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111 Cards in this Set
- Front
- Back
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(Pes Cavus)
Coleman Block Test |
-Assesses the influence of the forefoot (1st ray) on the rearfoot
-Allows the elimination of this influence to see if there is rearfoot varus -To assess the rigidity of the rearfoot -To identify anterior cavus |
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(Pes Cavus)
Talar Declination Angle |
- Decreased
- Less than 15 degrees |
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(Pes Cavus)
Calcaneal Inclination Angle |
- Increased
- Greater than 25 degrees |
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(Pes Cavus)
Meary's Angle |
- Talar 1st metatarsal angle
- Greater than 10 degrees, should be close to 0 |
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(Pes Cavus)
Bullet hole sinus tarsi |
- Indicates external rotation of the hindfoot caused by adducted forefoot and varus heel
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(Pes Cavus)
Both the medial and lateral aspects of the talar dome are visible (in radiographic exam) |
Indicates external rotation of the hindfoot caused by adducted forefoot and varus heel
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(Pes Cavus)
Kite's Angle (in radiographic exam) |
- Decreased AP Talocalcaneal angle
- Normal is 15-30, <15 indicates varus heel - Talar head is completely covered by the navicular |
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(Pes Cavus)
Metatarsus adductus angle |
- Normal is 12-14 degrees
- Increases with forefoot adduction |
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(soft tissue releases)
Steindler stripping |
- Release the following from the calcaneus: plantar fascia, long plantar ligament, abductor hallucis, flexor digitorum brevis, abductor digiti quinti
- The deformity must be flexible |
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Tendon Transfers
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- Purpose is to counterbalance muscular abnormalities
- Must counterbalance with the correct amount of tension |
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Jones Tenosuspension
(tendon transfers) |
- EHL rerouted through the 1st metatarsal head
- Compensates for the overpowering p. longus and FHL - Fuse the IPJ |
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Hibbs Tenosuspension
(tendon transfers) |
-Transection of EDL tendons with fixation of proximal stump into the lateral cuneiform
- Releases extensor subistitution pull causing hammering of digits - Arthroplasty or arthrodesis of PIPJ of toes |
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Tibialis Anterior Tendon
(tendon transfers) |
- Transfer in its entirety to the lateral cuneiform or cuboid
- Causes pronatory influence to the MTJ and STJ - Assists in dorsiflexion |
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Split Tibialis Anterior Tendon Transfer (STATT)
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- Split the TA in half and reanastamose the lateral half into the p tertius
- Causes pronatory influence to the MTJ and STJ - Assists in dorsiflexion |
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Tibialis Posterior Tendon Transfer
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aids in dorsiflexion of a weak anterior muscle group
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Tibialis Posterior Tendon Transfer (through the interosseous membrane)
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- Aids in dorsiflexion of a weak anterior muscle group
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Loading dose =
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Cp × Vd/F.
F = bioav |
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Peroneus Longus
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- Transfer down the extensor tendon sheath and attached to the lesser tarsus
- Can also do a split procedure - Assists in dorsiflexion and also removing the deforming plantarflexory force on the 1st ray |
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Cole
(osteotomy) |
- Tarsal midtarsal dorsiflexory
- must first perform a Stihler stripping |
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Japas
(osteotomy) |
- "The other one"
- Nobody uses it. |
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Dorsiflexory wedge based osteotomy- Lisfranc's joint
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- Tarsal meatatarsal
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Dorsiflexory wedge based oblique osteotomy- Metatarsal Bases
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- You preserve the joint.
- Difficult procedure |
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Dwyer closing wedge osteotomy
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- Closing base wedge of posterior calcaneas
- remove wedge bone |
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Arthrodesis of 1st MPJ
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Indications: significant degenerative changes at 1st MPJ
- Clinical & radiographic evidence of instability |
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Position of 1st MPJ Fusion
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- 15-25 degrees of DF
- 15-20 degrees of Abduction - Make 1st MPJ parallel to 2nd digit in transverse plane |
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Goals of surgery in the rhumatoid patient
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#1 goal= relieve "pain, lots of pain!"
- Restore some degree of function/create stability |
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Hoffman
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- Metatarsal Head Resection
- Plantar Transverse Incision 1) remove all met heads 2) does nothing to the bases 3) plantar transverse |
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Clayton
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- Dorsal transverse incision
- Vascular compromise |
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Kates
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- Plantar 'smile'
- Repositioning of the anterior displaced fat pad |
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Fowler
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Dorsal transverse (bone work)
Plantar 'smile' (Re-align fat pad) both transverse & plantar |
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Larmon
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- Resection of bases proximal phalanges
- 3 Dorso-Linear incisions |
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Hodor- Dobbs
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- 5 Dorso-linear incisions
- pan met head resection |
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Keller
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- resect prox phalaux
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Arthrodesis complications
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Hematoma- #1 on rhumatoid foot (due to bony bleeding)
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Thomson technique
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- Resection of the Abductor Hallucis at the insertion of tendon
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Heyman Herndon and Strong
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- 3 dorsal longitudinal incisions
- Tarsometatarsal soft tissue release- division of hte intermetatarsal, dorsal & medial capsule and ligaments - Leave the lateral plantar attachments intact to prevent dorsal and lateral displacement |
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Heyman-Herndon-Strong complications
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- Damage to 1st metatarsal growth plate
- unstable Lisfranc's Joint _ Dorsal arthritic ridge |
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Heyman-Herndon-Strong
post-op care |
WB cast 3 months
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Berman-Gartland osteotomies technique
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- Proximal base crescentic osteotomies
- Pin fixation of 1 & 5 - over age 8 - does not fixate 2/3/4 - very unstable |
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Arthrodesis of 1st MPJ
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- sig degenerative change at 1st MPJ
- clinical/radiographic evidence of instability |
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DJD at 1st MPJ
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- Geriatric hallux valgus
- nal |
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1st MPJ fusion
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- 15-25 degrees DF
- 15-20 degrees abduction - make 1st MPJ parallel to 2nd digit in the transverse plane - DF hallux 10-15 mm from weight bearing surface |
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1st MPJ fusion
post-op care |
NWB- 6-8 weeks
NWB 8-12 weeks w/graft or revision |
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1st MPJ fusion
complications |
- IPJ DJD -may want to fuse the IPJ also
- infections |
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Rhumatoid Arthritis
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- hammertoes, HAV, fat pad dislocation, IPKs, RA nodules
- #1 goal= to relieve pain; #2= function/stability |
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Surgical approaches
pan met head resection |
1) Hoffman
2) Clayton 3) Kates 4) Fowler 5) Larmon 6) Hodor Dobbs 7) Keller |
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Hoffman
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- plantar incision
- met heads only |
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Clayton
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- take met heads & bases of prox phalanges
- Dorsal transverse incision |
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Kates
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- take met heads
- plantar smile--> reposition fat pad |
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Fowler
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- combo of Kates & Hoffman
- plantar smile-->reposition fat pad - Dorsal transverse- bone work |
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Larmon
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- 3 dorsal linear incisions
- reset bases of proximal phalanges |
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Hodor Dobbs
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- pna met head resection
- 5 dorsal incisions (less neurovascular) - modified- Hodor Dobbs 4- incisions - maintain parabola w/ resections |
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Keller
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- resect prox phalaux
- complications- hematoma- m/c |
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(Pes Planus)
PLANAL DOMINANCE |
which direction is the deformity?
- sagittal plane - transverse plane - frontal plane (heel position) "If you can control the heel you can control the foot" |
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Sagittal plane deformity
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Midfoot sag
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Flexible Planovalgus-
nonweightbearing |
normal contour
normal longitudinal arch |
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Flexible Planovalgus-
weightbearing |
- longitudinal arch is flattened
- Decreased arch height - Valgus heel |
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Flexible Planovalgus
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Too may toes sign- viewed from posterior
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Hubscher maneuver/Jack's test (heel inverts)
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- inversion of the heel with arch elevations
- have pt rise on their toes or passive dorsiflexion of hallux |
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Rigid Planovalgus
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nonweightbearing vs weightbearing.
weightbearing + Hubscher's/Jack's |
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Cyma Line
(radiographic evaluation) |
anterior break
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Sinus Tarsi
(radiographic evaluation) |
Obliterated
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(Pes Planus)
Talar Declination Angle |
Normal = 15-20
increases with flatfoot |
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(Pes Planus)
Talo 1st Metatarsal Angle (Meary's Angle) |
- Bisection between the talus and the 1st metatarsal
- Pronated foot = talus line below 1st met line - Supinated foot = talus line above 1st met line |
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Talo 1st Metatarsal Angle
Pronated Foot |
talus line below 1st met line
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Talo 1st Metatarsal Angle
Supinated foot |
talus line above 1st met line
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Calcaneal Inclination Angle
(Pes Planus) |
INCREASES WITH FLAT FOOT
- AP WB film - normal = 0-5 - bisecting lines from the lat calcaneus and lateral cuboid |
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Calcaneal Cuboid Angle (Kite's)
(Pes Planus) |
- AP WB film
- Bisection of the calcaneus and the talus - Normal = 20-40 - should decrease with age |
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Talus Navicular Articulation
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- AP WB film
nomral = 75 % articulation - increase in uncoverage of the head of the talus |
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Johnson & Strom- Stages
(Pes Planus) |
Stage 1: Tendon Length Normal
Stage 2: Tendon Elongated, Hindfoot Mobile Stage 3: Tendon Elongated, Hindfoot Deformed & Stiff Satge 4: (Myerson) |
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(Pes Planus)
Johnson & Strom - Stage 1 |
Tendon Length Normal- medial foot and ankle pain with minimal deformity
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(Pes Planus)
Johnson & Strom - Stage 2 |
Tendon Elongated, HIndfoot Moblie
- Supple flatfoot with attenuation or rupture of the PTT - Radiographic changes evident |
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(Pes Planus)
Johnson & Strom - Stage 3 |
Tendon Elongated, Hindfoot Deformed & Stiff
- rigid, fixed pes planovalgus foot - additional degenerative changes evident on x-ray - severly degenerative or completely ruptured tendon |
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(Pes Planus)
Johnson & Strom - Stage 4 |
Myerson
- Valgus tilt of the talus within the ankle mortise - Lateral tibiotalar degeneration |
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Surgical Treatment - questions
(Pes Planus) |
#1 - Is the deformity rigid or flexible?
#2- Which plane is the deformity? |
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(Pes Planus)
Arthroersisis |
Must be a flexible deformity
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(Pes Planus)
Tarsal Coalition Surgery |
- Resection alone- remove bridge
- Resection with EDB interposition |
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Soft Tissue Procedures- Psedoequinus
(Pes Planus) |
caused by bony exostosis anterior distal tibia or dorsal talar neck
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Silverskiold test
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- dorsiflex
- tendoachilles - Lengthening (TAL)- frontal plane or saggital plane - Gastrocnemius recession |
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(Pes Planus)
Gastrocnemius Recession- Vulpius |
inverted "u"
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(Pes Planus)
Gastrocnemius Recession- Strayor |
strait cut
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(Pes Planus)
Gastrocnemius Recession- |
- Baker Tongue & Groove
- McClamry & Fulp-->inverted tongue & groove |
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Young Tenosuspension
(Pes Planus) soft tissue procedure; tendon transfer |
1) TAL
2) Rerouting tibialis anterior through a keyhole made in the navicular without detaching it from its insertion 3) Advance TP tendon beneath navicular 4) the opportunity to restore tension & tighten up spring ligament |
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Kidner Procedure
(Pes Planus) soft tissue procedure; tendon transfer |
- Removal of OTE (os tibialis externum)/hypertrophic navicular tuberosity
- Advance PT tendon plantarly and laterally, reattach using a soft tissue anchor |
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Lapidus Fusion
(Pes Planus) medial column procedure |
- TAL
- 1st metatarsal- medial cuneiform arthrodesis |
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Cotton Osteotomy
(Pes Planus) medial column procedure |
- Dorsal based wedge bone inserted into the medial cuneiform, opening wedge dorsally
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Hoke Fusion
(Pes Planus) medial column procedure |
- TAL
- Navicular medial cuneiform arthrodesis |
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Lowman Procedure
(Pes Planus) medial column procedure |
1) TAL
2) Talus- Navicular arthrodesis 3) Reroute medial slip of achilles tendon under navicular and suture to spring ligament 4) Tenodesis of medial arch w/slip of achilles 5) Desmoplasty of TN ligaments--tightening attenuated, stressed ligaments on medial side of TN joint |
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Miller Fusion
(Pes Planus) medial column procedure |
1) TAL
2) Navicular- medial cuneiform, medial cuneiform- 1st metatarsal arthrodesis 3) Raise osteoperiosteal flap that includes TP tendon & spring ligament--> advance flap anterior and lateral -- Goal is the restore physiologic tension of the attenuated soft tissues |
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(Pes Planus)
Calcaneal procedures: extra- articular Selakovich |
opening base wedge of sustentaculum tali
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(Pes Planus)
Calcaneal procedures: extra- articular Baker & Hill |
posterior facet - opening base wedge
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(Pes Planus)
Calcaneal procedures: posterior Dwyer |
closing base wedge on the medial side
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(Pes Planus)
Calcaneal procedures: posterior Koutsogiannis |
thou shalt not varus! do not cause varus- hard to fix
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(Pes Planus)
Calcaneal procedures Gleich |
- a posterior calcaneal osteotomy
- oblique calcaneal osteotomy displaced anteriorly |
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Surgical TX
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#1- is it rigid or flexible?
#2- what plane is the deformity? |
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Arthroereisis
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must be flexible
CI- rigid, under 3 years, obese, ankle valgus |
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Soft Tissue
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- address the equinus- psedoequinus
- Gastroc Recession - TAL - Young Tenosuspension Kidner procedure |
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soft tissue
Gastroc Recession |
Valpius
Strayor |
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Young tenosuspension
(soft tissue, Pes Planus) |
1) reroute tib ant through keyhole in nav w/o detaching from insertion
2) advnce TP beneath navicular 3) restore tension in spring ligament 4) TAL |
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Kidney procedure
(soft tissue, Pes Planus) |
1) removal ofOTE/ hypertrophic navicular tuberosity
2) advance TP plantar & laterally (OTE=os tibialus externum) |
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Medial column procedures
(Pes Planus) |
- Lapidus Fusion
- Cotton Osteotomy - Hoke Fusion - Lowman Procedure - Miller |
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Lapidus Fusion
(Pes Planus, medial column procedure) |
1) TAL
2) 1st met/medial cuneiform arthrodesis |
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Cotton Osteotomy
(Pes Planus, medial column procedure) |
Dorsal base wedge inserted into the medial cuneiform
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Hoke Fusion
(Pes Planus, medial column procedure) |
1) TAL
2) Navicular-medial cuneiform arthrodesis |
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Lawman Procedure
(Pes Planus, medial column procedure) |
1) TAL
2) Talus. navicular arthrodesis 3) reroute medial slip of achilles under navicular suture to spring lig 4) Tenodesis of medial arch w/slip of achilles 5) Desmoplasty of TN ligaments- tightening attenuated, stressed ligaments on medial side of TN joint |
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Miller
(Pes Planus, medial column procedure) |
1) TAL
2) Navicualar, medial cuneiform, 1st met fusion 3) advance TP & spring ligament anterior & lateral |
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Planal Dominance
(Pes Planus) |
Sagittal Plane --> midfoot SAg- ID the break
Transverse Plane-- forefoot adduction Hebling sign Too many toes sign |
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X-Ray
(Pes Planus) |
- Cyma line- ant break
- Sinus tarsi- obliterated - increase talar declination angle n-15-20 degrees - decrease calcaneal inclination angle n-20-25 -talo 1st met angle (meary's) tale below 1st met - increase CC - norm= 0-5 degrees - increase talo-calcaneal (Kite's angle) norm = 20-40 |
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Flexible Planovalgus- NWB
(Pes Planus) |
normal contour
normal longitudinal arch |
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Flexible Planovalgus- WB
(Pes Planus) |
- longitudinal arch is flat
lower/decrease arch height valgus heel - foot position calcaneus everted talus adducted & plantar flexed Talar bulge - too many toes sign - Hebling sign - Gait abducted gait; excessive pronation - Hubscher Maneuver/ Jack's test |
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Rigid Planovalgus - NWB
(Pes Planus) |
arch is flat
decrease arch height valgus heel |
