

 

Cover with IV Abs 10 days then oral until wound healing

 

2 stage procedure

 

No sharp corners on bone

 

Long plantar flap if available 

- otherwise fish mouth

- tensionless flap

- sutures 8/52

- non constrictive dressings

 

Delay Weight bearing and prosthesis

 

Amputations

 

Toe

 

Try & leave base proximal phalanx

 

If complete toe amputation 

- proximal to metatarsal neck

 

Hallux

- must stabilise sesamoids or they retract & expose base MT

 

2nd toe 

- avoid because get severe hallux valgus

- may need to fuse 1st MTPJ

 

Ray

 

Most useful for 1st or 5th ray

- central ray resection takes a long time to heal if wound left open

- avoid multiple ray amputations 

- often difficult to close wounds after ray amputation & may need to leave open rather than close under tension

 

Fifth ray 

- racquet for toe and then straight lateral

- preserve base of fifth (P brevis)

 

Transmetatarsal amputation 

 

Good 

- toe filler only, no shoe modification

 

A.  Lisfranc

- preserve base 5th MT

- leave PB attach

 

B.  Chopart

- reattach T Ant and T Post to neck of talus

- post op cast in dorsiflexion

 

Late equinovarus

- percutaneous TA lengthening

- 2 medial and one lateral

- in theory leaves more intact laterally

- +/- lateral transfer of Tibialis Anterior

 

Boyd 

 

Talectomy & calcaneotibial arthrodesis

- forward translation of the calcaneus

- similar flaps to Symes but longer

- Occasionally in children

- Poor in adults

 

Pirogoff 

 

Talectomy & vertical osteotomy of calcaneus 

- osteotomy thru midbody then forward rotation of calcaneum to appose tibial plafond

- good in kids, too long to unite / heal in elderly

 

Syme's 

 

Ankle disarticulation preserving heel pad

 

Advantages

 

1.  Able to go to toilet in night without prosthesis

- can ambulate short distances if need

 

2.  Bulb makes the socket self suspending

 

Disadvantages

- cosmetically poor because stump is very wide 

- many women unhappy with cosmesis

 

Partial Calcanectomy 

 

Indication

- for non-healing heel ulcers associated with vascular insufficiency 

- not so severe that wound won't heal

 

Technique

- ulcer excised & longitudinal incision proximal & distal

- T Achilles reflected

- all of posterior process of calcaneum excised

- this makes skin closure easy

- T Achilles can't be reattached & is left free

- patient must wear rigid AFO style partial foot prosthesis with cushion heel long term

 

Trans-tibial 

 

Long posterior flap now standard

- previously always 6 inches from knee joint but trend now is to make as long as possible 

- avoid distal 1/3 as poor soft tissue coverage & padding

 

Posterior flap length is equal to diameter of limb at level of bone cut plus 1cm

- fibula is cut 1-2cm shorter

- don't perform tibiofibular synostosis 

- usually get painful non-union 

- gastrocnemius myodesis 

 

BKA AP XrayBKA Lateral Xray

 

 

 

 

Investigations

 

Perfusion Estimation

 

1. ABI

 

Method

- use doppler US & BP cuff

- systolic BP at ankle & arm

- ABI = Ankle / Brachial

 

Normal Range

.9 – 1.3

 

Measurement in DM

- may be falsely elevated due to calcification of media

- “trusted when low but not high”

- <.9 suggestive of PVD

- <.7 severe PVD

 

2. Transcutaneous O2 Measurement  (TcPO2)

 

Measured by electrode placed on warmed foot

- affected by oedema/ infection / neuropthy

- <25 mmHg = unlikely to heal

 

3. Toe Blood Pressure

 

Measured by plethysmography

- >30 mmHg = good wound healing potential

- Less sensitive / specific than TcPO2

 

 Angiogram

 

 If foot pulses are absent / asymmetric

 

Osteomyelitis Imaging

 

1. X-Ray

 

- may not show changes in early stages (<14 days)

- later Stages - Triad– Osteolysis, periosteal reaction, bone destruction

 

2. MRI

 

Most sensitive imaging for diabetic foot infections

 

Findings    

- bone oedema

- abscesses (Low Signal T1; Gad Ring enhancement)

Management

Aim

 

Stable, shoe-able plantigrade foot

 

Multidisciplinary approach

 

Multidisciplinary foot clinics (MDFC) 1st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:

 

Endocrinologist +/- diabetic nurse

- glycaemic control crucial

 

Podiatrist

- non-surgical debridement

- orthoses

  

Orthotist / Plaster tech

 

Vascular surgeon

- referral if absent or asymmetrical pulses

 

Orthopaedic surgeon

- TCC

- foot reconstruction; amputations

 

Infectious Disease Consultant

- infected / nonhealing ulcers

 

Diabetic Foot Care

 

Foot Hygiene

- daily wash with mild soap & warm water

- powder between toes & moisturiser to ankle

- plain cotton socks inside out (2 socks ↓shear)

- minimum tds inspection

- report immediately all blisters / ulcers & unilateral warmth / swelling (Charcot’s fractures)

- no walking barefoot

 

Shoes / Orthoses

- custom made orthoses and shoes reduce DFU recurrence 1

- shoes should be

wide/ deep/ round toe box

soft leather (hard materials irritate)

adjustable

no/low heel

 

Issues

 

Infections

Ulcers

Charcot

Fractures

 

1.  Diabetic Foot Infections

(Therapeutic Guidelines; Version 15; 2015)

 

A.  Mild Cellulitis (+/- Ulcer)

 

Combination oral Abx

- Augmentin Duo Forte

OR Cephalexin PLUS Metronidazole 

OR Ciprofloxacin PLUS Clindamycin (Penicillin Allergy)

- offload ulcer (crutches, custom orthotics )

 

B.  Severe Cellulitis (+/- Ulcer)

 

IV Abs (Timentin or Pip-Taz; IV Cipro + Clind for Penicillin Allergy)

- Offload Ulcer

 

C.  Ulcer with Osteomyelitis

 

Diagnosis

- probe-to-bone test (Positive predictive value .57; Negative Predictive Value .98) 2

- plain films (low sensitivity; particularly early stage)

- MRI (high sensitivity and specificity; with plain films Ix of choice)

- Tc Bone Scan + Labelled WCC (if MRI contraindicated)

 

Management OM

- consider debridement & intra-operative deep MCS (more accurate)

 

Antibiotics

- broad spectrum initially / timentin or pip-taz

- adjust 2° to MCS

- ID consult

 

Diabetic Calcaneal Abscess

 

 

Diabetic Heel Abscess XrayDiabetic Heel Abscess MRIDiabetic Heel Abscess MRI 2

 

2. Neuropathic Ulcers

 

Diabetic Ulcer

 

 

Classification

 

1)Wagner Classification3

 

Most used classification for DFU in ortho literature

 

Grade 0      

 

Pressure area           

- Footwear Modification

 

Grade I      

 

Superficial Ulceration           

- local treatment, footwear modification

 

Grade II    

 

Deep Ulceration (probes to tendon / capsule)          

- TCC, footwear modification

 

Grade III   

 

Deep ulceration + secondary infection           

- debridement, antibiotics

 

Grade IV   

 

Partial foot gangrene

- Abx, amputation, hyperbaric O2

 

Stage V    

 

Whole foot Gangrene

- regional amputation, Abx

 

2) University of Texas4

 

Each wound has a grade and stage

- increasing stage, across all grades, more predictive of amputation & prolonged healing time

- UT better prognosticator than Wagner

 

Grade 1 Preulcerative

Grade 2 Superficial Wound

Grade 3 Deep wound penetrating to capsule or tendon

Grade 4 Deep penetrating to bone or joint

 

Stages A Clean

Stages B Nonischaemic Infected

Stages C Ischaemic Noninfected

Stages D Ischaemic Infected

 

Management

 

Nonoperative

 

1) Off-load 

TCC remains the gold standard

- other options: removable cast walkers; modified footwear

 

2) Increase healing rates

Hyperbaric O2 - short-term reduction ulcer size

Negative Pressure Wound Therapy (NPWT)

Biologic Therapy eg amniotic membrane (experimental)

 

Operative

1) Tendoachilles lengthening (TAL)

Aim to reduce forefoot pressures

 

Colen et al Plast Reconstr Surg 2013

- level 3 retrospective cohort

- 25% of patients with DFU & no TAL Vs 2% of DFU with TAL had recurrent ulcer

 

2) Gastrocnemius Recession

3) Toe Flexor Tenotomy

 

3.  Charcot Foot

 

See Charcot Foot

 

4.  Fractures in Neuropathic / Diabetic Feet

 

Principles

 

1.  Augment ankle ORIF

2.  Double time for sutures

3.  Double immobilisation period

- 12 weeks NWB

- 4-5 months in walking cast

4.  Brace for 1 year after surgery

- to prevent late Charcot arthropathy

- assume Charcot joint will develop

 

References 

1- http://www.ncbi.nlm.nih.gov/pubmed/22336901

2- http://www.ncbi.nlm.nih.gov/pubmed/17259493

3-  http://www.ncbi.nlm.nih.gov/pubmed/7319435

4- http://www.ncbi.nlm.nih.gov/pubmed/8986890

Foot Fractures

Chopart Dislocation

Background 

Francois Chopart (1743–1795)

French surgeon who described Chopart amputation 

 

Definition

 

Traumatic dislocation of TNJ or CCJ

 

Aetiology

 

High velocity injury

- MVA

- fall from height 

 

Crush Injury 

 

Management

 

Urgent Reduction

 

Assess stability

- K wire

- +/- primary fusion if joints severely damage

 

 

Cuboid Fractures

Types

 

1.  Capsular avulsions

 

2.  Body / Nutcracker fracture

 

Nutcracker fracture

 

Epidemiology

- rare

 

Mechanism

- forced eversion / abduction of forefoot

- cuboid crushed between 4th and 5th MT and calaneum

 

Pathology

- displaced cuboid fracture with subluxation of tarsus

- may interfere with peroneal tendons

- shortens lateral border of foot

 

Diagnosis

 

Oblique xray

- foot 30o medial

 

Management

- ORIF and bone graft

- rarely need bridging external fixation

 

 

March Fracture

 

Definition

 

Insufficiency fracture

- secondary to exceeding fatigue threshold

- usually of second or third MT shaft

 

Epidemiology

 

Onset of new and very intense / strenuous physical activity

- i.e. new army recruits / dancers

 

Women with postmenopausal osteoporosis

 

Association

 

Cavus feet

 

History

 

Pain after walking & then with walking

Swelling after activity

 

Examination

 

Tender swelling along MT shaft

 

Often visible dorsal swelling

 

X-ray

 

Initially normal

- may need oblique xray to diagnose

 

Second Metatarsal Stress Fracture

 

Later shows callus around fine transverse / oblique fracture

- usually midshaft or distal

- usually incomplete

- often 2nd or 3rd MT longer than 1st

 

Bone Scan / MRI

 

Show increased activity prior to xray changes

 

Second MT Stress Fracture Bone Scan

 

Management

 

Non operative

 

Symptomatic

- rest for 4-6 / 52

- MT dome

- may need strapping / cast / moon boot 

 

95% union rate

- complete fracture rare

 

Operative

 

Rarely required

 

Dorsal approach / plate / bone graft

 

Metatarsal Fractures

Metatarsal Fractures

 

Indications for Surgery

 

1.  Displacement > 4 mm

2.  Angulation > 10o

3.  Intra-articular

 

Base of 5th Metatarsal

 

Classification

 

Zone 1

- avulsion fractures

 

Base of fifth MT Fracture

 

Zone 2

- fracture at the metaphyseal-diaphyseal junction

- fracture closely akin to the injury described by Jones 

 

Fifth Metatarsal Undisplaced Avulsion Fracture5th Metatarsal Stress Fracture

 

Zone 3

- proximal diaphysis

- stress fracture of the proximal 1.5 cm of the shaft of the fifth metatarsal

- these fractures are not acute 

- always have prodromal symptoms or radiographic signs of repetitive stress injury

 

Base of 5th Metatarsal Fracture Zone 2Jones FractureJones Fracture 2

 

Zone 1

 

Definition

- tuberosity avulsion fracture

- usually extra-articular but may extend into cuboid-metatarsal joint

 

Aetiology

- Peroneus brevis contracture following inversion 

 

DDx

 

1.  Apophysis 

- smooth and longitudinal 

- appears F 9-11 M 11-14 

- can look displaced or fragmented

- fuses 2-3 yrs after appearance

- apophysis does not enter cuboid-MT joint

 

2.  Os peroneum

 

3.  Os Vesalium

 

Os Vesalium

 

Non Operative Management

 

WBAT in moonboot

 

Randomised trial

- cast v soft dressings

- better outcome without cast

 

Operative indications

 

Displaced intra-articular fracture > 30% of articular surface / > 2mm step

- rare 

- aim to restore integrity of the cuboid MT joint

 

Surgery

- open / closed reduction with pinning/screws

 

Zone 2 

 

Definition

- transverse fracture of 5th MT shaft 1.5cm from base 

- at diaphysis / metaphysis junction

- goes into the 4th/5th MT joint

 

Aetiology

- adduction to forefoot

 

Non Operative

 

Undisplaced fracture

- NWB for 6-8/52

- xray healing occurs from medial to lateral

- lags behind clinical healing by weeks to months

- lack of clinical healing after 8-10/52 NWB is not unusual

- consider continued protection / cast immobilisation / surgery at that time

 

Quill OCNA 1995

- 1/3 went on to re-fracture

- argument for early surgery

 

Operative 

 

Indications

- displaced / athlete / non union

- 50% either do not heal primarily or refracture

 

Options

- IM screw / TBW / plate +/- bone graft

 

Zone 3

 

Definition

- diaphyseal stress fracture

- distal to 4/5 MT joint

- secondary to repetitive distraction force

 

X-ray

- cortical hypertrophy, narrowing medullary canal & periosteal reaction

- prolonged immobilization often required

- may take 20/52

 

CT

 

 

Management

 

NWB initially

 

Competitive athlete 

- bone graft & IM screw +/- USS

- NWB 6/52

 

Lareau et al Foot Ankle Int 2016

- 25 NFL players with acute Jones fracture

- Jones specific screw with BMAC from iliac crest

- average RTP of 8.7 weeks

- 12% refracture requiring revision surgery

 

Jones Screw 2

 

 

Surgical technique

- shaft of 5th MT is not straight

- entry point is high and medial to get straight shot

- may need to sequential increase cannulated drill size

- Jones specific screws 4.5, 5.5, 6.0 with low profile heads

 

Neck of 5th / Shaft metatarsal fractures

 

Fifth Metatarsal Neck Fracture

Navicular fractures

Types

 

1.  Dorsal lip fracture / Tuberosity fracture

- avulsion fractures

- most common

- beware avulsion T post

 

2.  Body fracture

 

3.  Stress Fractures

 

Body Fractures

 

Types

 

A.  Transverse fracture in coronal plane

B.  Transverse from dorsolateral to plantarmedial

C.  Central or lateral comminution

 

Displaced Navicular FractureDisplaced Navicular Fracture

 

Management

 

ORIF if displaced

- aim to restore TNJ

- 70% satisfactory reduction

 

Complications

 

Stiffness

- lose some inversion / eversion as part of STJ

AVN 30%

OA

 

4. Stress fracture

 

History

 

Pain

No distinct trauma

 

Xray

 

Navicular Stress Fracture

 

CT

 

Navicular Fracture CT

 

Issue

 

Can go on to displaced nonunion

 

Navicular Stress Fracture DisplacingNavicular Stress Fracture Nonunion

 

Management

 

1.  Strict NWB in boot

- consider bone stimulator

 

2.  ORIF and graft

- if >50% of width of bone and failure of non-operative management

 

Navicular Stress Fracture UnionNavicular ORIFNavicular ORIF Union

 

 

 

Foot Tumours

Benign Bone Tumours

1. Giant cell tumour

 

Often present with a painful swollen area, lytic on X-ray

- calcaneus > talus

- rare in skeletally immature

- curettage and grafting

- local recurrence ~50 %

- may need to bone graft defects

 

2. Osteochondromas

 

Can occur in foot and ankle

- single or multiple

- simple excision at base

- malignant transformation very rare in foot

 

Subungal exostosis 

- under the toenail (esp 1st)

 

3. Osteoid osteoma

 

Especially in hindfoot

- difficult to diagnose on x-ray

- CT / MRI / bone scan

- excision / RF ablation (CT guided)

 

Osteoid Osteoma 2nd Toe Bone ScanOsteoid Osteoma 2nd Toe CTOsteoid Osteoma 2nd Toe MRI

 

4. UBC

 

Infrequent in foot

- calcaneum

- UBC can become symptomatic from stress fractures

- treat with curettage and BG

 

5. ABC

 

Originate in metaphyseal bone

- MT most common foot site (also calcaneus)

- treat with curettage and BG / excision

 

Foot Aneurysmal Bone CystFoot ABC MRIFoot ABC Excision and Autograft

 

 

Benign Soft Tissue Tumours

Assume all malignant until proven otherwise

 

1. Ganglion

 

Foot GanglionAnkle ganglion MRI

 

Mucoid degeneration of a joint capsule or tendon sheath

- may fluctuate in size or disappear

- firm subcutaneous nodule

- may be painful, especially if compressed

- often transilluminate

 

Treatment

- observe

- multiple aspirations / cortisone injections

- surgical excision

 

Surgical excision

- need to find neck

- may arise from AKJ / STJ / T post tendon

- tie off neck or excise segment of capsule

 

Foot Ganglion 1Foot Ganglion 2Foot Ganglion Neck 1

 

Foot Ganglion Neck 2Foot Ganglion Neck 3

 

2. Plantar fibromatosis

 

Most common soft tissue tumour in the foot

- see other notes

 

3. Fibroma

 

Discrete nodule of well differentiated fibroblasts

- on sole or dorsum

- slow growing

- pain uncommon

- usually subcutaneous, firm, not attached to skin

 

Treat

- local excision if required

(recurrence rare)

 

DDx

- Fibrosarcoma

- Plantar fibromatosis

 

4. Giant cell tumour of the tendon sheath

 

Ankle Giant Cell TumourAnkle Giant Cell Tumour

 

Usually in tendon adjacent to ankle (can be anywhere)

- well defined firm nodule with an obvious capsule

- not always painful

- pain with direct pressure

 

Treatment

- observe (may involute)

- surgical excision (recurrence rare)

 

5. PVNS

 

Common around the ankle or midfoot

- may involve multiple bones

- usually in young adults

 

X-ray

- may show bony erosions

- brown villonodular synovium

 

Treatment

- excision include complete synovectomy

- recurrences common but not all symptomatic

- DXRT if severe

 

6. Lipoma

 

Most common on dorsum

- subcutaneous

- soft feeling / mobile / grape like

- painless unless compressed

 

Treatment

- marginal excision

(local recurrence rare)

 

7. Neurilemmoma

 

Benign schwannoma

- well encapsulated solitary tumour

- originates from nerve sheath

- slow growing

- nerve fibres spread over its surface

- painful if compressed or causes compression

 

MRI

- hyperintense rim on T2

 

Management

- separate nerve fascicles

- excise neurilemmoma

- marginal excision

- attempt to preserve normal nerve fibres

 

8. Neurofibroma

 

Singular or multiple

- extend along course of the nerve 

- 1/2 not associated with NF

 

Often local pain especially with compression

- may affect distal nerve function

- malignant change rare in solitary lesion (occurs with NF)

 

MRI

- target sign

- can be seen with neurilemmoma

 

Treatment

- tumour arises from within the nerve

- excision usually cause further loss of function

 

9. Solitary Hemangioma

 

Present with episodes of dependent swelling

- often after local trauma

- diffuse edges / can be difficult to palpate

 

Diagnose on MRI

- hyper-intense on T2 FS

 

Treatment

- only needs excision if limits function

- often incomplete - recur

 

10. Glomus tumour

 

Presents as painful toe, sensitive to cold

- pain with local pressure

- usually subungual

 

X-ray

- may scallop adjacent bone on x-ray

 

Treatment

- marginal excision for pain

Malignant Bone Tumours

1. Osteosarcoma

 

Second / Third decade, M>F

- calcaneal

- diagnosis often delayed

- treat with radical resection

 

2. Chondrosarcoma

 

Middle age or older

- slow growing

- malignant change of osteochondroma / enchondroma

- treat with wide / radical resection

 

3. Ewing's

 

Lytic expansile mass in a MT

- can be anywhere

- Treat with wide resection / chemo / DXRT

 

4. Metastatic Tumours

 

Infrequent

- <1% all bony metastases

- often lung

- often below the diaphragm (i.e. ovarian)

 

Malignant Soft Tissue Tumours

Epidemiology

 

Most common malignant tumour

- malignant melanoma

 

Most common sarcoma

- synovial sarcoma 50%

- consider it for every foot lump

- most in dorsum and hindfoot

 

Foot and ankle considered single compartment

- Enneking staging

- unless tumour confined to singe ray

 

1. Synovial Sarcoma

 

Consider it for every foot lump

 

Diagnosis often delayed

- varied presentation

- slow growing firm fixed mass

- indolent course

- small latent mass with period of rapid growth

- rapidly growing mass

- painful (even before mass) or painless lump

 

Peak incidence 20-50

 

Spread via lymphatics (rare for sarcoma)

 

X-ray

- soft tissue mass (+/- Ca++)

 

MRI

- aggressive on appearance

 

Prognosis

- size can predict outcome

 

Treatment

- wide / radical excision +/- DXRT

- ? role of chemotherapy

 

2.  Malignant melanoma

 

Common in  the foot

- often in junctional naevi

 

Treatment

- wide excision

- depth of lesion most important prognostically

- assess lymph nodes

 

3. Subungal melanoma

 

Less aggressive than other MM

- present with loss of the nail

 

DDx

- haematoma

- mark nail with knife

- return 2 weeks later

- if melanoma the pigment will be in same position and the mark on the nail will be distal

 

Treatment

- toe amputation

- assess lymph nodes

 

4. Clear cell sarcoma

 

Highly malignant

- common in foot and ankle (43%)

- usually 2nd/3rd decade

- wide excision +/- chemotherapy

 

5. Epithelioid sarcoma

 

Innocuous nodule on the dorsum of the foot in young adults

- wide  / radical excision

- lymphatic & haematogenous spread

 

6. Hemangioendothelioma

 

Vascular tumor in bones or soft tissue

- any age

- multiple on same extremity

- wide excison +/- DXRT

- long follow up for all

- difficult to predict which will behave aggressively

 

7.  Acral Myxoinflammatory Fibroblastic Sarcoma

 

DDx ganglion, GCTTS, tenosynovitis

- low grade

- don't metastasise but can recur locally

- marginal excision

 

8.  Fibrosarcoma

 

Prognosis depends on histological grade

- wide / radical excision

- in childhood need less aggressive treatment

 

 

 

 

Plantar Fibromatosis

Definition

 

Fibrous proliferative lesion in plantar fascia

 

Epidemiology

 

Male, white, middle age

 

May arise in isolation

 

Association Dupuytren's Diathesis

- aka Lederhosen disease

 

Pathology

 

Proliferative Fibroblastic lesion

- May resemble fibrosarcoma histologically

 

Histology

 

Heavy strands of relatively acellular mature collagen

 

Enneking 3 Stages

- proliferative phase

- involutional (active) phase 

- final (residual) phase

 

History

 

Present with lump in foot

 

Often painless

- unlike Dupuytren's there is no inflammatory proliferative phase

- asymptomatic through growth

 

Examination

 

Tender subcutaneous nodule found in the medial half of the middle plantar fascia

- rarely causes contracture

 

DDx

 

Ganglion cyst

Neurofibroma / neurilemmoma

Fibrosarcoma / any of the other sarcomas

 

Rheumatoid nodule

 

Melanoma

Sweat gland carcinoma

 

MRI 

 

Useful

- T1 - low SI

- T2 - low or medium SI

 

Management

 

Non Operative

 

Observe if not symptomatic

 

Symptomatic

- padded shoes and orthoses

- transfer weight away

 

Operative

 

Indications

 

1.  Relieve associated symptoms from local extension & invasion

- may invade NV structures

2.  Pain when weight bearing

 

Problems

 

May recur after excision

- usually after incomplete / simple excision

- can recur & become locally invasive

- doesn't metastasise or become locally destructive

 

Technique Wide resection

 

Position

- prone

- tourniquet

 

Incision

- S shaped

- avoid 1st MT head

- avoid weight bearing arch

- minimise disruption of blood supply

- usual medial longitudinal incision interrupts most of the arterial supply to the skin beneath the longitudinal arch

 

Block resection of plantar fascia 

- 2 cm normal fascia proximal and distal

- entire width

- lateral plantar nerve is adherent to fascia on lateral side

 

Recurrence 

 

Consider radiotherapy

 

 

Great Toe

Dislocation

Epidemiology

 

Uncommon

- dancers

- athletes

 

Aetiology

 

Hyperdorsiflexion of the MTPJ

 

Pathology

 

MT head dislocates plantar

- may buttonhole through capsule

- can prevent closed reduction

 

Blocks to Reduction

 

1.  Sesamoids

2.  Conjoint tendon

3.  Intersesamoid Ligament

 

Management

 

Closed Reduction

 

Open Reduction

 

Dorsal Approach

- protect dorsal superficial nerve

- divide capsule medial to EHL

- may need to divide intersesamoid ligament

- may need to divide adductor hallucis

 

 

 

Hallux Rigidus

Definition

 

Painful restriction of dorsiflexion of the great toe 

- secondary to degenerative changes in MTPJ

- initially pain and synovitis

- osteophytes don't form medially or on plantar aspect

 

Epidemiology 

 

Two peaks

1.  Adolescence F > M

2.  Middle Age M > F

 

Aetiology

 

Often Idiopathic

 

Trauma

- OCD

- hyperextension injuries

 

Anatomical

- pronated foot

- abnormally long 1st MT

- pes planus

- DF 1st ray

 

Inflammatory

- gout

- CPPD

- inflammatory arthropathy

 

History

 

Pain on walking

- especially slopes & rough ground

- pain may become continuous

 

Numbness 

- compression of dorsomedial cutaneous nerve

 

Examination

 

Shoe shows excessive lateral wear

- toe off on lateral border 

- patient avoids dorsiflexion

 

Look

- hallux is usually straight

- MTPJ is enlarged

 

Feel

- synovial thickening

- palpable dorsomedial osteophyte & bunion 

- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes

 

ROM

- DF restricted & painful N = 90°

- PF often reduced and painful N = 30°

 

X-ray

 

Changes of osteoarthritis

- dorsomedial osteophyte

- joint space narrowing

 

Great Toe Dorsal OsteophyteHallux Rigidus Dorsal Osteophyte

 

Management

 

Non Operative

 

Options

 

Education & Reassurance

 

Orthotics

- initially stiff soled shoes

- rockerbottom sole

- high toe box

 

NSAID

HCLA

 

Operative

 

1.  Moberg Osteotomy

 

Indication

- young patient with mild OA & > 30° PF

 

Technique

- dorsal closing wedge osteotomy of P1 

- converts PF range into functional DF

 

2.   Cheilectomy

 

Mann 1988 JBJS

 

Concept

- removal of dorsal osteophytes

- increase painless DF range (average 20°)

 

Great Toe Cheilectomy

 

Indication

- for adults with minimal degenerative changes

- normal joint space in plantar half MTPJ

 

Disadvantage

- recurrence of pain

 

Technique

- dorsal incision over MTPJ

- joint incised either side EHL

- synovectomy

- remove ~ 1/3 of dorsal MT head

- remove osteophytes from base of P1

- need DF of ~ 90°

- stiff shoe till ROS

- then flexible sole and ROM exercise

 

3.  Arthrodesis

 

Great Toe MTPJ OAGreat Toe MTPJ Fusion APGreat Toe MTPJ Fusion Lateral

 

Indication

- adults with significant degenerative changes

 

Disadvantage

- lateral transfer metatarsalgia

- IPJ OA

- malposition

- limitation of footwear type

- non-union

 

Technique

- dorsomedial approach

- protect dorsal cutaneous nerve

- mobilise EHL laterally and open capsule

- divide collaterals

- free P1 of soft tissue attachments

- 15° valgus

- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft

- dorsal plate / crossed screws

 

Results

- 30% develop asymptomatic OA IPJ

 

Hallux Rigidus Fusion 2 screws APHallux Rigidus Fusion 2 screws Lateral

 

4.  Interpositional Arthroplasty

 

Indication

- severe OA & moderate demand

- minimal bone resection

 

Technique

- imbricate dorsal & volar capsule into joint space

 

5.  Swanson Arthroplasty

 

Indication

- adults with low demands

 

Disadvantage

- breakage

- silicon synovitis

- very difficult to salvage

 

6.  Keller's Procedure

 

Indication

- for elderly with low demands

 

Disadvantages

- lose windlass mechanism

- transfer metatarsalgia

- cosmetically poor

- drifts into both DF & valgus / Cock Up deformity

 

 

Hallux Valgus

Background

DefinitionHallux Valgus Severe

 

Bunion

- medial prominence of head of 1st MT

 

Hallux Valgus

- medial deviation 1st MT

- lateral deviation of great toe

 

Anatomy

 

Metatarsal head

- has 2 grooves separating ridge (cristae)

 

Sesamoid

- in each tendon of FHB

- sesamoids attach to P1

- no attachment to MT head

- sesamoid ligaments attach to sesamoids and plantar plate

- FHL passes plantar to the plate & between the sesamoids

 

Plantar plate

- formed by

- FHB / Abd. Hall / Add. Hall / Plantar aponeurosis /  capsule

 

Sesamoids and plantar plate stabilised

- abductor hallucis (medial)

- adductor hallucis & trans metatarsal ligament (lateral)

- insert into sesamoids & Base P1

- no muscles insert into head MT

 

Collateral ligaments

- from head of MT to base of P1

- insert into sesamoids

 

Biomechanics

 

Great Toe provides stability to the medial aspect of the foot

 

Windlass mechanism of plantar aponeurosis

- plantar aponeurosis arises from tubercle of calcaneum

- medial slip inserts into base of proximal phalanx via sesamoids

- as body passes over foot, P1 forced into DF & slides over MT head

- plantar aponeurosis winds around MT head & plantarflexes the 1st MT

- creates arch

 

In hallux valgus, windlass is less effective

- results in transfer of weight to lateral aspect of foot

- especially second MT head

 

Blood Supply

 

3 main

- 1st dorsal and plantar metatarsal artery

- superficial branch of medial plantar artery

 

Medial

 

Medial plantar artery

- remains plantar to the MT until the level of the neck when it runs obliquely dorsally

- divides into the medial cervical branch, and the medial sesamoid branch

 

Lateral

 

First plantar MT artery

- is formed by the deep plantar arch and a perforating branch from the DPA

- runs distally in the 1st MT space

- nutrient artery to neck (variable)

- cervico-sesamoid branch (constant)

 

Lateral Cervical branch

- enters plantar surface at base of neck

- supply major part of head

- care in not stripping under the neck to preserve the cervical branch

 

Dorsolateral

- small branch from DPA

- penetrates the dorso-lateral capsule near margin of  articular cartilage

- not big enough to provide sole supply

- can be sacrificed if needed

 

Characteristics

 

Great toe

- lateral deviation of the great toe  (HVA > 15o)

- medial deviation of the first metatarsal  (IMA > 9o)

- +/- subluxation of the first MTPJ

- hallux pronation

- prominent mediation eminence

- sesamoid rotation / uncovering

 

Lesser toes

- overriding of the second toe

- metatarsalgia

- lesser toe hammer & claw

 

Epidemiology

 

Two ages of presentation

 

1.  Adolescent form

- usually bilateral

 

2.  Adult form ~ 50's

- strongly familial

- positive FHx in 2/3

- F > M

- F:M = 9:1 in those needing operations

 

Aetiology

 

Likely multifactorial

 

1.  Shoe Wearing

 

Evidence

- more women are affected

- women's shoes are tight-toed

- unshod 2% vs 33% shod

- unshod toes separate on weight bearing

- in shoes, toes crowded & hallux abducted

 

2.  Hereditary

- usually strong FHx

- tend to present earlier

- AD with incomplete penetrance

- made worse by female's shoe wear

 

3.  Generalised Ligamentous Laxity

- splaying of forefoot

- excessive mobility of 1st TMT

- laxity of medial capsule of MTPJ

 

4.  Anatomical factors

 

Metatarsus Primus Varus

- associated with HV

- especially adolescent variety

 

Metatarsus Varus

 

1st MT

- long / short

- hyper pronated

 

2nd Toe amputation

- loss of lateral support for great toe

 

MTPJ

- rounded joint

 

TMTJ

- hypermobile

- medially slanted

 

Flatfoot

 

Short achilles tendon

 

5.  Pathological Conditions

 

Rheumatoid arthritis

- leads to loss of capsular support

- RA best treated with fusion

 

Neurological conditions

- CP best treated with fusion

 

Pathology

 

A.  Congruent MTP joint

 

Cause

- increased DMAA 

- Hallux valgus interphalangeus

 

Present

- enlarged medial eminence (bunion)

- pressure against shoe

- painful bursa or cutaneous nerve

 

Management

- MTP joint usually stable & won't sublux

- can’t do distal soft tissue release

- will sublux a congruent joint

 

B.  Incongruent MTPJ

 

Hallux Valgus Incongruent Joint, ex

 

Subluxed MTPJ

- usually progressive

 

Origin

- starts with lateral pressure on great toe

- tight high heels

- P1 moves laterally

 

Progression

- PI moves laterally & puts pressure on MT head

- moves it medially, thus increasing intermetatarsal angle

- attenuation of medial joint capsule

- sesamoid sling held in place by ADDH & transverse metatarsal ligament

- MT head moves further medially / varus deformity

- slides off sesamoids

 

Final deformity

- appearance of lateral migration of sesamoids

- however sesamoids maintain constant distance from second MT

- lateral sesamoid lies beside MT head in intermetatarsal space

- ADDH pronates the great toe

- medial extensor hood / capsule stretched

- EHL & FHL comes to lie lateral to MTPJ

- finally, lateral capsular structures become contracted & the deformity becomes fixed

 

C.  Medial Eminence

- MT head changes occur

- groove or medial sagittal sulcus develops at medial border of articular cartilage

 

D.  Bunion

- callosity of skin + bursa

 

E.  Lesser Toes

- MTP less stable & weight transferred to MT 2 & 3 -> callosities

- great toe may drift beneath 2nd toe

- alternatively, 2nd toe may subluxate laterally

- lateral toes become crowded

- often develop claw or hammer deformity

- increased weight bearing through middle MT heads may lead to metatarsalgia

- worse with clawing of lesser toes

 

History

 

Pain

- over medial eminence (75%)

- metatarsalgia under lesser toes

- degeneration of sesamoid joint

- dorsal aspect osteophytes / rigidus

 

Shoe problems

- wide foot

- difficulty fitting shoes

 

Secondary deformity of lesser toes

- especially hammer deformity of the second toe

- rubbing of the PIPJ on shoe

 

Cosmetic appearance

 

Examination

 

Hallux Valgus Clinical

 

Standing

- bunion

- HV

- clawing / hammer toes

 

Assess ROM ankle and STJ

- tight T Achilles

 

Look at wear patterns on foot

- callosities under 2/3 MT head

 

MTPJ

- tender bunion

- painful MTJP

- correctable / ROM correctable

- pain over sesamoids

 

TMTJ

- hypermobility

- > 9mm abnormal

 

Lesser toes

- deformity / correctable

 

Neurovascular examination

           

Weight Bearing AP X-ray

 

1.  Hallux Valgus Angle / MTPA

- metatarso-phalangeal angle

- normal < 15o

 

Hallux Valgus MTPA > 40

 

2.  Intermetatarsal angle/ IMA

- normal < 9o

 

Hallux Valgus Intermetatarsal Angle > 20 degrees

 

3.  Congruence

- place dots

- medial & lateral edges of the articular surfaces of the MT head & P1 base

- assess to see if line up / joint congruent

 

Hallux valgus Incongruent Joint

 

4. Interphalangeal angle

- normal is <10°

- identify hallux interphalangeus

 

5.  DMAA

- distal metatarsal articular angle

- normal < 6o

 

Hallux Valgus Increased DMAA

 

5.  Sesamoid subluxation

- amount of lateral sesamoid uncovered by MT

- medial sesamoid should not cross midline axis of MT

 

Hallux Valgus Lateral Sesamoid Uncovered

 

6.  MTPJ OA

 

7.  Size of the medial eminence

- amount of MT head medial to the line along the medial border of the MT

 

8.  TMT Angle

- medial sloping

 

Hallux Valgus Medial Sloping TMTJ

 

Mann Classification  

 

1.  Congruent

 

2.  Incongruent

 

A.  Mild

 

MTPA < 30°

IMA < 15°

Lateral sesamoid < 50% uncovered

 

Hallux Valgus Mild

 

B. Moderate

 

MTPA 30 - 40°

IMTA 15 - 20o

Lateral sesamoid 50 - 75% uncovered

 

C. Severe

 

MTPA > 40°

IMTA > 20°

Lateral sesamoid > 75% uncovered

 

Hallux Valgus Severe Unilateral

 

3.  Degenerative

 

Hallux Valgus Severe Degenerative

 

Management

Non-Operative

 

Education regarding shoe wear

- extra wide / large toe box

 

Insoles

- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities

 

Toe spacers

 

Analgesia

 

Operative

 

Indications

 

1.  Continued pain and discomfort

2.  Difficulties with shoe wear

- split size shoe requirements 

- difficulty fitting shoes

- only 60% wear "fashionable" shoe post-op

3.  Deformity of lesser toes

4.  Skin problems

5.  Cosmetic appearance – relative indication

 

Contra-indications

 

Poor peripheral arterial circulation

Current sepsis

Uncontrolled diabetes

Peripheral neuropathy (relative)

 

Aims

 

1. Correction of the hallux valgus and intermetarsal angles 

2. Creation of a congruent MTP joint

3. Sesamoid realignment

4. Removal of the medial eminence

5. Retention of functional range of motion of the MTPJ

6. Maintenance of normal weight bearing mechanics of foot

 

Surgical Options

 

Congruent

 

1. DMAA  < 15°

- treat hallux interphalangeus

- Akin with exostectomy

 

2. DMAA > 15°

- Chevron with closing wedge

 

Incongruent

 

Mild

- Chevron

- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy

 

Moderate

- DSTP & proximal osteotomy

- Scarf

 

Severe

- DSTP & proximal osteotomy

- arthrodesis

 

Rheumatoid

 

Mild to Moderate / Low demand

- arthroplasty

 

Severe

- arthrodesis

 

Hypermobile TMTJ

- fusion (Lapidus) & DSTP

 

Surgical Procedures

 

1.  Chevron

 

Hallux Valgus ChevronGreat Toe Chevron

 

Indications

- incongruent joint

- HVA < 30o / IMA < 15o

- patient < 60 years

 

Technique

 

Avoid lateral release = AVN 40%

 

Approach to Hallux Valgus

 

Dorsomedial approach in internervous plane

- don't go directly medial as will get sensitive scar

- protect dorsal sensory nerve

- distally based "V" capsular flap

- expose MTP joint

 

Exostectomy

- remove medial eminence with saw

- leave 1- 2 mm medial to medial sulcus

- otherwise risk hallux varus

 

60° osteotomy apex distal

- longer plantar limb to avoid sesamoids and inferior joint surface

- apex 1 cm from articular surface

- translate 5mm

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA

 

Fixation

- not always necessary

- sutures / k wire / screw

 

Closure

- imbricate capsule

- advance to tighten medially

 

Second toe releases as needed

 

Post op

- bandage / POP to maintain correction

- check wound at 1 week

- bunion boot / heel walk

- toe spacer

- 6/52

 

Hallux Valgus Toe Spacer

 

Results

 

GE 75% if IMA >12° 

GE 95% if IMA <12°

 

Complications

 

AVN is rare

- ensure apex 8-10 mm from articular surface

- avoid DSTP

 

2.  Distal Soft Tissue Procedure

 

Hallux Valgus Pre DSTPHallux Valgus Post DSTP

 

Modified McBride

- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)

- medial exostectomy (just medial to sagittal sulcus)

- medial capsular plication

 

(Modification: no longer excise sesamoid)

 

Indications

- mild HV with incongruent joint

- severe HV when combined with proximal osteotomy

 

Technique

 

1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence

 

2.  Incision first web space

- protect branches of DPN

- insert lamina spreader

- release ADD hallucis at P1

- cut capsule between sesamoid and MT

- divide transverse MT ligament



Results

 

92% good results

 

Complications

 

Nerve injury

- plantar cutaneous nerve

 

Hallux varus

- from releasing lateral FHB from sesamoid

 

3.  Proximal Osteotomy + DSTP

 

Indications

- severe HV

- correct IMA with osteotomy

- correct HVA with DSTP

 

Results

- in combination with DSTP

- GE 90 %

 

Options

- crescentertic

- opening wedge (lengthens)

- closing wedge (shortens)

 

Opening wedge

- extend medial incision

- incomplete ostetomy with saw at base MT

- use bone from bunionectomy to fill gap

- fixation with small plate

 

4.  Scarf

 

Indications

- moderate HV

- see separate technique

- technically challenging but good results

 

5.  Akin

 

Indications

- congruent joint

- DMAA < 15o

- hallux interphalangeus > 10o

- residual HV after other procedures

 

Technique

- medial closing wedge osteotomy of P1

- combine with cheilectomy

 

6.  Keller Procedure

 

Technique

- resection 1/3 of proximal phalanx

- should use pin to stop cock up deformity & to stiffen joint

 

Indications

- housebound / non ambulator

- elderly

- salvage

- marginal circulation - DM / PVD

- hallux rigidus if cheilectomy or arthrodesis contra-indicated

 

Complications

- instability / cock up deformity

- transfer metatarsalgia (in young)

 

Results

- 80% good results

 

7.  Arthrodesis

 

Indications

- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- RA

- salvage procedure for failed procedures

 

Position

- 15º valgus

- DF 10º relative to plantar aspect of foot

- DF 30° relative to ray

 

Technique

- dorsomedial approach

- release EHB / mobilise EHL / release collaterals

- Coughlin male and female reamers

- secure with cross screws or plate

 

Hallux Valgus Arthrodesis

 

8. Lapidus Procedure

 

Hallux Valgus SevereHallux Valgus Proximal Osteotomy and Lapidus

 

Indications

- TMTJ hypermobility

- fusion TMTJ

 

Problems

- difficult to achieve union

- difficult to get position correct

 

Joint multiplanar

- malrotation poorly tolerated

- shortens medial column

- can get metatarsalgia

 

Technique

- slight plantar flexion and lateral deviation

 

Lapidus APLapidus Lateral

 

Complications of Surgery

 

Transfer Metatarsalgia

 

Recurrence

- incorrect surgery

- poorly performed surgery

- high risk groups i.e. adolescent

 

Nerve injury

- dorsal and plantar cutaneous nerve

 

Cock up Toe

 

Cause

- post Keller’s

 

Management

 

Arthrodesis MP joint

- shorten if don't use graft

- fusion rate 95% (BG) vs 70% (no BG)

 

Hallux Varus

 

Cause

- excessive medial resection

- resection of fibular sesamoid

- excessive lateral release or medial plication

 

Clinical

- not always painful

- cosmetically unacceptable

- difficulties with shoe wear

- cockup deformity

- with time stiffens in extension & medial deviation

 

Options

- soft, well fitting shoe

- arthrodesis

- soft tissue reconstruction

 

EHL Reconstruction           

- lateral two thirds of the tendon removed from its insertion

- detached distally, passed under transverse ligament

- inserted into proximal phalanx

 

AVN

 

Rarely seen in Chevron

- due to disruption of volar blood supply

 

Great Toe AVN Post Chevron

 

Management

- arthrodesis / excise avascular fragment and shorten toe

Scarf Osteotomy

Technique

 

A.  Longitudinal Cut

- plantar proximal / dorsal distally

- ends up being parallel to sole

- leave strong plantar portion of head to prevent dorsiflexion

- mark centre of head

- distally to a point 2mm prox and 3mm above the centre of the head

 

B.  Transverse cuts

- plantar proximal / dorsal distal

- angle of 45o with the long cut

- directed slightly proximal (10-15o) to aid displacement

 

Displacement

 

A. Transverse plane

- Primary direction of displacement

- can be up to ¾ of the surface as the strong lateral strut is preserved

- lateral rotation should be avoided as it increases the DMAA

- medial rotation can be used (to improve DMAA) but limits the amount of lateral displacement

 

B. Frontal plane

-  Lowering of the 1st MT head is achieved via the obliquity of the transverse cut

-  It will act to relieve metatarsalgia

 

C. Sagittal plane

- Lengthening can be done but tends to increase soft tissue tension and lead to stiffness

- shortening can be readily achieved by

- increasing the obliquity of the transverse cuts (max shortening 3mm)

- resecting ends of prox  / distal fragments (doesn’t elevate head as II to sole)

 

Fixation

 

Cannulated screws over K wires

 

A. Distal

- start lateral where the bone is string and allows medial resection

- aim obliquely into the MT head

- screw to end 2mm prox to cartilage

 

B. Proximal

- important to respect the lateral part of the fragment to avoid fracture

- aim transverse from dorso-medial to plantar-lateral

 

The corner is then taken off the proximal fragment 

- rounded with rongeurs where bunion has been sliced off

 

 

Ingrown Toe Nail

Onychocryptosis

 

Aetiology

 

Improper nail trimming

Tight shoes & socks

Poor hygiene

Repetitive trauma to distal toe

Curved nail bed in elderly

 

Stages

 

1.  Inflammation

- painful irritation about embedded nail plate in lateral groove

 

2.  Infection

- overt infection with granuloma & discharge 

- starts as serous discharge then purulent

 

3.  Granulation

- stage 1 & 2 + chronic changes

- hypertrophy of lateral wall

- growth of epithelium over chronic granulation tissue 

 

Management

 

Stage 1 

- non-operative

 

Stage 2 

- oral ABx then non-operative

- if fails partial nail avulsion

 

Stage 3 

- often requires partial nail matrix ablation

 

Non Operative

- warm saline soaks x2 /day

- pledget under nail corner

- cleaning of lateral groove

- nail will grow 2 mm /month

- aim for nail plate that protrudes distal to hyponychium

 

Operative

 

1.  Wedge resection

 

Technique

- remove lateral part of nail

- partial ablation of nail matrix

- debulk tissue in lateral fold

 

Post op

- non adherent dressings 48/24 then warm soaks

- open toe box shoe 10/7

- 3-4 weeks before normal shoes again

 

Complications

- recurrence spicules nail plate 

- 5%

 

2.  Zadek's

 

Technique

- removal of nail plate 

- removal of entire germinal nail matrix proximal to lunule

 

3.  Terminal Symes procedure

 

Technique

- amputation of the distal half of the distal phalanx

- good for dystrophic and mycotic nails

- toe end appears bulbous

 

 

 

Juvenile Hallux Valgus

Epidemiology

 

More common in girls

High incidence of positive family history (75%)

 

Can be associated with mild CP

 

Pathology

 

Juvenile Hallux Valgus

 

Congruent joint

- 50% compared with 9% in adult HV

 

Metatarsus primus varus

- increased IM angle

- often the primary deformity

 

Epiphyses usually still open

 

Oblique first TMTJ Angle

 

Ligamentous Laxity

 

Difference from Adult HV

 

Less severe

- no arthrosis

- sesamoid subluxation & pronation less common than in adult

- medial eminence not as prominent

- HVA not as big a contributor

 

Examination

 

Ligamentous laxity

 

T Achilles tightness

 

TMTJ hypermobility

 

Neurological examination

 

X-ray

 

Normal Angles

- HV < 15o

- IMA < 9o

- DMAA < 10o

 

Often DMAA increased

 

Management

 

Non-operative

 

Delay any surgery until

- adolescence

- physis closed (but not CI if open)

 

Well fitting shoes

 

Flexible flat foot may benefit from medial arch support

 

Operative 

 

Aims

- reduce DMAA

- reduce IMA

 

Congruent joint 

- less likely to progress (therefore treat conservatively)

- requires extra-articular realignment

 

Options

 

1.  Double or triple osteotomies

 

A.  Akin / proximal phalangeal osteotomy

- corrects interphalangeal angle

 

B.  Chevron biplanar distal metatarsal osteotomy

- adjust DMAA by adding closing wedge osteotomy

 

C.  Proximal metatarsal osteotomy

- further corrects IMA

 

2.  Hypermobile TMTJ common

- Lapidus procedure

 

Hallux Valgus Lapidus Procedure

 

3.  1st Cuneiform Opening Wedge Osteotomy

- severe IM angle with open 1st metatarsal epiphysis

- marked M-C joint obliquity with high IM angle

- opening wedge (iliac crest graft)

 

Complications

 

20% recurrence rate

- failure to correct IMA

 

Hallux varus 

- split extensor hallucis longus transfer

 

AVN 

- rare even in combined distal procedure

 

 

 

Onychomycosis

Definition 

 

Fungal infection of the nail

 

Epidemiology

 

Toenail affected 4x more common than fingernail

Prevalence has increased x 4 in last 2 decades

 

Aetiology

 

Dermatophytes most common cause

 

99% T rubrum & T mentagrophytes

- destroy nail by chemical or enzymatic process

 

Pathogenesis

 

First

- keratin of hyponychium is infected by the dermatophyte

 

Second

- involves nail bed & nail plate

- initially invades ventral plate which arises from nail bed

- intermediate plate has soft keratin & can become involved

- dorsal nail plate rarely involved

 

Clinical

 

Usually cosmetic problem only

- may become painful

 

Diagnosis

 

Microscopy of nail scrapings & culture studies

-> hyphae

- can culture if necessary

 

Management

 

Non-operative

 

Debride & remove part or all of nail

 

Topical agents less effective than systemic because don't target matrix

 

Oral antifungals 

- griseofulvin & ketoconazole (need up to 1 year of treatment)

- terbinafine (Lamasil) & itraconazole (Sporanox) 

- more effective with shorter treatment (3-6m)

- remain in the nail for 6 months

 

Operative

 

Zadek's

Terminal Syme amputation

 

Sesamoids

Anatomy

 

3 Sesamoids may be present in great toe

- 2 almost always present on plantar aspect of MTPJ

- 1 may be present on plantar aspect of IPJ

 

MTPJ sesamoids most important

- embedded in FHB tendons

- held together by intersesamoid ligament & plantar plate

- each side of crista / inter-sesamoid ridge

- articulate with plantar facets of 1st MT

 

Tibial usually larger than fibula

 

Tibial more impacted in weight bearing than fibula

- higher incidence traumatic injury to tibial

 

Insertions

- FHB

- Adductor hallucis

- Abductor hallucis

- Plantar plate

- Intersesamoid Ligament

- Plantar aponeurosis

 

Orientation

- Proximal to MT head in stance

- Pulled under MT head with DF / toe off

 

Ossification

- between 7-10 years

- often multiple centers 

- may result in bipartite / tripartite appearance

 

Bipartite

- fibular rare

- tibial bipartite in ~ 10% 

- bilateral in ~ 25% of these

- congenital absence - one or both

 

Bipartite Sesamoid

 

Blood Supply

 

Type A 50% medial plantar artery and plantar arch

Type B 25% plantar arch

Type C 25% medial plantar artery

 

Increased risk of AVN if only single vessel into sesamoid

- which is seen in Type C more commonly than B

 

Functions

- absorb weight bearing pressure

- reduce friction

- protect tendons

- act as fulcrum to inc mechanical force of FHB

- Sesamoids and Collats provide medial / lateral stability of 1st MTPJ

 

History

 

Do not always present with symptoms directly referable to sesamoids

- generalized pain around Hallux

- pain after sudden pop or snap after running

 

Pain as hallux extends in terminal part of stance phase

 

Neuralgic symptoms or numbness if digital nerve compressed 

 

Examination

 

Local tenderness

Decreased strength on PF

Pain on passive DF

Loss of active & passive DF

 

Cavus foot

- plantar flexed 1st ray 

- excess axial load on sesamoid

 

Imaging

 

Standard lateral not very useful

- AP, medial oblique, lat oblique, axial

 

Bone scan 

 

Projection important to differentiate sesamoids from MTPJ

- may be obscured by AP scan

- PA or oblique with Collimation useful for DDx

- caution with increased uptake in ~25% of asymptomatic patients

- marked difference to contralateral side significant

 

MRI 

 

Useful for Osteomyelitis

 

CT 

 

Useful for post-traumatic changes 

- compared with contralateral side

 

Conditions

 

1.  Fracture

 

Difficult to differentiate from symptomatic multipartite sesamoid

- especially if fracture through bipartite 

- comparison X-ray with contralateral foot 

- MRI & bone scan with pin hole collimation useful

 

 Fractured SesamoidSesamoid Fracture CT

 

Non operative management

- initial treatment

- orthosis / dancer's pad / cast / MT bar

- especially stress fracture

 

Surgery

- excision of most comminuted fragment or entire sesamoid

- preferred over bone graft in most cases

- consider graft for athletes

 

2.  Osteochondritis

 

Infrequent

- osteonecrosis with regeneration & calcification may be present

- may be enlarged / deformed / sclerotic with mottling / fragmentation

 

3.  Infection

 

Rare except diabetic neuropathy

- Pseudomonas relatively common 

 

4.  Sesamoiditis

 

Repetitive trauma especially teens / young adults

- Inflammation & bursal thickening may be present

 

5.  Osteoarthritis

 

May be in conjunction with MTPJ OA / RA / Gout

 

Management

 

Stiff soled or rocker bottom shoe + MT pad

 

Sesamoidectomy

- may decreases pain

- Don't remove both

- leads to clawing of hallux

 

6.  Intractable Plantar Keratoses

 

Usually caused by

- sesamoid with plantar located osseous prominence

- plantarflexed first metatarsus / cavus

 

Management

 

Intractable lesions

- sesamoid shaving or resection

- avoid shaving if 1st MT is plantarflexed

- consider basilar dorsiflexion osteotomy

 

7.  Nerve Impingement

 

Impingement of medial branch plantar digital nerve on medial sesamoid

 

Sesamoidectomy

 

Principles

 

1.  Never excise both 

- high incidence of Hallux Valgus or Cock Up deformity

2.  Never make incision directly over sesamoid

3.  Always repair adductor if excising lateral sesamoid

 

Produce mechanical defect in FHB unit

- can excise up to 2/3 of either without disturbing ligamentous attachments

- may relieve pain without disrupting FHB mechanism

 

Tibial 

 

Tibial sesamoid excision

- 3cm plantar medial incision

- Medial branch plantar digital nerve identified & retracted

- Locate sesamoid by palpation

- Flex hallux 20-30o & retract FHL

- Incise inter-sesamoid ligament & pull sesamoid medial

- Shell out from capsule & plantar plate with knife

- Imbricate capsule

 

Tibial sesamoid shaving

- Plantar medial approach

- Excise plantar 1/2 with microsagittal saw

- Smooth with rongeur

 

Fibular

 

Approach

- either dorsal or plantar approach

- dorsal demanding due to depth

- plantar - NV bundle & FHL to negotiate  

 

Dorsal incision 

- from 2-3 cm proximal to web space

- Identify & protect branch SPN

- Interval between Adductor Hallucis & joint capsule opened

- Tendon of Add Hallucis reflected from lateral sesamoid

- Grasp sesamoid & divide inter-sesamoid ligament

- Release proximal & distal & excise

- repair adductor

- Close skin 

 

Plantar incision

- Flex hallux

- 4cm incision between MT 1 & 2

- Retract NV bundle either lateral or medial

- Locate FHL & open pulley over it

- Flex hallux to relax FHL & retract medially

- Divide inter-sesamoid ligament

- Excise proximally & distally

- Reattach cuff of FHB

- Consider oblique wire across MTPJ

 

Complications

 

Cock up toe

Hallux valgus or varus

Nerve injury

Fat pad disruption

Painful plantar scar if plantar incision

Turf Toe

Definition

 

Hyper-dorsiflexion injury to 1st MTP joint

 

Management

 

Grade 1 - Mild sprain

 

Symptoms

- minimal swelling / ecchymosis

 

Management

- return to play immediately

- RICE / NSAIDS

 

Grade 2 Partial tear plantar plate

 

Symptoms

- tender / swelling / ecchymosis

 

Management

- return to sport 1-2 weeks

- taping toe to prevent hyper-extension

- stiff soled shoes

 

Grade 3 complete tear plantar plate

 

Symptoms

- marked pain / swelling / ecchymosis / marked decrease ROM

- +/- sesamoid fracture / disruption of FHB

 

Management

- return to sport 3-6 weeks

- surgical removal of loose bodies

 

Unstable

- see proximal displacement of sesamoids

- require operative repair of plantar plate

 

Lesser Toes

Bunionette

Definition

 

Painful prominence of lateral eminence of 5th metatarsal head 

 

Coughlin Classification 

 

Type I deformity 

- prominent lateral condyle 5th metatarsal head

- lateral condylectomy

 

Type II deformity 

- lateral bowing of 5th metatarsal

- chevron osteotomy

 

Bunionette Type 2

 

Type III deformity 

- increased 4-5 IMA > 10° (N ~5°) 

- straight but laterally deviated 5th metatarsal

- midshaft osteotomy / Scarf

 

Type IV 

- combination (especially RA)

 

Clinical Features

 

Often leads to overlying corns & calluses

- lateral keratosis / plantar keratosis / combined

 

Bunionette

 

X-ray

 

4-5th IMA is normally 5°

5th MTPJ angle is 10°

 

Management

 

Non-operative

 

Pressure relief by padding

Shoe stretching

Changing to wider softer shoes

Broad-toed shoes & insole

Callus paring

 

Operative

 

Procedure depends on the underlying deformity

- true proximal osteotomies avoided due to blood supply 

- remember problems with Jones fracture

 

1. Lateral Condylectomy

 

Indications

- Type I deformity

- enlarged lateral metatarsal head

- no increase in IMA

 

2. Coughlin Proximal Osteotomy

 

Indication

- type II deformity / lateral bowing of 5th metatarsal

 

Technique

- medial displacement

- midshaft oblique osteotomy

 

3. Chevron Osteotomy

 

Indication

- Type III lesion 

 

4. Metatarsal Head Resection

 

Issue

- can get transfer pain

 

 

 

 

Claw / Hammer / Mallet / Curly

Background

Deformities

 

Mallet

- DIP flexed

- MTP / PIPJ neutral

 

Hammer 

- PIP flexion

- DIPJ neutral / extended

 

Simple - MTP not involved

Complex - MTP hyper-extended

 

Claw 

- PIPJ and DIPJ flexed

- MTPJ hyperextended

 

Curly toe 

- PIP and DIP flexion

 

Great toe 

- only have hammer 

- no mallet

 

Claw toe v hammer toe 

 

1. Claw toes frequently are caused by neuromuscular diseases

- often a similar deformity is present in all toes

- in hammer toe deformity only one or two toes are involved

 

2. Claw toes always have extension deformity at the MTPJ

- in hammer toe deformity extension of metatarsophalangeal joint may or may not be present

 

3. Claw toes often have a flexion deformity at the distal interphalangeal joint

- this usually does not occur in hammer toes

 

Anatomy

 

EDL 

- divides 3 slips over P1

- middle - P2

- sides - P3

- thus no insertion to P1

- but main action is to extend P1 at MCPJ  

- only extends IPJ if P1 neutral or flexed

 

EDB

- arises upper and lateral surface of calcaneum

- has four tendons

- one inserts into base P1 great toe - EHB

- other 3 into lateral side of EDL tendon toes 2 - 4

 

FDL 

- inserts P3

- flexes DIP

 

FDB 

- inserts P2

- flexes PIP 

 

Interossei 

- dorsal to transverse ligament

- insert P1 (mostly) and extensor hood

- mainly MTPJ flexor

 

Lumbricals 

- plantar to transverse ligament

- insert extensor hood only

- mainly allow IPJ extension with MTPJ flexion

 

Aetiology

 

Shoe Wear

- main cause is ill-fitting shoes

 

Hallux valgus

 

Trauma

- compartment syndrome

- fracture

- tendon or ligament injury

 

Anatomic 

- long 2nd ray with buckling of toe

- irregularly shaped P2 with deviation of P3

- long 4th toe with curling under 3rd toe

 

Neuromuscular

- Polio

- CMT

- MD

 

Inflammatory arthritis

- RA

 

Congenital

- Syndactyly

- CMT

 

Insensate Foot

- DM

- Hansen's disease

 

Claw Toe

Definition

 

Hyperextension of MTPJ and PIPJ / DIPJ flexion

- usually all toes affected 

 

Claw Toes

 

DDx

 

1.  Complex hammer

- hammer toe with MTPJ extension

- hammer usually affects second toe

 

2.  Curly toe

- normal MTPJ

- flexed PIPJ and DIPJ

 

Associations

 

Cavus foot 

Compartment syndrome

Diabetic neuropathy

Rheumatoid arthritis

 

Pathology

 

Imbalance between intrinsics and extrinsics

- intrinsic weak (MCPJ flexion and IPJ extension)

- extrinsics strong

 

MTPJ  

- extension strong

- flexion weak

 

IPJ

- extension weak

- flexion strong

 

P1 subluxes dorsally

- it pushes the MT head plantar-ward 

- leading to metatarsalgia

 

Cavus foot 

- claw occurs not only due to intrinsic weakness but because of plantar flexed MT's 

- lead to dorsiflexion at MTPJ's 

- results in flexion of IPJ's as seen above

- If claw flexible may correct if reduce MT's

 

History

 

Pain & callosities under MT heads (metatarsalgia)

 

Examination

 

Hindfoot

- cavus

- coleman block

 

Forefoot

- characteristic deformity

 

Calluses

- dorsum PIPJ

- bleow MTPJ

 

Mobile or fixed of MTPJ / PIPJ crucial

 

Flexible

- claw disappears with ankle PF 

- returns with DF ankle (tight long flexors)

 

Cavus foot

- when DF to correct MT claw actually improves (tight plantar fascia) 

 

Management

 

Non-operative

 

Extra width and depth toe box shoe 

MT dome

 

Operative

 

Significant deformity of the hindfoot ± a cavus foot should be addressed first if symptomatic

 

Surgical Algorithm

 

1.  Flexible Deformity PIPJ / MCPJ

 

Girdlestone Taylor FETT 

- divide FDL in two and suture dorsally over P1

- +/- Extensor tenotomy & Dorsal MTPJ capsulotomy

 

2.  Fixed PIPJ Deformity / Flexible MCPJ

 

A.  Du Vries Excisional Arthroplasty PIPJ

- resection of head & neck of P1 

- stabilise with K wire

- aiming for fibrous union

- ROM 15o

 

B.  Extensor tenotomy + PIPJ Fusion

 

+/- Dorsal MTP capsulotomy MP joint

 

3.  Fixed PIPJ / MCPJ 

 

PIPJ arthrodesis + Extensor tendon tenotomy 

+ dorsal MTPJ capsulotomy

+ MT neck osteotomy

  

4.  Great toe involved

 

Jones procedure

- arthrodesis of IPJ

- EHL to MT neck 

 

Metatarsal options

 

Persistent MTPJ DF main cause of failure

 

Options

1. Excision of MT head (Keller's)(RA)

2. Distal metatarsal oblique osteotomy (Weil)

3. Hibbs (if from cavovarus)

 

Techniques

 

1.  FETT Technique / Modified Girdlestone Taylor

 

A.  Release FDL distally / divide into two

- 2 plantar incisions P2 and P3

- transverse incision plantar aspect P3

- divide FDL, protect NV bundles

- transverse incision plantar aspect P2

- harvest FDL and split in two

- can do single longitudinal plantar incision

 

B. Pass FDL over plantar aspect P1

- dorsal incision over P1

- place clamp each side of hood

- don't trap digital nerve

- bring tendon through incision slot in extensor tendon over P1 on each side 

- if over P2 will not work

- toe placed in approximately 20 degrees of plantar flexion at the MTP joint

- suture to each other & ED

- if varus or valgus take whole FDL either side

 

2.  PIPJ fusion 

 

Principles

- important to shorten the toe

 

Technique

- Ellipse of skin excised over dorsum PIPJ

- Extensor tendon taken in the ellipse

- release the collaterals so that P1 subluxes into operative field 

- elevate volar plate off P1

- bone cutters to resect P1 condyles

- resect base P2

- retrograde K wire out through P2 and P3 first

- back through P1, rest against subchondral bone

- bend wire over and tape

 

Risk

- check blood supply at end of case

- if problematic

- release dressings / warm / increase BP

- can use antispasmodic

- will usually reperfuse over 5 minutes

- keep patient asleep in meantime

- need to have ischaemia as part of consent

 

3.  Weil Osteotomy 

 

Technique

- Dorsal metatarsal exposed

- web space incisions if doing multiple toes

- homan retractors each side of MT

- saw enters at edge of articular surface dorsally

- Blade angled as low / horizontal as possible

- When osteotomy complete the MT head slides back

- Needs to slide back at least 5mm

- Then fix with screw from dorsal to distal plantar

- Amputate leading edge of proximal fragment

- if have valgus or varus deformity then can correct for this

 

Weil Ostetomy PIPJ FusionWeil Osteotomy PIPJ Fusion Lateral

 

 

Curly Toe

Definition

 

Under-riding toe

- toe lies beneath adjacent toe

- congenital deformity

 

Pathology

 

Due to tight FDL & FDB

- capsule initially normal

- becomes constricted with time

 

Clinical

 

Usually 3rd toe

- flexed, ER, medially deviated

 

Deformity accentuated when standing

 

Ankle dorsiflexion

- increases deformity

 

May present with

- cosmetic concerns

- callus & blister formation

 

Management

 

Non-operative

 

Most don't require treatment

- most non symptomatic

- 25% improve spontaneously

 

Operative

 

If symptoms judged sufficient

- wait till > 4 years old

 

Options

 

Flexible deformity 4 - 12 year old

- flexor tenotomy thru plantar skin

- just divide FDL

 

Fixed deformity > 12 years old

- resection / arthrodesis of IPJ

 

Case scenario

- 2 year old with curly toes

- nil other abnormality

- vast majority will improve

- give stretches for parents to do

- only if continual problem, do FDL release

 

 

Hammer Toe

Definition 

 

Flexion deformity PIPJ with

- MTPJ normal / simple

- MTPJ hyper-extended / complex

- DIPJ any position

- P1 may become subluxed or dislocated

 

Aetiology

 

Uncertain

 

Long second toe / MT

Hallux valgus

Tight shoes

 

Examination

 

Hammer Toe Clinical Photo

 

Calluses

- dorsum of PIPJ

- beneath second MT head

 

Rigid v flexible

Correctable / Non correctable

 

Management

 

Non-operative

 

Extra depth or padded shoe, low heel

 

Operative

 

Concepts

- need to ensure enough room for corrected toe / shorten toe

- may need to treat HV as well

- may need to release flexor tendons if tight

 

1.  Flexible Deformity

 

Girdlestone-Taylor FETT

 

2.  Fixed PIPJ

 

A. DuVries Arthroplasty

 

B. Extensor tendon tenotomy + PIPJ fusion

 

C. Partial Proximal Phalangectomy

- leaves toe floppy

- poor cosmesis

- only as salvage

 

3.  Fixed PIPJ and Subluxed MTPJ

 

Extensor Tendon Tenotomy + PIPJ fusion

+ Dorsal MTPJ capsulotomy

+ MT osteotomy

 

PIPJ Fusion Weil OsteotomyPIPJ Fusion Weil Osteotomy Lateral

 

 

 

Mallet Toe

Definition

 

Flexion deformity of DIPJ 

 

Aetiology

 

Usually in 2nd toe

- Long second MT

- Constrictive footwear

 

Clinical

 

Pain over

- tip of toe

- over dorsum of DIP joint

 

May be corn on tip of toe 

 

Fixed or flexible

 

Management

 

Non-operative

 

Shoes with roomy toe box

 

Operative

 

Surgical Algorithm

 

1.  Flexible

 

Percutaneous FDL tenotomy

 

2.  Fixed

 

A.  Excision arthroplasty of DIPJ  ± FDL release

 

B.  Arthrodesis 

 

C.  Terminal Symes amputation

 

3.  2nd MTPJ Dislocation

 

Reducible dislocation 

- Hammer toe repair

 

Reducible but unstable 

- FETTS + Hammer toe repair

 

Irreducible 

- E/O MT head + FETT + Hammer toe repair

 

 

Fifth Toe

Over-riding Fifth Toe

 

Deformity

 

5th toe adducted & overrides 4th toe

- extended, adducted & laterally rotated at MTPJ

 

Pathology

 

Toe arises more dorsally than it should

 

Contracture of EDL tendon

Contracted dorsal skin & dorsal MTPJ capsule

 

Aetiology

 

Usually congenital deformity

- toe usually hypoplastic

 

Clinical Features

 

Cosmetic deformity

Problems with footwear

Usually bilateral

Usually needs surgery (compared with underriding or curly)

 

Non-operative Management

 

Strapping & taping ineffective

Broad toe box

 

Operative Management

 

Mild / Moderate - Butler procedure 

- racquet shaped incision dorsally

- dorsal limb over extensor tendon

- circumferential limb must preserve NV bundle

- EDL and dorsal capsule divided

- toe swung back into position and sutured

 

Severe - Lapidus procedure 

- EDL transfer to AbDM

- curvilinear incision

- cut EDL over mid MT proximally leaving attached distally

- capsule release MTPJ

- tendon transferred medial, plantar and laterally around P1

- sutured to abductor digit minimi

 

Underriding fifth toe

 

Opposite deformity of above

 

Thompson excisional arthroplasty

- Z incision laterally over P1

- proximal phalanx resection and capsule imbrication

- K wire

 

Cock Up Deformity 

 

Deformity

- of MTP 

- realign at MTPJ & IPJ

- usually hammer toe deformity as well

 

Surgical Algorithm

 

Mild to moderate 

- extensor tenotomy & fixed hammer toe repair

 

Severe 

- Ruiz-Mora procedure

- resection arthroplasty of proximal phalanx

- elliptical plantar incision with proximal phalyngectomy

 

Salvage

- end up with floppy toe 

- syndactylisation may be salvage

- but swapping one deformity for another

 

 

 

Keratotic Deformities

Definitions

 

Corn

- accumulation of keratotic layers of epidermis

- thickened epithelium elevates prominence causing further pressure

 

Hard Corn

 

Due to extrinsic pressure from footwear

- most common on lateral aspect of 5th toe

- over head of proximal phalanx

 

Soft Corns

- on the condyle of proximal phalanx between the toes

- due to pressure between adjacent bony prominences

- DDx fungal infection

- soft due to moisture

- commonest is medial aspect 5th toe

- also common at base of web space overlying 4th proximal phalanx lateral condyle

 

Aetiology

 

Combination of Extrinsic or Intrinsic pressure

 

Extrinsic 

- shoewear increasing compression 

 

Intrinsic 

- underlying prominent condyle of P1

 

X-ray 

 

See on plain film with marker over corn

 

Non-operative Management

 

Usually not successful long term

- education re shoewear / wide shoe with extra depth toebox

- lambs wool dressing or foam pads

- trim hyperkeratosis

 

Operative Management

 

Isolated small keratosis over 5th PIPJ

- treat with condylar resection of 5th PIPJ alone

 

Keratosis over 5th PIPJ & base 4th web

- treat with resection of 5th condyle & lateral proximal phalangeal condyle of 4th toe

 

Intractable Plantar Keratoses

 

1.  Resection Arthroplasty of Mann and DuVries 1973

 

Results

- 85-90% patient satisfaction

 

Technique

- dorsal Incision over MTP

- retract EDL

- divide transverse MT ligament

- severe collaterals and deliver head

- remove 2-3mm of distal MT head

- remove the plantar lip so approximately 50% of head has been excised

 

2.  Giannestra Shortening Oblique MT Osteotomy

 

Best when long MT

- aim to shorten 5-6mm

- fix with screw

 

3.  Dorsal Closing Wedge Osteotomy

 

Aim for dorsal wedge of 2-3mm

- fix with cross K-wires

- must pop for 6/52

 

 

 

 

 

Lis Franc

HistoryLis Franc

Jacques LisFranc De St-Martin (1790 - 1847)

General Surgeon in Napoleonic army

 

Mechanism

 

High energy

 

1.  Twisting / Abduction injury of forefoot

- original description is fall from horse with foot caught in stirrups

- MVA

 

2.  Axial Loading

 

A Extrinsic axial compression applied to heel

B Extreme ankle equinus with axial loading of body weight

 

3.  Direct Crushing

- to dorsum of mid-foot

- greatest risk of compartment syndromes and open fractures

 

Classification

 

A: Quenu & Kuss; Modified by Hardcastle (JBJS 1982)

 

1. Homolateral 

- all 5 metatarsals displaced in same direction

- most common

 

Homolateral Lis FrancLis Franc Homolateral

 

2.  Isolated 

- only 1st MT injured / displaced

 

3.  Divergent 

- 1st MT displaces medially

- other 4 MT displace laterally

- least common

 

B: Myerson

https://www.ncbi.nlm.nih.gov/pubmed/3710321

A: Total incongruity (medial or lateral)

B: Partial incongruity

  B1: Medial

  B2: Lateral (most common)

C: Divergent displacement

  C1: Partial

  C2: Total

 

Anatomy 

 

Bony Stability

 

1-3 MT articulate with cuneiforms

4 & 5 articulate with cuboid

 

Bases of MT wider dorsally than plantar

- form 1/2 of Roman arch 

 

Metatarsal Base Roman ArchFoot CT

 

2nd MT is keystone of transverse MT arch

- medial cuneiform is recessed proximally

- mortise provided for base of second

 

Ligamentous stability

 

Lis Franc ligament

- plantar structure

- 1 cm long x 0.5 cm diameter

- base 2nd MT to medial cuneiform

- avulsion as 'fleck fracture'

 

Note: no intermetatarsal ligament from 1st MT to 2nd

 

Mobility (Sagittal)

 

Medial Column (1st MT) - 3.5 mm

Middle Column (2/ 3) - .6mm

Lateral Column (4/5) - 13mm

 

Examination

 

Swelling and pain

- out of proportion

- must suspect Lis Franc

 

Brusing plantar aspect foot

- indicative of Lis Franc Ligament rupture

 

Signs compartment syndrome

 

X-ray

 

Fleck sign

- avulsion of LF from base of 2nd MT

- can be only sign of isolated Lis Franc Injury

 

Lis Franc Fleck SignLis Franc Fleck Sign

 

Diastasis between 1st & 2nd MT

- may need to perform bilateral weight bearing stress view

 

Lis Franc Diastasis

 

AP / Assess medial column

- medial border 1st MT should line up medial border medial cuneiform

- medial border of 2nd MT should line up with medial border middle cuneiform

 

 Lis Franc Medial Column ViewFoot Medial Column Normal

 

Internal Oblique 30o / Assess lateral column

- medial border 3rd MT line up with medial border lateral cuneiform

- medial border of 4th MT line up with medial border cuboid

 

Lis Franc Lateral ColumnLis Franc Lateral Column Disruption

 

CT scan

 

Confirm displacement of MT from respective joints

 

Lis Franc Displaced TMT Joints CT0001Lis Franc Displaced TMT Joints CT0002

 

Identify fleck sign

 

Lis Franc CT Fleck SignLis Franc CT Fleck Sign and Diastasis

 

Identify dorsal displacement of metatarsals

 

Lis Franc CT Dorsal Displacement MTLis Franc Dorsal Displacement

 

Compression fractures / nutcracker of cuboid

 

Cuboid Fracture Lis Franc

 

MRI

 

Confirm oedema or tear of Lis Franc ligament

Bone brusining tarsometatarsal ligaments

Subluxation of ligaments

 

Intraoperative

Curtis stress views

Hindfoot stabilised & forefoot pronated/ abducted

 

Prognosis

 

Residual pain & stiffness with non-anatomical reduction

- 2° OA

- progressive planovalgus

 

Management

 

Non Operative

 

Sprains with no displacement

- 6/52 in NWB SLPOP

- close serial follow up

- strapping/ medial arch support 6/12

 

Operative

 

Indications

 

Any displacement

 

Closed Technique

 

Indication

- isolated Lis Franc with diastasis

- early diagnosis and treatment

 

Technique

- longitudinal traction

- reduction first intermetatarsal joint

- percutaneous fixation screws

- from medial cuneiform to 2nd metatarsal

 

Lis Franc Isolated Injury FixationLis Franc Medial Column ORIF

 

Open Technique

 

Timing

- wait for swelling to reduce

- may take 2 - 3 weeks

 

Goal

- reduced and stabilise all MTJ that are injured

 

First incision

- dorsal

- between 1st and 2nd MT

- lateral to EHL

- protect branches of SPN

- dorsalis pedis and DPN are in this intermetatarsal space

- very difficult to identify

 

Reduction

- clean out joint

- reduce first and second metatarsal to cuneiforms

- check AP reduction

 

Provisional fixation

- K wire 1st MT to medial cuneiform

- K wire 2nd MT to intermediate cuneiform

- K wire medial cuneiform to base 2nd MT

- +/- K wire medial to intermediate cuneiform if unstable

- insert 4.0 mm cannulated screws

 

Lis Franc Post ORIF

 

2nd incision between 3rd and 4th MT if required

- reduce 3rd and 4th MTPJ

- K wire / screw 3rd MT to lateral cuneiform

- Fix 4th and 5th to cuboid with K wires

- 5th K wire usually inserted percutaneously

- check with oblique view

- may use screw / k wire to 3rd MTPJ

 

Post op

 

Strict NWB for 8/52

- Lis Franc ligament takes time to heal

 

Removal of K wires at six weeks

 

Screw removal

- no sooner than 4/12

- broken screws rarely bothersome

 

Complications

 

Compartment Syndrome

 

Open fracture

- closed reduction and hold with external fixator

 

Midfoot Arthritis

- can develop later

- require midfoot fusion

- some surgeons advocate primary fusion if joint surfaces very damaged / comminuted

 

Metatarsalgia

DDx Metatarsalgia

Definition

 

Pain in the forefoot in the region of the MT heads

 

3 groups

 

1.  Localised

 

Morton's neuroma

Freiberg's

Stress fracture

Infection / tumour

Plantar Keratosis

Plantar Wart

 

2.  Systemic disease

 

RA

 

3.  Altered forefoot biomechanics / Transfer Metatarsalgia

- irregular Distribution of MT load

 

A  1st ray insufficiency syndrome

- splayed forefoot

- 1st ray unloaded

 

Metatarsalgia Splayed Foot

 

B.  Short 1st MT 

- > 2 cm back from 2nd MT

- varus 1st MT

- 1st ray unloaded

 

Metatarsalgia Short 1st Metatarsal

 

C.  Hyper-extended MTPJ with claw toe

 

D.  Iatrogenic

- bunion surgery

- excision of metatarsal head

 

E.  Lax soft tissues

- Lis franc injury

 

F.  Flatfoot

- supination, elevation of 1st metatarsal

 

Freiberg's

Definition

 

Crushing osteochondritis of metatarsal head

 

Frieberg's

 

Epidemiology

 

Usually 2nd metatarsal (80%)

- occasionally third

- can occur in any

 

Age 10-15 years

- peak 15 year old girls

- F:M = 3:1

- occurs during the growth spurt at puberty

 

Bilateral in 6%

 

Aetiology

 

Trauma / repetitive stress

- interrupts blood supply to epiphysis

- fragmentation and AVN

 

2nd MT prone to stress fracture & AVN

- long MT

- fixed base

- thin shaft

 

Pathology

 

Ischaemic necrosis of epiphysis

 

Commonly have synovitis as well

 

Clinical

 

Tender enlarged MT head

- pain on dorsiflexion

- limited dorsiflexion due to synovitis or degenerative change

 

DDx

 

MTPJ synovitis / arthritis / synovial cyst

Interdigital neuroma

Stress fracture

 

X-ray

 

Enlarged flattened MT head

- widened joint space

- osteolysis & collapse in late stages

 

Leads to MTPJ OA

 

MRI

 

Friebergs MRIFriebergs MRI

 

Classification Smillie 

 

Stage I 

 

Subchondral fissure in epiphysis

 

Xray normal

Bone scan / MRI positive

 

Stage II 

 

Collapse of dorsal central portion of MT head

 

Xray

- slight widening of joint space

- sclerosis of epiphysis

 

Stage III 

 

Friebergs Stage III

 

Xray

- progressive flattening of the head / osteolysis / collapse

 

Stage IV 

 

Xray

- fragmentation of epiphysis

- multiple loose bodies

 

Stage V 

 

Friebergs Stage V

 

Xray

- advanced degenerative arthrosis

- joint space narrowing

- hypertrophy of MT head

- osteophyte formation 

 

MRI

 

 

Management

 

Non-operative

 

Algorithm

 

Limit activities 6/52

Metatarsal bar / preMT dome to unload MT head

Avoid high heels

Consider POP / moonboot to reduce symptoms

 

Operative 

 

Options

 

Synovectomy & joint debridement / removal of loose bodies

 

Indication

- stage II / III disease

 

Osteophyte removal / Cheilectomy

 

Closing wedge extension osteotomy

 

Concept

- dorsiflexion osteotomy

- most affected portion MT head is dorsal

- redirects plantar articular surface

 

Excision of MT head 

 

Indication

- severe disease

 

Issue

- not a great operation 

- associated with hallux valgus and transfer metatarsalgia

Morton's Neuroma

Definition

 

Benign enlargement of the common digital branch

- usually 3rd webspace

 

Mortons Neuroma Common Site

 

Anatomy

 

Found at level of or just distal to MT heads

- deep to the deep transverse MT ligament

 

Epidemiology

 

Classically women between 40 and 60

 

Aetiology

 

Can be traumatic but usually degenerative

 

Pathology

 

Demyelination of nerve fibres with fibrosis

 

History

 

Pain with weight bearing

- worse with wearing tight shoes

- in the ball of foot

- may be shooting type pain

 

Numbness / tingling in the affected toes

 

Examination

 

Mulder sign

- palpate webspace with fingers superiorly and inferiorly

- with other hand compress metatarsal heads together

- either palpate the lump or feel a click

 

Mulders Sign

 

Xray

 

Usually normal

- can have splaying of MT heads

 

US / MRI

 

Aid in confirming the diagnosis

 

Management

 

Non operative

 

Wide toe box

Metatarsal Pads

HCLA - Temporary relief

Sclerosing injections / phenol

- can solve problem

 

Operative

 

Options

- resection (dorsal or plantar)

- decompression

 

Resection Technique

 

Dorsal incision

- beginning at webspace edge

- separate MT with lamina spreader / retractor

- divide deep MT ligament / can preserve especially in athletes

- identify common digital nerve proximally

- identify neuroma / place forceps under

- resect proximal to neuroma

- resect distal to bifurcation

- send to pathology to confirm

 

Mortons Neuroma IncisionMortons Neuroma 1Mortons Neuroma 2

 

Mortons NeuromaMortons Neuroma

 

Complications

 

Patient will have numbness

Painful stump neuroma (revise via plantar approach)

Hammer toe (inadvertant lumbrical resection)

Pain secondary to instability / division intermetatarsal ligament

Plantar Warts

Pathology

 

Human papilloma virus

 

Occur in any part of sole

 

Clinical Features

 

Do not project above level of skin

- because of pressure of weight bearing

- seldom more than 1cm in diameter

- skin surrounding wart thickened and raised

- edge clearly demarcated from surrounding skin

 

Severe localised pain on walking

 

Local tenderness on pressure

 

DDx

 

Plantar callosities

- warts occur anywhere

- callosities occur over points of pressure

- warts have clearly defined edge with possible cleft between it and skin

- callosities blend with surrounding skin

- warts have punctate bleeding

 

Treatment

 

Non-operative

 

Cauterisation / freezing / Paring

 

Operative

 

Curettage and cauterisation of base

- (care taken with digital nerves etc)

 

Miscellaneous

Accessory Medial Cuneiform

Accessory Medial Cuneiform0001Accessory Medial Cuneiform0002Accessory Medial Cuneiform0003

 

Accessory Navicular

Incidence

 

1 - 2 %

 

Anatomy

 

Medial Aspect of foot

- proximal to navicular

- part of T posterior tendon

 

Usually will fuse with navicular (50%)

 

Issues

 

1.  Probably not a cause of flat foot

- excising accessory navicular / rerouting / reattaching tibialis posterior

- will not help pes planus

 

2.  Pain

- may fracture

- may cause insertional tendonitis

 

Classification

 

Type 1

 

Small ossicle proximal to insertion

 

Type 2

 

Synchondrosis

- may fracture with injury

 

Accessory Navicular Fractured SynchondrosisAccessory Navicular

 

Management

- treat in cast 6/52

- excise if symptomatic

 

Type 3

 

Large cornuate navicular

- likely that the accessory has fused

 

Accessory Navicular Cornuate

 

Bone Scan

 

Acessory Navicular Bone Scan

 

Identifies if accessory navicular cause of symptoms

 

MRI

 

Show oedema about a symptomatic accessory navicular

 

DDx

 

T Posterior tendonitis

Navicular stress fracture

 

Management

 

Non operative

 

Rest

Moon Boot

 

Operative

 

Kidner Procedure

- medial incision dorsally over navicular

- enucleate accessory navicular from tendon

- may need to take away navicular prominence

- reattach tendon if necessary through drill holes

 

Brailsford Disease

Definition

 

Adult form

- 45 year old females

- more severe than Kohler's

 

Symptoms

 

Intense pain +/- oedema & inflammation

- often pronounced limp

- marked flat foot with prominant navicular

 

Radiology

 

Navicular narrowed

- lateral part dense, sclerotic & thin

- occasional fracture line

- degenerative TNJ

- due to wedge shape concentrating forces dorsally

- fracture collapses

 

Surgery

 

Often necessary

- to graft navicular & restore anatomy

Gait

Gait cycle

 

Definition

- from point of initial contact of one foot with the ground

- until that foot hits the ground again

 

Two parts

 

1.  Swing phase

- foot not in contact with ground

- 40% walking gait

 

2.  Stance phase

- heel strike to toe off

- 60% of walking gait

- 3 rocker phases

 

Rocker Phases

 

1st rocker phase / Heel Strike

 

Ankle plantar flexes 

The foot is lowered onto the ground under the control of the eccentrically acting tibialis anterior

Foot pronates with flattening of medial arch, and hind foot in valgus to allow show absorption

 

Lose with

- heel pain

- fixed equinus

- true or apparent LLD

 

2nd rocker phase / Stance Phase

 

Progressive  dorsiflexion of the ankle allows the tibia and the centre of gravity to progress over the foot

- modulated by the eccentrically acting triceps surae

- maximal pronation

 

3rd rocker phase / Toe Off

 

The foot rotates over the MT heads

Foot moves into supination, heel into varus

Tibialis posterior locks Midfoot so foot can act as a rigid lever

Concentric contraction of the triceps surae and FHL provides pushoff 

 

Loss

- painful forefoot (Hallux valgus / rigidus)

- loss of PF (NM, stiff hindfoot, ruptured TA)

 

Running

 

Walking ground reaction force 1.5 X body weight

Running ground reaction force 3 X body weight

 

Running has floating phase

- neither foot touching ground

 

Heel Pain DDx

Children

- Sever's disease

- Tarsal Coalition

- JRA

 

Adults

 

Trauma

- calcaneal fracture

- stress fracture

- lateral talar process fracture

 

Infection

- soft tissue

- calcaneal osteomyelitis

 

Tumours

- osteoid Osteoma

- osteochondroma

- bone Cyst

- ewing's Tumour

- metastasis

 

Inflammatory

- plantar fasciitis

- tibialis posterior tendonitis

- peroneal tendonitis

- achilles tendonitis

- retrocalcaneal bursitis

- fat pad atrophy

- tarsal tunnel syndrome

- RA / seronegative arthropathy

 

 

Sinus Tarsi Syndrome

Anatomy

 

Osseous canal between talus and calcaneum

- interosseous talo-calcaneal ligament

- cervical ligament

- joint capsule

- nerve endings / arterial anastomoses

 

Sinus Tarsi

 

Aetiology

 

Flat foot / overpronation

Inversion / sprain

 

Pathology

 

Hypothesis

- compression / pinching injury

- develop scarring of ligament and capsule

- predisposes to further pinching

 

Symptoms

 

Pain at lateral aspect ankle

- below lateral malleolus

 

May get pain when running on outside of foot / track work

 

Pain on uneven ground

 

Examination

 

Tenderness sinus tarsi

- soft indentation below and anterior to LM

 

Pain with eversion / inversion STJ

 

HCLA

 

Diagnostic

- relieves pain

 

MRI

 

Display fluid in sinus tarsi

May detect excess scar tissue

 

Management

 

Non operative Management

 

Usually very effective

 

Options

 

Rest

NSAIDS

Subtalar joint manipulation

Correction of over pronation / orthotics

HCLA

Orthotics to stabilise STJ

 

Operative

 

Lee et al Arthroscopy 2008

- 33 cases of subtalar arthroscopic debridement

- 88% good or excellent

- 12% fair

 

Findings

- partial tear interosseous ligament 88%

- synovitis in 55%

- partial tear cervical ligament 33%

- arthrofibrosis 24%

- soft tissue impingement 21%

 

 

Tarsal Tunnel Syndrome

Definition

 

Entrapment neuropathy of posterior tibial nerve within the tibial tunnel

 

Anatomy

 

Taral Tunnel

 

Flexor Retinaculum 

- medial malleolus to posterior calcaneum

 

Tarsal tunnel

- roof is flexor retinaculum

- tibia anteriorly

- talus and calcaneum laterally

 

Contents

- T. Post

- FDL

- Posterior tibial artery, tibial nerve

- FHL

 

Tibial nerve

- 3 terminal branches

- medial and lateral plantar

- medial calcaneal

- usually divide within tunnel

 

Aetiology

 

Specific cause identified in 60% cases

 

Idiopathic 

- 40% cases

- most common

 

Post-traumatic

- scarring after sprain

- bony prominence 2° calcaneal fracture

 

Inflammatory 

- RA

- tenosynovitis

 

SOL

- tumours

- ganglion of tendon sheath

- lipoma

- neurilemmoma (Schwannoma) 
- varicose veins

- medial talo-calcaneal bar

 

Accessory muscles

- FDL

 

History

 

Diffuse pain plantar aspect

- burning, tingling or numbness

- 1/3 have proximal radiation to leg

 

Aggravated by activity

 

Examination

 

Tenderness over Tarsal Tunnel

 

Positive Tinel's sign    

 

Palpate for thickening or swelling (cyst, ganglion etc)

 

Usually no sensory loss or weakness 

 

May see wasting of abductor hallucis

 

NCS 

 

At best 90% accurate

- Prolonged sensory conduction time in 75%

- Prolonged motor latency in 50%

- conduction velocity of CPN done to exclude peripheral neuropathy

 

MRI

 

MRI positive in 85% 

- FHL synovitis, dilated veins, mass, fracture, scar, etc

- 25% have contralateral MR findings with no symptoms

 

Diagnosis

 

At least 2 of

- Hx of tingling & burning

- positive tinels

- positive NCS

 

DDx

 

Local

- plantar fasciitis

- fracture

- tenosynovitis

 

Neurological

- peripheral neuritis

- diabetic neuropathy

- leprosy

- neurilemmoma

- neuroma

- spinal compression

 

Management

 

Non-operative

 

Of little benefit

- try NSAIDs

 

Operative

 

Surgical release by division of Flexor Retinaculum

 

Incision 

- 10 cm proximal to medial malleolus

- curved distally to TNJ

 

Release

- flexor retinaculum

- proximal investing fascia

- individual tendon sheaths / tibialis posteror in separate sheath

- abductor hallucis fascia

 

Follow and release both plantar nerves

- protect medial calcaneal branch

- runs off lateral plantar

 

Post op

- NWB for 3/52

 

Results

 

75% success if no underlying causes

Pantalar Fusion

Pantalar Fusion APPantalar Fusion Lateral

 

Indications

 

RA

AKJ and STJ arthritis

Trauma

Deformity

Talar AVN

 

Technique

 

Incision

- curved incision

- posterior border fibular

- curved anteriorly along peroneal tendons

- towards 4th MT

 

Exposure AKJ

- excise distal fibular

 

Exposure subtalar joint

- elevate peroneals and EDB

- divide TC interosseous ligament

 

Prepare arthrodesis

- decorticate / remove cartilaginous surfaces

- drill holes

- correct deformity

- AKJ 5o valgus, plantigrade, ER 10o

- STJ 5o valgus

 

Pantalar Fusion Talus AVN APPantalar Fusion Talus AVN Lateral

 

Fusion with IM nail

- insertion point

- in line with 2nd MT

- junction of posterior 2/3 and anterior 1/3 heel

- should pass through anterior aspect posterior subtalar joint

- insert nail

- distal locking screws calcaneum

- insert bone graft

- compress

- proximal locking

 

 

Peroneal Tendons

Dislocation

Definition

 

Anterior displacement of peroneal tendons out of peroneal groove

 

Epidemiology

 

Most common in young adults

 

Acute injury often missed 

 

Aetiology

 

Congenital

 

3 % neonates

- resolves spontaneously

 

Traumatic  

 

Occurs following sporting activities

- snow skiing

- football

- gymnastics

 

Forced DF and inversion

 

Anatomy

 

Fibro-osseous tunnel

- retro-malleolar groove

- lined by fibrocartilage

 

Anterior

- fibula 

 

Medial

- PTFL

- CFL

- PITFL

 

Peroneus longus

- posterolateral to PB

 

Superior Peroneal Retinaculum

- 2 bands

- fibula to lateral T Achilles

- fibula to posterolateral calcaneum

 

Inferior peroneal retinaculum

- lateral wall calcaneum below sinus tarsi

- no role in stability

 

Pathogenesis

 

1.  Traumatic

 

Violent contraction of Peroneal muscles 

 

Forced dorsiflexion and inversion

- injury to superior peroneal retinaculum

 

May be predisposition

- laxity of retinaculum

- shallow groove

 

Patient may also have tears

 

2.  Subluxation within sheath

 

Raikin JBJS Am 2009

- described intrasheath subluxation

- superior retinaculum intact

- patients still having painful snapping

- demonstrated by US

- half had peroneal tendons switching positions

- these patients had a convex groove

- these where treated with groove deepening and retinaculum reefing

- other half had a tear in PB through which PL could sublux

 

History

 

Acute

- sudden pain behind lateral malleolus

- snap may be heard

- unable to continue with activities

 

Chronic

- painful snapping of lateral ankle with activity

 

Examination

 

Tenderness & swelling behind LM

- pain or dislocation reproduced by active eversion & DF

 

Peroneal Tendon Dislocation 1Peroneal Dislocation 2

 

X-ray

 

Usually normal

 

May be avulsed fragment of cortical bone lateral to LM

- fleck sign

 

CT

 

Defines anatomy & relationships of tendons

- may detect anatomical variants

 

US

 

Very good at demonstrating subluxation

 

MRI

 

Detects tendinous & ligamentous injuries

 

Management

 

Opinion divided regarding acute injuries

- non-operative management v surgical repair

 

Most treat chronic injuries surgically

 

Non-operative

 

Acute injuries

- cast in plantarflexion for 6/52

 

Operative 

 

Indications

- acute injury in athletes

- chronic injuries

 

Acute Repair

 

Options

 

1.  Superior retinaculum stripped

- reattach to fibula via trans-osseous sutures / anchors

 

2.  Retinaculum torn

- primary repair

 

3.  Bony avulsion

- fragment reattached with sutures, wires or screws

 

Chronic

 

1.  Groove Deepening

- if necessary

- elevate cortical flap / decancellation / cortical recession

 

2.  Address tears in tendons

 

3.  Address superior peroneal retinaculum

 

A.  Direct repair / Advancement of superior peroneal retinaculum if able

 

B.  Reconstruction of SPR if attenuated

- periosteal flap from fibula

- slip of T Achilles left attached distally

- free plantaris / palmaris graft

 

C.  Rerouting under CFL

- substitution of CFL for peroneal retinaculum

- tendons transposed into inframalleolar tunnel

- division & repair CFL or fibular bone block with CFL

 

4.  +/- lateral ligament repair if needed

 

Surgical Technique

 

Findings

- chronic subluxation / anterior dislocation

- normal groove

- retinaculum stretched and not attached to normal insertion anterior fibula

- repair and tightened with suture anchors

 

Anterior Peroneal DislocationAnterior Peroneal DislocationAnterior stripping of SPR

 

Normal GrooveNormal GrooveSuture Anchors

 

Sutures PassedSutures Passed 2Repair 1

 

 

Tendonitis / Tendonopathy

Anatomy

 

Lateral compartment of leg

- run through retromalleolar groove

- pass superior and inferior to peroneal tubercle

- covered by inferior peroneal retinaculum

 

Peroneus longus

- origin lateral condyle of tibia and head fibula

- tendon PL superficial and inferior to brevis in retromalleolar groove

- runs in cuboid groove 

- insert plantar surface base of 1st MT and lateral aspect medial cuneiform

- everts the foot / plantar flexes the first ray / plantar flexes the ankle

- stabilises the medial arch in stance

 

Os peroneum

- sesamoid in PL

- level CCJ / articulates with cuboid

- 20% population

 

Os Peronei

 

Peroneus brevis

- origin middle third fibula and intermuscular septum

- inserts tuberosity base 5th

- abducts and everts the foot / plantar flexes the ankle

 

Nerve supply

- SPN

 

Definitions

 

Tendonitis

- inflammation of tenosynovium

 

Tendonosis

- degenerative change in tendon

-  can lead to tears

 

Aetiology

 

Tendonitis

 

Prolonged or repetitive activity

- usually after period activity

- runners and ballets dancers

 

Cavovarus hind foot

 

Tears

- acute injury

- chronic tendonitis

- dislocation / subluxation

 

Associations

 

Chronic lateral ankle instability

Peroneal tendon subluxation

Cavovarus hindfoot

 

Peroneal Tendon Tears

 

Incidence

 

P. brevis torn more frequently than longus

 

Classification

 

Sobel & Mizel 1993

 

Zone 1 

- behind lateral malleolus

- brevis more commonly injured 

 

Zone 2 

- distal to tip of fibula 

- longus only 

- cuboid tunnel acts as a fulcrum

- can get inflammation & swelling

- loss of excursion as brevis & longus skirt around pulley

 

History

 

Acute or chronic lateral ankle pain

 

Examination

 

Tenderness / swelling along tendons

 

Peroneal Tendon Swelling

 

Pain

- passive inversion and PF

- active eversion

 

DDx

 

Lateral instability

Fracture fibula / 5th MT / cuboid / Calcaneal

OCD talus

Loose body ankle

OA ankle

Sinus tarsi syndrome

Tarsal coalition

 

MRI

 

10 tendons about ankle

- axial views most usefull

- T1 displays anatomy

- T2 STIR shows tears 

- beware magic angle (fibres orientated 55 degrees to scan)

 

Findings

- tendon thickening / tendonopathy

- fluid about tendons / tendonitis

- tears

 

Peroneal TendonitisPeroneal Tendonitis MRIPeroneal Tendonitis MRI 2

 

Management

 

Non Operative

 

NSAIDS

Modification activities

Lateral heel wedge if hindfoot varus

Moon boot / SL walking cast

 

Operative

 

1.  Tenosynovitis

 

Open debridement and tenosynovectomy

- incision posterior to fibula and to base 5th MT

- sural nerve halfway between peroneals and T Achilles

- open peroneal tendon sheath

- debride synovitis

 

Peroneals Intra-operatively

 

Must also treat any

- inflamed os peroneum

- varus heel

- tears

 

2.  Tears

 

A.  <50% 

- excise &  repair tears by tubularisation

- incision 1 cm posterior to fibular

- from 5 cm above to base of 5th metatarsal

- immobilise with foot PF and everted to rest in POP

- after 2 weeks in moonboot for progressive mobilisation

 

B.  > 50%

 

One tendon torn

- tenodesis to other tendon

 

Both tendons torn

1.  2 stage reconstruction

 

2.  Tendon transfer FDL to PB / plantaris to PL

 

Pes Cavus

Calcaneo Cavus

Definition

 

Pure Cavus Deformity characterised by 

- dorsiflexion of Calcaneus 

- plantarflexion of Forefoot

 

Aetiology

 

Weakness of Tendoachilles

 

Usually neuromuscular

- Polio (Most common worldwide) 

- Spina bifida

- CP (can be due to overcorrection of T Ach)

- Spinocerebellar Degen (Friedreich's Ataxia)

- CMT

- Spinal dysraphism

 

Compartment Syndrome Deep Posterior 

 

Pathology

 

Imbalance of tendoachilles and dorsiflexors

- dorsiflexion of calcaneus

- moves insertions of T Achilles anterior

- further weakens the lever arm

 

Forefoot becomes flexed because of

- gravity 

- action of muscles during gait

- result is elevated longitudinal arch 

 

History

 

Difficulty walking 

Obvious deformity 

Shoe fitting & wear problems 

Painful callosities

 

Examination

 

Elevated longitudinal arch 

 

Prominent heel with abundant callus on plantar aspect 

- called pistol grip deformity 

 

Heel usually in neutral

 

Usually claw toes 

 

Xray

 

Lateral xray

- calcaneal pitch > 30o

- Meary's angle > 30o

 

MRI 

 

Exclude dysraphism

 

Management

 

Non-operative

 

Modification of shoe wear & orthoses required 

- cannot control deformity alone

- doesn't work

 

Operative

 

Age 0 - 5

 

Best avoided

 

Tendon transfer

- T Ant to T Achilles

 

Age 5-12

 

Grice arthrodesis STJ 

- extra-articular

- stabilise STJ

 

Transfer muscles

- must be > Grade 5 power

 

Options

- Tibialis anterior

- Tibialis posterior

- peroneals

 

Age >12

 

As Above

 

Triple arthrodesis

 

 

Cavo Varus

Background

Definition

 

A fixed equinus deformity of the forefoot in relation to the hindfoot 

- resulting in an abnormally high arch that fails to flatten with weight bearing

- deformity may be forefoot, hindfoot or combination

 

Foot CavusFoot Cavovarus

 

Aetiology

 

2/3 have neurological disorder

1/3 have CMT

 

Neuromuscular

Congenital

Traumatic

RA

Idiopathic

 

Muscle imbalance of intrinsics and extrinsics

 

1. Neuromuscular

 

A. Central 

- Friedreich's Ataxia (absent ankle jerks & balance)

- Cerebral Palsy

- Hydrocephalus

 

B. Spinal cord

- Spinal Dysraphism / spina bifida

- Diastematomyelia /Syringomyelia

- Spinal Cord tumours

- CMT Type 2 (degeneration of spinal axons)

 

C. Anterior horn cell

- Polio (imbalance between anterior and posterior m)

- SMA

 

D. Peripheral nerves (+roots)

- CMT type 1 (demyelinating peripheral neuropathy)

- Polyneuritis

 

E. Muscle Disease

- Muscular Dystrophy

 

2. Congenital

 

Congenital cavus foot

Residual clubfoot

Arthrogryposis

 

3. Traumatic

 

Compartment Syndrome

Malunion of fractured foot

 

4. Degenerative

 

OA / RA of hindfoot

 

5. Idiopathic

 

CMT / HSMN

 

Inherited disorder of nerves

- most common inherited neurological disorder

- heterogenous group

- characterised by weak muscles and abnormal sensation

- positive FHx

 

CMT 1

- most common 80%

- demyelinating disorder

- peripheral nerve roots

 

Symptoms

- glove and stocking parasthesia

- nil reflexes

- claw toes, cavus feet, stork legs

- loss of intrinsics in hand

- abnormal NCS

 

CMT 2

- second most common 20%

- primary axonal neuropathy

- degeneration of spinal axons

 

Symptoms

- normal DTR

 

CMT 3 / 4 / X 

 

Pathophysiology

 

Rang Tripod concept

- heel / MTPJ 1st / MTPJ 5th 

- all must touch ground

- if 1st MTPJ plantaflexed

- heel must move into varus

 

Imbalance is the key to understanding

- PL creates cavus and equinus

- TP creates varus

 

A.  PL > T Ant 

- equinus forefoot

- plantar flexed first ray

- cavus foot

 

B.  T Post > PB 

- varus

 

C.  Weak Intrinsics & EDL < FDL

- clawing

 

Deformity

 

A.  Cavus foot

 

PF 1st ray initially 

- weak T Ant

- EHL & EDL act to DF ankle

- this increases windlass mechanism 

 

Contracture of plantar fascia 

- fixed Cavus

- fixed navicular-cuneiform & 1st CMTJ

- holds MT plantar flexed

 

B.  Varus heel 

 

Causes 

 

1.  Overpowering T Post & long toe flexors

- T post may be primary deforming force

 

2.  Supination of forefoot due to PF 1st ray

- then need varus heel to place lateral column on floor with PF ray

- may be primary deformity

 

C.  Clawing of toes  

 

Weak intrinsics 

- unopposed flexors and extensors

- hyper-extended MCPJ +/- dorsal subluxation MTPJ's

- claw toes

 

D.  Ankle Instability

 

Weak P Brevis

- Loss of dynamic restraint

 

Varus heel increases inversion moment on ankle 

 

DDx

 

1.  Bilateral Cavovarus

 

Central Pathology

- Spinal Cord Tumour / Dysraphism

- CNS 

 

2.  Unilateral Cavovarus 

 

Peripheral or Local Pathology

- Polio

- clubfoot

- Incomplete spinal cord or Cauda equina trauma

- Deep posterior Compartment Syndrome

- Compartment Syndrome of Foot

 

3.  CalcaneoCavus

 

Hindfoot Cavus 2° DF of calcaneus only

 

The apex is the differential

- Midfoot Cavus has apex in tarsus

- Forefoot Cavus from PF of 1st Ray (form seen in CMT)

 

Stages

 

1. Flexible cavus / Flexible 1st MT

- plantarflexion corrects with pressure on 1st MT

 

Cavus FootCavus Foot Flexible First Metatarsal

 

2. Fixed 1st MT equinus / hindfoot mobile varus

- hindfoot corrects with Coleman block test

 

3. Fixed lesser MT's equinus / fixed hindfoot varus

 

4. Bony changes

 

History

 

Family history

 

Is it progressing?

 

Metatarsalgia

 

Lateral ankle sprain 

- secondary to hindfoot varus

 

Ulcerations due to clawing

 

Foot numbness

 

Difficulty shoewear

 

Examination

 

Goals

- aetiology

- define deformity / correctability

- motor drive to deformity

 

Look

 

Front

- dysmorphism

- stork legs

- shoes

- parents

 

Side

- cavus foot / plantar flexed first ray

- claw toes

 

Back

- varus heel

- signs spinal dysraphism

 

Walk

 

High stepping gait

- weak T Achilles

- drop foot

 

Back knee gait

- fixed equinus

 

Heel walk 

Toe walk

Squat

 

Coleman Block  / Lateral Block Test 

 

Technique

- block under lateral foot

- first ray touches the ground

 

Aim

- eliminate forefoot deformity

- if hindfoot corrects with this test the hindfoot is flexible

- forefoot surgery should be sufficient to correct hind foot

 

Foot

 

Toes

- Claw toes - ? correctable

- Plantar keratoses from uncovering MTPJ

- Dorsal toe corns from claw toes

 

Plantarflexed 1st MTPJ 

- ? correctable

 

Motor examination

- T Post / T Ant /  PB & PL

- Ankle DF & STJ Eversion weak 

 

Silverskiold

- is T Achilles tight ?

 

Neurology

- abdominal reflexes

- LL neurology

- CMT 1 abnormal sensation and absent reflexes

 

X-ray

 

Lateral x-ray

- sinus tarsi easily seen

- PF 1st ray

 

Meary's angle

- talo - 1st metatarsal angle 

- normal 0o

- increased in cavus > 30o

 

Calcaneal Pitch

- normally 20o or less

- > 30o abnormal

- will demonstrate hindfoot DF

- demonstrates calcaneovarus

 

Pes CavusCalcaneal Pitch

 

MRI spine

 

Exclude spinal dysraphism

 

NCS

 

Can help diagnose CMT

 

Neurology review

 

Management

Non Operative

 

Options

 

Metatarsalgia

- preMT dome

 

Claw toes

- wide deep toe box

 

Foot drop

- AFO

 

Insensate foot

- custom orthosis

 

Varus

- lateral heel wedge

- AFO (flexible)

- medial iron with lateral T strap

 

Ankle Orthoses

 

Operative

 

Pes Cavus Post Op

 

Indications

 

Difficulty with Footwear

Pain

Lateral instability 

 

Contra-Indications

 

Need to ensure is not progressing

- otherwise surgery will not work

- i.e. does patient need spinal surgery first for dysraphism

 

Options

 

Soft tissue surgery

- for dynamic / flexible deformity

 

Bony surgery

- for static / fixed deformity

 

Algorithm 

 

Stage 1 / Flexible 1st MT PF

 

Shoe modification

 

Stage 2 / Fixed 1st MT + Flexible Hindfoot

 

Steindler release (plantar fascia release)

Jones / 1st MT osteotomy

Lesser toes as necessary

T post transfer if weak dorsiflexion

PL to PB transfer if weak eversion

 

Stage 3 / Fixed 1st MT / Fixed Hindfoot

 

Above +

Lateral Shift Calcaneal Osteotomy

T Achilles lengthening

 

Stage 4 / STJ and other bony deformities

 

Triple arthrodesis

Tarsal / MT osteotomy

 

ForeFoot

 

Soft tissue

 

1.  Steindler Release / Plantar fascia release

 

Best < 8 years

- for cavus

 

Incision

- medial incision extending 1.5 inches anterior to calcaneal tuberosity

 

Dissection

- separate above and below fascia

- divide plantar fascia & Long Plantar ligament at calcaneum

- excise 1 cm of fascia

- NV lie between 1st & 2nd layers

- if stay on periosteum will avoid damage to NV

- lateral plantar nerve is at lateral edge of fascia

 

2.  Tibialis Posterior transfer

 

Indicator

- weak dorsiflexion

 

Technique

- through interosseous membrane to lateral cuneiform

 

3.  P Longus to Brevis transfer 

 

Removal of 1st ray PF & increase eversion

 

4.  First Toe / Jones Procedure

 

Indication

- great toe clawed

- MTP hyperextended and IP flexion

 

Technique

 

A.  Leave EDB to P1 intact

- will drive extension toes

 

B.  Harvest distal EHL

- pass through drill hole neck MT

- suture to itself

 

C.  Fusion of IPJ

- K wire

 

5.  Hibbs 

 

EDL transfer

- plug into middle cuneiform 

- act as DF instead of weak T Anterior

 

6.  Lesser Claw Toes 

 

A.  Girdlestone FETT if flexible

B.  Extensor Tenotomy / PIPJ fusion / MTPJ dorsal capsulotomy / Weil's osteotomy if fixed

 

Bony

 

1st MT osteotomy 

 

Description 

- dorsal closing wedge osteotomy

- extension osteotomy

 

Indication

- incomplete correction of first ray

- mature patient with closed physis

 

Technique

- dorsal closing wedge osteotomy

- base of MT

- leave plantar surface intact

- 3-4 mm wedge

- close osteotomy, fixation with K wires

- +/- 2nd and 3rd

 

Hindfoot

 

Soft Tissue

 

1.  Tendo achilles lengthening

 

Indications

- unable to reach plantigrade

 

Technique

- percutaneous

- 2 medial and one lateral to take out of varus

 

2. Lateral Ligament reconstruction 

 

If complain of ankle instability

 

Bony

 

1.  Dwyer lateral closing wedge Calcaneal osteotomy 

 

Indication

- correct fixed hindfoot varus 

 

Problem

- shortens foot further

 

2.  Calcaneal Lateral Shift Osteotomy

 

Lateral approach

- curve just behind peroneals

- homann in front of tenoachilles

- homann under calcaneum

 

Oblique osteotomy 

- 45o

- behind posterior facet

- osteotome

- open with lamina spreader

- split periosteum medially with osteotome

- this avoids damage to medial structures

- transfer laterally 1 cm

- may need to lengthen T Achilles

 

Fix with screw or lateral staple

 

3.  Midtarsal Osteotomy / V shaped

 

Indication

- fixed, difficult cases

 

Cole Osteotomy

- use ilizarov

 

4.  Triple Arthrodesis

 

For salvage of rigid deformity

 

Planovalgus Foot

Aquired Adult Flatfoot Deformity

Definition

 

Acquired Adult Flatfoot Deformity (AAFD)

- collapse of medial longitudinal arch

- secondary to ligament / tendon / joint or bony pathology

 

Classification

 

1. Congenital

 

Flexible / Physiological

 

Ligamentous Laxity (DIAL HOME)

 

Rigid 

- Congenital Vertical Talus 

- Tarsal Coalition

 

2.  Acquired

 

Tibialis Posterior Dysfunction

 

RA Flat Foot

 

Neurological

- Charcot Foot

- spinal dysraphism

- CP

- polio

 

OA

 

Midfoot OA / Lis Franc injury

 

Midfoot OA Planovalgus

 

Subtalar joint OA (calcaneal fracture)

Ankle OA

 

Ankle OA Valgus Tilt

 

Ligament

- isolated spring ligament rupture (rare)

- iatrogenic / traumatic plantar fascia rupture (rare)

 

Compensory to Rotational & Coronal plane deformities

- tibial torsion

- genu valgum

- ankle equinus 2° tight TA

 

Biomechanics of FlatFoot

 

Normal Gait / 3 phase rocker

 

1.  Heel Strike 

 

Tibia IR 

 

Hindfoot Everts

- unlocks TNJ & CCJ 

- forefoot pronates

 

Allows shock absorption by hind/mid/forefoot

 

2.  Stance 

- WB axis passes through ASIS to patella to middle of foot

 

3.  Toe Off

 

T Posterior "locks" the midfoot (i.e. the transverse tarsal joints)

- T Anterior inverts the hindfoot

- T Achilles plantar flexes the calcaneum

- Tibia externally rotates

 

Flatfoot Gait

 

The above components are exaggerated

- More stress on ligament structures

 

WB axis shifts medially, causing

- increased femoral anteversion

- internal knee rotation

- increased Q angle

 

T Achilles becomes evertor

 

Increased pronation

- may cause Hallux Valgus

 

Specific Conditions

 

Lisfranc Joint OA

 

Acquired Adult Flatfoot

 

Aetiology

 

1.  Post injury

 

Degenerative arthritis develops after fracture dislocation

- Acute injury often missed

- Adequate acute treatment may not prevent occurrence

 

2.  Idiopathic 

- not related to trauma

 

3.  Charcot

 

X-ray

 

Degenerative changes invariably involve second MT/ 2nd Cuneiform joint

- may involve 1st & 3rd joints

- rarely involves 4th & 5th joints

 

Midfoot AP Secondary to Missed Lis Franc

 

Non-operative

 

Moulded arch support / UCBL initially if correctable

Lateral Single Upright caliper with Medial T strap if not

 

Operative

 

Realignment of Lisfranc joint with arthrodesis

 

Rheumatoid Flat Foot

 

50% will get flat foot

- subtalar OA

- spring ligament attenuation

- tibialis post dysfunction

- progressive valgus deformity at hindfoot 

 

OA of Ankle Joint

 

Usually post traumatic

- valgus tilt of Talus leads to pronation of Talus & Calcaneus

 

Flatfoot def corrected when AJ realigned

 

Charcot Flat Foot

 

90% changes in hind and midfoot

- repetitive microtrauma in presence of neuropathy leads to microfracture

- 2° to Sensory & Autonomic Neuropathy

 

Progressive subluxation / collapse

 

Usually associated with Diabetes

- may be marked collapse

- develop bony prominence on medial sole

- may cause ulceration

 

Plantar Fascia Rupture

 

Traumatic or spontaneous

- pain at calcaneal origin

- palpable gap

- often 2° excess HCLA

 

Management

- arch support

- longitudinal arch will slightly flatten, but rupture should heal

 

Spring Ligament Rupture

 

Rare

- ? Repair

- probably in reality treat as for PTTD

 

 

Flexible Flat Foot

Symptoms

 

Complain of pain with prolonged standing

 

Complain feet tire easily

 

Examination

 

Adult Flatfoot Clinical Valgus Hindfoot Clinical

 

Overall alignment

 

Heel raises

 

Flexibility of Flat foot / STJ

 

T Achilles tightness

 

X-ray

 

Planovalgus Lateral XrayPlanovalgus Foot Meary's Angle

 

Meary's angle

- Talus - first MT angle

- lateral weight bearing view

 

Grading

- 0o normal

- mild - 15o

- severe  - 30o

 

Non Operative

 

Medial arch support

Medial heel raise

UCBL

 

Operative

 

Indications

- failure non operative measures

- inability to wear shoes

 

Surgery

 

1.  Evans anterior calcaneal osteotomy

 

Theory

- lateral column lengthening

 

Technique

- incision tip of fibula to base of 4th MT

- elevate EDB anteriorly

- peroneal tendons anteriorly

- sural nerve posteriorly

- identify CCJ joint but do not open capsule

- insert Homan retractor and identify interval between middle and anterior facet

- osteotomy between the two, 1.5 cm from CCJ

- insert lamina spreader, assess arch at this point

- insert tri-cortical iliac crest bone graft (slightly trapezoidal) with bone tamp

- 1cm opening wedge

- stabilise with plate or screws

 

Evans Osteotomy + MT Osteotomy + FDL transferEvans Osteotomy + MT Osteotomy + FDL transfer Oblique

 

2.  Medial reefing / repair spring ligament / FDL Transfer

- incision at inferior aspect head of talus

- above tibialis posterior tendon

- excise segment of spring ligament approximately 6mm

- reapproximate ligament with non absorbable sutures

 

3.  Medial Cuneiform Plantarflexing Osteotomy

 

Indication

- Restore weight bearing tripod

 

Technique

 

Dorsal osteotomy mid-substance cuneiform

- lever open with osteotome

- 4 - 7 mm tri-cortical graft

- fixation with 2 x screw

 

Post operative

- back slab

- wound check at 1 week

- sutures out at 2 weeks unless DM or RA

- SL POP for 6/52 NWB

- then WBAT in boot 6/52

 

4.  +/- T Achilles lengthening

- if unable to passively DF ankle past 10o with knee extended

 

Post op

- POP for 6/52 (mould into arch)

- arch support / UCBL for 6/12

 

Tibialis Posterior Dysfunction

Background

Aetiology

 

Intrinsic

- inflammatory

- degenerative

 

Extrinsic

- traumatic

- spur

 

Epidemiology

 

F > 40

 

Associations 60% of cases  

- hypertension

- diabetes

- obese

- trauma 

- prior surgery

- steroids

 

Aetiology

 

RA 

- flat foot also secondary to synovitis TNJ and STJ

 

Hypermobile flat foot

 

Seronegative disorders

- Ankylosing spondylitis / psoriasis / reiter's

 

Anatomy Tibialis Posterior

 

Origin

- posterior tibia, fibula and inter-osseous membrane

- acute angle around medial malleolus

- flexor retinaculum holds TP in groove 

- no mesotenon

- relative hypo-vascular zone 1-2cm distal to medial malleolus

 

Insertion

- navicular tuberosity

- plantar cuneiforms

- 2,3,4 MT

- sustentaculum tali

 

Excursion 

- 2cm only

 

Nerve Supply

- tibial nerve (L4/5, S1)

 

Action

 

1.  Runs medial to axis STJ

- inverts STJ & adducts forefoot

 

2.  Runs posterior to axis AKJ

- plantar flexor

 

3.  Maintains longitudinal arch

 

4.  Locks the midtarsal joints

- allows T Achilles to perform heel raise

- otherwise T Achilles acts at TNJ

 

Opposed mainly by peroneus brevis

 

Pathophysiology

 

Avascular zone 

- behind medial malleolus

- paratenon is supplied by blood vessels from a mesotenon on its post aspect

- tendon is composed of fibrocartilage where it changes direction around the med malleolus 

 

Tendon Changes

 

Starts with varying combination

 

1. Paratendinitis

- fluid in sheath 

- synovial proliferation

 

2. Tendinosis 

- tendon degeneration 

- tendon enlarged

- longitudinal splits develop 

- becomes yellowish 

 

Tibialis Posterior Tendinosis

 

3. Elongation of tendon

 

4. Rupture

 

5. Deformity 

- loss TP function leads to acquired Planovalgus

- initial deformity is collapse of medial longitudinal arch

 

Dysfunction

 

1. Medial arch collapses

2. STJ everts

3. Valgus heel

4. Foot abducts at TNJ

5. Achilles tendon acts as evertor when heel in valgus

6. Calcaneus impinges on fibular causing lateral AJ pain

7. Attenuation of TNJ capsule, spring ligament and deltoid ligament

 

History

 

Pain medially at first

- swelling

 

Lateral pain with impingement of fibula

 

Foot shape changes / progressive deformity

 

Difficulty wearing shoes

 

Examination

 

Any sign of RA

 

Look

- flattened medial arch

- valgus heel

 

Too many toes sign

- abducted forefoot

- > 2.5 toes

- more than on other side when in symmetrical posture

 

Single Heel Raise

- unable to heel raise

- need T Post to invert STJ & lock hind foot rigid so T Achilles can pull up Calcaneus

 

Sit over edge

- AKJ

- STJ

 

Feel

- tender medial

- is tendon thickened

- may be tender laterally

 

STJ

- fixed or flexible

 

AKJ

- fixed or flexible

 

T Achilles

- silverskiold

 

Power

1.  T Post with foot inverted in equinus

2.  Foot equinus and everted

- ask patient to invert the foot

 

NV examination

 

X-ray

 

Lateral weight bearing

 

Early 

- reduced talo-metatarsal angle (Meary's angle  0-10°)

- medial cuneiform to floor distanced reduced (N= 2.5cm)

- talus plantar flexed

 

Late

- STJ OA

 

AP weight bearing of foot and ankle

 

Early - abduction of forefoot with navicular lateral to talus

 

Late - ankle OA / TNJ OA

 

MRI 

 

Enlarged T Post - tendinosis

 

Thickned Tibialis Posterior

 

Torn T Post - half size of FDL

 

Johnson Classification

 

Stage 1 

- T Post tendonitis 

- no deformity

 

Stage 2 

- T Post rupture

- unable SHR

- foot remains flexible

 

IIA - minimal forefoot abuction

IIB - forefoot abducted throught THJ / > 30% uncovered

 

Stage 3 

- fixed deformity of STJ (may have STJ OA)

 

Stage 4 

- valgus angulation of talus & OA of ankle joint

 

 

Management

Surgical Algorithm

 

Stage 1 Tendonitis

 

Non-operative

 

Walking cast / NSAIDS

- 6/52

 

UCBL

- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch

 

Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)

 

Stage 2  Tendon Rupture

 

Non Operative

- UCBL

 

Operative

 

2A - FDL transfer & calcaneal osteotomy +/- T Achilles lengthening

2B - + Lateral column lenthening to correct abduction

 

Stage 3 Rigid valgus hindfoot

 

Non Operative

 

Rigid AFO

Caliper: Outside iron with inside T strap

 

Operative

 

Triple arthrodesis

 

Stage 4 / Abnormal AKJ

 

Pathology

- valgus angulation of talus

- deltoid ligament gone 

- early degeneration of ankle joint

- degenerative changes in subtalar & midtarsal joints 

- valgus angulation of talus

 

Non Operative

- double metal uprights with PTB

 

Operative

- pan talar fusion 

 

Operations

 

Tibialis Posterior Synovectomy and Debridement

 

Position

- supine on table

- foot falls into ER

- tourniquet

 

Incision

- tip of medial malleolus to navicular

- open tendon sheath

- often fluid and synovitis

 

Synovectomy

 

Repair any fissures

 

Inspect insertion

- if partially avulsed

- FDL transfer

 

Close tendon sheath

 

S/L cast for 3/52

 

Results

- 75% good results

 

Calcaneal Osteotomy / Medial Calcaneal slide

 

Aim

- shifts calcaneum medially

- reduces valgus thrust on hindfoot

- pull of gastoc/soleus is medial to STJ

 

Indications

- stage 1 or 2

- in combination with FDL transfer

 

Timing

- perform osteotomy first, then tension FDL

 

Set up

- sandbag under ipsilateral hip

- table rolled over to expose lateral heel

- then unroll bed to expose medially

 

Calcaneal Sliding Osteotomy LateralCalcaneal Sliding Osteotomy Harris Axial

 

Incision

- lateral incision

- in line with peroneal tendons

- need to protect sural nerve posteriorly

 

Osteotomy

- protect peroneals

- protect T Achilles

- behind posterior facet STJ

- transverse osteotomy at 45o to plane of foot

- complete with osteotome to protect medial structures

- use osteotome to gently break up periosteum

- use lamina spreader to break up final adhesions

- translate 10mm medially

 

ORIF

- K wire lateral to T Achilles, towards CCJ

- check II, 6.5 mm partially threaded cannulated screw

 

Lateral column lengthening

 

Indications

- midfoot abduction

 

Technique

- anterior calcaneal ostetomy

- insertion bone graft wedge

- stabilisation plate or screws

 

FDL transfer 

 

Reasons

- FDL easily found by reflecting abductor hallucis

 

Indications

- foot should be supple with no fixed deformity 

- stage 1 / 2

 

Incision 

- along entire length T posterior

- 10 cm proximal to medial malleolus

- to metatarsal cuneiform joint

 

Superficial dissection

- expose T posterior in sheath

- may be ruptured, avulsed, deficient, fissured

 

Deep dissection

- abductor hallucis reflected plantarward

- find fat / Knot of Henry

- release Master Knot of Henry 

- crossover of FDL & FHL 

- FDL plantar to FHL

- suture together and release proximal FDL 

 

TNJ

- open to visualise

- 4.5mm drill hole through navicular

- Reinsert FDL into underside of navicular

- plantar to dorsal

- pulled tight with ankle in equinus & forefoot in varus 

- close TNJ capsule

- No need to attach proximal T Post to FDL

 

Repair spring ligament

 

Closure abductor fascia

 

Post op

- 6/52 in equinus and inversion NWB

- x-ray to check osteotomy has healed

- 4/52 weight bearing in removable cast with ROM exercises

- may need physio

 

Triple Arthrodesis

 

Indication

- fixed hindfoot deformity with lateral joint pain

 

Aim

- realign hindfoot

- plantigrade surface

- maintain integrity of adjacent jts

- avoid neuromas

 

Issues

 

1.  Fuse TNJ first 

- this should passively align STJ

- need medial approach to reduce TNJ

 

2.  Fuse STJ 

- slight valgus not neutral or varus

- lateral approach

- may need large lateral bone wedge

- may have issues with lateral skin closure

 

 

Plantar Fasciitis

Definition

 

Pain at attachment of thickened central part of plantar aponeurosis to Medial Calcaneal Tuberosity

 

Anatomy Plantar Fascia

 

Origin 

- medial calcaneal tuberosity

 

Inserts 

- 5 bands superfical & deep layers

 

Superficial

- insert transverse MT ligament & skin

 

Deep 

- flexor sheath, volar plate & periosteum of P1

 

Action

- when toes passively DF in toe off

- inelastic

- stabilises and elevates arch of foot

- windlass mechanism

 

Fat Pad 

- absorbs 20-25% of force at heel strike

- U-shaped, fat arranged in fibro-elastic septa

 

Epidemiology

 

Usually middle-aged male

- age 40-70 years

- M:F = 2:1

- usually unilateral

 

Predisposing factors

- obesity

- certain occupations i.e. Policeman's heel

- athletes and repetitive stress

 

Aetiology

 

Usually idiopathic

 

May be associated condition especially if bilateral

- Reiter's Disease

- Ankylosing Spondylitis (enesopathy)

- Gout

 

Pronated feet / cavus feet / planus feet

Obesity

Tight tendoachilles

 

Theories

 

1.  Degenerative change fat pad most common finding 

- decreased ability to cushion heel

 

2.  Injury to windlass mechanism with micro trauma

 

3.  Nerve entrapment

 

4.  Heel spur present in 50% with heel pain

- spur is in origin FDB (short flexors) not plantar fascia

 

Shmokler 1000 patients

- 13.2% incidence heel spurs

- 5.2% of which had heel pain

 

Williams

- 45 patients 52 painful heels

- 75% painful heels with spur

- 65% opposite heel had spur

 

Foot Calcaneal Spur

 

Pathogenesis

 

Degeneration 80% 

 

Repetitive stress at attachment

- leads to microscopic tears & cystic degeneration

- maybe periosteal reaction & spur formation

 

Entrapment 20%

 

Nerve Entrapment Syndrome

- lateral plantar nerve / Baxter's nerve

- mixed motor and sensory

- motor to abductor digiti minimi

- runs superior to plantar fascia

- may be compressed by spur or fascia

- difficult to diagnose

 

History

 

Pain at inferomedial aspect of heel

- worse when first rising from bed

- worse with prolonged standing or extreme exercise

 

Examination

 

Local tenderness at inferomedial aspect of Calcaneal tuberosity

 

Pain aggravated by passive dorsiflexion of toes

 

Tinel's sign

 

Cavus / Planus

 

Tight T Achilles

 

X-ray

 

Maybe calcaneal spur (50%)

- exclude tumour & infection

 

Bone Scan

 

Can be useful in atypical presentations

 

MRI

 

Plantar fasciitis MRIPlantar Fasciitis MRI

 

Inflammation of the plantar fascia at its insertion

May show compression of 1st branch of lateral plantar nerve

 

DDx

 

Inferior heel

- calcaneal stress fracture

- fat pad atrophy

- calcaneal apophysitis

- nerve compression / tarsal tunnel

 

Posterior heel

- Achilles tendonitis

- retrocalcaneal bursitis

- STJ OA

 

NHx

 

80-95% settle with non-operative management

- in 6-12/12

 

Management

 

Non-operative

 

Acute cases respond better to HCLA

Chronic better to orthoses

 

Soft Heel Cup with Instep

 

Physiotherapy

- T Achilles stretches

- Plantar fascia stretches

- can rolling

 

Orthoses

- well padded running shoes

- viscous heel cushions + longitudinal arch support

- Soft Heel Cup with Instep

 

Night splint 

- hold in 15o DF

- very effective

- maintain night-time stretch

 

NSAIDS

 

ECSW

 

Aqil et al. CORR 2013

- meta-analysis of RCTs

- safe and effective treatment

- effects evidence at 12 weeks, last up to 12 months

 

High energy ECSW v low energy ECSW

- evidence for both

 

Cast immobilisation 

- keeps plantar fascia under constant stretch and minimises microtrauma

- patient should undergo this treatment before consideration for surgery

- very effective treatment

 

Injections

 

Cortisone

- ? US guided

- max 2 (plantar fascia can rupture)

 

PRP

 

Acosta-Olivo et al. J Am Podiatr Assoc 2016

- RCT of cortisone v PRP

- equally efficacious

- no between group difference

 

Botox

 

Ahmed et al Foot Ankle Int 2016

- RCT of saline v Botox

- significant improvement in botox group

 

Operative

 

Indication

- must have minimum 12 months non-operative treatment

- 5% of patients

- results of surgery variable

 

Results

 

Contompasis

- 129 patients

- 43% complete improvement

- 38% some improvement

- none worse off

 

Open Release of Plantar Fascia

 

Set up

- tourniquet

- prone / lateral / supine

 

Incision

- medial longitudinal incision

- this is often vertical in line with posterior border medial malleolus

- protect medial calcaneal branch 

 

Dissection

- divide ABHB fascia

- reflect this superiorly

- identify plantar fascia origin from tuberosity

- FDB is above plantar fascia

- insert homan retractors above and below

- lateral plantar nerve deep to abductor, above FDB laterally

 

Resection

 

Resect medial rectangle of plantar fascia

- divide 3/4 of fascia

- don't release in full unless very old and decrepit

- take 6 deep by 2 mm thick rectangle

 

+/- neurolysis

 

+/- Resect spur

- reflect FDB

- remove with osteotome / nibbler

 

B.  Endoscopic release

 

Ogilvie-Harris Arthroscopy 2000

- 53 patients with 65 feet

- complete resolution of pain in 89%

- 71% returned to unrestricted sport

 

Results

 

Cochrane Review 2012

- no evidence for laser or ultrasound

- limited evidence for dorsiflexion night splints

- limited evidence topical corticosteroid

- some evidence for injected CS

- equivocal for ECSW

Rheumatoid Foot

Forefoot

Issues

 

1.  Painful Bunion / Hallux valgus

 

Rheumatoid Forefoot Hallux Valgus

 

2.  Metatarsalgia / MTPJ dislocation

 

Rheumatoid Foot

 

3.  Claw toes

 

Claw Toes

 

Pathology

 

Earliest manifestation is synovitis of MTPJ 

- capsular destruction 

 

Dorsal subluxation MTPJ

- claw toes develop (MTPJ hyperextended, PIPJ flexed)

 

Plantar fat pad displaced distally

- MT heads exposed to plantar skin

- corns develop over PIPJ & under MT heads

 

Management

 

Non-operative Management

 

Shoe-wear modification

 

Extra-depth shoe / low heel / roomy toe-box

Custom-made arch support

Pre-MT dome for metatarsalgia

Heel cup to prevent heel valgus

STJ - single lateral upright with medial T strap

AKJ - double upright with square ferrule

 

Operative Management

 

Indications

 

Continuing pain

Increasing deformity

Footwear modification failure

 

Issues

 

Poor wound healing

Infection

Non-union

Recurrence of deformity

 

Timing in multiple joint surgery

 

Forefoot often first

- eliminates pedal sepsis

 

Hallux Valgus / Rigidus

 

Options

- arthrodesis

- arthroplasty

- Keller's procedure

 

Arthrodesis

 

Rheumatoid Forefoot Fowlers MTPJ Fusion

 

Procedure of choice

- provides forefoot power & buttresses lesser toes

 

Contra-indication

- involvement of IPJ 

- need to have mobile IPJ to put tip of toe onto the ground

- consider arthroplasty

 

Complication

- non-union

- malposition

- stress transfer to IPJ

 

Silicone Arthroplasty / Double-Stemmed Swanson

 

Indication

- low-demand patient

- IPJ of hallux affected

 

Complication 

- breakage

- silicone synovitis

 

Keller's Procedure

 

Indication

- in low demand patient where bony union expected to be difficult

- salvage procedure

 

Complication

- cock up deformity

- transfer metatarsalgia

- loss of power

- recurrence

 

Metarsalgia

 

Options

- synovectomy

- Weil's osteotomy

- Fowler's procedure

 

Synovectomy

 

Indication

- early disease / synovitis

 

Technique

- 3 incision

- one over first MT

- 2 between 2/3 and 4/5

- incise extensor hood

 

Weil's Osteotomy

 

Indications

- enlocated MTPJ

- i.e. in conjuction with treatment of claw toe

 

Technique

- transverse osteotomy

- MT head moved proximally

- secured with screw

 

Fowler's operation 

 

Fowlers

 

Indication

- dislocation MTPJ

 

Concept

- cascading excision of II - V MT heads 

- 2nd 3 mm longer than 1st or 3rd

- 3rd 3mm longer than 4th

- 4th 3 mm longer than 5th 

 

Technique

 

Single dorsal transverse skin excision just proximal to toe webs 

- can be performed via transverse plantar ellipse

- with severe dislocation may be easier to approach through plantar aspect 

- MT heads subcutaneous & NV bundle usually subluxed dorsally

 

Extensor tenotomy

 

MT heads excised in gentle curve

- dorsal distal to plantar proximal

- contoured on plantar surface to give rounded surface

- very little length removed from 5th MT 

- must not leave bony fragments in weight bearing pad

 

Second incision on plantar surface 

- proximal to MT heads

- ellipse of skin only excised 

- closed to pull skin of forefoot under MT ends

 

Claw toes

 

EPL lengthening / EDB tenotomy / PIPJ fusion

 

 

General Concepts

Definition 

 

Disorder of immune system 

- antigen-antibody complexes

- stimulate release of proteolytic enzymes

- leading to vasculitis, synovitis and cartilage destruction

 

Characterised

 

Articular Effects

- synovitis

- ligamentous and capsular laxity

- cartilage destruction

- osseous erosion

 

Vasculitis

- rheumatoid nodules

- digital ischaemia

- skin ulceration

- poor wound healing

 

Neuropathy 

- mononeuritis multiplex

 

General

 

90% will have foot problems

 

Forefoot

 

Most commonly involves forefoot

- 10x more common than hindfoot

 

1.  Hallux Valgus

2.  Dorsal Subluxation MTPJ

3.  Clawing of toes

 

Midfoot

 

TNJ OA

 

Hindfoot

 

STJ > AKJ

 

A.  STJ / Planovalgus (50%)

- destruction of soft tissues especially STJ capsule and interosseous ligament

- + Destruction of TNJ 

- leads to Planovalgus foot

- May be initiated or exacerbated by rupture of Tibialis Posterior (common)

- hindfoot valgus leads to T Achilles contracture

 

B.  Ankle

- Rarely affected (10%)

- Destroyed Ankle rarely occurs in isolation

- i.e. typically would have pan-talar arthritis

 

Management

 

Multiple Joint Surgery Timing

 

1.  Forefoot OT

- great symptomatic relief

- minimal patient stress

- eliminates pedal sepsis

- wound problems common & occur before prostheses implanted

 

2.  THR 

- easier to rehabilitate following THR with deformed knees

- allows correction of proximal limb contractures & lordosis

 

3.  TKR

 

4.  Hindfoot OT

- usually for planovalgus

 

Pre-operative

 

Vascular assessment

- ABI > 0.7

- ankle pressure > 90 mmHg

 

Examine for neuropathy

 

Medications

- stop MTX

- ? stop steroids

 

Infection prevention

- clean skin meticulously prior to surgery

- repeat in OT

- prophylactic ABx for 72hrs

 

C spine x-ray

 

Post operatively

 

Leave sutures in for 3/52 due to delayed healing on steroids

- elevate feet for 2-3/7 post-op

- change dressing that evening if large drainage or oedema

 

 

 

Midfoot / Hindfoot

Midfoot

 

A.  Lis Franc Joints OA

 

May cause flat foot

Treat with midfoot fusion

 

Rheumatoid Foot APRheumatoid Midfoot OA

 

B.  TNJ OA

 

May be affected in isolation early

- may cause passively correctable valgus foot

- UCBL insert

 

Talonavicular Arthrodesis

 

Indication

- erosion confined to this joint

- correct valgus deformity

 

Technique

- dorsomedial incision

- protect saphenous nerve and vein

 

Result

- will lose 80% STJ motion

 

Rheumatoid TNJ Fusion LateralRheumatoid TNJ Fusion AP

 

Hindfoot

 

A.  Tendo Achilles Insertional Tendonitis

 

Ankle Synovitis

 

Rheumatoid involvement of bursa at T Achilles insertion

- nodules may develop within the tendon

- can weaken attachment & precipitate rupture

 

Treatment

- excision of nodules

- may need tendon augmentation / reconstruction

 

B.  Retrocalcaneal Bursitis

 

Common

- heel lift initially

- may need debridement and excision of posterosuperior calcaneal prominence

 

C.  Tibialis Posterior Tendonitis /  Rupture

 

Synovitis of sheaths of T post & Peroneal tendons common

- treat with tenosynovectomy

 

Rupture of TP with flatfoot

- FDL transfer in Stage 2 

- triple arthrodesis in Stage 3

- pan talar arthrodesis in Stage 4

 

D.  Planovalgus

 

Causes

- STJ OA

- TNJ OA

- tibialis posterior rupture

- synovitis and rupture of the talocalcaneal interosseous ligament

- tight T Achilles

 

Pathology

- subtalar joint valgus angulation

- talar head drops into plantarflexion

- navicular subluxes laterally

- get planovalgus foot with forefoot abduction

 

Non Operative

 

Brace

- double upright with square ferrule

 

Operative

 

Triple Arthrodesis

 

Indication

- fixed painful hindfoot

- TNJ and STJ OA

- AKJ preserved

 

F.  AKJ OA

 

Total Ankle Replacement

 

Attractive concept

- reduces loading across other joints

- results similar to OA

 

Ankle Arthrodesis

 

Treatment of choice

 

Complicated by

- prolonged period to union  - 6/12

- non-union in 10%

 

Talus

OCD

DefinitionTalus OCD MRI Coronal

 

Fracture talus through articular cartilage into subchondral bone

- 2° force transmitted from distal tibia

 

Osteochondritis dissecans v osteochondral fracture

 

Epidemiology

 

6% ankle sprains

Average age = 25 

M > F

 

Location

 

1.  Anterolateral 50% 

 

Talus OCD Anterolateral FragmentTalus OCD Anterolateral 2

 

2.  Posteromedial 50% 

 

Talus OCD MedialAnkle OCD Medial

 

Aetiology

 

30% associated with other injuries

- medial and lateral malleolar fractures

- ankle sprains

 

A.  Traumatic / anterolateral

 

2° to inversion injuries

- will usually heal

 

B.  Atraumatic / posteromedial

 

2/3 caused by trauma

- 1/3 no history trauma 

- are chronic and won't heal 

 

Non-traumatic causes

- ? AVN 

- 20% bilateral (can be asymptomatic)

- some patients have multiple joints with OCD

- can have family history of talus OCD

 

Pathology

 

Start as acute intra-articular fracture

 

Bony fragment may

- revascularise & unite

- undergo AVN & not unite

 

Overlying cartilage may degenerate

 

Cyst may develop under fragment

 

Berndt & Harty Xray Classification

 

Stage 1 

- subchondral compression fracture

 

Stage 2 

- partially attached osteochondral fragment / flap

 

Stage 3 

- fragment detached in-situ / not displaced

 

Talus OCD Medial Type 3

 

Stage 4 

- detached displaced fragment

 

Talus OCD Medial Type IV

 

MRI 

 

Determine stability of fragment

- stable lesion has intact overlying cartilage

- unstable lesion has fluid at fragment-crater interface

 

Stage 1

- stable

- no detachment, no synovial fluid

 

Stage 2

- partially detached, some synovial fluid

 

Talus OCD Type 2

 

Stage 3

- completely detached, not displaced

 

Talus OCD Anterolateral MRI0001Talus OCD Anterolateral MRI0002

 

Talus OCDTalus OCD

 

Stage 4

- displaced

 

History

 

Lateral ankle sprain from inversion injury

 

Chronic symptoms after ankle sprain settled

- activity-related pain, stiffness & swelling

- crepitus, instability & locking (true locking rare)

 

Symptoms of lateral ligament instability

 

Examination

 

Tenderness around ankle joint

 

Pain with dorsiflexion / eversion

 

Decreased ROM, especially dorsiflexion

 

Effusion

 

Test for ligament instability

 

DDx

 

Chronic ligament instability

Lateral gutter ST impingement

Calcaneal fracture

Lateral process fracture

Tarsal coalition

Sinus tarsi syndrome

  

Management

 

Non Operative

 

Higher success with acute injury

- POP & NWB 6/52

- progressive to weight bearing over 3 - 4 months

 

Tol et al Foot Ankle Int 2000

- meta-analysis

- 14 studies with 201 patients

- 45% success rate

 

Operative

 

1.  Percutaneous Drilling

 

Indication

- Type 1, 2

 

Ankle OCD ArthroscopyAnkle OCD Percutaneous Drilling 1Ankle OCD Percutaneous Drilling 2

 

2.  ORIF

 

Indications

- acute

- large type 2 , 3

- in situ but unstable and not healing

 

Approach

 

A.   Lateral lesion

- approached through anterolateral approach

- ± Fibular osteotomy if large 

 

B.  Medial lesion

- approached through anteromedial approach

- ± medial malleolar osteotomy

 

Medial Malleolar Osteotomy

 

Technique

- partially displace

- debride base

- insert bone graft as paste

- fix with bioabsorbably headless compression screws

 

3.  Excision / curettage / abrasion / microfracture

 

Indications

- small lesion

- fragment detached with chondral lesion

 

Results

 

Tol Meta-analysis

- 88% success stage 3 and higher

- less if no curettage or dilling

- can do so arthroscopically

 

Ankle Scope OCD Grade 4Ankle Scope OCD Abrasion

 

Talus Chondral LesionTalus OCD Bleeding

 

4.  Allograft

 

Indications

- large lesions

- > 1cm diameter and > 5mm thick

 

Post operative

- PTB brace 1 year

 

Results

 

Gross Foot Ankle Int 2001

- 3/9 resorbed

 

4.  Osteochondral autograft / mosaicoplasty

 

Indications

- stage 4 lesion

 

Donor Site

- taken from knee NWB surface

- allograft

 

Technique

- fresh frozen talus

- 6.5 mm chisel used to take 10 mm plug

- medial malleolar osteotomy

- 6.5 mm drill into OCD site with drill guide, over drill 4 mm

- dilator

- insert plug, countersink 1 - 2 mm

 

Medial Malleolar Osteotomy

 

Talus MosaicplastyTalus Mosaicplasty 1Talus Mosaicplasty 2

 

Results

 

Management Algorithm

 

Stage 1

 

Restricted activity / watch to see if heals

 

Stage 2 

 

Symptomatic 

- SL POP for 6/52 

- Successful in 90%

 

Failure

1.  ORIF

2.  Removal of necrotic fragment & drill base 

 

Stage 3 

 

Surgery probably indicated as very unstable

- ORIF

 

Stage 4 

 

Surgery

- acute ORIF if possible (i.e fragment is replaceable)

- chronic may have to discard fragment 

- manage chondral defect / abrasion

Talar Body Fracture

Definition

 

Body Fracture

- fracture line exits inferior surface behind lateral process

- into posterior facet

- intra-articular body fracture

 

Neck Fracture

- fracture line exits inferior surface anterior to lateral process

- in front of sinus tarsi

- extra-articular neck fracture

 

Types

 

1.  Shear

2.  Crush

3.  Posterior Process

4.  Lateral Process

5.  Talus Head

 

1.  Shear

 

Boyd & Knight classification

- coronal or sagittal 

- horizontal

 

Epidemiology

 

13-20% of all talus fractures

 

Issues

 

Involves both AJ and posterior facet STJ

 

CT Talar Dome FractureCT Talar Dome Fracture 2

 

Prognosis

 

A.  50% develop post-traumatic arthritis

 

B.  25-100% AVN

- Usually patchy and so avoid collapse

 

Management

 

Undisplaced

- POP

 

Displaced 

- ORIF 

- either medial or lateral approach

- may need medial or lateral malleolar osteotomy

 

Talar Dome ORIF APTalar Dome ORIF Lateral

 

Talar Dome ORIF APTalar Dome ORIF LateralTalar Dome ORIF Non Union

 

Nonunion

 

Talus Body Nonunion CTTalus Body Nonunion CT2Talus Body Nonunion MRI

 

Talus Body Nonunion ORIF 1Talus Body Nonunion ORIF 2

 

2.  Crush

 

High energy

- associated injuries common

- prognosis as above

 

Management

- as above 

 

3.  Posterior Process Fractures

 

Anatomy

 

Composed of Posterolateral & Posteromedial tubercles

- separated by sulcus for FHL

- lateral larger than medial 

 

PL tubercle

- size variable

- Superior surface non articular, attaches PTFL

- Inferior surface in continuity with posteror articular surface of Talus

 

PM tubercle

- also varies in size

- deep & superficial Deltoid ligaments attach

 

Os Trigonum

- accessory bone seen in association with PL tubercle of talus

~ 50% of feet

- may be unilateral or bilateral

- may be fused to talus or calcaneus 

- relationship to PL tuberosity varies from complete separation to fusion

 

Os TrigonumTalus Posterior Tubercle Synchondrosis

 

Mechanism

 

A.  Forced PF 

- impingement especially ballet / soccer

 

B.  Excess DF 

- increased tension on PTFL with avulsion

 

Examination

 

Tender posteriorly

Crepitus with PF

Pain with motion of Hallux in groove

 

DDx 

 

Lateral process fracture

Fracture of fused os trigonum

Disruption of synchondrosis of os to talar body

 

Investigation

 

Xray

 

Talus Posterior Process Fracture

 

Bone Scan / CT useful in Dx

 

Talus Posterior Process Fracture CT

 

Managment

 

Same for medial & lateral

- conservative initially

 

Persistent symptoms >6/12 

- excision of fragement

- posteromedial or posterolateral approach

- Persistent problems from non-union not uncommon 

 

4.  Lateral Process Fractures

 

Talus Lateral Process FractureTalus Lateral Process Fracture CT

 

Eponymous name

 

Snowboarder's fracture

 

Anatomy

 

Wedge shaped prominence

- most lateral aspect of talar body

- point of attachment of lateral talocalcaneal, cervical, bifurcate & ATFL

- fracture involves talofibular and STJ

 

Mechanism 

 

Acute dorsiflexion & inversion of foot

- most are avulsion fracture

 

Clinical

 

Identical to lateral ankle sprain

 

X-ray

 

Best seen on mortise view

 

Lateral Process Fracture

 

Management

 

Depends on size and displacement

 

1.  Large and non displaced

- non operative

 

2.  Large and displaced

- ORIF

 

3.  Comminuted

- non operative

- excise if problematic 

 

5.  Talus Head Fractures

 

Talar Head FractureTalar Head Fracture CT

 

Epidemiology

 

< 10% of all talus fractures

- rare

- often missed

 

Pathology

 

Disability via involvement articular surface 

- late TNJ arthritis

- associated with subluxation / dislocation of transverse tarsal joints

 

Types

 

1. Compression fracture

- impaction injuries with force through navicular to compress head

- hyperdorsiflexion

- may also produce compression fracture of navicular

 

2. Shear fracture

- secondary to inversion injury

- causes midtarsal adduction with navicular tearing off portion head

 

Management

 

Non-displaced 

- cast NWB

 

Displaced 

- ORIF via medial approach

- if extremely comminuted consider TNJ arthrodesis

 

Talar Neck Complications

AVN  

 

Largely related to degree of displacement

 

Incidence

 

Hawkins Type I

- 0% to 13% 

 

Talus AVN Hawkins 1

 

Hawkins Type II 

- 20% to 50% 

- usually only patchy and not a problem (rarely collapses)

- usually unites 

 

Hawkins Type III / IV

- 90% to 100% 

- often a problem

 

 Talus AVN Post ORIF

 

Talus AVN 1Talus AVN 2

 

Hawkins Sign 1970

 

Means talus is vascularised

- makes diagnosis of AVN unlikely

 

AP view

- at 6 - 8 weeks see disuse atrophy of bones

- due to NWB

- thin rim of radiolucency under cartilage of talar dome

- subchondral atrophy

 

MRI 

 

Best method to diagnose AVN

 

Talus AVN MRI

 

CT

 

Talus ACN CT 1Talus AVN CT 2

 

NHx

 

Usually posterolateral corner

- furtherest from medial blood supply

 

Collapse occurrs despite years of NWB

- NWB does not prevent collapse 

 

Creeping substitution can take up to 36 months

Collapse in most is well tolerated

Hawkins advocates weightbearing once united as re-ossification takes years

 

Management Limited collapse with OA

 

Arthrodesis of the affected joint

 

Management Complete collapse

 

Issue

- have a dead talus

- very difficult to obtain tibio-talar-calcaneal fusion

 

1.  Blair fusion / tibio-talar arthrodesis / sliding anterior tibial graft

 

Ankle Blair Fusion APAnkle Blair Fusion Lateral

 

Advantage

- maintains length

 

Anterior approach between EDL and EHL

- excise avascular body

- use saw to take 5 x 2.5 cm graft anterior tibia

- slide graft from distal tibia

- insert into notch in residual viable talar neck and head

- foot in 0o DF, 5o valgus, 10o ER

- single screw x graft into tibia

- additional tibio-talar scrws

- Pack cancellous bone grafts around the fusion site.

- Apply a long leg cast with the knee flexed 30o

 

Results

- 4 united, 3 pseudos

- 5 good, 1 fair, 1 poor

 

2.  Pantalar fusion with IM nail

 

3.  Ilizarov Tibio-calcaneal Fusion 

 

Disadvantage talus excision

- makes leg short

- 3cm short on average

 

Technique

- frame tibio-calcaneal fusion

- Ilizarov proximal corticotomy and lengthening

 

Mal-union 

 

Incidence

 

More of a problem than AVN in Type II 

- may be up to 40%

- most common with non operative or single incision operations

 

Issue

 

Varus secondary to medial comminution

- creates cavus foot with supination

- walk on lateral border of foot / walk with IR foot

- predispose to premature OA

 

Options

 

1.  Talus osteotomy

2.  Medial column lengthening with tri-cortical graft

3.  Lateral column shortening

 

Arthritis

 

Subtalar joint arthritis

- most common complication

- rarely requires fusion

 

Non operative

 

STJ 

- UCBL

 

Ankle 

- moulded AFO

 

Operative

 

Fusion

 

Delayed Union 

 

Definition

- > 6 months

- incidence is 10%

- very common

 

Non-union

 

Definition

- >12 months

- rare

Talar Neck Fracture

Epidemiology

 

Second most common  hindfoot after calcaneal fractures

 

Aetiology

 

Aviators Astragalus

 

Fall from height

- hyper-dorsiflexion injury

- neck of talus strikes the anterior tibia

 

Anatomy

 

More than half surface covered by articular cartilage

- medial articular wall straight

- lateral articular wall curves posteriorly

- meet at posterior tubercle

 

Neck of talus

- medially 10 - 44o from axis of body

- plantar 5 - 50o

 

No muscle or tendon attachments

 

Ligaments

- deep deltoid medially

- ATFL, PTFL

- FHL tendon in groove posteriorly

- head supported by spring ligament (CN ligament)

 

Facets

- posterior / middle / anterior

- correspond to calcaneal facets

- sinus tarsi between posterior and middle

 

Blood Supply

 

3/5 talus covered by articular cartilage

- blood can only enter through 2/5

 

1.  Posterior tibial / artery of tarsal canal

- main supply to body

- branches to deltoid ligament

- enters talar neck and supplies most of body

 

2.  Anterior tibial / Dorsalis pedis

- supplies head and neck

 

3.  Peroneal / artery of tarsal sinus

- supplies head and neck head and neck

 

Pathology

 

Often with rotation 

- with DF body of talus locks in mortice 

- fracture neck on tibia

- remainder of foot displaces medially thru STJ 

- disrupt inter-osseous and lateral / posterior ligaments 

- dislocation of STJ and AKJ 

 

Body of talus is forced out postero-medially swinging on intact deltoid

- comes to lie posterior to medial malleolus & anterior to T achilles

- often associated medial +/- lateral malleolus fracture

 

Classification Hawkins 1970

 

1.  Undisplaced fracture

 

Fracture of neck between posterior and medial facet

- precluded by any displacement of 1 - 2 mm

- may need CT to confirm

- means only one blood supply is disrupted

 

AVN 10%

 

2.  Subluxation / dislocation STJ

- subluxed posteriorly or medially

- blood supply through neck and in canal disrupted

- blood supply through medial body usually maintained

 

AVN 39% Vallier et al JBJS Am 2004

 

Talar Neck Fracture

 

3.  Subluxed STJ &  AKJ 

 

Body extruded postero-medially

- head maintains relationship with navicular

- 25 % open 

- all three blood supplies are disrupted

 

Talus Fracture Type 3

 

AVN 67% Vallier et al JBJS Am 2004

 

4.  Type 3 + subluxed TNJ

 

Dislocation of head and neck

- poor outcome

- significance is that blood supply to head may also be disrupted

 

AVN 90 - 100%

 

Hawkins 4 Talar Neck FractureHawkins 4 Talar Neck Fracture AP

 

Examination

 

Open wounds

 

Compound Talus

 

Skin under threat (Type III / IV)

 

NV compromise

- fragment can compress circulation

 

X-ray

 

Canale view

- evaluates talar neck

- foot 15o pronated

- beam angled 75o to foot

- look for medial shortening / varus

 

CT

 

Management

 

Non-operative

 

Indication

 

Only for true type 1 injuries

 

Technique

 

Frequent review to prevent loss of position

SL NWB POP 6/52

 

Operative Management

 

Goal

 

Anatomic reduction

- rotation / length / angulation of talar neck

 

Any displacement of 2mm

- increases contact stresses of STJ

- leads to premature STJ OA

 

Closed Reduction

 

Occasionally need to do closed reduction

- pressure on skin

- vascular compromise

- patient severely injury

 

Technique

- flex knee to relax gastrocnemius

- traction on plantarflexed foot to realign head and body

- varus / valgus correct as required

- place temporary percutaneous K wires

 

Timing of Surgery

 

Does early reduction prevent AVN?

 

Vallier et al JBJS Am 2004

- 102 patients

- no evidence that surgical delay increased AVN

- AVN associated with neck comminution and open fractures

- recommend is reasonable to wait for swelling to subside

 

Sanders 2004 JBJS Am

- similar conclusion

- 29 patients

- delay in surgery did not affect union or AVN rates

 

Surgical Technique

 

1.  Closed Type 2 - 4

 

Position

- supine on radiolucent table

- tourniquet, IV Abx, II available

 

Incisions

- 2 incision technique

 

Anteromedial 

- just medial to T anterior tendon 

- begin at TNJ

- can extend to MM

- no stripping of dorsal neck

- preserve deep deltoid for blood supply

- may require medial malleolar osteotomy

- in this case can curve incision up and around medial malleolus

 

Anterolateral

- allows assessment of reduction

- lateral screw prevents compression into varus and loss of medial length

- lateral to EDL, mobilise EDB

- > 7 cm skin bridge

- expose lateral talar neck

 

Reduce and ORIF

- only accept anatomical reduction

- avoid varus and shortening medial neck

- anteromedial and anterolateral K wires

- insert proximal to articular surface of head

- aim into posterior body

- parallel

- check II

- cannulated lag screws (titanium for future MRI)

- minifragment screws for osteochondral fragments

 

Talus ORIF APTalus ORIF LateralTalus ORIF

 

2.  Devitalised Type 3 / 4 with compound wound

 

Managment is controversial

 

1.  Reasonable to clean / replace / ORIF

- if become's infected remove 

- Abx spacer

- apply frame

- fuse late once infection cleared +/- lengthening

 

Compound Talus ORIF 1Compound Talus ORIF 2Compound Talus ORIF

 

Talus ORIF APTalus ORIF Lateral

 

2.  Can discard primarily & close wound

- fusion once soft tissues healed

- acute shortening and fusion with frame with proximal corticotomy and lengthening

Triple Arthodesis

Biomechanics

 

Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ

 

Average loss of DF 30% / PF 10%

 

Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5o valgus 

- permits TTJ mobility

- if varus TTJ locked & patient tends to walk on lateral aspect of foot 

 

Indications for STJ arthrodesis

 

 Subtalar Arthritis

 

Post traumatic / calcaneal fracture

 

RA

 

Primary OA

 

Coalition

 

Talar Coalition CN 1Calcaneonavicular coalition subtalar OA MRI

 

Tibialis posterior dysfunction

 

Neuromuscular disorders

- instability

- CMT / polio / nerve injury

 

Indication for Triple Arthrodesis

 

Valgus deformity

OA of CCJ / TNJ

 

Triple Arthrodesis

 

Technique STJ Fusion

 

Subtalar ArthrodesisSubtalar Arthrodesis 2

 

Approach

 

Position

- patient supine

- roll under hip to expose lateral aspect foot

- tourniquet, IV Abx, radiolucent table, II available

 

Incision 

 

Direct lateral approach -  Tip of fibula toward base of 4th MT 

- internervous plane between SPN and sural nerve

 

Superficial dissection

- peroneal tendons lifted dorsally

- elevate EBD

- fatty tissue over sinus tarsi

- expose STJ / CCJ / sinus tarsi

 

Deep dissection

- remove TC interosseous ligament

- clear out sinus tarsi

- diathermy artery of tarsal sinus

- insert lamina spreader to expose posterior facet

- need to expose medial facet medially

 

Debridement

- curette / osteotomes / burr

- simply remove cartilage if no deformity

- otherwise remove bone to correct deformity

- recreate 2 flat surfaces that come together in 5o valgus

- drill holes to stimulate bleeding +/- bone graft

- if previous calcaneal fracture, decompress lateral wall  

(5 - 10mm removed) 

 

Reduction technique in valgus foot

 

Deformity

- talus internally rotated on calcaneum

- navicular abducted on talus

 

Issues

- need T Achilles lengthening

(assess at end) 

- need to perform TNJ and CCJ fusion

- likely need to have open reduced TNJ / CCJ before STJ reduction

- may need lateral bone block

- often deficient skin laterally

 

STJ

- reducing calcaneum back under talus difficult

- calcaneum also abducted like navicular

- lamina spreader between lateral process talus and anterior aspect of calcaneum

- open it up

- calcaneum internally rotates / talus externally rotates

- screw like motion

- need to have all joints opened and exposed for this to occur

- need care to ensure don't place foot into varus

 

Fixation

 

Insert K wires for 6.5 mm/ 8.0 mm cannulated screw

 

- One or two from inferior calcaneum via stab incisions into body and neck of talus

 

Check position of K wires on II before screw insertion

 

Bone graft

- local usually sufficient 

http://www.boneandjoint.org.uk/content/jbjsbr/87-B/2/175.full.pdf

- if large correction take from proximal lateral or medial tibia  

 

TNJ fusion

 

Arthrodesis CCJ TNJ

 

Indications

- isolated TNJ OA (lose 80% subtalar joint motion)

- as part of triple arthrodesis

 

Midfoot Approach

 

Incision

- medial to T anterior, anterior to T posterior

- talar neck to naviculo-cuneiform joint

- protect saphenous nerve and vein

- Tibialis posterior guide to navicular

 

Exposure

- can sometimes only expose 2/3 of joint medially

- may need to utilize the lateral approach for full exposure

- inserting lamina spreader aids exposure to debride

- reduce forefoot onto navicular by adducting /plantar flexing and pronating it

- must not leave in varus

- provisionally fix with K wires

 

Fixation

- 2 x 4.0 mm cannulated screws

- from navicular into talus

- parallel or triangular 

- may need to make notch in medial cuneiform 

 

CCJ fusion

 

Incision

- exposed through continuation of lateral approach 

 

Fixation

- 2 x screws

- must hug lateral border

- alternatively can use specific plates

 

T Achilles lengthening

 

Indication

- tight T Achilles

- if don't will have to take a lot of bone to get foot plantigrade

 

Technique

A.  Formal Z lengthen

B.  Hoke lengthening

- want to lengthen laterally more than medially

- 2 incisions halfway laterally

- 1 half incision medially between them

- stretch out the T Achilles

 

Post-operative 

Back-slab for 2/52 

Wound inspection at 10 - 14/7

NWB in full cast for 4/52 

WBAT in walking cast for a further 6/52

6/52 radiologic assessment until union 

(pain-free WB with evidence radiologic union)