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80 Cards in this Set
- Front
- Back
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A patient presents with a flexible pes valgus deformity. what would you expect see on Clinical examination.
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everted heel, abduction of forefoot on the rearfoot, collapse of the medial column, flexibility of the foot with reducibility of the deformity, foot functiong maximaly pronated through gait cycle with little or no resupination, posterior equinus (most probable)
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what compensation occurs with equinus is a pes valgus foot?
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early heel off, subtalar joint and midtarsal joint pronation, medial column sag, tarsometatarsal breech.
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Describe the biomechanical mechanism invilved with compensation for equinus in a pes valgus foot.
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Ankle equinus prevents dorsiflexion of the talus, which maintains its posisiton while the remainder of the foot (including hte calcaneus and navicular) dorsiflex, abduct, and evert form beneath it. THis leads to a subluxatory collapse of hte rearfoot on the forefoot.
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If transverse plane deformity dominates, which calcaneal osteotomy would be indicated?
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Evans calcaneal osteotomy
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X-rays of a patient with pes valgus reveal a widening of the lesser tarsal area on the DP view, decrease of the first metatarsal declination angle, decrease of hte height of seustentaculum tali and increase superimposition of the lesser tarsal area on the lateral view. What is the dominant plane of deformity.
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Frontal plane.
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A patient with a unilateral flatfoot deformity unable to perfor the single limb heel rise test . diagnosis?
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posterior tibial dysfunction or ruture.
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Axis altering artreresis devices (i.e.STA-peg) are used for flafoot exhibiting primarily what plane of deformity?
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frontal plane
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calcaneal osteotomies are classified (by Jacobs and associates ) into three groups. Name the groups.
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extra-articular, anterior, and posterior osteotomies
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Nme the procedures in each category above
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extra-articular = chambers, baker-hill, selakovich
anterior = evans posterior = Gleich, Dwyer, Silver, Koutsogiannnis |
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What are some cause of rigid pronated feet?
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Congenital convex pes plano valgus (vertical talus), improperly corrected clubfoot, tarsal coaliton, peroneal spastic flatfoot, trauma, late stage of neuropathy.
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A patient with a unilateral flatfoot deformity unable to perfor the single limb heel rise test . diagnosis?
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posterior tibial dysfunction or ruture.
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Axis altering artreresis devices (i.e.STA-peg) are used for flafoot exhibiting primarily what plane of deformity?
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frontal plane
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calcaneal osteotomies are classified (by Jacobs and associates ) into three groups. Name the groups.
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extra-articular, anterior, and posterior osteotomies
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Nme the procedures in each category above
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extra-articular = chambers, baker-hill, selakovich
anterior = evans posterior = Gleich, Dwyer, Silver, Koutsogiannnis |
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What are some cause of rigid pronated feet?
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Congenital convex pes plano valgus (vertical talus), improperly corrected clubfoot, tarsal coaliton, peroneal spastic flatfoot, trauma, late stage of neuropathy.
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Describe the aveage axis of the STJ as originally described.
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42 degrees up form the transverse plane and 16 degrees from the sagittal plane. This allows approximately equal amounts of Frontal Plane motion as well as Transverse Plane motion. W
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What is the Hubscher maneuver?
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While the patient is in relaxed stance, the hallux is passivley dorsiflexed to determine the flexibility of the arch. With passive dorsiflexion, the windlass effect is invoked and this tightens the medial band of the plnatar fascia and long flexor of the hallux increas
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Whatis the Kidner procedure.
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Resection of hte accessory navicular and any hypertrophy of the tuberosisty , transposition of theinsertion of the tibialis posterior tendon into the underside of th navicular.
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Describe the Young procedure
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Rerouting tibialis anterior tendon through a slot in the navicular without detaching the tendon from its insertion of the tibialis posterior tendion into the underside of the navicular.
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DEscribei the midtarsal joint when the subtalar joint is in it smaximally pronated posiion with the calcaneus everted?
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Talonavicualr and calcaneocuboid jionts become divergent from each other with their axes more parallel allowing full, independent range of motion of each of these joints and increasing the range of motion of the MTJ itserf.
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Where is the osteotomy made for the evans procedure?
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appoximately 1.5 cm proximal and parallel to the C-C joint.
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How is this ostoeotmy (evans) directed and why?
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directed anteriorly to avoid the middle facet ofthe STJ.
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Nme possible etiologies of flexible pes valgus (underlying causes of excessive pronation)?
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compensated forefoot varus, compensated flexible forefoot valgus, reafoot equinus, condgeital talipes calcaneovalgus, torsional abnormailities of adduction or abduction, muscle imbalance, ligamentous laxity, neurotrophic feet, medial shift in WB (i.e. obesity).
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During gaint, the talus and the leg internally rotate and adduct to take up motion in what plane?
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transverse plane.
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What incisional approach is necessary when performing a triple arthrodesis for pes valgus?
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two-incision approach used o to afford adequate access to the midtarsal and subtalar joints.
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Describe the Dwyer osteotomy.
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Opening wedge with bone graft in lateral calcaneus (more common) or closing wedge i medial calcaneus (closing wedge can be performed in a large heel).
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How is congenital calcaneovalgus deformity easily distinguished form congenital convex pes plano valgus deformity on clinical examination.
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Congenital calcaneovalgus is flexible and allows for passive correction.
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How much dorsiflexion at the ankle joint is necessary during a normal gait cycle ot avoid compesation ofr limitation of motion?
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10 degrees.
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If the StJ axis fell parallel to the transverse plane, motion around the axis would primarily be in what plane?
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frontal plane
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If the STJ axis fell is more vertical for an individual, what plane of motion will be dominant?
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tranverse plane motion.
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Imbalance or dysfunction fo what muscle will quickly led to a pes valgus deformity?
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Tibialis posterior
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In a flexible pes valgus deformity, describe what happens ot he foot (ie. 1st ray reafoot, etc. when the Hubscher maneuver is performed. How would this compare ot a patient with a tarsal coalion?
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plantarfexion of 1st ray, supination of RF, exgternal rotation of leg, significant increase in height of medial arch. In tarsal coalition, foot would fail to show response.
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When wight bearing, eversion of the calcaneus and foot take up motion in what plane?
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frontal plane.
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What deformity cannot be present if the evans procedure is planned?
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metatarsu Adductus
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What is the consequence if hte EVans is performed in a foot with the above deformity?
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Unmasking and exaggeration o fth emetatarsus adductus and an in-toe gait.
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In patients under 1 year of age, what is one of the most common forerunners of pes valgus deformity?
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congenital calcaneovalgus deformity.
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Describe the incision when performing the Kidner procedure?
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Dorsally arched longitudinal incision extending along the dorsomedial side of the foot from below the tip of the medial malleolus ot the midshaft of the first meatarsal.
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Name the muscles and tendons visibile in dissection when performingth eYoung's procedure.
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Tibialis anterior tendon, tibialis posterior tendon, abductor hallucis muscle.
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What muscle will be encountered when performing ghe Evans procedure?
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EDB muscle belly
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Where is the bone graft inseted when doing hte Evans procedure
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Distal 1/3 of the calcaneus
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How is the calcaneal inclination angle affected with positional changes of pronation and supination in the normal foot? How does this compare to the pes valgus foot?
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Normal foot changes very little. Calcaneo-inclination angle in pes valgus foot will be stgructually lowered by subluxation of the reafoot on the forefoot over a period of time.
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Instability of which column of hte foot is more indicative of a pathological flatfoot condition?
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lateral column
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Ligamentous laxity can occur due to a defect in collagen synthesis. Name thes disorders.
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Ehlers-Danlos syndrome. Marfan's syndrome, and osteogenis imperfecta
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What are the radiographic manifestations for a pes valgus deformity with sagittal plane dominance?
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Increased talar declination angle, naviculocuneiform breach, increased talocalcaneal on lateral view, decreased calcaneo-inclination angle.
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Name some abduction deformities fo the lower extremity than cn lead to a flexible pes valgus deformity?
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metatarsue abductus, forefoot abductus, external malleolar torsion, extermanl tibial torsion, external femoral torsion, tight lateral hamstrings.
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List he radiographic angles and measurements used i nthe evaluation of pes valugs?
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calcaneal inclination angle, talar declination agnle, 1st metatarsal declination angle, cuboid declination angle, cuboid abduction angle, talonavicular cungruency, talocalcaneal angle, cyma line position.
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what are the goals of therapy (surgical or conservationve) in the treatment of flatfoot.
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releif from pain, biomechanicla control of excessive pronation, prevention of pregression of the deformity.
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nAME TH EVARUS PRODUCIONG OSTEOTOMIES PERFORMED IN THE CLACANEUS FOR FLAFOOT CORRECTION
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gleich, dwyer, silver, koutsogiannis
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Examination of a patient in relaxed stance reveals marked abudtion of ht forefoot and midfoot on the rearfoot with an apparent lateral break a the calcaneocuboid joint. Medially, a significant talar bulge is seen. What plane is dominant for this deformity based on the above findings?
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Transverse plane.
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Non-weight-bearing examination of a patient with pes valgus reveals that hte amount of calcaneal eversion is far greater than calcaneal abduction and midfoot abduction. On weightbearing, there is an excessive valgus position of the heel. What is the dominant plane of deformity in the patient?
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Frontal plane
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Posterior calcaneal osteotomies are most useful in the correction of flatfoot with th what dominant plane of deformity?
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Frontal plane dominant.
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Where is the osteotomy and bone grafting performed for the Selakovich procedure?
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patients who have not yet reache skeletal maturity.
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What are some causes of conngenital flatfoot?
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Vertical talus, tarsal coalitions, Z-compensated met adductus, short achilles tendon, hypermobility.
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What are the indications ofr a rearfoot arthrodesis i na pes valgus foot?
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Severe DJD, Sever triplane deformity with pain, paralytic deformity, and long standing rupture of TP with collapse of the foot and adaptive change.
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What are the primary and secondary goals of surgical treatment for a pes valgus?
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primary goal is restgoration of joint stability; secondary goal is restoration of the herigh of the arch.
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What are two problems with doing an isolated subtalar fusion i nthe correction of a severe pes valgus deformity?
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Fusion of one portion of hte subtalar joint-midtarsal joint complex results in degenerative arthrosis of the other joints, and no correction occurs int he forefoot with this procedure.
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Describ ehte cyma line in a pes valgus foot?
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anterior break i the midtarsal cyma line.
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What is Kite's angle?
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talocalcaneal angle.
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What is planal dominance?
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Determining via clinical and radiographic findings, the primary plane (direction of motion) of deformity and compensation. - useful in determing appropriate treatment of deformity.
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What is an adjunctive procedure that is most often a part of surgery for the pes valgus foot type?
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correction of equinus element
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What is th emost common cause of peroneal spastic flatfoot?
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tarsal coalition
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What joint(s) are fused in the Miller procedure?
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Navicular 1st cueiform joint and cuneiform - 1st metatarsal joint.
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For arthrereisis to be effective, what must be reducible?
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heel valgus as well as forefoot varus or supinatus
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What plane of deformity does the Evans procedure predominantly correct?
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transverse plane
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Which procedure elevates the posterior facet by insertion of a lateral bone graft beath it?
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Baker-Hill
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Which procedure used for flatfoot creection lenghens hte lateral column of hte foot?
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Evans
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Which flatfoot procedure(s) include(s) a talonvicular arthrodesis
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Lowman prcedure, subtalar arthrodesis, and triple arthrodesis
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What special radiographic view would be helpful in evaluating a patient with a pes valgus deformity?
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A stress DF latgeral view (charger view), harris and Beath views, Neutral position WB - DP and lateral vies.
Stress DF lateral view is used to determine if an osseous block is present a tht eankle joint, HB views helpful in ruling out talocalcaneal coalition of the posterior and middle facets, neutral position DP and lateral views give clinician a better idea what the foot would look like in its corrected position following surgical correction as well as being helful for unmasking metatarsu aductus in a Z-foot or compensated metatarsu adductus. |
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When is subtalar joint arthroeisis indicated?
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When conservative treatment is inadequate to control patholgoical subtalar joint pronation in flexible pes balgus deformity
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What neural structures may be encountered when performing the Evans procedure?
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Sural nerve and intermediate dorsal cutaneous nerve.
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When performing a triple arthrodesis for the pes valgus foot, describe hte desired position of the hell and foot.
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Slight heel valgus, apprximately 15 degrees of abduction fo the foot from the line of progession, and a rectus forefoot to rearfoot relationship.
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When the subtalar joint is pronated, what tendons/muscles have less than optimal function?
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Peroneus longus and ftibialis posterior muscles
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Which calcaneal ostoetomies follwo the artroerisis principle?
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estra-articualr calcaneal osteotomies (i.e. Chambers, Elakovich, Baker-Hill).
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Which calcaneal osteotomy uses a bone graft under the sinus tarsi to block translocation of the talus on the calcaneus?
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Chambers
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Which procedure(s) is described as a dispalcement osteotomy of hte calcaneus shiftng the posterior fragment medially until lies below the sustenaculu tali?
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koutsogiannis
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Which procedure(s) in the correction of flatfoot inclues naviculocuieform arthrodesis
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Miller (navicular 1st cueniform joint fusion), Hoke (navicular 2st , 2nd cuneiform fusion)
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Whic rearfoot arthodesis provides stabilityu to the reafoot and midot and allows for triplane correction?
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Triple arthrodesis.
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When performing the evans procedure, what dendons mus tbe retracted inferiorly?
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peroneals
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With abnormal pronation of hte STJ and unlocking of hte MTJ, hypermobilty and loss of stability occur distally. Describe these.
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Arch fatigue adn cramping form ineffective attempt of intrinsic and extrinsic muslce sto recreat stabilty, 1st ray instability (in transvers plane get buion, in sagittal plne get hallux limitus), contracted digits, medial distrbution of body weight adding ot subluxing and deforming forces.
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Radiographic evauation reveals an increased DP talocalacneal angle, and increased cuboid abduction angel, a decreased forefoot adductus angle, and decreased percentage fo talonavicular congruency. Wht is the dominat plane of defomity in thei flafoot?
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Transverse plane.
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