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66 Cards in this Set

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Indications for ankle and pantalar fusions.
OA: post-traumatic
OA
Charcot deformity
Dropfoot, paralytic deformity
RA
Alternatives to ankle and pantalar fusions.
Bracing
Orthoses
Anti-inflammatories
Implant
Goals of Fusion
Reduce pain
increase stability
reduce deformity
reduce need for bracing
Position at fusion and materials used.
Foot at 90 to leg
Externally rotated 10-15 degrees
Cannulated screws
-->crossing 7.3mm tibiotalar + talar-tibia
*avoid contact with STJ
Internal vs External fixation for ankle fusion.
Literature review states internal fixation has fewer complications, greater fusion rate, and great patient acceptance.
Post-Op care for Ankle fusion.
Jones compression 48hrs.
AK cast 4 weeks for poor bone
--> otherwise 8-10 weeks NWB in BKC
Partial WB in camwalker 2-4 wks
Follow-up Xrays every 4 weeks
Complications for ankle fusions.
Stress fractures in tibia from screw holes.
Nonunion
AVN
Poor position
Hardware problems
Pantalar fusions: general and position considerations.
1. Position to be fused with the foot, ankle and knee in final position for contact to the ground.
2. Two points of fixation for joints
3. Ankle screws may penetrate to calcaneus.
4. Consider AK cast where feasible.
Glissan's 4 requirements for bone fusions.
1. complete removal of cartilage
2. accurate + close fitting of bones
3. optimal position
4. maintain position until healed
3 focal points of Cavus foot evaluation.
1. Muscle inventory
2. Structural deformity
3. Positional adaptation
3 points of evaluation of the structural component of a Cavus foot surgical candidate.
1. locate the apex
2. recognize severity
3. indentify compensation
Cavus foot classification based on 3 types of cavus foot.
JAPAS (1968)
Elaborate the JAPAS classification for cavus foot.
Anterior pes cavus
Posterior pes cavus
Combined pes cavus
Surgical procedure options for Cavus foot type.
1. Cole osteotomy
2. JAPAS
3. Dwyer calcaneal osteotomy
4. Steindler stripping
5. Triple arthrodesis
Cole Osteotomy indications.
1. Anterior Cavus
2. NON-PROGRESSIVE
3. Apex in lesser tarsus
Determination of apex in Cavus foot type in radiographs
Evaluate lateral xray for:

1. Meary's Angle: 1st met + talus
2. Hibb's Angle: 1st met + calcaneus
Cole osteotomy techniques:
1. how many incisions
2. important muscle reflection
3. steinmann fixation
1. 2 incisions
2. Reflect TA
3. Steinmann fixation
2 planes corrected in Cole osteotomy
1. Sagittal (plantarflexion component)
2. Transverse (adductory component)
What is the JAPAS procedure?
Dorsal "V" cut; only corrects sagittal
*creates dorsal bump!
Cole Osteotomy associated procedures.
Dwyer calcaneal osteotomy
DFWO 1st met
Steindler stripping.
Cole Osteotomy Post-Op course
Cast NWB 6-8 weeks
Cast WB 4-6 weeks
Pin removed 8-12 weeks
Literature review on Cole osteotomy outcomes.
Saunders (1935)
86 pts, 102 cases
58% excellent + good
40% fair
2% poor
Complications of Cole Osteotomy
Shortening
Delayed / non-union
Calcaneus gait (pseudoequinus reversal)
Indications for a Triple Arthrodesis
Progressive neurological cavus
Severe deformity (rigid)
Joints fused in a Triple Arthrodesis
Talo-calcaneal
Talo-navicular
Calcaneo-cuboid
Modifications to Triple Arthrodesis for cavus foot correction.
1. DFWO at MTJ
2. Wedge STJ to decr. heel varus
3. Derotate MTJ to decr. forefoot valgus
What are the STJ osteotomies for correction in each plane.
1. Frontal = lateral wedge; results in valgus heel
2. Sagittal = posterior wedge; decr. CIA
3. Transverse = slide/shift; incr. Kite's angle
What are the MTJ osteotomies for correction in each plane
1. Frontal = slide; derotates
2. Sagittal = dorsal wedge + shift calc. anteriorly; dorsiflexes
3. Transverse = lateral wedge; abduction.
Where is the most common location for non-union in cavus foot corrections?
-->revision surgery success rate?
-->how much shortening on avg?
Patterson et al. (1950)
89% of non-unions at TNJ
Revision surgery has 75% success
Shortens usually 11/16"
Objectives for Cavus foot Tendon transfer.
1. Reduce supination components
2. Treat dropfoot
3. Incr. pronation components
Muscle inventory evaluation and purpose for cavus foot tendon transfers.

Goals of tendon transfers?
1. Identify primary deforming force
2. Select transferrable muscles

*remove deforming forces + add to antagonists of deformity
Literature review on pathogenesis of Cavus foot states which muscle as major contributor to symptomatic forefoot pes cavus?
Tynan et al. (1992)
Overaction of the PERONEUS LONGUS (in comparison to its antagonist)
Which tendons are major choices for balancing cavus deformities? Alternative choices?
1. Tibialis posterior
2. Peroneus Longus

Other options: Hibbs, Jones, STATT, FDL.
Elaborate the TPTT procedure
Tibialis posterior tendon transfer:
-moves TP to dorsum of foot
-transfer through IO membrane
-out of phase transfer***
Literature review for tendon HEALING and STRENGTH PROGRESSION for tendon transfers (in a bone tunnel).
Rodeo et al; JBJS (1993)
Strength progressively incr. over 12 wks
-->greatest incr. in first 4 wks
-->failure mode changed from 8-12 wks
Protect healing for 8-12 weeks**
TPTT attachment site options?
Tendon: TA, peronus tertius (split transfer)

Bone: 3rd cuneiform (w/ bone anchor)
Elaborate the PLTT procedure.
Transfer PL from lateral to anterior cmpt
via split or single transfer.
Ancillary procedure for Cavus foot correction.
Plantar fasciotomy
Difficulties caused by pre-op limited ankle dorsiflexion.
1. promotes extensor substitution
2. Limits success of anterior tendon transfers
Tibialis posterior dysfunction etiology + pathology.
Tissue degeneration:
Inflammatory dz vs. mechanical
Zone of hypovascularity in tendon
Effect of peroneus brevis
Accessory navicular
Literature Review on vascularity of Posterior Tibial Tendon + FDL
Frey et al; JBJS (1990)
Posterior tibial vascular supply is:
1. abundant at insertion + muscle
2. hypovascular 14 mm to insertion***

FDL has no hypovascular zone
Literature Review on MEAN AGE of inflammatory vs. mechanical PTTD
Myerson et al; F&A (1989)
Group A = 39** (inflam.+ enthesopathy)
Group B = 64** (isolated mechanical)
Clinical features of posterior tibial tendon dysfunction (PTTD).
1. Talonavicular congruity
2. Heel + ankle valgus
3. Flexibility
4. superstructural deformity
5. talo-calcaneal divergence
6. pain?
Valgus deformity in PTTD is indicative of what?
Deltoid + spring ligament attenuation**
Effects of rearfoot valgus in PTTD.
1. Forefoot supinates (to purchase)
2. knee valgus
What are the superstructural deformities associated with PTTD?
1. Tibial varum
2. Genu valgum
3. Equinus
Muscle sizes of PT and FDL after rupture.
PT atrophies, FDL hypertrophies
After partial rupture of PT with residual function, what should be the treatment?
FDL tenodesis or Cobb repair.
Radiographic considerations in PTTD.
Talo-calcaneal divergence
indirect measure of:
TN congruence + CC-abduction

Also associated w/ heel valgus
What is the PTTD classification based on insertion, mid-substance, in-continuity, and tenosynovitis?
Funk classification (1986)
PTTD classification based on clinical staging system? (3 stages)
Johnson & Strom (1989)
PTTD classification based on MRI findings of tissue degeneration?
Conti
Elaborate on the Funk classification of PTTD.
Group 1: avulsion at insertion
Group 2: mid-substance tear @ m. mal
Group 3: longitudinal split w/o rupture
Group 4: tenosynovitis w/o disruption
Elaborate the definition and treatment for STAGE 1 PTTD of the Johnson + Strom classification.
Stage 1: peritendonitis
normal rearfoot alignment
mild focal pain
mild weakness w/ heel rise test

Tx: conservative 3 months, then synovectomy, debride, immobilize
Elaborate the definition and treatment for STAGE 2 PTTD of the Johnson + Strom classification.
Stage 2: elongation,
mobile pes valgus rearfoot
moderate medial pain
marked weakness w/ heel rise test
too many toes sign
marked degeneration
Tx: includes transfer of FDL + PT
Elaborate the definition and treatment for STAGE 3 PTTD of the Johnson + Strom classification.
Stage 3: tendon elongation
fixed rearfoot valgus
medial + possible lateral moderate pain
marked weakness w/ heel rise test
too many toes sign
marked degeneration
Tx: FDL transfer, TN fusion, calc ost.
Elaborate the definition and treatment for STAGE 4 PTTD of the Johnson + Strom classification.
Stage 4 (Myerson addition)
same as Stage 3 w/
--> lateral ankle pain + instability
Tx: Triple Arthrodesis
PTTD soft tissue repair options?
Soft tissue:
-primary repair
-FDL, FHL transfer
-Graft repair
-medial arch tenosuspension
What's the criteria for PTTD soft tissue repair?
Soft tissue repair indicated for:
-->small defects
-->short duration
-->no DJD
-->less deformities
What are the key elements of soft tissue repair for PTTDq
1. stabilize the N-C joint
2. restore/replace TP power
3. MTJ + lateral column must be stable
Procedure options for OSTEOTOMY + FUSION options for repair of PTTD.
Evans Calcaneal osteotomy
T-N fusion
N-C fusion
Criteria for osteotomy + fusion repair for PTTD.
larger defect
limited djd
deformed joints (but localized)
moderate duration
Key elements/goals for osteotomy + fusion repair of PTTD.
re-align TNJ
decr. talo-calcaneal divergence
stabilize medial column
lock lateral column
Post-Op for osteotomy + fusion repair of PTTD.
3 months casting
up to 6 months recovery
Effects on the foot from Evans Calc osteotomy.
Adducts foot at MTJ
decr. STJ eversion
creates stable fulcrum for PL
Ancillary procedure for PTTD surgical repair.
TAL: elimating deforming force

*difficult to balance - prevent overlengthening