Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
134 Cards in this Set
- Front
- Back
|
list the 5 stages in bone graft healing
|
1. vascualr ingrowth
2. osteoblast proliferation (build new bone) 3. osteoinduction 4. osteoconduction 5. graft remodeling |
|
|
osteoinduction
|
-process by which nonosseous tissue is induced to produce bone
-a bone morphogenic protein present in bone matrix acts as a inductor substance |
|
|
osteoconduction
|
-occurs after osteoinduction in bone graft healing
- process in which bone graft functions as a scaffold for migration of new bones are it replaces old necrotic bone -this is known as creeping substitution |
|
|
what is the most imp property of cancellous bone grafts
|
-they posess a lattice network which is a structure for osteogeneisis
-also contain the largest amount of viable cells and inductive morphogenic protein -used when vascularity and not strength is most imp |
|
|
what is a con of cancellous bone grafts
|
-they are fragile and offer no stability
-but incorporate quickly |
|
|
most imp property of cortical bone grafts
|
-dense and compact to provide strength and stability
-give good sites fot attachment of fixation devices |
|
|
how do cancellous grafts appear on radiograph
|
-radiodense as they heal (bc they get stronger as they heal)
|
|
|
how do cortical grafts appear on radiograph
|
-loose their strength as they heal, so they appear radiolucent
|
|
|
common site for corticocancellous grafts and its qualities
|
-iliac crest
-combines the strength of cortical bone with the rapid osteogenic capabilities of cancellous bone |
|
|
what are the diff types of allogenic bone grafts available
|
-frozen allograft
-freeze dried allograft -demineralized or decalcified allograft -artifical allograft (hydroxyapatite) |
|
|
artifical allograft such as hydroxyapatite offers only one of the properties of graft bone healing...
|
osteoconduction-they provide a scaffold and are very strong
-NO osteoinduction or osteoconduction |
|
|
DBM (demineralized bone matrix) functions as what property of bone graft healing
|
-osteoinduction
|
|
|
list types of DBM
|
-Grafton
-Dynagraft -Osteofil -Allomatrix |
|
|
ability to provide structural framework
|
osteoconduction
|
|
|
formation of new bone by osteoblasts
|
osteogenesis
|
|
|
recruitment of stem cells from graft site, where they differentiate into osteoblasts
|
osteoinduction (BMP and platelet derived growth factors can induce osteoinduction)
|
|
|
creeping supstitution
|
movement of new
tissue through channels made by blood vessels invading a transplanted bone |
|
|
what is the gold standard of bone transplantation
|
-autogenous bone graft
|
|
|
3 basic differences between cortical and cancellous bone grafts
|
1) cancellous autografts are
revascularized more rapidly and completely than cortical grafts, 2) cancellous autografts undergo creeping substitution whereas cortical grafts undergo reverse creeping substitution, 3) cancellous autografts tend to repair completely with time, whereas cortical autografts remain a mixture of necrotic and viable bone |
|
|
many structures other then the plantar fascia can pull on the periosteum of the calc and cause heel pain: list them
|
-plantar fascia
-abductor hallucis -FDB -long and short plantar ligaments |
|
|
DDx of heel spur and plantar fascitis
|
-calcaneal apophysitis
-calcaneal fracture -medal plantar calc nerve entrapment -plantar fascial tear -tumor -CT disorder(RA, Reiters, psoriatic arthritis, ankylosing spondylitis) -infection -contusion -tendonitis |
|
|
Duvries procedure
|
-resect the calcaneal spur through a medial incision and do a fasciotomy
|
|
|
endoscopic plantar fasciotomy
|
-incision anterior and inferior to the medial calcaneal tubercle
-resect the medial 1/3 or 1/2 of the plantar fascia -minimum 6 months of conservative care b4 procedure is performed |
|
|
what is the MC complication of endoscopic plantar fasciotomy
|
-lateral column instability (Calc-cuboid/midtarsal pain, peroneal tenosynovitis, sinus tarsi syndrome)
|
|
|
if a pt has a 1st met-cuneiform exostosis, what can be the etiology
|
-hypermobility of the first ray creates jamming at the first met-cuneiform joint
|
|
|
if a pt has a 1st met-cuneiform exosotosis, what nerve can receive pressure b/w the bump and a shoe causing neuritis
|
-intermediate dorsal cutaneous (from the superficial peroneal nerve)
|
|
|
DDx for Haglunds deformity
|
-calc bursitis
-achilles tendonitis -tendo achilles calcification -achilles rupture -gout -tumor -fracture -CT disease (RA, reiters, psoriatic arthritis, ankylosing spondylitis) |
|
|
Fowler and Phillip Angle; what measurement is present with haglunds
|
--intersection of a line tangent to the posteriosuperior promience and a line tangent to the anterior tubercle and medial process of plantar tuberosity
-greater then 75 degrees measured on lateral xray |
|
|
Total Angle (Vega) for haglunds defomity
|
-the calc inclination can contribute to formation of bump
-so add the CI angle to the Fowler and Philip angle -greater then 90 degrees is considered pathological |
|
|
Fowler Philip Angle for Haglunds
-greater then 75 degrees |
|
|
Paralell Pitch Lines for haglunds
-any area above PPL 2 is Haglunds |
|
|
Keck and Kelly
|
-remove a wedge from the posterior superior calcaneus for Haglunds
|
|
|
Fowler and Philip sx procedure
|
-transverse skin incision on posterior heel
-with a mercedes incision of the TA and resect the Haglunds bump |
|
|
Dickensen surgical procedure
|
-curvilinear medial incision from SM to IL to remove Haglunds bump
|
|
|
what is the difference b/w a retrocalcaneal exostosis and Haglunds disease
|
-enthesopathy at Achilles insertion
-haglunds is a bursal projection of the posterior superior (PL) calcaneus |
|
|
etiology of retrocalcaneal exostosis (the dystrophic calcfication is caused by...)
|
-repetitive trauma or overuse
-equinus -haglunds deformity -retrocalcaneal bursitis |
|
|
functional equinus
|
-foot cant DF 10 degrees past the right angle of the ankle
|
|
|
classic equinus
|
-foot cant DF 90 degrees on the leg
|
|
|
list 4 types of equinus
|
-gastroc equinus
-gastro-soleal equinus -osseous equinus -pseduo equinus |
|
|
Silverskiold test
|
-flex the knee and DF the ankle, if equinus is present with knee straight but not knee bent, then gastroc equinus is present
|
|
|
osseous equinus
|
-bony abutment b/w the talus and tibia anteriorly on a lateral stress DF xray
-this type of equinus is not resolved with Silverskiold test |
|
|
pseudoequinus
|
-apparent equinus due to abnormal FF to RF relationship
-this is a cavus foot type |
|
|
equinus is present with the knee flexed and the knee extended
|
gastroc-soleus equinus
|
|
|
equinus is present with the knee extended, but not with the knee flexed
|
gastroc equinus
|
|
|
other then tight gastrocs and soleals, contracture of what other soft tissues structures can cause equinus
|
-tight tibialis posterior,
-tight long flexors, -tight peroneals as well as contracture of the posterior ankle joint capsule. Remember the posterior ankle joint capsule alone could prevent a proper amount of dorsiflexion at the ankle. |
|
|
Remember the Law of Davis when addressing conservative measures for equinus deformities
|
-soft tissues will adapt with stress
-so you can cast an equinus foot in 90 degrees |
|
|
how can you clinically differ an osseous equinus from a muscular equinus
|
-you will notice an abrupt end range of motion with osseous equinus
|
|
|
how can the knees compensate for ankle equinus
|
they can hyperextend (genu recurvatum)
|
|
|
name 3 surgical tx for gastroc equinus
|
-gastroc recession
-achilles lengthening -Murphys Achilles advancement (for spastic equinus such as in CP) |
|
|
what changes can be seen on a flatfoot AP radiograph
|
-increased in Talocalc angle
-TN congruency decreases (talar head uncovering) -cuboid abduction angle inc -wedge shape navicular -FF adductus angle dec |
|
|
what changes can be seen on a flatfoot Lateral radiograph
|
-talar declination increases
-calcaneal inclination decreases -talocal angle increases -midfoot saggind (navi-cune breach) -Talo-1st met increases (negative Meary's angle) |
|
|
surgical procedures for flat foot are based on planal dominance, what does this mean
|
-the primary plane of flatfoot deformity is the plane which is most effected
-however all planes are effected to some extent, so sx procedures provide triplanar correction |
|
|
Calcaneal procedures for aquired flatfoot
|
-Evans calcaneal osteotomy
-Koutsigiannis transpositional osteotomy -Dwyer, Silver, Lord, Gleich |
|
|
Evans calc osteotomy
|
-insertion of bone graft into the calcaneus 1.5 cm from the calc-cuboid joint
-lengthens the lateral column and realigns the midtarsal joint (Tc, calc-cub) |
|
|
Koutsogiannis transpositional osteotomy
|
-for flat foot
-straight cut in the calc behind the peroneal tendons -fragment shifted medially to increase the supinatory action of the achilles |
|
|
list the 4 main things that support the medial longitudinal arch to prevent flatfoot
|
-plantar fascia
-long and short plantar ligament -spring lig (calc-navi) holds up the head of the talus -TP tendon |
|
|
Kidner procedure
|
-can be used for faltfoot
-removal of navi tuber or accessory navi -transposition of TP tendon plantarly into the navi |
|
|
how can you lengthen the lateral column in flat foot(this protects the spring ligament from overload during WB)
|
-calcaneal cuboid joint distraction arthrodesis
|
|
|
Hoke procedure
|
-navi cuneiform fusion to reinforce the medial colum and the weak ligaments and muscles believed to cause flat foot
|
|
|
Young medial arch suspension
|
-suspends TA through navi, basically creates a new ligament at the navi-cune joint
|
|
|
in flat foot, Evans thought the lateral column was short and this caused the problem; explain
|
-the short lateral column causes abduction of the FF and collapse of the medial column
-adding graft to the lateral column puts the long and short plantar ligaments under tension to PF the medial column |
|
|
Cottom osteotomy for flat foot
|
-opening wedge ostetomy of medial cuneiform to PF the medial column
|
|
|
Cobb
|
-split the TA and reflect half of it to augment the TP
|
|
|
where is an arthroesis implant placed for flatfoot
|
-into the sinus tarsi to restrict STJ pronation
|
|
|
what is the MC cause of cavus foot
|
-neuromuscular (Charcot-marie-tooth, CP, myopathy, polio, SC tumor)
-#2 cause is familial |
|
|
Local anterior cavus
|
-PF of the 1st ray only
|
|
|
Global anterior cavus
|
-entire FF is PF
|
|
|
pseudoequinus
|
-inadequate ankle joint DF secondary to rigid anterior cavus deformity
|
|
|
what is the coleman block test
|
-used to find the cause of cavus deformity
-have the pt place their lateral foot on the block with 1st met hanging off -a PF 1st ray will pull the hindfoot into inversion -if the heel goes from varus into neutral; this means you have a flexible forefoot and varus is caused by PF 1st ray -if the heel stays in varus, it is a rigid and not just caused by PF ray, so look for other causes such as TP spasm or fixed hindfoot inversion |
|
|
if you did an exam of a CMT pt what would you find?
|
-peripheral muscle strophy
-stork leg appearance from atrophy -absent reflexes -pes cavus caused by weak anterior group -PL is the last muscle to go, so often used for tendon transfer |
|
|
Which type of anterior cavus?
dorsal bone prominence at the 1st met-cuneiform joint |
-metatarsus cavus (PF with the apex at the lisfranc joint)
|
|
|
Which type of anterior cavus?
prominence over the entire lesser tarsus |
lesser tarsus cavus
|
|
|
Which type of anterior cavus?
dorsolateral prominence at head of the talus in NWB |
-Forefoot cavus (apex is at the midtarsal joint)
|
|
|
lateral radiograph of cavus foot
|
-decreased talo-calcaneal angle
-inc CIA (>30) -dec TDA -posterior break in cyma line -bullet hole sinus tarsi |
|
|
AP radiograph of cavus foot
|
-dec Talo-calcaneal angle
-inc met adductus |
|
|
what is Meary's angle and where does it intersect for anterior cavus
|
-bisect the talus and bisect the 1st met
-intersects at the navi-cune joint |
|
|
what is Meary;s angle and where does it intersect for posterior cavus
|
-bisect the talus and bsect the 1st met
-they intersect at Choparts joint |
|
|
test that helps you differentiate between structural varus and varus created by PF of 1st ray
|
coleman block test
|
|
|
sx procedures for a rigid anterior cavus or NM cavus
|
-Cole
-Japas -Dwyer -DFWO of 1st met -triple arthrodesis |
|
|
list some soft tissue procedures that can be used for flexible cavus deformity
|
-plantar fascial releases
or -Steindler stripping: includes the fasca, abductor hallucis, FDB, abductor digiti minimi and long plantar ligament |
|
|
Cole
|
-DF wedge osteotomy through the navi-cune joints and cuboid
|
|
|
Dwyer
|
-lateral closing wedge osteotomy of the calcaneus
|
|
|
Japas
|
-displacement V shaped osteotomy through the cuboid, navi and medial cuneiform
|
|
|
Tarsal tunnel syndrome entraps
|
tibial nerve
|
|
|
Anterior tarsal tunnel syndrome entraps
|
deep peroneal nerve
|
|
|
tarsal tunnel syndrome can be caused by direct causes or functional causes; list functional causes
|
-pronation (internal rotation of the leg with tightening of flexor retinaculum)
|
|
|
tarsal tunnel syndrome can be caused by direct causes or functional causes; list direct causes
|
-edema or space occypying lesions
-trauma to nerve -varicosities can cause venous congestion in the area -os trigonum syndrome -abductor hallucis hypertrophy (space occupying) -neurofibroma, lipoma, ganglion etc in the area -tenosynovitis (bc it produces edema) -iatrogenic |
|
|
how can os trigonum cause tarsal tunnel syndrome
|
-inflammation and edema of the FHL tendon can cause increase pressure in tarsal compartment
|
|
|
list some iatrogenic causes of tarsal tunnel syndrome
|
-intra operative
-steroid injections -tourniquet trauma -casting |
|
|
what are some systemic causes of tarsal tunnel syndrome
|
-DM with associated neuropathy
-inflammatory arthritis (RA, ankylosing) -gout -CT disease (SLE) -myxedema (synovial thickening) |
|
|
what is the venous tourniquet test
|
-place a blood pressure cuff above the tarsal tunnel
-inflate to a level above the pt's systolic pressure, leave for 1-2 minutes -if there is an increase in pain, tarsal tunnel syndrome may be present |
|
|
clinical presentation of tarsal tunnel syndrome
|
-nocturnal burining pain that wakens them
-decreased pin prick and two point discrimination -tinel or valleix sign -palpation of cord like swelling -venous tourniquet test -reproducing symptoms with forced DF and eversion of foot |
|
|
conservative tx for tarsal tunnel
|
-steroid injections
-PT nerve blocks -immobilization -orthosis to prevent pronation |
|
|
surgical tx for tarsal tunnel
|
-external neurolysis (release the laciniate ligament)
|
|
|
recurrence rate of external neurolysis (lacinate ligmament cut) for tarsal tunnel
|
5-20%
|
|
|
triple arthrodesis fuses what joints
|
-subtalar
-TN -calcaneo cuboid |
|
|
triple arthrodesis can be used for correction of deformities; what deformities
|
-valgus
-varus -flatfoot -cavus -clubfoot -fixed equinus -fixed dorsiflexion |
|
|
Ryerson
|
-classic triple arthrodesis
-simple joint resection and fixationw ith screws, pins, staples etc |
|
|
Elmslie
|
- double tarsal wedge osteotomy
1. take a wedge out of the of the TN and calc-cuboid joint 2. then weeks later a posterior wedge is taken from the STJ |
|
|
Hoke triple arthrodesis
|
-remove the talr head, resect the articular surface and replace
-fuse the rest of the joints |
|
|
Lambrinudi triple arthrodesis
|
-used for fixed equinus foot type
|
|
|
Brewster triple arthrodesis
|
-countersink the talus
-fuse the 3 joints |
|
|
Grice triple arthrodesis
|
extra articular fusion of the STJ (with a plate, etc: picture looks like a plate from talus to calc on the lateral side)
|
|
|
how much muscle strength is lost through tendon transfers
|
1 muscle grade
|
|
|
Jones tendosuspension
|
-EHL tendon is looped through a hole in the 1st met and sutured back on itself dorsally
-performed with fusion of the hallux IPJ to prevent flexion deformity -used for cock up hallux from cavus or PF 1st ray |
|
|
Panmetatarsal tendosuspension procedure
|
-used for flexible hammertoes
-any or all of the met heads can be suspended as in the Jones suspension (EHL or EDL is fixed through the met) -performed with digital fusions and/or transfer of distal part of tendon to the EDB |
|
|
Kidner procedure
|
-used for medial column flatfoot
-resect the navicular tuberosity or hypertrophy -move the TP tendon to a more lateral plantar position -usually performed with an osseous flatfoot procedure |
|
|
Hibbs tendosuspension
|
-used for equinus
-transect the EDl tendons adn transfer them to the midfoot into the inter or lateral cuneiform -suture distal EDL's to EDB tendons |
|
|
why is Hibbs tendosuspension used for functional equinus
|
-gives the EDL greater mechanical advantage in DF
|
|
|
TA transfer
|
-transect the TA and use it to correct for CMT muscle paralysis or drop foot
|
|
|
Split TA tendon transfer
|
-used for flexible varus or equinus deformities (increases DF and eversion)
-lateral half of the tendon is sutured to the P tertius or cuboid. |
|
|
young tenosuspension
|
-actually a transposition
-used for flexible pes planus -PT tendon is moved to the plantar navicular |
|
|
TP tendon transfer
|
-out of phase transfer, so it can cause flatfoot
-used for equinus -TP transferred to lateral cuneiform |
|
|
Peroneus Longus tendon transfer
|
-used for drop foot or equinus
-PL is removed from the cuboid and sutured to the lateral cuneiform |
|
|
Murphys tricep advancement
|
-used for spastic triceps in CP
-advance the achilles anteriorly, just posterior to the posterior joint of STJ -reduces the lever arm of ankle PF by 50% and reducing the lever arm of propuslion by only 15% |
|
|
the deltoid (medial) ankle ligaments consist of a deep and superficial part; describe where each connects
|
-superficial is tibiocalcaneal ligament
-deep consists of anterior tibiotalar, tibionavicular, posterior tibiotalar |
|
|
frontal plane instability of deltoid ligaments is demonstrated by stress eversion mortise films; what is positve for rupture of tibiotalar and tibiocalcaneal ligament
|
-more then 10 degrees of talar tilt
|
|
|
what is the talar tilt test
|
angle produced by the tibial plafond and the dome of the talus in response to forceful inversion of the hindfoot
|
|
|
what are the lateral ligaments and which ones are intracapsular
|
-anterior talofibular
-posterior talofibular -calcaneofibular -anterior and posterior are intracapsular |
|
|
how do you test the ATF
|
-anterior drawer test
-anterior displacement of more then 2mm is positive for rupture |
|
|
what degree of talar tilt is considered positive for a calc-fib ligament rupture
|
-10 degrees greater then the contralateral limb
|
|
|
Many different structures can be used to reconstruct a ruptured ATF ligament: but where are they passed, attached etc
|
-PB, PL, plantaris, part of the Achilles etc can be used
-these structures are passed through the fibula and talus, sometimes the calc; following the anatomic oritentation of the ATF ligament(thread it through holes in the fibula and talus) |
|
|
Procedures to repair the ATF and Calc-fibular ligament
|
-elmslie
-christman snook -winfield (uses PB) -storen II (uses Achilles graft) -Brostrom uses direct repair of ligs with reattachment of lateral portion of ex ret to tip of fibula (that was Goulds modification) |
|
|
Elmslie procedure for ATF anf CF repair
|
-utlizes the fasica lata
|
|
|
Christman Snook procedure for ATF and CF repair
|
-uses split PB tendon
|
|
|
If all 3 lateral ligaments need replaced; what should be used
|
-use fascia lata
|
|
|
what diameters do arthroscopes come in
|
-1.7mm
-2.2 mm -2.7 mm -3.5 mm -4.0 mm |
|
|
list the 5 arthroscopic portals of the ankle
|
-Anterior portals (central, medial and lateral)
-Posterior portals(medial and lateral) |
|
|
when is the anterior central portal of the ankel used
|
-placed b/w the extensor tendons
-most ankle sx is performed through here |
|
|
when is the anterior medial and lateral ports used
|
-for viewing the medial and lateral gutter structures and for placement of hand or power instruments
|
|
|
where are posterior medial and lateral portals placed
|
-medial and lateral to the achilles
|
|
|
List the Grades of ankle sprains
|
grade 1; partial ATF or CF tear
Grade 2: torn ATF, CF intact Grade 3: torn ATF and CF |
|
|
what is the prognosis of the grades of ankle sprains
|
-Grade 1 have good prognosis
Grade 2 - half do well w/o sx, half dont (cant strengthen the Peroneal tendons to control the looseness caused by ATF tear) Grade 3 in high levels atheletes dont do well w/o surgery |
|
|
how can one correct lateral ankle instability and maintain both the full PF and DF needed in a ballet dancer w/o sacrificing peroneal fxn
|
-Gould's modification of the Brostrum procedure
-brostrum directly repairs the ATF and CF ligament -Goulds modification reattaches the lateral ext ret to the inferior fibula and helps to 1) reinforce the lig repair 2) limit inversion to prevent future injury 3) correct the STJ component of instability |
