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80 Cards in this Set
- Front
- Back
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What view should be included in the radiographic evaluation of a bunion deformity?
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AP (DP), Lateral, forefoot (plantar) axial
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What arethe angular and positional relationships commonly measured on radiographs prior to correcting a bunion deformity
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HA < 15
IM < 8-12 MA < 15 PASA < 8 DASA < 8 HAI < 10 MPD + 2mm -2mm TSP number < 3 |
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What is the relationship between the IM angle and the metatarsus adductus angle?
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As the metatarsus adductus angle increases above 15 degrees, the IM angle becomes moe significant at a lower angle. A simple formula which helps demonstrate thsi concept is:
(Effective IM angle) = (Metatarsus Adductus angle) - (15 degrees) + (the measured IM angle). In other words, every degree of MA angle over 15 degrees is added to the IM angle. |
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Relative to the examination of the 1st MPJ , what is meant by the term "tracking"
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"Tracking refers to the tendency of the the hallux to drift back into an uncorrected position, when putting it through a rangeo of dorsiflexion and platarflexion, after having first placed it into a "corrected" or sagittal plane position. This tendency to drift bcki into an abducted position is either due to tight lateral soft tissue structures i the 1st interspace or due to an adapted or laaterally deviated articular surfaceo f the 1st metatarsal head.
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What are the possible cause of an iatrogenic hallux varus?
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Staking the 1st metatarsal head, removing too much bone blantarly when resecting the medial eminence, fibular seamoidectomy, vertical lateral capsulotomy, over aggressive capsulorrhaphy, over aggressive correction of the IM angle; most often several of these mistakes must be made in order to develop a hallux varus.
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What are the contraindications to an adductor transfer?
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The adductor tendon should not be transferred if the fibular sesamoid is degenerated , if the plantar metatarsal head articular surface is degenerated, if the fibular sesamoid hypertrophied, or if the adductor tendon itself is atrophied.
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What is "hallux purchase"?
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Hallux purchase is the ability of the hallux to rest firmly on the supporting surface without any attemple by the patient to actively hold it there.
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What is the difference between a positional deformity and structural deformity?
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When PASA + DASA = HA angle, the deformity is considered to be structural. When PASA + DASSA < HA angle, the deformit is considered to be positional component if the PASA or DASA are nto normal.
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What are the preoperative indications for a Silver bunionectomy?
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A Silver bunionectomy is a partial osstectomy fo the medial aspecto f the 1st metatarsal head, simply a 'bumbectomy." It is indicated for a patient with a large medial eminence only. In reality however, it is sometimes used as a partial measure for an elderly patient who cannot or does not want a complete corrrection of theri bunion deformity but onl relief of bump pain. in these cases the patient should always be advised that the remainder of their deformity will continue to exist and may progress.
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What are the use sof an adductor tendon transfer?
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To reposition the sesamoids if it is sutured intothe medial 1st MPJ capsule, or to reduce the IM angle it it sutured intot he 1st metatarsal itself.
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What pathology is associated with a tibial sesamoid position of < or = to #4.
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Medial and dorsal shift of the 1st metatarsal. The flexor plate and the sesamoids are displaced laterally witht he abduction of the proximal phalanx of the hallux. The medial capsular ligaments are stretched while the lateral capsular ligaments are contracted. An impalance develops between the abductor hallucis muscle and the adductor hallucis muscle in which the adductor gains a mechanical advantage in it s pull on hte hallux. The flexor hallucis longus tendon is displaced laterally. Additionally, there may be erosion of the crista by the drifting tibial sesamoid. The tibial sesamoid may come to lie on the lateral plantar aspect of the 1st metatarsal head while hte fibular sesamoid shifts int the interspace.
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How is metatarsus primus elevatus demondstated on a lateral wight bearing radiograph?
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by comparing the dorsal cortical lines of the 1st and 2nd metatarsal shafts The cortex of hte 1st metarsal will be seen to diverge from that of the 2nd metatarsal.
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Does and increased hallux interphalangeus affect the function of the 1st MPJ?
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This deformity does nto affect function directly. However, the surgeon must be vigilant not to over correct the hallux abductus due to the false impression that adequate correction has not been attained i the face of incresed hallux interphalngeus.
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What is the most common reason for a poor post operative
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Capsular adhesions aggainst the 1st metatarsal head.
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How can the chance of aseptic necrosis be reduced when performing a distal metaphyseal osteotomy such as an Austin bunionectomy?
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By preservation of soft tissue attachments to the capital fragment of the osteotomy, the periosteal blood supply is maintained.
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What is the correct way to resect the medial eminence? And why?
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The eminence is resected in line with the medial cortex of the shaft of the 1st metatarsal. Do not use the sagittal groove as a guide. Take care to remove more bone dorsally than plantarly. The medial plantar shelf of bone is preserved to prent medial subluxation of the tibial sesamoid and possible development of hallux varus.
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What structures are cut when excising a fibular sesamoid?
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Lateral joint capsule, fibular sesamoidl ligament, lateral head offlexor hallucis brevis, ligament between fibular sesamoid and the proximal phalanxx, interseamoidal ligament.
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What is the technique for removing the fibular sesamoid?
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A linear, transverse incision is made o the lateral aspect of the 1st metatarsophalngeal joint cpasule just superior tothe adducto tendon and fibular sesamoid. The #15 blade is then inserted under the sesamoid and is moved proximally, taking care to stay in contact with the sesamoid as you move the blade. At the proximal aspect of the sesamoid the blade is turned 90 degrees upward and the lateral had of the flexor hallucis brevis is severed. the blade is then re-inserted under the sesamoid and in a simalar manner, the cutting edge is moved distally. When the distal aspect of the fibular sesamoid is reached, the blade is again turned 90 degrees upward and the ligamentous attachment between the sesamoid and the proximal phlanx is severed. The sesamoid is now pulle distally and laterally while the plade is re-inserted under the sesamoid. the intersesamoidal ligament is now severed by approaching it fro the proximal aspect as the sesamoid is pulled distally and laterally. the sesamoid is then removed from the surgical site and the long flexor tendon is inspected to be sure it was not severed i the process. The dissectio of the sesamoid is facilitated by the use fo a soft tissue tag, which can be held with a Brown Adson forceps. this tag is created with the first linear incision i the laterearl capsule superior to the sesamoid. The small piece of capsule inferior to theis incision, and attache dot thedorsal lateral aspect of the sesamoid, is the tag.
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What are the advantages of distal metaphyseal osteotomy type bunionectiomies?
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The cancellous bone of the metaphysis has a better blood supply and allows for good healing; the patient is able to remain ambulatory post operatively; the procedures can be performed in a child with an open epiphysis since the epiphysis is at the base of the 1st metatarsal.
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Relative ot the examination of the 1st metatarsophalngeal joint, what is meant by the term "tracking" what is it's significance?
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"Tracking fefers to the tendency for hte halux t drift back into an uncorrected position, when putting it through a rangeo f dorsiflexion and plantarflexion, after having first placed it into a "corrected or saggital plane position. This tendency to drift back into tan abducted positon is either due to tight lateral soft tissue structures int he 1st interspace, or due to an adapted or laterallyu deviated articular surface of the 1st metatarsal head.
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Relative ot the examination of the 1st metatarsophalngeal joint, what is meant by the term "tracking" what is it's significance?
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"Tracking fefers to the tendency for hte halux t drift back into an uncorrected position, when putting it through a rangeo f dorsiflexion and plantarflexion, after having first placed it into a "corrected or saggital plane position. This tendency to drift back into tan abducted positon is either due to tight lateral soft tissue structures int he 1st interspace, or due to an adapted or laterallyu deviated articular surface of the 1st metatarsal head.
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What is hallux purchae
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hallux purchace is the ability of the hallux to trest firmly on the supporting surface without any attempt by the patient o actively hold it there.
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What is the difference between a positoinal deformity and structural dformity?
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When PASA + DASA = HA angle, the deformity is considered ot be structural. When PASA + DASA < HA angle, the deformity is considered to be positional or to have a positional component if the PASA or DASA are nto normal.
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Whata re the preoperative indications for the Silver bunionectomy?
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A Silver bunionectom is a partial osteotomy of the medial aspect of the 1st metatarsal head, simply a "bumbpectomy." it is indicated for a patient witha large medial eminence only. In reality however, it is ometimes used a s a partial measure for an elederly patient who cannot or does not want a complete correction of their bunion deformity but only relief of bump pain. In these cases, the patient should aloways be advised that the reaminder of their deformity will continue to exist and may proges.s
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What are the possible cause of an iagtrogenic hallux varus?
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Staking the 1st metatarsal head, removing too much bone plantarly when resecting hte medial eminece, fibular seamodectomy, vertical lateral capsulotomy, over aggressive capsulorrhapy, over aggressive crrection of the IM angle; most often sveral of these mistakes must be made in order to develop a hallux varus.
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What is the apical axis guide or axis guide pin and what is iits purpose?
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This is a k-wire (0.045 inch), which is inserted into the metatarsal head to define hte apesx of the osteotomy distally. The k-wire is driven across the metatarsal head from medial to lateral and serves to align the orientation of hte osteotomy cuts
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How can the axis guide pin be oriented in the frontal plane? for what purpose?
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Pin inserted from dorsal medial to plantar lateral - metatarsal head is plantarflexed as it is transposed laterally. Pin inserted from plantar medial to dorsal lateral - metatarsal head is dorsiflexed as it is transposed laterally.
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What is the potential problem with making the apex too distal when performing an Austin bunionectomy?
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Could result in fracture of ther metartsalhead upon impaction of the osteotomy.
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Does an Austin bunionectomy correct the abnormal IM angle
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No. It corrects relative intermetataarsal angle by moving the 1st met head closer to the second met head. Correcting the actual IM angle requires moving the shapt and head othe 1st met closer to the second.
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Modifying an Austin bunionectomy to allow fixation with a dorsal cortical screw requires changing the angle betweent the arms of the ostetomy. How is it changed?
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The angle is reduced from approximately 60 egrees to 50-55 degrees. This allows a long dorsal arm which can be fixated with a dorsal screw.
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What is the Green modification to a Reverdin bunionectomy?
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The green modifcation is a plantar cut which serves to protect the sesamoids. An initial plantar cut is made, which corresponds ot he horizontal arm of an "L". This cut is parallel to the weigh bearing surface fo the 1st metatarsal and extends from an area approximately 1 cm. proximal to the articualar suface and runs proximaly, exiting hte metatarsal where the hed and shaft meet. This is a complete ostoetomy from medial to lateral. This cut serves to protect he dorsal articular surface of hte seamoids as well as the plantar articular suface of hte mettarsal head. The dorsal arm of hte "L" is then created
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What is the Lair modification to a Reverdin-Laird bunionectomy
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This is when the higne of the osteotomy is purposely fractured 9cut through) and the captial freagment is transposed laterally in order ot reduce the relative IM angle.
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What is a "geode" in reference to a bunion deformity?
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A "geode" is a degenerative cyst usually seen in the medial eminence.
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In what specific circumstances would a mitchell bunionectomy be performed?
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A Mitchell is used ot correct amoderately increased intermetatarsal angle in a patient with a long 1st metatarsal
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What are the indications fro a proximal Akin osteotomy?
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This osteotomy is used to correct an increased DASA.
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What are the indications for a Distal Akin Osteotomy?
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This ostoetomy is usd to correct an ncrased hallux abductus interphalangeus.
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What is a "cheater" Akin osteotomy
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This is a proximal phalangeal osteotomy (akin) which is performed in an attempt to correct hall abductus when the DASA and the Hallux interphalangeus Abductus angle are normal. As such, a "cheater Akin" falls outside of the normal criteria for an Akin osteotomy.
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What is the major indication for a Keller bunionectomy?
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Painful dgenerative joint diseas of the 1st MPJ.
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What are common post operative complications associated witha keller bunionectomy?
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Retraction of hallux; lack of hallux toe purchase; instability and decreased with bearing of the 1st MPJ; increased weight beraing of the lesser MPJ's sometimes associated with lesser metatarsalgia and stress fractures of the lesser metatasal.
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What is a juvara procedure?
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An abductory, oblique, closing base wedge osteotomy of the 1st metatarsal (apex medial, base lateral)
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Whata re the modficatoins to a Juvara bunionectomy
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3 basic ones - A, B, C
Type A: Standard oblique abductory base wedge osteotomy only Type B the medial cortex (the hinge) is purposely cut through after the abductory wedge is accomplised and the scrw is applied. This is done to allow the distal segment of the metatarsal to be plantarflexed. After the plantarflexion is accomplished, the screw is again tightened. The screw must be placed perpendicular to the long axis of the shaft to allow for plantarflexion. A second screw is then applied perpendicular ot the osteotomy. Type C: an oblique abductory base osteotomy witohut a wedge. The hinge or medial corex is puposely cut throgh after the scew is applied loosely. This is done to allow the distal segment of the metarsale to be plantarflexed. AFthe plantarflexion is accompled, the screw is again tightened. The xcrew msut be appled perpendicular to the osteotomy. |
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How is the screw placed, if a base osteotomy of the 1st metarsal is fixated wth a single scrw?
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The screw is palced halfway between the perendicualr to the ong axis of hte shaft of the metarsal and the perependiucalr to theosteotomy. This is a compromis. Perpendicular ot the osteomtomy would provide the best copmression but would dot prevent axial movement well. Perpendicualr to the long axis of hte shaft , prevents axial maovemtn but provides poor compression.
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What is the tangential angle to the second metarsal axis (TASA)
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This is the angle formed by a lne representingthe efective articualr surfaceo fthe 1st metarsal na dhte perpendicualr to the longtiudinal axias of hte second metarsal. The normal value is + or - 5 degrees.
TASA = PASA - IM angle. TAsa reflects changes in obth the proximal artricular set angle and the tinermetatarsal angle in any given foot. |
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Name th common mid-diaphyseal osteotomies.
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Ludloff osteotomy, mau osteotomy, scarf osteotmy,.
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Describe a ludloff osteotomy?
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This is a diaphyseal ostoemotomy extending form dorsal proximal to distal palntar.
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Describe hte Mau ostoetomy
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This is a diaphyseal osteootmy extending form dordeaal distal to plantar prosimal.
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Describe the Scarf otoetomy
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This si a horizontally directed (medial to lateral ) Z-dispalcemnt osteotomy of the head and shaft of the 1st metatarsal. The distal arm exits the head and the proximal arm exits the shaft just distal to the base. The central limb is placed at he level fothe middle and lower one third of the metarsal shaft.
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What is the major complication, hwenm transposing hte distal segment of the osteotmies. laterally
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troughing is seen if lateral displacedmnt exeeds the cortical margins inm the diaphyseal region of hte metarsal. This cna reslut in delaye dhealing and in forntal plane rotation of hte capitnal frament.
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What is the name associated wiht an opening abductory b ase wedge osteotomy?
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In 1923 trethowan performed this osteotomy, utilikzng the medial emeinece to keep the wedge open. n 1957 Stamm used the TRethowan technique but uilized the exised base of the proximal phalnx as the bone graft.
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Whyy is hte opening abductory base wedge osteotmy a good procedure for correction of matarsu primus adductus whenm ti is combined wiht a joint destructive procdure to correc a degernative 1st metarsophalagneal joint?
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It is ueseful becasue it add lenght to the first metarsal and may threefore decrese the cnase of post keller metarsalgia
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Whay i a stape agood chnoice to fixted an opening wedge osteotomy
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It will hold open the osteotomy to the correct postion even if the graft is resorbed faster than bone islaed down
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What are the indications of a lapidus proceduer
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juveninge hallux falgus eith obliquity or hypermobility at ht e1st metarsal cuneiform jont
]parylytic hallux valgus , osteoarthrits, tarumatic DJD secondary to an old Lisfranc njury, severe adualt hallux valgus iwhnt nermetartasal angle sexceeding 18 degrees, and an ancilliary proceure for the correction flatfoot. |
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What is the incedenceo fo nonuinoin folloowing a lapidus procedure?
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In up to 10 % of acae according to Clark and in 6 of 54 casess according ot SAffo eta l.
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What precasutions must be taken during the soft tissue dissection for a lapidus procedure?
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Care msut be taken to prewserve the medial dorsal cuatenous nerve, hte attachment of hte tibialis anterior, as well as the distal attachments of hte posterior tibial tendon in some instances
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What is the procedure first described by Loison and Balasescu
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A closing abductory base wedge osteotomy of the 1st metarsa in which the osteotmy is perpendicular of hte metarsal
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When is the cresentic or arcuate base ostoetomy a potientially useful procedure ot consider?
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whenthey sureion is dealing with a short meatarsal (metarawsal protursion distance shroter thatn (-) 2 mm. A wedge of bone is not removed thsu less shorenting is obtained
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Describe the Scarf otoetomy
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This si a horizontally directed (medial to lateral ) Z-dispalcemnt osteotomy of the head and shaft of the 1st metatarsal. The distal arm exits the head and the proximal arm exits the shaft just distal to the base. The central limb is placed at he level fothe middle and lower one third of the metarsal shaft.
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What is the major complication, hwenm transposing hte distal segment of the osteotmies. laterally
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troughing is seen if lateral displacedmnt exeeds the cortical margins inm the diaphyseal region of hte metarsal. This cna reslut in delaye dhealing and in forntal plane rotation of hte capitnal frament.
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What is the name associated wiht an opening abductory b ase wedge osteotomy?
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In 1923 trethowan performed this osteotomy, utilikzng the medial emeinece to keep the wedge open. n 1957 Stamm used the TRethowan technique but uilized the exised base of the proximal phalnx as the bone graft.
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Whay i a stape agood chnoice to fixted an opening wedge osteotomy
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It will hold open the osteotomy to the correct postion even if the graft is resorbed faster than bone islaed down
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When is the cresentic or arcuate base ostoetomy a potientially useful procedure ot consider?
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whenthey sureion is dealing with a short meatarsal (metarawsal protursion distance shroter thatn (-) 2 mm. A wedge of bone is not removed thsu less shorenting is obtained
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Why is the crescentic or arucate osteotomy utilized so infequently?
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It is an inherently usntable ostetomy becaue ther is no pinto ffixation, such as a hinge, and becaue it technically difficult ot fixate we..
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What is the name associated with a double ostoetomy of hte 1st metatrsal
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logroscino
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What is a logroscineo procedure?
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An abducotrioy wegve osteotomy at ht ebase fo the 1st metarsal , either opening or clsing and a distal adductroy wedge ostetomy fo the a1st metarsal head.
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What is the major complicaotn of any 1st metarsa base ostetomy?
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1st metatarsal elvatus is the major complication alghotushorteing acan also be a prolem both may result in lesser metatarsalgia, transfer lesion, stress fracurew os tgh lesser metarsals, and decrese proupsive force in toe off.
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When arthrodesign the 1st metaqrsophalngeal joint, shoudl the adductor tendon be reease?
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No, when the proximal phalnx is fused to th 1st metarsal head, the adducto tendion is no longer a defiomring force and infact itqgains mechanical advantage and helpst ot pull the proximal phalnx and 1st metarsal cler to the 2nd metarsal. If the adductor is release it may cause a splaying of hte forefoot and lead to a hallux varus.
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What are the ndicatin fro a 1st metarsophalngeal arthrodesis?
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Severe hallux valgus, hallux rigidus, rheumatoid arthrits, salvage of failed bunion surger, failure of keller procedure, poset infection arthoissi, psot raumatic arthosi, neuromuscualr diesae,..
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What is the ideal psoiton of hte hallux when arthrodesing the 1st MPJ?
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most autgher agree that the hallux shoudl b eplaed in:
transvers plane 15 -25 degrees of abductus and in line wiht the lesser toes Frontal plane: no frontal plane rotation fo the hallux Sagittal plane: 10 degrees of dorsiflexion of the hallux above th horizontal plane. This a 25 degree angle between the hallux and hetatrasal declination angle |
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What is a cheilectomy?
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this is a conservative procedure for hallux limitus in which the osseous proliferation found overliying hte hjot is excised. t is easily perfomred, reduces dorsal enlargemnt, allows increased jont motin in may caes, allows immediate ambulaitn and createsminimal posteoprative diabily.
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Describe the Kessel & Bonney procedure
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This is a procedure to address a hallux limius deformity , in which a dorsal wedge osteotm is performed on the base of the porxmal phalnx of hte hallux, to bring it into a more doreal postion. This allwos the limited jont motin to occur in a more dorsal manner.
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What is a Regnauld procedure?
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This is a procedure n which one htird of the base of hte proximal phalanx is resected, removed romthe surgical site, fashioned into a hmei implant configuration, and then reinserted back into the proxmial pahlax as an augtogenic bone graft. Soemtimes referredto as the enclavement procedrue.
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Describe a Waterman procedure.
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This si a procedure t oaddress a hallux limtus deformity, inwhic a dorsal wedge osteotomy is performeed onthe head othe 1st metarsal. The plantar cartilage is htus directed mroe doresally whch brings the hallux more doresally.
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What is the younswick modification of the Austin bunionectomy?
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A modification of ht ausitn bunionmecogtmy, which produces shoren of the 1st metarsal and limite palnat dispalcemnt of the capial fragment. This is done by makeing a second dorsal cut parallel to the doraswal arm of hte osteotomy but poroximla to it. in this way , a small segment of bone is removed orally, allowing fo ht eshrtenign and palntarflexion.
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What is the difference between hallux limitus, hallux equinus, and doral bunion?
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there is none. They all describe the sme condtion.
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List the common etiologies of hallux limitus.
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Metarsau primus elvatus secondary to abnormal pronation nd hypermbility of hte 1st ray
Dorsiflex psisotin of the 1st metarsal secondary to muscl imbalcne. D Dorsiflexed 1st metarsal secondary to saggital plane structual malalgnment of he 1st metarsal. Abnoramlly long 1st meatarsal. Prolonged 1st MPJ imobilizaion Athritic condition of hte 1st MPJ. Iatrogenic sencondar to previos foot surugery. |
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What is the Engel angle? how is it measure?
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Thi is a so-called , simplfied measurement of metarsau sadductus. ti si the angle fomred by thneinersection of the longitudinal bisectin o fhte second meatrsa nd thlongtiudnal bisecton of hte 2nd or intermediate cuneiform.
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What is the realitnship of theengle angle to the matarsu adductus anle?
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ThenEngle angle is genterally aobut 3 degrees higher thant hte traditional metarsau adductus angle.
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A patient presents to your office compaoing of a painful deformed hallux. Pernent readiographic measurements incled PASA 8 degrees, DASa 6 degrees, HAIA (hallux interphalngeus( 20 degrees, IMA 8 degrees. What is the best prcedure ot addres this patients painful defomrity?
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Distal Akin procedure
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which surgical procedure would be most appropriate to correct a PASA of 12 degres anda n IM angoe of 7 degrees
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Reverdin procedure.
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