ABFAS Questions

DL tendons are detached distally and reattached together to the base of 3rd metatarsal or third cuneiform bone. Distal stumps are attached to corresponding brevis tendons to maintain function of the toes. Slips of the longus to the 4th and 5th toes are attached to the 4th brevis tendon. ii. Goals: release the retrograde buckling at the MTPJs and enhances dorsiflexory power of the foot. iii. Indications: Flexible FF or metatarsal equinus with or without claw toes, flexible cavus deformity with claw toes secondary to extensor substitution. iv. Complications: skin slough, dorsal anesthesia, tendonitis of the long extensor tendons beneath the cruciate ligaments due to excessive tension.

Hibbs Tenosuspension:

blocks excessive CKCP that the arthroereisis is meant to restrict, by resetting the maximally pronated position of the STJ (less calcaneal eversion and foot abduction). By restricting excessive pronation, the arthroereisis stabilizes the foot for propulsion during pronation the lateral process of the talus contacts the floor of the sinus tarsi, the talus is then blocked from further pronation b. By elevating the floor of the sinus tarsi, there will be a decrease in pronation (Chambers)

How does arthroresis work

via Lat XR: Equinus CIA <15; Cavus CIA>15. heel cord lengthening will benefit equinus while making cavus worse

How to differentiate Pes CAVUS VS Equinus Tx

1. Apophysitis of the 5th metatarsal base 1. Self limited disease 2. Seen in athletic adolescents and in boys more than girls. 3. Minimal edema, erythema and warmth 5. Best seen on lateral oblique radiographs - enlargement and fragmentation of the epiphysis, along with widening of the junction between the primary and secondary centers.

Iselin Disease

most protective among inhaled anesthetics can increase HR by 50%

Isoflurate Sevoflurane

1. The CCJ is usually the primary site for delayed healing

#1 problem for STJ fusion

rare in foot blood-filled cavity separated by a network of fibrous septa enclosed within a thin periosteal shell. multinucleated giant cells. MC are long tubular bones of the LE and the spine mild pain and swelling of affected part.

Aneurysmal bone cyst

originates from the smooth muscle layer of blood vessels. Mass is almost always painful secondary to pressure Solitary, encapsulated mass that is freely movable because of its location in the SQ. Usually <2cm at time of presentation.

Angioleiomyoma:

i. 1. When a tendon rounds a corner, changes direction, or passes under ligamentous structures, it is surrounded by a tendon sheath, through which the tendon is prevented from bowstringing.

Angled course- Tendon or Synovial Sheath:

what happens when the STJ can't correct the amount of ankle joint varus abnormality

Ankle varus (LDTA >92°) that deformities that exceed subtalar joint eversion motion lead to compensatory forefoot pronation. a. Arch height increases as the first ray plantarflexes, decreasing the WB surface of the foot.

Logrischino

CBWO + Peabody/Reverdin Corrects high IM +Abnormal PASA

benign. cartilage tumor. rare. mild pain CC i. Small, sharply demarcated, lobulated lesions with spotty calcification in histologic "chicken-wire" or "picket fence" matrix pattern. i. MC occurs in patients 10-25 years of age, and in 70% of cases, the physes are still open. M>F 1.5:1, likely larger in lesions of the foot. ii. MC encountered geographic lytic lesion of the talus and/or calcaneus.

CHondroblastoma

Malignant tumor arising from cartilage cells; 3rd MC primary malignant bone tumor site: calcaneus cc: development of pain and swelling or the sudden growth of a mass in a previously asymptomatic lesion Tumors are centrally or eccentrically located within the metaphysis The presence of scattered, punctuate calcifications within the tumor matrix produces a "snowflake" appearance and is a reliable radiologic finding.

CHondrosarcoma

Sanders CT

Calc Fx Based on CT coronal projection of the articular surface. Higher prognostic value; Prognosis worsens with the increase of articular comminution.

Essex Lopresti i. Tongue-type (A): Secondary fracture line extends directly posterior from the vertex of the angle of Gissane to the posterior tuber of the calcaneus, including one large posterior fragment that is usually divided into medial and lateral parts. ii. Joint Depression-type (B): Secondary fracture line extends posterior and dorsal to encircle lateral portion of the fractured articular surface of the posterior facet (called the "thalamus", or "thalamic portion"- depressed).

Calc fx described 2 primary intra-articular fracture patterns with the same primary fracture line,

Brodens view calc axial

Calc fx imaging Most commonly utilized intra-operatively when CT is not available for evaluation of reduction of the STJ. Patient is supine with central beam is directed 2-3cm anterodistal to the lateral malleolus with the foot and leg internally rotated 45°; 4 projections are taken: 10-40° in 10° increments. Beam approaches from posterior to anterior distal, 30° to the film, which is placed flat on the platform.

cancellous vs cortical screws

Cannulated cancellous screws are used for metaphyseal fractures while cannulated and noncannulated cortical screws are used as lag screws for fixation of diaphyseal fractures. The main advantage of cannulated screws is that they can be inserted over a guide wire or guide pin. The diameter of the guide pin is much smaller than the cannulated screw Cannulated screws have a hollow central shaft. Both cortical and cancellous screws can be cannulated.

¥ If the RF is able to realign to vertical when the 1st ray is off-weighted, then an elevating OT of the 1st MT can be used (to correct the hindfoot inversion that occurs d/t the effect of the FF on the RF). ¥ A proximal DFWO is utilized to elevate the 1st MT to the level of the 2-5 Mts ¥ If the heel alignment is in fixed varus, then a valgus-realigning OT of the calcaneus (Dwyer) is used to reposition the heel . DFWO of the 1st MT

Cavus: ¥ Frontal: forefoot valgus or PF 1st ray, and a varus (inverted) heel.

When to sx correct lisfranc

>2mm displaced wait 14 days if too much edema

Chondroma benign cartilage Encondroma Olliers-mult encondroma, younger Maffuci-mult encondroma

Chondroma Encondroma Olliers Maffuci

least common tumor of cartilage the LE in the long tubular bones, in the foot, the MTs, then phalanges, calcaneus, and the talus. i. Tumor is slow growing, well-circumscribed, osteolytic lesion that is eccentrically located within the metaphysis, with an oval morphology that parallels the long axis of the bone, fusiform expansion with thinning of both cortices ad even pathologic fracture, indistinguishable from an ABC.

Chondromyxoid fibroma

¥ Reudi and Allgower ¥ Type I: fracture of the distal tibia without significant displacement ¥ Type II: fracture of the distal tibia with significant displacement ¥ Type III: fracture of the distal tibia with severe comminution, significant displacement, and loss of the WB portion of the tibial plafond

Classify Pilon fractures

a. ABC: MRI, intralesional "double density" signals, low-signal internal septation, low T1 and high T2 b. Expansile component of UBC rarely exceeds the width of the epiphyseal plate (although they can in the small bones of the foot). c. ABC demonstrates internal loculation and low-signal internal septa.

ABC vs UBC

Pain, swelling, with a history of previous injury or trauma. May have mechanical symptoms such as clicking, locking, or grinding.

AVN diagnose by a. Plain XR and MRI remain the most used and beneficial modalities.

what is Hawkins sign

AVN=Hawkins sign: subchondral radiolucent line along the superior aspect of the talar dome, which classically begins on the medial side of the talar dome, and appears 6-8 weeks after injury. indicative of talar revascularization; seen on AP or mortise view.

1. Type I fracture recommendation - cephalosporin (usually cefazolin) with or without an aminoglycoside. Clinda PCN allergy 2. Type II or III fracture - cephalosporin and an aminoglycoside Gentamicin (generic version is IV only) Amikacin (IV only) Tobramycin. Kanamycin. Streptomycin. Neomycin (

Abx recommendation for Gustillo Anderson

70-80 % long bones, tibia tx: en block resection prox amputation i. Extremely rare primary malignant bone tumor ii. Considered tumor of long bones and of adolescents and younger adults, avg. age 35 years . Soap bubble app. may contain cyst like cavities

Adamantinoma:

1. Evaluate posterior muscle groups, as if a TAL or gastroc would also be indicated, this will decrease the strain on the medial column

Adjunct procedure for TNJ

Patients with rigid flatfoot secondary to coalition can have success with arthroereisis following coalition resection to realign the rearfoot.

Contraindications: arthritic STJ or joints adjacent to the STJ, rigid flat foot.

rare. soap bubble pain in area Considered tumor of long bones and of adolescents and younger adults, avg. age 35 years. i. Lobulated, well demarcated, may contain cyst-like cavities; rarely causes cortical destruction. Soap bubble app.

Admantimona

a. Must be distinguished from a fracture of the posterior process of the talus (Shepard's fracture).

Ddx of os trigonometry

CPN: deep and superficial PN anterior leg anke between EHL and TA at ankle devides to med/lat branch med goes wth Dorsalis pedis*terminates to supply 1st interspace

Deep Peroneal nerve

the skin dermal and epidermal layers with the accumulation of clear, sterile fluid between the layers

Define blister

compartment pressures are greater than 30 mmHg

Define compartment syndrome pressure

a. Always consider systemic hypothermia: core body temperature <95°F (35°C) and signs of shivering, slow mentation, muscle rigidity, hypotension, and depressed respiration. Mechanism Occurs through a process of extracellular and intracellular crystal formation followed by vasoconstriction, resulting in inadequate tissue perfusion.

Diagnose Frostbite

base of proximal phalanx (aka proximal akin) of hallux what does it correct

Distal Angle DASA Fix pasa with mt head osteotomy like REVERDIN=lat cortex intact proximal cut parallel to 1st mt and distal cut parallel to articular surface Fix DASA W/ proximal akin

MCC direction lisfranc displaces

Dorsal and Lateral

4. FTSG contain epidermis and dermis and its appendages 1. Can obtain from sinus tarsi, anterior ankle, medial arch, inguinal regions and popliteal fossa.

FTSG, sites of harvest

Frontal: forefoot valgus or PF 1st ray, and a varus (inverted) heel. • Valgus FF compensates in the hindfoot through the STJ and MTJ and this leads to a varus (rigid) or inverted (flexible) heel.

Frontal plane abnormalities of Cavus foot

iv. Chest Radiography: when a malignant lesion is diagnosed, CXR should be obtained to rule out metastatic spread, if CXR is unequivocal, a whole-lung CT scan should be done. First site of metastatic spread is usually pulmonary, and about 15% of patients presenting with ST sarcoma have a pulmonary metastatic lesion.

Why is chest xray imporant in treating soft tissue masses

detach TA (dec DF force) keyhole in navicular *supports the arch, can still DF but adds a supinatory force, PL can act better

Young's tenosuspension

1. Anterior drawer sign, greater than 4mm represents laxity 2. CFL is tested with talar tilt. Different of 5 to 15 degrees between limbs is significant 3. Syndesmosis can be tested with external rotation. If painful it is positive 4. Tibial-fibular squeeze test, positive if painful

ankle ligament tests

i. supinatus deformity will reduce on its own over time in younger patients, although a Young's tenosuspension, Kidner, or combined medial arch procedure may be required (age >9). A fixed or rigid FF varus will not reduce with a arthroereisis, and a Cotton should be performed.

arthroresis: what happens if have supinatus deformity what about rigid FF varus

i. MRI: Low T1 and high T2 SI. Typically used to differentiate between simple cysts from intraosseous lipomas when the calcaneal neutral triangle is involved.

difference with bone cysts vs lipomas

fusion of the entire TMT joint complex is not recommended, lateral column is rarely indicated.

do u fuse the tmt? Posttraumatic or primary arthritis almost always involves the medial column

1. Majority of lateral OCD lesions are anterior or middle dome and are easily accessible through an anterolateral arthrotomy. 2. Most of the medial lesions are in the middle or posterior aspect of the talus and are obscured by the malleolus Sometimes a medial malleolar osteotomy is needed

easier access for repair? medial or lateral OCD

MOA of lateral talus injury

eg snowboarding MOA - Inversion and DF during when a compressive force is transmitted to the lateral process, foot must be locked into inverted position to occur

codman, onion skin. diaphysis.boys

ewings

Malunited AFx or fusion with internal rotation is compensated for by

external hip rotation and foot pronation.

signs of lisfranc on xray

fleck sign (1 and 2 met bases) first ray elevated arch flattens

MO

best view to see CN bar

MO/Lateral

best view to see calc cuboid and TN coalition

DP Medial plantar artery

blood supply to the midfoot

Differentiation via Lat XR: Equinus CIA <15; Cavus CIA>15. Determination important

cavus vs equinus?? both will present with limited DF in the swing phase

chicken wire/white picket fence epiphesys

cbe. chondroblastoma in the epiphysis

short acting. IV hypnotic.amenestic used for induction high lipid solubility-->rapid onset, but short duration metab by liver (like amides) mech*GABA receptors/Na+ blocker soybean/egg/glycerol/lechitin***

characteristics of propofol

scalloped snowflake metaphysis

chondrosarcoma

disadvantage of the fusion vs plasty is the

fusion has less hallux propulsion and it can shorten which can then lead to contracture of the ehl or fhl You can walk it immediately vs plasty you cant

female, Asians, can transform to malignancy "beaker" shaped, centrifuge spread** thin, sclerotic rim** talus , calc affected epiphysis assoc with Paget's (soft bones)

giant cell (osteoclastoma)

a. Movement: i. Early movement is important to prevent adhesions. ii. Start just after 3 weeks post-op. iii. Lack of tension beyond 3 weeks leaves the repair cells and fibers disoriented for a weaker union.

how soon to start motion after tendon repair

pronation and abduction of the FF will cause pain and discomfort.

how to excacerbate TMT arthritis

i. vertebra compression fracture and a joint depression calcaneal fracture. ii. AT rupture or an anterior tibial axial compression or pilon fracture. iii. hip fracture or low back injury. iv. talar neck fracture. v. a supination or pronation subtalar joint dislocation.

i perpendicular fall, knee extended and locked iii An anterior movement with the knee fully extended iii posterior movement iv A forced ankle DF movement with the knee flexed v . A lateral Transverse fall

When to AJ, STJ, or both (TTC) for AVN

i. Fusion of the AJ, STJ, or both (TTC) are reserved for severe total body talar AVN or salvage procedures. 1. Rationale: In the face of significant talar body AVN, salvage options are limited and joint salvage is no longer possible. TTC fusion may be preferable to TC fusion and talectomy due to limb shortening issues and loss of TNJ anatomy.

Classification of AVN

i. Hawkins type I fractures are non displaced vertical neck fractures. AVN is 10%. ii. Hawkins type II fractures consist of a vertical talar neck fracture with either subluxation or displacement of the STJ. AVN is 42%. iii. Hawkins type 3 fractures are characterized by a vertical talar neck fracture with subluxation or dislocation of both the ankle and STJs. AVN 91%. iv. Hawkins type IV fractures vertical talar neck fracture with subluxation or dislocation of the ankle, STJ, and the TNJ. AVN of 100%.

MRI presentation of AVN

i. MRI is the most widely used modality to dx and potentially prevent further talar damage due to AVN. a. Normal T1 images will show a strong SI due to bone marrow elements in trabecular bone. b. In early AVN, diffuse marrow edema produces low signal intensity on T1 images and high SI on T2. c. In advanced stages, the diagnosis of AVN on MRI includes decreased SI on both T1 and T2 weighted images indicative of areas of devascularization or necrotic bone.

normal STJ motion

i. Normal STJ ROM is 15 degrees eversion, 30 degrees of inversion

1. Inflammatory (exudative) phase: 48-72 hours 2days 2. Fibroblastic (formative) phase: 5-15 days 2 weeks 3. Remodeling (organizational) phase: 15-28 days 1month

i. Phases of tendon healing:

what is tolerated better recurvatum or procurvatum?

i. Procurvatum of the ankle or tibial plafond is less well tolerated than recurvatum because the available ankle joint dorsiflexion is less than that in plantarflexion- further limited by the anterior impingement of the neck of the talus on the anterior lip of the distal tibia. ii. Recurvatum better tolerated because of the large amount of available compensatory plantarflexion.

1. Immediately following surgery, strength of the union is no greater than that of the suture material. 2. Following 2 weeks the suture can withstand a little strain 3. 3 weeks - limited isometric or passive ROM exercises can be initiated as the union increases in strength. 4 weeks - need for further immobilization is reduced because the danger of rupture is lessened, and gradual

i. Progressive Strength of the Healing Tendon:

1. Along tendons with a straight course, the surrounding elastic areolar tissue is known as the paratenon. i

i. Straight course- Paratenon

a. Danis-Weber Classification:

i. Type A: Avulsion of the distal tip of the fibula by an intact calcaneal fibular ligament. The fracture is TV and is at or below the TV joint line. 1. Stage 1 SADD injury. ii. Type B: short oblique or spiral oblique pattern beginning at the articulation between the tibia and fibula. 1. PABD or SER. iii. Type C: occur above the ankle joint and correlate to LH PER fracture patterns. 1. Involves rupture of the syndesmotic ligament from the level of the ankle proximally to the level of the fibular fracture.

deltoid ligament injury and lateral talar translation.

i. Widening of medial joint space >4mm indicates

blood supply to talus

i.posterior tibial artery, artery of the tarsal canal dorsalis pedis artery, perforating peroneal artery.

i. Cast should be placed at time of surgery and can be changed at 4 weeks, if bone work was done then cast for up to 6 weeks. ii. Bivalve can be used and around 3 weeks to start minimal passive ROM.

immobilization/casting after tendon repair

i. Early passive ROM after 3 weeks to stimulate collage fibers to realign themselves parallel for strength. Progressive WB and strengthening should be used.

importance of movement of tendons after repair

encondroma and osteocondroma (Cap)

in phalanges

1. medial mal and tibialis anterior tendon, start at the ankle and go to the NC joint 2. Watch out for the medial marginal vein (great saphenous), which is found in the deep fascial layer

incision placement for TNJ structures to avoid**

a. Pediatric flexible flatfoot, pediatric tarsal coalitions following resection, and stage II PTTD.

indication of arthroresis

Malunited AFx or fusion with external rotation is compensated for by

internal hip rotation and foot supination.

cocade sign-calcification inside the lesion cortical expansions

intraosseous lipoma

an inversion force is applied on a dorsiflexed foot, a wafer-shape 2. Greater incidence of stage IV lesions occurring laterally visualized easier with the foot in the dorsiflexed position.

lateral OCD mechanism position of the foot xray position

The lis franc ligament is the main stabilizer of this joint, it the strongest interosseous ligament

lis franc ligament

bundle of grapes nonossifying fibroma

mcc bening bone tumor

1. Very common, Inversion, adduction, on a plantarflexed foot, which causes ATFL with CFL and PTFL injury

mech for ATFL with CFL and PTFL injury

inversion and plantarflexory ankle forces with concomitant lateral rotation of the tibia on the talus. appear deep and cup shaped in appearance. medial talar dome lesions can be obtained by taking the AP view with the foot plantar flexed

medial ocd mechanism xray position

Approach to ORIF lisfranc fx

middle cunii start proximal superior medical >to the base of the 2nd mt possibly, 3rd mt. the first lag screw=KEY to REDUCTION. T if needed do a few more lag screws from the the bases metatarsals >cuni. If cuni instability **screw across the cunis.communition=plates.

how much do u lengthen a short limb via ex fix perday?

Lengthening performed at 0.5-0.75mm/day after a latency of approximately 5-7 days.

MC benign STT in the body. i. Subcutaneous, soft, moveable, asymptomatic. ii. Most commonly in middle decades, obese patients. iii. Cutaneous/Superficial (more common and well-circumscribed) or Deep-seated (rare and not well-circumscribed). iv. Excision is extracapsular marginal. v. MRI: Low signal intensity identical to subcutaneous fat. Well-circumscribed, lobulated mass, often traversed by thin, fibrous septa.

Lipoma

i. Superficial deltoid: 1. Tibionavicular: blends with spring (plantar calcaneonavicular) ligament at insertion. 2. Tibiocalcaneal 3. Anterior tibiotalar ii. Deep deltoid: 1. Posterior tibiotalar

Name Deltoid ligs

MC benign benign bone tumor kids/preteens typically occur within the metaphysis of growing tubular long bones Sharply marginated lytic lesions with radiolucent internal matrix and scalloped, multi-loculated, bubbly or bundle of grapes appearance

Nonossifying fibroma*bening cortical defect

15-35 <5: poor healing

Normal Prealbumin values

Bernt/Harty 1 compression/bruising 2 partial avulsion 3 avulsion, not displaced 4 detached displaced

OCD classification*

Cole

Surgical Procedure for Purely Sag deformity of Cavus

• If the RF is able to realign to vertical when the 1st ray is off-weighted, then an elevating OT of the 1st MT can be used (to correct the hindfoot inversion that occurs d/t the effect of the FF on the RF). • A proximal DFWO is utilized to elevate the 1st MT to the level of the 2-5 Mts If Coleman block doesnt cause change • If the heel alignment is in fixed varus, then a valgus-realigning OT of the calcaneus (Dwyer) is used to reposition the heel

Surgical procedures to do after Coleman block test

1. TN arthrodesis is procedure of choice 2. Triple required if FF varus present or instability 3. Has been described to removed the navicular and place graft for talar-cuneiform fusion.

Sx procedures ***If pt fail tx below for MW/Kohlers: 1. Immoblization of affected foot in short-leg walking cast for 4 to 8 weeks, followed by continued support of the medial longitudinal arch with orthoses. 2. Serial radiographs are taken every 3 months to follow the progression of healing, which usually takes up to 1 year.

1. Actively immunized 0.5mL toxoid or absorbed tetanus toxoid( hypersensitivity to diphtheria toxoid ) 2. 0.5mL diphtheria toxoid ++ 250 to 500U of tetanus immunoglobulin intramuscularly

Tetanus Status 1. Actively immunized within the past 10 years 2. Questionable immunization h

Dwyer: • Varus heel deformity is corrected by removal of a laterally based wedge through the body of the calcaneus; • Typically a 1-1.5cm lateral wedge of bone is removed

Treatment of frontal plane deformity cavus Foot

i. 3 factors work in concert to contribute to adhesion formation: immobilization, suture, sheath excision

what contribute to adhesion formation

pKa. low pka, higher base**these are the fastest onsent eg lidocaine

what controls how fast local anesthesia works

Special attention needs to be paid to patients with met adductus: In the pronated foot with the abduction of the FF on the RF, met adductus may be hidden (skew foot, serpentine foot); Flexible FF varus or supinatus may also be present: needs to be reducible. If present with equinus deformity then the equinus needs be addressed

what else to watch before arthroresis

As the foot pronates, the talus adducts and plantarflexes and the lateral aspect of the talus rotates forward, until the lateral process of the talus contacts the floor of the sinus tarsi,

what happens to talus when foot pronates

Muscles transferred to function out of phase were generally unable to fire in their new position

what happens when u take muscles out of their phase

1. 56.3% incidence of medial lesions, usually located in the posterior 3rd of the medial border of the talar dome.

what is more common medial or lateral ocd?

TC

what type of coalition will show in harris beath view

charcot, do not remove base of 4/5

when NOT to perform lateral ankle arthroplasty

aka trephine fusion of the midfoot Preferable to maintain length or overall anatomy of the osseous segments such as when a short first ray or medial column fusion is present 1. More difficult to see bridging on x-ray so the patient will begin initial WB without definitive radiographic evidence of fusion.

when to perform dowel fusion 1. Pain, instability, but with alignment suitable 2. Less soft tissue disruption cant correct large malalignment

end stage lisfranc arthrosis Anchovy resect base of 4/5 with articulation to cuboid. use a spacer (EDL/PT) of bases

when to perform lateral ankle arthroplasty name procedure

Medial clear space >5mm on XR taken in DF/external rotation was

xray views/findings most predictive of deep deltoid rupture after distal fibular fractures.

the posterior plafond in significant central comminution anterior plafond

¥ A vertical impact while the foot is in a plantarflexed position will results in fracture of?? ¥ Impact with the foot in a neutral position results A vertical impact while the foot is in a dorsiflexed position results in

¥ Varus heel deformity is corrected by removal of a laterally based wedge through the body of the calcaneus; ¥ The more anterior the OT, the greater degree of correction- the dorsal exit point should be 1-2cm posterior to the STJ and the plantar exit point should be 1-2cm proximal to the CCJ Typically a 1-1.5cm lateral wedge of bone is removed

¥ Dwyer OT of the Calcaneus

injuries to the talus.

¥ The MC injury associated with pilon fractures

Dwyer +DFWO should be used the deformity that is semirigid and frontal plane dominant Subtalar arthrodesis with DFWO should be used in patients with valgus FF with unstable/arthritis STJ with or without peroneal pathology Cole OT with DFWO should be used in patients with sagittal plane dominant cavus with FF valgus (PF 1st ray)

¥ correcting Frontal + TV plane deformities:

MM Osteogenic Sarcoma (Osteosarcoma

most common malignant bone tumor 2nd most common (1st in adolescents/young teens)

1st MPJ arthrodesis position

neutral rotation of the hallux, 10-15 degrees of valgus 20-30 degrees of dorsiflexion in reference to the axis of the first metatarsal

pronate 2-4 degrees

normal pronation allowed

fallen fragment sign

pathopneumonic for true cystic lesions

MCC of talar AVN

post-traumatic talar fracture

Calcaneus in the sagital plane

sagittal plane, the plantar aspect of the calcaneus is inclined by approximately 20-30 degrees.

a. wing phase: Tibialis anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius b. Stance phase: All others

swing vs stance phase muscles

symptoms may arise in this foot type d/t poor shock absorption (arch pain, intrinsic muscle fatigue, plantar fasciitis), compensation for the deformity (extensor sub HT, ankle joint instability/arthritis), or overuse syndromes

symptoms cavus Sagittal plane deformity of the foot that is characterized by a high-arch foot typ

what is corrected more ankle varus or valgus

the largest amounts of deformity that can be compensated for are 30° of valgus and 15 degrees of varus when normal STJ ROM is present.

i. Goals: 1. PT is a strong muscle with potential to provide good DF power when replacement is needed; transfer to the dorsum of the foot involves switching it from a stance phase muscle to a swing phase muscle- will require well-planned PT. ii. Indications: Weak/paralyzed anterior muscle group, equinovarus deformity, spastic equinovarus deformity, spastic equinovarus deformity, recurrent clubfoot, dropfoot, CMT, peroneal nerve palsy, leprosy, Duchenne muscular dystrophy. iii. Results and Complications: Controversy regarding effectiveness in spastic conditions; loss of PT may lead to development of severe pes planovalgus deformity (patients with limited RF motion are at less risk for this problem, and subsequent deformity may be circumvented by concominant triple arthrodesis). 1. Considerable success in spastic equinuovarus deformity in CP patients.

Tibialis Posterior Tendon Transfer:

transferring the PT to the dorsum of the foot: 1. 3 incision technique: a. Initially, the tendon is released from its attachments at the navicular bone, next the second incision is made on the anterior leg b. The tibialis anterior MB is separated c. The PTT is identified Instruments retrograded through the 3rd incision up the extensor sheath to accept the PTT and to draw it distally to fix to the third cuneiform.

Tibialis Posterior Tendon Transfer:

Tillaux-Chaput's : Tibia Wagstaffe tubercle: Fibula : Volkmann fracture: Posterior Mal (Tib)

Tillaux-Chaput's (child) . (adult) Wagstaffe tubercle : Volkmann fracture

6 hours from injury to debridement of open fractures. **b/c bacteria will spread w/in 6H-->becomes infected**

Treatment as Emergent/Golden Period

finger and balloon , espansile, blood filled

aneurysmal bone cyst

a. Enchondromas occur in older age range, lesions are typically centrally located with lobulated contours, expansion is less dramatic, and calcification is not uncommon.

1. ABC vs. enchondroma:

1. Preserving blood supply to fracture or fusion 2. Obtaining anatomic reduction 3. Providing stable fixation 4. Begin early, active ROM of the involved body part

1. AO principles

what happens when the STJ can't correct the amount of ankle joint valgus abnormality

1. Ankle valgus (LDTA <86°) deformities that exceed subtalar joint inversion motion lead to compensatory forefoot supination. Arch height decreases as the first ray dorsiflexes to compensate, thereby increasing the WB surface of the foot. Valgus of the distal tibia produces early ankle joint arthritis and disruption of the ankle mortise by overloading the lateral side of the ankle joint despite being well compensated for by the ample subtalar joint inversion motion available.

1. Osteochondrosis of the Cuneiforms 1. children ages 5 to 13 2. Report aching pain around medial aspect of midfoot, exacerbated by activity. 3. No edema, erythema, warmth or loss of motion is noted 4. Cavus foot is more at risk 5. MRI or CT warranted if symptoms persist despite appropriate conservative treatment 1. Will show similar results as avascular necrosis of navicular

1. Buschke Disease 1. Treatment 1. reducing activities 2. arch supports and orthoses 3. NSAIDs are used to control pain. Can place in cast for more painful cases. 4. Complete resolution is visible on radiographs within 8 to 9 months 5. Only surgical treatment is excision of loose fragment followed by abrasion arthroplasty

i. Geographic destruction with an ill-defined margin

1. Equivocal lesions (not clearly benign) 2. Destructive process probably extends beyond radiographic margins

head of lesser metatarsals 1. Ages of 13 to 18 most commonly, Female:Male ratio of 5:1 2. Etiology 1, poor mechanics, repetitive micro-trauma, rigid metatarsal, hypermobility of adjacent metatarsals, short 1st, high heeled shoes, activity, vascular disruption, iatrogenic. 3. Clinical Presentation 1. Pain and limited motion - pain worse with activity and WB, relieved with rest. 2. Periarticular edema and soft tissue thickening secondary to synovitis 4. Increased temp, plantar callosities, mild erythema, post static dyskinesia

1. Freiberg Disease

1mm of talar shift can result in a 42% decrease in tibiotalar contact

1mm of talar shift can result in a _________decrease in tibiotalar contact

i. Vascularized EDB pedicle graft surgical technique:

1. Incision made 2 cm anterior to the tip of the lateral mal, curving toward the base of the 3rd MT. 2. Deep dissection carried down to lateral EDB muscle. An OT of the anterior calcaneal tubercle is performed, preserving the EDB muscle attachment. 3. Bore hole made into the lateral talar half of the talar neck extending into the talar body. Thorough curettage of the subchondral necrotic bone through the tunnel is performed. 4. Vascularized bone graft then contoured and snugly fit into the talar body without fixation. 5. PO Course: NWB cast 6-8 weeks with gentle ROM beginning at 6 weeks. Protected WB in fracture boot for another 4 weeks, then PT. Restriction of activity for the first year PO.

1. Osteochondrosis of the Navicular 1. Usually seen in children between 2 and 9 yo. 2. m/c in boys and b/l 20% to 30% of cases 3. Most with this disease have a delay in ossification of the navicular which increases the risk for vascular insult 4. Symptoms 1. painful limp, pain around the medial longitudinal arch, edema, warmth and pain with compression.

1. Kohler Disease 1. X-rays indicate increased density and thinning bone distal to proximal direction. A case of coalition has been heard of following Kohler's disease

1. similar as Kohler but seen in adults 2. More common in women and 20 to 75 3. b/l conditions is more common that in Kohlers 4. Caused by chronic compression from adjacent joints, leading to avascular necrosis 5. Similar symptoms as Kohler's but are more prolonged. 1. Pain is normally located on the lateral aspect of the navicular body, instead of the dorsal aspect as seen in Kohlers. May also have crepitation in the TN joint which is also not seen in Kohlers

1. Mueller-Weiss Syndrome xray loss of volume at the lateral aspect of the bone rendering a comma-like appearance, and an increase in radio density. Doral osteophytic changes and fragmentation.

1. The joint will always lie just below the anterior tibial tendon DF the hallux that will result in PF of the medial column

1. NCJ not usually indicated at primary procedure 2. Think of the NCJ as a ball and socket type joint with triplanar motion state facts

types of Bone Grafts for Talar AVN

1. Nonvascularized cancellous autograft can be taken from the iliac crest, calcaneus, or femoral head. Useful only in small, contained defects since this does not supply structural support. 2. Vascularized pedicle autograft: Rationale: limited area of necrotic bone can be debrided and removed and a vascularized graft is plugged in to bring in fresh, viable bone and perfusion. 3i. Bone allograft: 1. Nonvascular bulk allografts using fresh cadaver talus are a viable option for partial talar AVN. 2 Fresh talar bulk allograft

1. OATS procedure - Harvest initially then after growth is chondrocytes take patient back to OR 2 to 3 weeks later. Subchondral bleeding will allow marrow to contaminate the chondrocytes. A periosteal graft has to be taken from the ipsilateral knee, which will be secured over the defect with vicryl with the cambium layer facing toward the bon. Fibrin glue is placed over the surrounding articular cartilage. Chondrycytes are placed within the defect. NWB for 6 to 7 weeks.

1. OATS procedure -

1. Periosteal dissection 1. Provides 80% of blood supply to bone 1. Periosteum is continuous with the joint capsule and is connected to bone by Sharpey fibers.

1. Periosteal dissection Define: Sharpey fibers

1. Calcaneal Apophysitis - by far the most common cause of heel pain in the adolescent population 2. Athletic boys 6 to 13, aggravated with activity and relieved with rest 3. Physical Exam 1. no erythema, no edema, no warmth. Pain with direct palpation of the posterior calc. Classic sign is tenderness with medial to lateral compression

1. Sever Disease

Pronation-Abduction:

1. Stage 1: Involves either rupture of the deltoid ligament or a TV fracture of the MM. 2. Stage 2: Rupture of the anterior and posterior syndesmosis (or Tillaux-Chaput/Wagstaffe fracture). 3. Stage 3: TV or oblique fracture of the lateral malleolus usually, at the level of syndesmosis- "butterfly fragment" (HALLMARK). iii. Supination-External Rotation: 80% of ankle fractures.

Pronation-External Rotation: i.e. baseball player sliding into base.

1. Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus. 2. Stage 2: Rupture of the anterior tibiofibular ligament and the interosseous ligament and membrane (or Tillaux-Chaput/Wagstaffe fracture). 3. Stage 3: Fracture of the fibula that occurs 5-7cm above the syndesmosis but can occur at any level more proximally. a. Fractures that occur at the fibular neck are known as Maisonneuve fractures. 4. Stage 4: Failure of the posterior syndesmosis or posterior tibial fracture.

i. Supination-Adduction:

1. Stage 1: TV avulsion fx of the LM with the syndesmosis and collateral ligaments intact (HALLMARK) or rupture of ATFL, CFL, PTFL. 2. Stage 2: Vertical "push-off" fracture of the MM caused by impaction of the talus. (HALLMARK). 3. Example: Tennis player with lateral movement or stepping off a curb.

1. TTC arthrodesis for talar AVN surgical technique:

1. TTC arthrodesis for talar AVN surgical technique: a. Incision made following the distal 1/3 of the fibula and brought distally in a J shape to the sinus tarsi. b. An OT of the fibula is made just proximal to the distal tibiofibula joint and the distal fibula is removed. c. This fibular autograft is morselized with a bone mill to provide rich and abundant autograft. d. The AJ and STJ are exposed, and all articular cartilage is denuded to bleeding cancellous bone. e. A medial arthrotomy incision is made just medial to the TA tendon exposing the medial gutter of the AJ. Arthrotomy completed. f. A 90 degree box cut is created at the intersection of the MM and distal tibia surfaces to allow medialization of the hindfoot and ankle on the tibia- the medullary canal of the tibia must be aligned with the central portion of the talus and calcaneus if retrograde nail fixation is to be used. The talus is also translated posteriorly. g. Hindfoot and ankle are temporarily fixated and an IM rod is inserted from the plantar aspect of the calcaneus with the foot and ankle held in the corrected position. h. After reaming, but prior to the insertion of the rod, the fibular autograft mixed with BMA is packed into the ankle and subtalar fusion sites. i. The nail is been inserted, compressed, and locked per protocol. j. Proximal locking of the nail is recommended for stability but not absolutely necessary. k. PO Course: NWB for 6 weeks followed by protected weight bearing in CAM for another 4-6 weeks. Proximal locking screws can be removed at 3 months to allow rod dynamization.

mcc for ex fix

1. m/c complications involve bone healing and not infection others: 1. delayed, nonunion, implant loosening, fracture, chronic pain, soft tissue inflammation, ulceration, or gross infection including osteomyelitis

talar tilit a. A distance of more than 2mm between these lines indicates an abnormal ankle. 2mm of lateral fibular displacement can result in 1-2mm of lateral talar tilt.

1. reliable indicator of lateral ankle stability.

i. Supination-External Rotation: 80% of ankle fractures.

1.Stage 1: Rupture of the anterior syndesmosis, a bony avulsion of the anterior lateral aspect of the tibia (Tillaux-Chaput) or of the fibula (Wagstaffe). 2. Stage 2: Spiral oblique fracture of the fibula beginning at the level of the ankle joint and syndesmosis- anterior distal to proximal posterior (HALLMARK). 3. Stage 3: Rupture of the posterior syndesmotic ligament or a fracture of the posterior malleolus (Volkmann's fx) with the syndesmosis remaining intact 4. Stage 4: Rupture of the deltoid ligament or a transverse fracture of the medial malleolus.

Rules for bunions in the Juvenile pt

14-16 yrs. Ideal time frame to do sx for them is near skel. Maturity 11-15 yoa. Don't do anything joint destructive /don't remove the fib sesamoid. take mt adductus into consideration in a peds patient. Transpositional osteotomies ideal e.g. austin, kalish, offset V for rectus foottype and mod. IMA. But if they have Mt Adductus, really high IM or really high PASA

Bifurcate ligament attaches the os trigonum medially and laterally i. FHL runs through the bifurcate ligament, where it contacts the os trigonum.

2 structures close to os trigonum

Diastasis for Lisfranc = a fracture is present

2-5 mm of diastis betwen 1st and second mt base Chronic lisfrancs--->ct=1 mm diastasis betwen 1st and 2nd mt or an increase of more than 15 degrees in the tarso-metatarsal joint

Normal ROM of the ankle Which has more compensation

20 degrees of dorsiflexion, 50 degrees of plantarflexion the largest amount of deformity that can be compensated for is 50 degrees of recurvatum 20 degrees of procurvatum in the normal ankle joint

Distal metaphyseal peds osteotomies

Austin, offset v, reverdin, mitchell, wilson and peabody. Mitchell and wilson SE including shortening, transfer lesions, elevatus, metatarsalgia

How to fix bunion in a peds pt with IM >15

Base procedure aka proximal metaphyseal osteotomy. -closed or open base wedge, cresentic procedure, lapidus =goal to make first and 2nd mt parallel without damaging the open physeal plate.

a. Ganglion Cyst: MC STM in the foot/ankle. Plantar Fibroma b. Lipoma: MC benign STT in the body. c. Neurofibroma: d. Neurilemmoma: e. Hemangioma: a. Ganglion Cyst: MC STM in the foot/ankle. Plantar Fibroma b. Lipoma: MC benign STT in the body. c. Neurofibroma: d. Neurilemmoma: e. Hemangioma: f. Pigmented Villonodular Synovitis: g. Angioleiomyoma: h. Epidermal Inclusion Cyst:

Benign Soft Tissue Masses

¥ Pes cavus is a sagittal plane deformity within the foot that compensates through the adjacent joints available ROM Frontal plane FF valgus deformities compensate through the RF via heel inversion, ¥ deformity exceeds the ability of the foot to compensate for frontal plane contractures, the ankle joint will become unstable and arthritis in the direction of varus

Biomechanics of pes cavus

should be longitudinal- transverse biopsy incisions are contraindicated!

Biopsy direction In the foot, ankle, or leg

Bohler's Angle 20-40 Cx fx: decreased Angle of Gissane 130-140 Cx fx: increased

Bohler's Angle Angle of Gissane

Normal Bohler's angle and critical angle of Gissane -what happens to these angles in calc fx

Bohler's angle (N=20-40°) and critical angle of Gissane (N=90-105°) - decrease in BA increase in CAG is seen.

Closed Biopsy: Disadvantages- retrieval of insufficient tissue for interpretation/inaccuracy of diagnosis. Fine-Needle Aspiration: 25 gauge needle and a small syringe to aspirate the ST mass. Core-needle Biopsy Open Biopsy: Incisional: Removing a portion of the tumor and leaving the remaining main mass in situ. MC for larger tumors ** tumors malignant (less potential for tumor spread). Excisional: removal of entire tumor . Indicated for small lesions (<2cm in diameter), for shallow tumors

Closed Vs Open Biopsy Incisional Vs. Excisional Biopsy (portion) ( E-entire)

Ewigs sarcomma

Codmans triangle

evaluates flexibility of hindfoot place 1" block under the lateral foot eliminates contribution of the plantarflexed 1st ray and forefoot pronation to the hindfoot deformity findings flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of foot rigid hindfoot will not correct to neutral ** determine whether or not the RF has the ability to pronate if the effect of the PF 1st ray is eliminated

Coleman block test

a. Results from an increase in interstitial fluid pressure within the foot compartments and when presenting acutely is generally associated with some form of trauma. b. Signs and symptoms: Best indicator is pain out of proportion to the injury. Pain with passive ROM of the toes, decreased light-touch, two-point discrimination, and vibratory sensation are also reliable indicators.

Compartment Syndrome

multistick needle catheterization for intracompartmental pressure measurements- **although CS can be present in cases of normal compartment pressures i. Compartment pressures >30mmHg or if a compartment pressure is 10-30mmHg below the patient's diastolic blood pressure require open fasciotomy. Never use local (directly increases intercompartmental pressure) or regional anesthesia (causes vasodilation). Use conscious sedation if needed.

Compartment Syndrome diagnosis DO NOT USE.....

Ankle procurvatum (apex anterior):

Compensated through the ankle joint by dorsiflexion

Ankle recurvatum (apex posterior): compensation

Compensated through the ankle joint by plantarflexion. jb.going down for compensation.

Rowe

Extra Articular Fx

MC solitary lesion of phalanges centrally located in medullary canal Well-circumscribed, round to oval geographic lytic lesion of the metaphysis, often with lobulated contours, with thin, sclerotic margins.

Enchondroma

i. Discrete, intraosseous area of sclerosis commonly referred to as a bone island. ii. Histologically consist of compact lamellar bone; nest of cortical bone surrounded by cancellous bone. iii. Cause unknown; no link to trauma or disease. iv. Can be seen in any bone except the skull, most texts state male predominance. v. Oval or round intramedullary osteosclerotic lesions of cancellous bone with characteristic "brush-like" border. "Cold" on radionucleotide scan but can be positive on bone scan if changing size.

Enostosis

traumatic causes epidermal cells into the subepidermal layer. >produces keratin, >forms mass ii. A sinus tract >cheesy material containing keratin and cell debris.

Epidermal Inclusion Cyst:

• Tongue-type fx : The secondary fracture line extends directly posteriorly, producing a large superior, posterior, and lateral fragment, with the rest of the body forming the inferior fragment. • Joint depression fx: The secondary fracture line begins at the crucial angle, extends posteriorly and exit the bone just posterior to the posterior articular facet.

Essex-Lopresti classification: There are two fracture lines in this classification and based on the location of the secondary fracture line, there are two types of fracture:

onion skin. codman's triangle. i. XR: aggressive, poorly defined area of permeative bone destruction, with grade III rate of growth. A ST mass is a constant finding in Ewing sarcoma that is easily detected in the extremities. Lesion of children and adolescents, 80-94% occurring in the first 2 decades, symptoms include pain with local tenderness at the site of a palpable mass. Systemic symptoms such as fever, general malaise, secondary anemia, leukocytosis, and an increased sedimentation rate

Ewings Sarcoma

solitary bone cyst, UBC

Examples of bone cyst

i. All patients with frostbite should be admitted to the hospital; rule out systemic hypothermia. Give Tetanus prophylaxis. ii. Rapid re-warming wrapping the limbs in multiple pre-heated blankets, administering warm IV NS, and/or Bair Hugger. If whirlpool bath is available, may submerge affected feet for 15-30 minutes at 104°F-108°F. Pain management. iii. IV abx prophylaxis with good staph and strep coverage (first generation cephalosporin).

Frostbite Treatment

1. Joint preparation (cartilage removal) 2. expose bleeding bone 3. plantar grade position 4. stable fixation

Fundamentals of pantalar arthrodesis

MC STM in the foot/ankle. i. Origin: myxoid degeneration of connective tissue of either the tendon sheath or peri-capsular tissue. ii. Well-circumscribed, soft, fluid-filled, freely moveable, located in subcutaneous tissue, transilluminates, and most commonly found on the dorsum of the foot. iii. Lesion should be removed with adjacent capsular tissue, intralesional excision assocated with high recurrence rate. iv. MRI: Low to intermediate signal intensity on T1 weighted images, high signal intensity on T2. Well demarcated, homogeneous.

Ganglion Cyst

Slowest grade of growth rate and is most likely a benign process

Geographic destruction

multinucleated giant cells in the cellular composition MC misdiagnosed as ABC which can be removed intralesionally- 20-50 years old, 3rd decade MC, infrequent

Giant Cell

Eccentric, ovoid, epimetaphyseal intramedullary zone of geographic destruction with a thinly sclerotic rim. 20-50 years old, 3rd decade MC, infrequent in patients before physeal closure or >55 Pain of insidious onset MC complaint, with or without ST mass. -I. 3x MC in LE than UE, with MC site distal femur/proximal tibia. MC misdiagnosed as ABC which can be removed intralesionally Recurrence rate as high as 40% with curettage and bone grafting associated with Paget's disease.

Giant Cell Tumor (aka osteoclastoma

1. Type I: Skin laceration less than 1cm, results from an inside out perforation, little or no contamination; the fx is simple 2. Type II: Skin laceration is greater than 1cm but is associated with little or no contusion of the surrounding tissues; fractures displaced with some comminution and with minimal to moderate crushing component 3. Type III: Extensive soft tissue damage greater than 10cm, with or without severe contamination; the fracture is highly unstable Type IIIA: Adequate soft tissue coverage of bone Type IIIB: Extensive soft tissue loss occurs with periosteal stripping and exposed bone; severe contamination Type IIIC: An arterial injury is present that requires repair **I or II but 8h +

Gustilo and Anderson Classification <1, 1, 10 cm+

Indications for Amputation 1. Variables to look at 1. Limb Ischemia 2. Nerve Injury 3. Patient age 4. Shock 5. degree of skeletal and soft tissue injury 2. Can look at Mangled Extremity Score, Predictive Salvage Index, Limb Salvage Index and Hannover Fracture Scale-97.

Indications for Amputation **Variables to look at

i. May be difficult to differentiate from UBC, howeber UBC typically present at an earlier age and do not have intralesional calcifications, which occurs in 60% of IL. Additionally, UBC do not typically demonstrate cortical expansion, which can occur in IL.

Intraosseous Lipoma

There are inter metatarsal ligaments between 2-5, Nothing between 1 and 2.

Is there a ligament between met base 1 and 2.

Technique: The EHL is transected at the HIPJ, then rerouted through a medial-to-lateral drill hole in the head of the 1st MT and sutured back onto itself dorsally. Tendon can also be attached to the neck of the 1st MT with a bone anchor. The stump of the EHL should be attached to the EHB to maintain some extensor function to the great toe. 1. To prevent hammering of the hallux, the HIPJ requires arthrodesis.

Jones Tenosuspension:

bence jones (urine). mcc bone tumor malignant renal/hypercalcemia/immune disfunction plasma cell tumor osteopenia

MM

Nut-cracker"- type compression or fracture within the posterior aspect of the rear foot and ankle, an impingement between the superior aspect of the calcaneus and the posterior malleolus of the tibia.

MOI for ostrigonum injuries

Osteoid Osteoma

MRI is preferred for bone tumors. When is CT.?

i. MC diagnosed STS; 5 subtypes: pleomorphic, myxoid, giant cell, inflammatory, and angiomatoid. ii. Occur in patients between 50-70 yrs, except angiomatoid (adolescence). MC in males. iii. Pain in extremity as well as inflammatory syndrome (fever, chills, myalgia) may be associated with the tumor, most located below the deep fascia. iv. Require wide surgical margins.

Malignant Fibrous Histiocytoma:

Malignant Fibrous Histiocytoma: Synovial Sarcoma: Fibrosarcoma: Liposarcoma:

Malignant Soft TIssue Masses

1. medial marginal vein 2. Anterior TIbial Tendon - retract dorsally 2. Important to prep the medial and intermediate MCJs

Medial Column Fusion: NCJ

MC malignant bone tumor MC complaint is bone pain fever, weight loss, lethargy, weakness, bleeding, neurologic signs. bone marrow aspirate. bence jones protein in urine. axial skeleton (hematopoietic red marrow- vertebral spine, ribs, skull, pelvis, proximal femur), resulting from uncontrolled proliferation of plasma cells. MM commonly presents in the 6th or 7th decade; rare in patients <30 hypercalcemia, renal dysfunction, and impaired immune dysfunction. 1. Pneumonia and renal failure are the two MC causes of death in this disease.

Multiple Myeloma:

Dull pain localized to affected area, not nocturnal, does not respond to salicylates Benign, highly vascular 70% of cases <30 yrs not as severe as OO and vertebral body MC occurs in the dorsal talar neck.

Osteoblastoma

benign. painless bony mass. tumor bony projection covered by hyaline cartilage caused by trauma (salter harris injury) Aut dominant varriant with mult exostoses i. MC benign bone tumor, <20 yrs old (70%) and have predilection for femur, humerus, tibia, fibula. 1.5:1 M:F.

Osteochondroma

i. Pain, swelling (early); enlarging mass, gross deformity, and decreased ROM at neighboring joints (late). High propensity for metastasis lungs 75% of cases between 15-25 years Malignant bone tumor composed of a highly virulent stroma MC sites distal femur, proximal tibia, proximal humerus MC found in the metaphysis of long bones, can extend into diaphysis

Osteogenic Sarcoma (Osteosarcoma

a. Predilection for talus. Nocturnal pain that may wake patient lucent, lytic nidus that can have varying levels of calcification

Osteoid Osteoma:

PB: Strong everter of the foot during midstance and propulsion, stabilizer of the fifth metatarsal during midstance and early propulsion, an antagonist to those muscles that supinate the subtalar and midtarsal joints, (PT, FHL, FDL, and TA), that is, a weak plantarflexor of the ankle.

PB

PB and PL are antagonsits to PT, FHL, FDL, and TA therefore they both function as dynamic stabilizers of the LCL of the ankle during excessive inversion and are important in ankle proprioception.

PB and PL are antagonsits

PL: Stabilizer of the first ray during midstance and propulsion, weak plantarflexor of the ankle joint during propulsion, and a strong everter of the foot during the early phase of propulsion, and a weak decelerator of ankle joint DF during the heel lift period of the propulsive phase of gait

PL

MC used in transfer procedures, however in lesser degree deformities, PL can be released distally and anastomosed to the PB, which eliminates its effect of PF the 1st ay and assists in everting the midfoot.

PT and peroneus longus MC used (and MC implicated in causing cavus)

Ankle, STJ, TN and CC injections, PT, bracing, rocker sole shoes ipsilateral knee degeneration

Pantalar Arthrodesis conservative to try first: complication

0- 5 degrees valgus 0 to 5 degrees dorsiflexion talus should be translated posteriorly 0.5 to 1.0 cm

Pantalar Arthrodesis ideal position

cavus (elevated longitudinal arch) plantarflexion of the 1st ray and forefoot pronation hindfoot varus forefoot adduction

Pediatric Cavovarus

Ewing sarcoma, osteosarEwing sarcoma, osteosarcoma, and solitary metastasis coma, and solitary metastasis infectious processes such as osteomyelitis and subperiosteal abscess by pus, by

Periosteal reaction a. During periods of rapid normal growth, response to injury, or some local or central pathologic stimuli, the periosteum becomes thick, and the two layers become distinctly separate.

i. Technique: approached and performed in the same manner of PL transfer. ii. Goals and Indications: Same as Longus transfer. Results/Complications: Will change phase spontaneously when required to do so; choice for most ankle stabilizations

Peroneus Brevis Tendon Transfer:

Initial incision at junction of middle and lower third of the lateral leg, the PL tendon lies superficial to the brevis The second incision along the lateral cuboid, where the PL courses inferiorly into the plantar peroneal tunnel. t is sutured to the brevis transferred into the anterior compartment through the anterolateral intermuscular septum. is delivered down the extensor sheath, beneath cruciate retinaculum and attached to base of 3rd metatarsal or 3rd cuneiform, or is split and sutured into the tendons of tibialis anterior and peroneus tertius. ii. Indications: Anterior muscle group weakness or paralysis, dropfoot deformity. iii. Results and Complications: PL does well switching phases in high percentage of patients. Complications are few and generally the same as other transfers.

Peroneus Longus Tendon Transfer:

most commonly on the anterior aspect of the ankle. presents with pain, swelling, and limitation of motion of the affected joint. Joint aspirate yields serosanginous brownish fluid. Palpable mass can often be felt iBenign but aggressive proliferative process of synovial membranes; ii. Usually occurs in adults 20-50 years of age with no sex predilection. iii. 3 types: extra-articular tenosynovial giant cell tumors, solitary intra-articular nodules, and a diffuse, villous, pigmented process that involves the entire synovial membrane of a joint. iv. from the synovial lining of a tendon,Treatment is marginal local excision. v. Diffuse PVNS may occur about any joint,

Pigmented Villonodular Synovitis:

to improve DF *split TA and insert to the cuboid use for: equinovarus/forefoot varus/too strong invertors flexible equinovarus/DF

STATT

subcutaneous thickening of the plantar fascia, most commonly involving the medial or central bands. i. Most commonly in males, 20-40 years old. BL in 10-50% of patients. ii. Excision through plantar zig-zag lesion, should remove portions of uninvolved fascia adjacent, distal, and proximal to the mass.

Plantar Fibroma:

post op avn sx

Posterior splint until sutures removed followed by NWB cast for 4 weeks. 1. 5-6 weeks PO, patient placed into a patellar tendon WB boot walker or brace but still kept strictly NWB (NWB ROM exercises started). 2. 8 weeks PO, XR are taken and the integrity of the talus is judged, PWB allowed on the PTB boot and as healing continues WB is progressed. Patient is then in rigid AFO for the first 6 months.

Types I-III do not involve the subtalar joint. Type I (20%) the fracture line may be through the tuberosity, the sustentaculum tali, or anterior process of the calcaneus. Type II or beak fractures are uncommon. Type III (20%) are oblique fractures. Types IV and V(60%) involve the subtalar joint. Type V fractures are comminuted fractures with a centrally depressed fragment.

Rowe Classification:

1. Fixation of TNJ Large cancellous screw, inserted from distal inferior aspect of the navicular and directed proximally up into the neck of the talus 2 STJ from the medial aspect of the neck of the talus directed towards the posterior, inferior lateral corner of the calcaneus. 3. Large cancellous screw. Inserted from dorsal lateral aspect of the distal cuboid and directed proximally across the CCJ and into the mid portion

STJ Fusion Direction of Screws 1. TNJ 2. STJ size: Large 6.5 cancellous screw with 32-mm thread pattern 3. CC

talus remains seated within the ankle mortise (until later in the disease in which deltoid insufficiency leads to a valgus talar tilt). The calcaneus subluxes posteriorly, creating a valgus position relative to the talus. TNJ and CCJ axes become more parallel, leading to increased flexibility of the MTJ. With correction of the STJ axis, the TNJ and CCJ axial relationship is restored providing stability and alignment to the MTJs.

STJ arthritis pathomechanics why it requires fusion

STJ is a triplanar joint; axis courses posterior, plantar, lateral to anterior, dorsal, medial 30 degrees: 20° inversion/10° eversion. close kinetic chain calcaneal eversion and/or talar tibial inversion, talar plantarflexion and adduction

STJ biomechanics

The thin 0.008 to 0.012 inches, intermediate 0.012 to 0.016 inches thick is 0.016 to 0.020 inches.

STSG. thin,G*,Thick

• Type I: nondisplaced posterior facet • Type II: one fx line in posterior facet (two fragments) • Type III: two fx lines in posterior facet (three fragments) • Type IV: three fx lines in posterior facet (four and more fragments)

Sanders classification: Based on coronal CT image at the level of posterior facet

i. Guide wire from 6.5 to 8mm screw set is driven from posterior inferior to anterior superior through the calcaneus into the talus, and screws should be perpendicular to the posterior facet. ii. Screws should be within the central bodies of the talus and calcaneus and should not violate the ankle joint.

Screw sizes and orientation for STJ fusion

triple fusion In addition to a triple arthrodesis, a 1st MT DFWO is required if there is residual FF valgus (PF 1st MT) In longstanding deformities where there is ankle varus and degenerative arthritis that has occurred, a pan-talar arthrodesis or triple plus ankle fusion neurological weakness may demonstrate a dropfoot deformity, >muscle-tendon balancing + bony correction; **goal of tendon transfers is to weaken the deforming forces and augment swing-phase DF

Severe, Rigid, Multiplane Pes Cavus

check dorsiflexion with both knee flexion and knee extension if tight only with knee extension, then gastrocnemius is tight if tight also with knee flexion, then soleus is also tight gastronemius tightness often present with cavovarus foot

Silfverskiold test

1. Surgical Treatment 1. Joint-Sparing Procedures 1. Removal of loose bodies, excision of osteophytes, partial synovectomy 2. Currettage of the avascular bone, reduction of the collapsed articular surface and use of autogenous cancellous grafts for stages I through III. 3. Autogenous epiphysiodesis to decrease stresses at the affected metatarsal head 4. Core decompression of the metatarsal head 5. Dorsal closing wedge osteotomy at metatarsal neck 6. Decompression - can develop floating toe 7. Interpositional arthroplasty 2. Joint-Sacrificing Procedures 1. Metatarsal head resection and joint replacement arthroplasty - fallen out of favor owing to associated complications 1. transfer metatarsalgisa, hyperkeratosis and a shortened, floating, retracted digit. 2. Complications from arthroplasty - floating toes, bone resorption at the implant interface, loosening of the prosthesis, fracture of the prosthesis, dendritic synovitis, decreased ROM, loss of transverse plane stability and foreign body reaction 2. Debridement of the metatarsal head and phalangeal base resection in conjunction with syndactylization with an adjacent lesser digit.

Sx tx of Freibergs

1. Muscles tend to produce their greatest force at 120% of their resting length, therefore it is important to reestablish normal muscle tension in the transfer of a musculotendinous unit, which is accomplished by maintaining their physiologic length. 2. This is done by approximating the origin and insertion of a muscle, placing the foot in the position produced by maximal contraction of the transfer, and then removing all the slack from the tendon.

T/F Muscles tend to produce their greatest force at 100% of their resting length

drained, de-roofed, and underlying skin treated as an ulceration

Tx hemorrhagic blister

1. Early surgical intervention for central transchondral lesions because of the high level of compression transmitted through the central portion of the talar dome

Tx of transchondral lesions

i. Release of equinus contracture is performed. ii. Incision for STJ fusion begins at the tip of the fibula to the CCJ. just superior to the peroneals tendons and sural nerve and inferior to the course of the IDCN refelct EDB retract Peroneals down

WHat is an adjunct procedure to STJ fusion Where is the incision?

IF 8 hours ++ or greater

When do you not closes lacerations?

Abx should be considered in wounds that are heavily contaminated or in immunocompromised patients. MC organism found in pedal traumatic lacerations is Staph aureus-

When to use Abx in laceration? MCC bug to grow?

Why perform arthroscopy for AVN

a. Arthroscopic Debridement and Core Decompression: i. Rationale: Thought to enhance revascularization and decrease intraosseous pressure. 1. Indicated in treatment of F&A stages I and II (partial AVN and those without collapse). ii. Technique: Standard AM and AL portals used for arthroscopy with a lateral sinus tarsi (lateral process) approach for retrograde drilling.

ideal ankle fusion realignment position

a. In the sagittal plane, the foot is placed at a right angle to the limb (plantigrade, 90°), tibial middiaphyseal line coincides with the lateral process of the talus. b. In the TV plane, the foot is externally rotated to the limb so that the thigh-foot axis is 10-15° externally rotated. c. In the axial plane, the calcaneal bisection line should be parallel or slightly valgus (0-2°) to the middiaphyseal line of the tibial. The middiaphyseal line of the tibia should pass through the center of the talus. d. The affected limb should be 1cm shorter than the unaffected limb.

i. Goals: Used to correct or prevent cockup of the hallux by eliminating the deforming force on the digit. ii. Indication: flexible cavus foot, flexible PF 1st ray, prophylaxis for hammered hallux when sesamoids are removed, and relieve lesser metatarsalgia. iii. Results and Complications: Unsatisfactory in young children because the long extensor tends to regenerate and return to its normal insertion at the distal phalanx.

a. Jones Tenosuspension:

MCC complication of AVN sx

a. MC complication delayed or nonunion due to large amounts of necrotic talar bone present or the amount of nonliving graft used.

Discuss Nonvascular bulk allografts using fresh cadaver talus for partial talar AVN.

a. Matched for side, gender, and approximate size and contain living cartilage. b. Rationale: fresh talar allografting may be selected over core decompression or EDB pedicle transfer when early collapse or overlying cartilage death has occurred and in cases in which clear margins of viable and necrotic bone are present. i. Allows large portion of diseased talus to be excised and replaced.

Discuss Fresh talar bulk allograft surgical technique:

a. Often lateral, medial, or both malleoli OTs required for adequate exposure. b. MC, the MM is OT- curvilinear incision made over the medial gutter, and the MM is predrilled with 2 4.0mm cannulated cancellous screw guide pins. The wires are measured and the proximal cortex is overdrilled prior to removal of the guide pins. c. Chevron OT performed to flap down the MM with the deltoid ligaments still attached to expose the medial shoulder of the talar dome. Posterior structures must be protected. d. Access to lateral talar lesions may require transection of the lateral collateral ligaments or fibular OT. A 5-hole 1/3 tubular plate is contoured and pre-drilled to stabilize the lateral OT to assist in assuring exact reduction at the completion of the case; the OT is made transversely under power at the level of the AJ. e. An anterior approach is used for central defects or in cases in which the partial AVN affects the entire talar ankle joint surface (between EHL and TA tendons). f. Once exposure is adequate, the talar defect is inspected; margins of necrotic bone are probed and identified. This is debrided down to vascular, bleeding bone. g. The base and edges of diseased bone are cut squarely with a saw and the inner surfaces is cut with a curved osteotome to construct a geometric shape. h. The donor site is reinspected for viable bone and cartilage margins, making sure that all necrotic bone is resected. i. Location of AVN and dimensions of the recipient's excavated bone are used to determine the exact matching site for harvesting the donor allograft. It is advised to slightly oversize measurements. j. The bulk talar allograft is press fit into the recipient's matching void. k. Chondral darts and resorbable or headless screws are used to permanently fixate the graft into place. Malleolar OT is realigned with their pre-drilled hardware. l. PO Care: Strict NWB for at least 8 weeks with gentle ROM exercises beginning at 4 weeks, protected WB in PTB boot is usually allowed at 8-10 weeks, depending on radiographic healing. Progression to protective brace or AFO at 4 months with protection from impact activities for 1 year. m. MRI can be performed at months to determine healing and incorporation.

i. Goals: increase the true DF of the foot by balancing power laterally. ii. Adjunct procedures: DF osteotomy of 1st met, claw toe correction, calc osteotomy, triceps lengthening. iii. Indications: spastic rearfoot varus, spastic equinovarus, fixed equinovarus, excessive invertor power, FF equinus with extensor substitution and claw toes, flexible cavovarus, excessive supination, dorsiflexory weakness. iv. Complications - tenosynovitis (MC), nerve damage, simple procedure with little danger of overcorrection.

a. Split Tibialis Anterior Tendon Transfer:

i. Technique: 1. Requires 3 incisions to move ½ of the TA laterally: Incision is made first near the TA tendon's insertion; the second is over the tibialis anterior at the anterior surface of the leg just above transverse cruciate ligaments. The tendon is split to its insertion, the lateral fibers are pulled proximally through the second incision, and a 3rd incision is made over the peroneus tertius tendon, 1 inch proximal to insertion. The foot is placed in slight eversion with dorsiflexion to neutral and the lateral fibers are placed through peroneus tertius

a. Split Tibialis Anterior Tendon Transfer:

long bones, tibia, soap bubble

adamantinoma

Which does not affect bone healing: 1. Nutritional status, Rheumatoid or methotrexate patient, DM, tobacco hx, extent of initial injury, osteoporosis, other metabolic diseases, neuropathy

all do

in childhood or adolescence and cease to grow once skeletal maturity Well-defined, round or oval, purely lytic lesion. Slow growing (cortex intact) i. MC in long bones (proximal humerus and femur); most cases in the foot present in the calcaneus. no pain/no pathologic fx i. Fluid filled (serum) which supports the theory that these lesions develop as a result of venous obstruction Tx i. Intralesional steroid injections have proven effective, along with surgical excision/curettage and packing with bone chips to prevent recurrence. .

solitary bone cyst, UBC

1. heel lifts, viscoelastic heel cups, arch supports, taping and orthoses in conjunction with ice, NSAIDs and stretch are helpful. 2. Severe or recalcitrant forms - short leg walking cast applied for 2 to 4 weeks. If does not improve and eventually goes on to surgery than can perform tendo-achilles lengthening

tx sever's disesase

repetitive sagittal plane ankle motion in heavy weight-bearing sports, such as ballet, soccer, and gymnastics.

types of sports causing os trigonum injuries

a. Tendon Transfer: detachment of a tendon of a functioning muscle at its insertion and then its relocation to new insertion or attachment. b. Tendon Transposition: rerouting of the course of a normal muscle tendon without detachment. c. Muscle-Tendon transplantation: detachment of a muscle-tendon at both its origin and insertion and moving it to a new location with its NV support structures. d. Tendon suspension: (tenosuspension) procedures designed to support a structure.

types of tendon movements