Crozer-Keystone Ex Tern Ship Manual

Crozer-Keystone Residency Manual 2nd Edition, by Brett Chicko, DPM 1



The Crozer-Keystone Residency and Externship

Manual

Second Edition



Table of Contents Introduction by Dr. William Urbas, DPM………………………. pg 7 Introduction……………………………………………………… pg 8 Chapter 1-Antibiotics……………………………………………. pg 9 Chapter 2-Anatomy……………………………………………… pg 24 Chapter 3-Medicine……………………………………………… pg 30 Chapter 4-Clinical Podiatry……………………………………… pg 43 Chapter 5-Trauma……………………………………………….. pg 46 Chapter 6-Labs and Patient Management………………………... pg 48 Chapter 7-Surgery………………………………………………... pg 53 Chapter 8-Drug of Choice………………………………………... pg 62 Chapter 9-Gout…………………………………………………… pg 67 Chapter 10-Case Number 1…………………………….………… pg 69 Chapter 11-Case Number 2……………………………………….. pg 71 Chapter 12-NSAIDS……………………………………………… pg 73 Chapter 13-Classifications………………………………………... pg 76 Chapter 14-Name that Surgery…………………………………… pg 105 Chapter 15-Normal Range of Motion……………………………… pg 116 Chapter 16-Special Surgeries

Introduction into Special Surgeries…………………………pg 124 Achilles Tendon repair……………………………………. pg 125

Ankle Arthroscopy………………………………………… pg 127 Ankle fracture……………………………………………… pg 129

Webber A Surgical Choices Screw Placement…………………………... pg 129 Tension Band wiring………………………. pg 130

Webber B Fixation with 2 lag screws………………… pg 131 Lateral Plate & Anterior-to-Post Lag Screw pg 132 Posterior Antiglide Plate………………….. pg 128

Medial Malleolar Fractures Two Screw Stab Incision-Procedure……… pg 135 Open Procedures For Screw Fixation or Plate Insertion…….. pg 136 Tension Band of Medial Malleolus……….. pg 137

Posterior Malleolar Fracture……………………… pg 138 Syndesmotic Fixation…………………………….. pg 139

Ankle Fusion Tibio-Talar Arthrodesis…………………………… pg 141 Tibio-Calcaneal Arthrodesis……………………… pg 143

Arthrosurface 1st Metatarsal Implant……………………… pg 145 Brostrom-Gould…………………………………………... pg 147 Calcaneal Slide Osteotomy……………………………….. pg 148 Delayed Repair of the Achilles Tendon…………………… pg 149


Evans Calcaneal Osteotomy……………………………….. pg 151 Excision of Calcification of Achilles Tendon……………... pg 152 Fibular Derotational and Lengthening Osteotomy………… pg 153 Ilizarov’s Method………………………………………….. pg 154 MBA Implant Procedure…………………………………… pg 155 Murphy’s Procedure……………………………………….. pg 156

ORIF Calcaneus……………………………………………. pg 157 ORIF Talus Neck………………………………………….. pg 159 Osteochondral Lesions of the Talus……………………….. pg 161

Peroneal Brevis Tendon Repair and Reconstruction……… pg 162 Posterior Tibial Tendon Repair-Substitution……………… pg 163 Posterior Tibial Tendon Transfer………………………….. pg 165 Split TA Tendon Transfer (STATT) And Tibialis Anterior

Tendon Transfer (TATT)……………………………pg 166 Subtalar Arthrodesis……………………………………….. pg 168 Talo-Navicular Fusion………………………………………pg 169 Tarsal Tunnel Release……………………………………… pg 171 Tibial Periarticular Fx Reduction & Fixationpg…………… pg 172 Triple Arthrodesis………………………………………….. pg 176

Chapter 17-Special Studies………………………………………… pg 178 Chapter 18 The Social Interview………………………………….. pg 182


Introduction Dear Student: In the pages that follow is useful information that will help make your externships, interviews and transition from student to resident a little bit easier. This information contained within is not the end all on the subject, but the tidbits that need to be on your “Mind’s Fingertips”. This booklet is a useful guide on the need-to-know, need-to-keep information. Please use it as it was intended--a guide on the ever-changing world of medical information. My thanks go out to the Podiatric Surgical Residents at Crozer-Keystone Health System for the formation of this manual. Sincerely,

William M. Urbas, DPM Crozer-Keystone Residency Director


Author’s Introduction This manual is NOT meant to replace “McGlamry’s”, the “Presbyterian Manual”, the “Podiatry Institute Manual” or any other reference source. Those manuals are excellent resources and should be used to continue to learn the information. To this day, I still use those texts for information and reference. This manual is based on questions I came across as an extern or a resident, either from my own questions or questions from a superior. I would write these questions down and after I looked up the answers, I would keep the questions with their answers in a log. Later, as a resident, I was quizzing a student in order to get her ready for her interviews. The student asked me, “Why can’t there be a book of these questions?” After that I started to put together the manual. I also added some additional items to complete the manual. In no way, shape or form do I claim that the answers written here are the only answers possible, nor do I even claim that they are all 100% correct. These answers are the ones that I came up with when I researched the questions. It is up to you to go to the true references--not only to make sure that the answers are correct, but also to make sure that you understand why. Therefore, the purpose of this manual is so that the reader can have some questions and answers so that he or she can go to the sources and really learn podiatry. I am not able to provide all of my sources because when I started writing down the answers, I had no idea of turning it into a manual. However, my major sources are, “The Comprehensive Textbook of Foot Surgery”, “The Presbyterian Manual” and “The Podiatry Institute Manual”. A special thank you to my attendings and co-residents at the Crozer-Keystone Health Systems in Springfield, PA, especially Dr. Urbas our residency director, mentor and friend. Good Luck and Happy Studying,

Brett Chicko, DPM P.S. I wrote this book for the sole purpose of helping my profession of Podiatric Surgery and Medicine. I have not received any compensation, nor will I, for writing this book. If you would like to order this book use the URL http://www.lulu.com/content/ paperback-book/crozer-keystone-residency-and-externship-manual/8301922 or go to www.lulu.com and search the book by the title or author. The cost of the book is the price for printing and shipping only. Also, the book can be downloaded free from the same site. As stated earlier, I do not make any money off the book.


Antibiotics What do you always want to check before giving an antibiotic? 1. Kidney function (as seen on bun and creat in a SMA-7): if the antibiotic to be used is metabolized by the kidney (most are) you want to make sure the kidneys are functioning properly 2. Allergies 3. If the patient is on an antibiotic already. Often someone will prescribe an ABX without checking if the patient is already on one. Don’t do this. Always know what medications a patient is on before you prescribe something. 4. If a gram stain and C&S has been done and if the results are in 5. Any other reason you may or may not want to give the antibiotic

Name that drug What is in Augmentin? Amoxacillin/clauvulonic acid Unasyn? Ampicillin/sulbactam Timentin? Ticarcillin/clauvulonic acid Bactrim? Tmp/smx (trimethoprim/sulfamethoxazole) Primaxim? Imipenem/cilistatin Zosyn? Piperacillin/tazobactam Rocephin? Ceftriaxone (3rd generation Cephalosporin) Which drug is nicknamed ‘Gorillamycin’? Imipenem because it has the broadest spectrum of any drug. Avelox? Moxifloxacin hydrochloride Invanz? Ertapenem sodium


Unasyn What is the dosing for Unasyn? 3.0g IV q 6° 1.5g IV q6° for pt with renal impairment When is Unasyn usually used? It is a good initial IV choice for a polymicrobial infection. What is an alternative to Unasyn for a patient with a PCN allergy? Cipro/Clinda Levaquin (There are others) Will Unasyn work against Psuedomonas? No.

Augmentin What is in Augmentin? Dosing? Amoxicillin/clauvulonic acid 500 or 875 mg one tab po bid How much clauvulonic acid is in Augmentin 500mg? For Augmentin 875 mg? Both have 125 mg When is Augmentin usually used? It is a good oral drug for a polymicrobial infection. Does Augmentin work on Pseudomonas? Nope.

Zosyn Indications for Zosyn? Infections of skin and skin structures, including DM foot infection Dosing 3.375g IV q 4-6° Renal dose 2.25g IV q 4-6° Alt does 4.5g IV q4-6° Will Zosyn work on Pseudomonas? Yes


Timentin What is Timentin? Ticarcillin/clauvulonic acid What to watch out for with ticarcillin? Increased Na+ load by 5.2 meq/gram What is the Na+ load of ticarcillin? 5.2 meq/gram Dosing? 3.1g IV q4-6° What is Timentin’s coverage? Polymicrobial, broad spectrum including pseudomonas

Penicillin What is the drug of choice for a diabetic foot infection with a penicillin allergy? Clindamycin How are PCN’s excreted? All are renal except for mezlocillin, azlocillin, piperacillin (the ureidopenicillins are 20-30% renal) Name 2 IV alternative antibiotics for PCN allergic patients Clindamycin Levaquin Vancomycin Bactrim (There are others) Which PCN’s are anti-psuedomonal? (The fourth and fifth generation PCN’s) Ticarcillin, Timentin Piperacillin, Zosyn Carbenicillin, Mezlocillin, Azlocillin

Cephalosporins % of cross sensitivities between cephalosporins and PCN? 1-5% (depends who you talk to).


Are Cephalosporins contraindicated for a patient with a PCN ALL? Many people will say yes, but according to Dr Warren Joseph, DPM-

“Cephalosporins are only contraindicated when a patient has an anaphylactic response to a penicillin. Cephs can usually be used safely when there is a history of “rash” or “stomach upset”. Personally, I will give a cephalosporin to a pt with a PCN ALL if all he or she had was a stomach upset and I document this. However, I do not give a cephalosporin to a pt with a PCN ALL with a history of rash unless the pt has a past history of taking a cephalosporin without any complications. I am sure to document the pt’s h/o no side effects with cephalosporins. How are cephalosporins excreted? Renal except for ceftriaxone and cefoperazone How to treat serious hospital acquired gram negative’s 3rd gen ceph, aminoglycoside (i.e. rocephine, gentamycin) Name 2 oral cephalosporin for each class. (There are others, these are the ones I chose to remember) 1st generation- Keflex, Duricef 2nd generation-Ceftin, Ceclor 3rd Generation-Suprax, Vantin What is the coverage for cephalosporins at each class? 1st Gen-gram positives (staph and strep)

certain gram negatives (Proteus, E. Coli, Klebsiella Samonella Shigella) pneumonic-PECKSS

2nd Gen- gram positives-staph (less than 1st gen) and strep gram negatives H. influenza, Neisseria, Proteus, E. Coli, Klebsiella Samonella Shigella pneumonic HEN PECKSS

3rd Gen-gram positives (staph and strep but less than 1st and 2nd) gram neg (ceftazadine and cefoperazone active against pseudomonas) 4th Gen- coverage is essentially 3rd gen’s gram negative plus 1st gen’s gram positive What is the 4th Generation Ceph? Cefipine (Maxipime)

Vancomycin What is Vanco’s main indication MRSA What is Vanco’s coverage? Gram positives including MRSA and MRSE


Dosing of Vanco? 1 gm IV q12 hours slow infusion

When do you give oral vanco? C. difficile colitis (give 125 mg po qid) What happens when you give vanco too fast? Red neck syndrome- erythema and pruritis usually to the head, neck and upper torso. It is caused by an anaphylactoid reaction where histamine is released by mast cells. (Some people will call it Redman syndrome. Others will say Redman syndrome is caused by Rifampin) What are the peaks and troughs of vanco? Peak 15-30 mg/ml Trough <10 mg/ml How are vanco levels taken and how do you adjust the levels? For vanco you take the peak and troughs (sometimes called pre and posts) Peak: take the level 30 min after the 3rd dose, Trough: take the level 30 min before the 4th dose. If the peak is too high, decrease the amount of the dose. If the peak is too low, increase amount of dose. If the trough is too high, increase the interval between doses. If the trough is too low, decrease the interval between doses. How can you decrease the risks of Vanco causing red neck syndrome? Slow infusion, give dose over one hour How do you treat a too rapid infusion of Vancomycin? Antihistamines (Benadryl 10-50mg IV tid) until symptoms go away What are the major side effects of Vanco? Ototoxicity Nephrotoxicity Does the duration of time a pt has been on Vanco increase the risk of side effects? Yes, Vanco has a reservoir effect meaning the more times one gives Vanco to the pt, the higher the chances of getting either ototoxicity or nephrotoxicity. Therefore, use Vanco carefully-it is a powerful drug with severe side effects.

Aminoglycosides What are the side effects of aminioglycosides? Which one is irreversible? Ototoxicity-irreversible


Neprotoxicity Neuromuscular blockade What is the aminoglycosides coverage? Gram-negative aerobic rods What are the major aminoglycosides? Gentamycin, Tobramycin and Amikacin What are the doses, peaks and troughs of the aminoglycosides? Dose Peak (ug/ml) Trough (ug/ml) Gent and Tobramycin 3-5 mg/kg q8° 4-10 2 Amikacin 15 mg/kg q8° 20-30 10 How to dose gentamycin? 1. Get the creatine clearance CC= (140-age)(weight in kg) (72)(serum creatinine) For females, multiply the CC by .85 The result of the CC is the Renal Function. I.e. if the CC is 75%, then the patient has 75% of the kidney function. Then you want to use only 75% of a normal dose of Gent. 2. Loading dose is 2 mg/kg (regardless of CC) 3. Give 3-5 mg/kg q8° with adjustments for the CC.

Bactrim What is Bactrim? Trimethoprim/sulfamethoxazole (TMP/SMX) How to dose Bactrim? How much of each? One tab po bid Single strength 80mg TMP/ 400 mg SMX Double strength (DS) 160 mg TMP/ 800mg SMX How does Bactrim work? TMP-inhibits bacterial dihydrofolate reductase (stops production of folinic acid) SMX-inhibits folic acid production What allergy to avoid when prescribing bactrim? Sulfa Spectrum of activity? Broad spectrum Staph and strep (including MRSA and MRSE) Gram negatives (including pseudomonas)


Contraindications? Pt’s on oral hypoglycemics and G-6-PD deficiencies Adverse reactions? Hemolytic anemia Hypersensitivity

Zithromax Generic name of Zithromax? Azithromycin ½ life of Zithromax? 68 hours How to dose Zithromax? 250mg po, two tabs on first day, one tab for the next four days What is Zithromax’s coverage? Staph and Strep, and some anaerobes (but not bacteroides) Can you give Zithromax with a PCN ALL? Yes.

Primaxin What is in Primaxin? Imipenem/Cilistatin How does Primaxin work? Imipenem=antibiotic Cilistatin=renal dihydropeptidase inhibitor (prevents imipenem from being metabolized by the liver) Spectrum of Activity of Primaxin? Very Broad spectrum Most gram positives, Most gram negatives including pseudomonas Most aerobes and anaerobes Dosing of Primaxin? 500 mg IV q6-8° (most common) or 1 gm IV q6-8°


Side effect and frequency of Primaxin? Seizures with pt with history of seizures

-1% risk with 500mg dose -10% risk with 1 gram dose

Aztreonam What is aztreonam’s major side effects? None, nada, zippo What is aztreonam’s coverage? Gram negatives, aerobes, psuedomans (it’s main indication) Dosing? 1-2 gram IV q8° Why isn’t Aztreonam used more often? It is expensive

Quinolones What are the two most common quinolones? Cipro and Levaquin What is their coverage? Gram negative bacilli including pseudomonas Staph (levaquin has increased gram positive coverage) Who can you not give a quinolone? Children-it is contraindicated because it may lead to a defect in cartilage Pneumonic-‘quinolones kills children’s cartilage’-sort of rhymes What is Cipro’s dosing? 200-400 mg IV q12° 250-750 mg PO bid What is Levaquin’s dosing? 250-500 mg IV or PO

Avelox What is Avelox’s generic name? Moxifloxacin What is Avelox’s dosing? 400 mg q24° IV or PO


What is Avelox class and coverage? A fluoroquinolone. Its coverage is broad-spectrum and has excellent coverage against Gram-positive cocci while retaining good activity against Gram-negative bacteria and atypical pathogens. In addition, it has good in-vitro activity against anaerobes.

Invanz What is Invanz’s generic name? Ertapenem sodium What is Invanz’s dosing? 1 gm IV q24° What are Invanz’s indications? Invanz is approved for use in adults for the treatment of moderate to severe infections caused by common gram-positive and gram-negative aerobic and anaerobic bacteria. What is Invanz drug class? Invanz is a structurally unique 1-(beta) methyl-carbapenem related to beta-lactams

Cubicin What is the generic name for Cubicin? Daptomycin What is Cubicin’s main indication? MRSA

Antibiotic Associated Diarrhea What are the two main causes of Antibiotic associated diarrhea? Psuedomembranous Colitis-closridium dificle Non-specific Colitis-Staph aureus How to test for C Diff? (Write the order) ‘Check stool for C Diff’ What gives you Clostridium difficille-mc cause? Clindamycin (although any antibiotic can give it to you) How do you treat for C Diff? Vanco 125mg po tid or Flagyl 500mg po bid


VRE How to treat VRE? Linezolid or Dalfopristin-Quinupristin What is the only PO for VRE? Linezolid (can also be given IV) What is the generic name for Zyvox? Linezolid Why isn’t Zyvox used more often? It is expensive. What is the generic name for Synercid? Dalfopristin-Quinupristin Dosing for Zyvox 400-600mg IV q12° infuse over 1 hour Tabs 400 or 600 mg

Psuedomonas Name drugs you can treat pseudomonas with. Aztreonam Aminoglycosides-gentamycin, tobramycin, amikacin Cipro Cabencillin Ceftazamine, Cefeprime, Cefoperazone Ticaracillin, Timentin Piperacillin, Zosyn

MRSA What antibiotic do you use against MRSA? What oral agents can you use? What topical? MRSA-IV

Vancomycin Linezolid Minocycline Cipro/rifampin Bactrim/rifampin Synercid Cubicin (Daptomycin)

PO for MRSA-


Linezolid Minocycline Cipro/rifampin Bactrim/rifampin Topical for MRSA Bactroban

Surgical prophylaxis When should one use surgical prophylaxis?

1. Prolonged cases (greater than 2 hours) 2. Trauma surgery 3. Immunocompromised patient 4. Implants (joint, internal fixation) 5. Endocarditis (SBE)

What antibiotics are most commonly used for surgical prophylaxis? Ancef (Cipro is PCN ALL), Vanco (if concerned about MRSA)

Miscellaneous What antibiotics are metabolized by the liver? Antibiotics excreted by liver- 4 C’s and 1E C-Cefmandole C-Clindomycin C-Cefoperazone C-Chloramphenicol E-erythromycin Can antibiotics affect PT/INR? Yes, ABX can affect normal flora, which alters Vit K. The PT/INR can go up. What antibiotic has the side effect of discoloring body fluids red/orange? Rifampin What can Beta Lactams cause? Leucopenia When do fever peaks occur? Between 4-8 pm What open fractures should be treated with antibiotics? Grades 2 and 3.


What gives Red Man/Red Neck syndrome Red Man Rifampin (makes body fluids red) Red Neck Vancomycin What are the Macrolids’s MOA? It binds to 50s bacterial ribosome inhibition protein synthesis What is the Aminoglycosides’s MOA? It binds to 30s bacterial ribosome inhibition protein synthesis Pneumonic for the above questions- A boy at 30 does not become a Man until 50 Aminoglycosides-binds to 30s bacterial ribosome inhibition protein synthesis Macrolids-binds to 50s bacterial ribosome inhibition protein synthesis

Drug of Choice (DOC) and Alternatives (Also see Bugs and Drugs section)

What is the drug of choice (DOC) for a diabetic with a PCN allergy? Clindamycin DOC for severe limb threatening infection? Primaxin DOC for bite wounds? Augmentin

Gram Positives Drug of choice for staph? Keflex for PO, Ancef for IV Alternative for staph? Clindamycin, Levoquin, Vanco, Azithromycin, Dicloxacillin, Naphcillin Alternative for staph if PCN all? Clindamycin, Levoquin, Azithromycin, Vanco DOC for Strep? Keflex for PO, Ancef for IV Alternative for Strep? Clindamycin, Levoquin, Vanco


Alternative for Strep if PCN all? Clindamycin, Levoquin, Vanco DOC for MRSA? Vancomycin for IV, for PO-Bactrim if sensitive or Linezolid Alternative for MRSA? Synercid or Linezolid DOC for VRE? Linezolid or Dalfopristin-Quinupristin (Synercid) DOC for enterococcus? Amoxicillin PO or Vancomycin IV Alternatives for enterococcus? Augmentin PO, Linezolid PO or IV

Gram Negatives DOC for E. Coli? Keflex or Ancef Alternative for E. Coli if PCN all? Cipro or Levaquin DOC for proteus? Keflex or Ampicillin Alternative for proteus if PCN allergic? Cipro or Levaquin DOC for E/C/S/M group? Quinolone (Cipro/Levaquin) Alternatives for the E/C/S/M group? 3rd gen ceph, aztreonam, bactrim DOC for Psuedomonas Aeruginosa? Cipro IV or PO Alternatives for Psuedomonas Aeruginosa? Ceftazamine (a 3rd gen cephalosporin), aztreonam, bactrim


Anaerobes DOC for bacteroides (anaerobes) for the diabetic foot? Augmentin PO, IV-Unasyn, Timentin, Zosyn Alternatives for bacteroides (anaerobes) for the diabetic foot if PCN allergy? Clindamycin/cipro, primaxin, flagyl

Less Common Organisms Drug choices for Clostridium? PCN, clindamycin, tetracycline DOC for Aeromonas? Cipro IV or PO Alternative for Aeromonas? Bactrim Doc for Xanthamonas? Bactrim Alternative for Xanthomas? Ceftazidime DOC for Pseudomonas Cepacia? Bactrim Alternative for P. Cepacia? Ceftazidime DOC for Diptheroids? Vanco DOC for Lyme disease (Borrelia)? Rocephin, doxycycline Alternative for Lyme disease? Amoxicillin Antibiotic for superficial thrombophlebitis? Timentin Topical ABX against MRSA? Bactroban


Why is gas gangrene a surgical emergency? Because it progresses rapidly to shock and renal failure. Fatal in 30% of cases. Treatment for Ghonnorhea? Ceftriaxone, or PCN if sensitive DOC for Necrotizing Fasciitis? Primaxin 250-1000 IV q6-8° (most commonly 500 mg IV q8°) Treatment for Lyme disease? Doxycycline 100 mg po qd or Rocephin 1g IV qd Treatment of Cutaneous Larva Migrans? Promethia under occlusion


Anatomy How many foot bones? 26 (not including sesmoids) How many foot joints? 35 What are the layers of the foot? Going from superficial to deep

1. Abductor hallucis, flexor digitorum brevis, abductor digiti minimi 2. Quadratus plantae, 4 lumbricles 3. Flexor hallucis brevis, adductor hallucus, flexor digiti minimi 4. 4 dorsal interossei, 3 plantar interossei

Name the accessory ossicles Os Tibiale Externum accessory navicular Os Vesalianum off tip of 5th met tuberosity Os Peroneum sesmoid bone in PB tendon Os Supra Navicular dorsal aspect of navicular Os Sustentaculi post aspect of sustentac. tali Os Calcaneous Secondarius dorsal and ant process of calc: At junction of calc, cuboid, talus + nav Os Subfibulare distal to lat malleolus Os Subtibiale distal to medial malleolus Os Cuneo-1-met-1-plantare plantar of 1st met-med cuneiform Os Trigonum post aspect of talus What layer of the foot does the FDL run? 2nd

Think, the FDL is the origin of the lumbricals and the insertion of QP so it must run in their layer. How is EDL attached to proximal phalanx? Sling wraps around capsule attaches to plantar plate, DTML, flexor tendon sheath-thus attaches to plantar proximal phalanx, not dorsal. No direct insertion to prox phalanx Are the sesmoids capsular or extra-capsular? Capsular How is periosteum attached to bone? Sharpey’s fibers What is Hoke’s tonsil? Fibrous fatty plug in the sinus tarsi


What is the superficial and deep portion of the deltoid ligament? Deep-Anterior tibiotalar Superficial-talocalcaneal lig, Posterior tibiotalar, Tibionavicular What structures attach to fibular sesmoid? Plantar met-phalanx lig Lat met-sesmoid lig. Intersesmoid lig. Phal-sesmoid lig. FHB tendon ADH tendon What ligaments compose the bifurcate ligament? Calcaneocuboid and calcaneonavicular Which ankle ligaments are capsular? Which are extra-capsular? Calcanofibular ligament is extra-capsular, all others are capsular Which is the strongest part of the lateral ankle lig.? Post-talofibular Which is the deepest of the deltoid ligaments? Anterior tibiotalar lig. Which is stronger-lateral ankle ligaments or deltoid ligaments? Deltoid ligaments What is another name for the laciniate ligament? Flexor Retinaculum What is another name for the transverse crural ligament? The superior portion of the extensor retinaculum What is another name for the crural cruciate ligament? The inferior portion of the extensor retinaculum In what layers of the foot do the plantar nerves run? Lateral plantar nerve-between 1st and 2nd Medial plantar nerve-in 1st layer (between FDB and abductor hallucis) Name the nerves that make up the sural nerve? Medial sural cutaneous nerve of the tibial nerve and the sural communicating branch. The medial sural cutaneous nerve comes off the tibial nerve. The sural communicating branch is a branch off the lateral sural cutaneous nerve, which comes off the common peroneal nerve.


What is Pes Anseritis? Bursa between Gracilis, semitendinosis, and sartorious (bursa medial proximal tibia) Does the deep transverse intermetatarsal ligament lie above or below the neuroma? Dorsal to the neuroma Name the osteochrondritities Theiman phalanges Freiberg met heads Islen 5th met base Buschke cuneiforms Kohler navicular Lance cuboid Severe calcaneous Osgood-Schlatter tibial tuberosity Blount prox tibial epiphysis Kohler patella What is the blood supply to the talus? Essentially the 3 major blood supplies to the foot

1. Branch to superior surface of neck from anterior tibial artery or dorsalis pedis 2. Medial side of body-posterior tibial artery approx 1 cm before bifurcation 3. Lateral turbercle-anastamosis of branch of peroneal artery with medial calcaneal

branch. Tell us the path of drop of blood from left ventricle to the big toe. Ascending aorta Aortic arch Descending aorta Thoracic aorta Abdominal aorta Common iliac a. External iliac a. Femoral a. Deep femoral a. Popliteal a. Ant tibial a. Dorsalis pedis 1st dorsal met a. 1st dorsal digital a. What is the innervation to the plantar muscles of the foot? Blood supply? Never LAFF at A FAD 1. Medial plantar Nerve-1st Lumbrical, ABH, FHB, FDB (innervated by both medial and lateral plantar nerves) 2. Medial plantar Artery-FDB, ABH, 1st Dorsal interossei


What is the most common coalition in the foot? MC of foot if coalition of distal and middle facet of 5th toe Name 3 types of coalitions in the rearfoot. Which is most common? Which is the most symptomatic? For the subtalar jt: Talonavicular, calcaneonavicular and talocalcaneal middle facet MC of rearfoot is T-C middle facet, although C-N is close 2nd The C-N is the most symptomatic 3 causes for brachymetatarsia? Turners Downs Hyperparathyroidism Poliomyelitis Hbs Plus many, many more 5 causes for hallux varus? Congenital Trauma Staking the head (cut into sagital groove) Removal of fibular sesmoid Bandaging too far into varus Overzealous medial capsuloraphy What is staking the head? When doing the sagital cut (dorsal medial prominence) of a bunionectomy, you want to preserve the sagital groove for articulation of tibial sesmoid. If not, then you strike the head hallux varus. Name the types of non-unions Hypertrophic Elephant foot Horsehoof Oligotrophic Atrophic Torsion wedge Comminuted Defect Atrophic What are the stages for skin graft healing? Stages of skin graft healing

1. Plasmatic stage


2. Inosculation of blood vessels 3. Re-organization 4. Re-innervation

MC complication of skin grafts? 1st seroma 2nd hematoma What are the phases of wound healing? Phases of wound healing.

Substrate phase (day 1-3 or 4) a.k.a. lag phase Proliferative phase (day 3 or 4 to 21) a.k.a. repair phase Remodeling phase (day 21+) a.k.a. maturation phase

What are the bone graft phases of healing? Bone graft phases of healing

1. Vascular ingrowth 2. Osteoblastic proliferation 3. Osteoinduction 4. Osteoconduction 5. Graft remodeling

What are the phases of bone healing? Bone either heals via primary (with no motion) or secondary (with micro-motion). Primary healing (does not have any callus formation)

1.Inflammation 2. Induction 3.Remodeling

Secondary healing- (callus formation) 1.Inflammation 2. Induction 3. Soft callus 4. Hard callus 5.Remodeling

What are the angles for a Tailor’s bunion? Angles for a tailor’s bunion 4th IMA-6° norm, pathological 8.7°

-As described by Fallat and Buckholz: angle between bisection of 4th met and medial cortical border of 5th met (note Schoenhause says 4th IMA norm =8°)

Lateral Deviation angle-lateral bowing -As described by Fallat and Buckholz) norm 2.64°, pathologic >8°: angle of line bisecting head and neck of 5th met and line adjacent to medial cortex

Intermetarsal angle of 2nd and 5th met -Bisection of 2nd and 5th met, norm 14-18° Intermetarsal angle of 1st and 2nd met


>12° met primus adductus, high predilection of splayfoot Therefore if IMA of 1st and 2nd >12° and IMA of 4th and 5th >8° splay foot What are the branches of the femoral nerve?

1. Nerve to femoral artery 2. Small muscular branch to pectineus 3. Anterior division (cutaneous)

a. Anterior femoral cutaneous b. Nerve to sartorious c. Intermediate femoral cutaneous nerve d. Medial femoral cutaneous nerve

4. Posterior division (muscular) a. Saphenous nerve b. Infrapatellar branch c. Medial crural cutaneous n. d. Nerve to rectus femorus e. Nerve to vastus medialus f. Nerve to vastus intermedialus g. Nerve to vastus lateralus

What are the branches of the femoral artery? Branches of Femoral Artery

1. Superficial epigastric a. 2. Superficial circumflex iliac a. 3. Superficial external pudendal a. 4. Deep femoral (profunda femoris) a. 5. Medial femoral circumflex a. 6. Lateral femoral circumflex a. 7. Descending genicular a.

Popliteal a. is the continuation of the femoral a.

What is Haglund’s deformity? Pump bump (of the posterior calcaneus) Name the x-ray measurements for Haglund’s deformity Fowler and Phillip Total angle of Vega Parallel pitch lines


Medicine

Post Op Fever Name reasons for post op fever Wind (12-24 hours) 1. Atelelctasia

2. Post op hyperthermia Water (~24 hours) 1. UTI Walk (~48 hours) 1. Thrombophlebitis

2. Pulmonary embolism. Wound (~72 hours) 1. Post op wound infection Wonder Drugs (anytime) 1. Drug fever Treatments of post op fever Wind atelectasia (from muscle relaxers) To prevent use incentive spirometer (blow into tube) Get chest x-ray Water strait catheter, drain 500cc Get urine gram stain, culture and sensitivity Urine analysis (UA) Treat with antibiotic if necessary Walk heparin protocol To prevent use TEDS stocking, SCD or get the patient up and out of bed Wound antibiotic, x-ray, gram stain, culture and sensitivity, blood cultures Wonder Drug d/c drug, give drug to reverse if necessary. Triad of Pulmonary embolism

1. Dyspnea 2. Chest pain 3. Hemoptysis (although tachycardia is more common)

Anticoagulation What is Virchow’s Triad? Venous stasis Hypercoaguability Abnormalities of vessel walls What is Virchow’s triad used for? Risks of DVT Diagnosis of DVT-clinically Classic symptoms

1. Pain, heat, swelling in affected limp


2. Homan’s and Pratt’s test 3. Pulmonary embolism

For long term DVT prophylaxis, what drugs do you order and why? Heparin and Coumadin. Heparin works right away Coumadin takes 3-5 days and causes an initial transient hypercoaguable state. Risks for DVT? I AM CLOTTED I-immobilization A-arrhythmia M-MI, past history C-coaguable states L-longevity (old age) O-obesity T-Tumor T-trauma T-tobacco E-estrogen D-DVT, previous history What to do with patient with prior DVT? Greenfield filter At what level of the body is a Greenfield filter inserted? In inferior vena cava below the renal veins What does PT/PTT/INR tell you? The coaguable state of the patient If one of these is high, it means that the patient will take longer to stop bleeding or it is harder for the pt to develop a blood clot. It only takes blockage of one of the pathways to anticoagulate the patient. What causes the PTT to be high? Heparin What is the normal value for PTT? 10.1-13.1 seconds Which pathway does PTT check? Intrinsic Which pathway does PT check? Extrinsic


What can cause the PT/INR to be high? Coumadin (most likely) Malnutrition Alcoholism Antibiotics Metabolic disorders What does INR stand for and why was it developed? International Normalized Ratio. The INR was developed because there are different ways to determine the PT and thus there are different lab values of normal and abnormal. INR was developed to take all off the different PT’s and make it into a set of lab values (the INR) that would be constant regardless of the method to develop the PT. What is heparin’s half-life? 1/2 –2 hours How do you order a Heparin drip? Usually I will order a ‘Heparin drip, level one protocol with bolus’, especially when I am getting a patient ready for surgery, but the patient needs to be continuously anticoagulated. I will shut the Heparin drip off off 2-3 hours before surgery. After surgery I will restart the heparin drip until the patient becomes anticoagulated by Coumadin, or I will start the patient on Lovenox (and not start the heparin drip). How to use Heparin in DVT prophylaxis? 5000 units SQ 2 hours before surgery 5000 units SQ q12 hours until patient ambulates What pathway does heparin use? Intrinsic How does heparin work? Intrinsic pathway Increases activity of antithrombin III 100 fold, which inhibits the serine protease (in the clotting cascade) How to reverse heparin? Protamine Sulfate 1 mg per 100 units of heparin What is Lovenox (Enoxaprin)? Low molecular weight heparin How do you order Lovenox for DVT risk? 1mg/kg SUBQ, usually until oral anticoagulated by Coumadin. (Sometimes physicians will just use Lovenox the duration of the anticoagulation which is usually 7-10 days after


surgery.) An alternate way to order Lovenox is 30mg subq bid. If renal impaired, order 30 mg once a day. Advantages of Lovenox vs. regular Heparin? Disadvantages? Advantages- longer plasma ½ life Significant anticoagulation in trough Disadvantage- increased post-op complications when used with spinal/epidural anesthesia No way to test effects of Lovenox How do you check Lovenox? No real test How does Coumadin work? Extrinsic pathway Interferes with clotting factors II, VII, IX, X How do you check Coumadin’s level/effects? By the INR. (PT used to be used, but now doctors should only use INR) How do you order Coumadin? 5-10 mg po daily for 3-4 days, then adjust by the INR. How long before Coumadin works? 3-5 days What are the INR values? Normal=1 Upper margin for elective surgery 1.4 Upper margin for surgery non-elective 1.7 Intense anticoagulation=2-3 High intensity=2.5-3 How to reverse Coumadin Fresh frozen plasma, Vitamin K Peri-operative Management for Coumadin Minor procedures (under local): keep them on their meds if P.T. is stable. Major procedures: stop oral meds 3 days prior to surgery and start back post-operatively. How much control for Heparin and Coumadin Coumadin-keep 2 times normal INR Heparin-keep 2 to 3 times normal PTT What do you want the INR to be for most surgeries? Under 1.4


What to do if the INR is over 1.4? Tell your attending/senior resident Transfuse Fresh Frozen Plasma (FFP). Under normal circumstances, one unit of FFP should decrease the INR 0.2, however, this is not a hard rule. Two units of FFP will take approximately 6 hours to work. Rember to order a STAT INR after the transfusion. 10 mg of Vit. K is an option, but it will only bring it the INR a small bit and it takes over 24 hours to work. When is it ok to have an INR higher than 1.4? 1. The risk of surgery outweighs the risk of excessive bleeding (i.e. If it is an emergency surgery and you have anesthesia’s ok) 2. With a patient with PVD and you are doing a debridement or amputation. I have seen debridements with an INR at 1.6. Note: if the patient has PVD, make sure you have Vascular Surgery’s OK for surgery. In this case it is acceptable for the patient to bleed a little extra-that is what we are hoping. If you do surgery on a patient that has a high INR, what to you want to watch? The hemoglobin and Hematocrit. Make sure the patient is not anemic. If the Hemoglobin goes below 8 or the Hematocrit goes below 24, think about transfusing with prbc’s. When to discontinue aspirin before surgery? 7 days When to d/c the coumadin before surgery? 3-5 days When to d/c the heparin before surgery? 24 hours before surgery, but I have seen it as low as 8 hours. When to d/c a heparin drip before surgery? 2-3 hours. What is the dosing of Coumadin? 4-5 mg daily PO for one week, then get INR. Aim for an INR around 2.2 What to do if the patient is low on platelets? Order a ‘six pack of platelets’ which is ‘six pooled platelets concentration’. Mind you, if I do this I consult a hematologist.

Local Anesthetics Mechanism of action for local anesthetics? Block Na+ channels and conduction of action potentials along sensory nerves Only local anesthetic with vasoconstriction? Cocaine


Toxic doses of Lidocaine 300mg plain (30cc of 1% plain) or 500mg w/ epi (50cc of .5% w/ epi) or 4.5 mg/kg plain or 7.0 mg/kg w/ epi Toxic doses of Bupivicaine 175 mg plain (35 cc if .5% plain)or 225mg with epi (45cc of .5% w/ epi) or 2.5 mg/kg plain or 3.2 mg/kg with epi

How are amides broken down? Liver-hepatic enzymes (amides are lidocaine and marcaine) How are esters broken down? Plasma psuedocholoesterase What does MAC (as in local with mac) stand for Monitored anesthesia care What breaks down cocaine? Plasma psuedocholoeresterace (just like other esters)

Pain Medications Pain management with a codeine allergy? Stud-n (sttuddd-n) S-Stadol T-Toradol T-Talwin U-Ultram D-Darvocet D-Darvon D-Demerol N-Nubain First choice for oral is Darvocet N-50 one to two tabs po q4-6° prn pain or Darvocet N-100 one tab po q4-6° prn pain First choice for non narcotic oral Ultram (Tramadol) 50 mg one to two tabs po q4-6° prn pain, max daily dose of 400 mg per day. I usually give this with Vioxx because it has a synergistic effect with Ultram First choice for non-narcotic IV Toradol 30-60 mg IV Choice narcotic IV pain med Demerol. ***Note, many hospitals, including our own, does not allow the use of Demerol due to its side effects. Name two non-narcotic analgesics. Ketoralac (toradol) Tramadol (ultram)


Name the Drug and Usual dosage Percocet? Oxycodone and Acetaminophen, 5/325 (5/325 =5mg Oxycodone and 325 mg Acetaminophen) 1-2 tabs po q4-6° prn pain or 1 tab po q3° prn pain Vicodin Hydrocodone and Acetaminophen, 5/500 1-2 tabs po q4-6° prn pain or 1 tab po q3° prn pain Darvocet? Propoxyphene and Acetaminophen, N50= 50/325, N100=100/650 For N50 1-2 tabs po q4-6° prn pain or 1 tab po q3° prn pain For N100 1 tab po q4-6° prn pain Darvon? For Darvon -Propoxyphene Hydrochloride and Acetaminophen For Darvon 65 Pulvules-Propoxyphene Hydrochloride, ASA and caffeine 65mg/389/32.4 1 tab po q4-6° prn pain For Darvon N-100mg of Propoxyphene Napsylate Toradol? Ketorolac (an NSAID) do not use more than 5 days IV dose is 30 mg IV q 6° PO dose 10 mg q4-6° prn pain. Toradol is not to be used more than 5 days due to kidney side effects Ultram? Tramadol 50 mg 1-2 tabs po q4-6° prn pain or 1 tab po q3° prn pain Morphine? Morphine sulphate Variable dosing. For severe pain (post surgery) dosing: 2-4 mg IV q2-4 hour For a very painful dressing change or bedside debridement: 2mg IV x one dose Demerol? Meperidine, Our hospitals do not use this due to its side effects Dilaudid? Hydromorphone 2 mg tabs: 1-2 tabs po q4-6° prn pain or 1 tab po q3° prn pain IV: 0.5-2mg IM/SC This drug is very, very strong.


Tylenol #3? 30 mg Codeine phosphate and 300 mg acetaminophen 1-2 tab po q4-6 hours MS Contin? Morphine sulfate controlled release Start at 30mg tab, 1 tab po q8-12° Oxycontin? Oxycodone, narcotic agonist, controlled release One tab po p4° What is the difference between Percocet and Percodan? Percocet has 325 mg of acetaminophen and Percodan has 325 mg of ASA

RSD What is RSD? Reflex Sympathetic Dystrophy RSD is when the body doesn’t heal in an orderly manor and pt will have an unexpected degree of pain, swelling, stiffness and dysfunction even though proper treatment was given. MC Causes of RSD? General

1. Abnormal response in sympathetic nervous system 2. Abnormal reflex leading to vasomotor instability and pain

Specific 1. Trauma 2. Peripheral nerve injury 3. Drugs-anti-TB, barbiturates, cyclosporines

But anything can cause it. What are the stages of RSD?

1. Acute-constant pain (intense burning) Possible edema, muscle wasting Pain increased by light touch, movement and emotion

2. Dystrophic- increased edema that is indurated Constant pain by any stimulus Skin is cool pale and discolored X-ray shows diffuse osteoporosis

3. Atrophic- intractable pain spreads proximally to involve entire limb Decreased dermal blood flow, thin shiny skin Fat pat atrophy


Joint stiffen, may proceed to ankylosis Can RSD show up on X-ray? Plain film findings in RSD include periarticular, mottled, irregular bony demineralization (seen in 30-60% of cases) and cortical thinning. Will RSD show up on a bone scan? The 3-phase bone scan has sensitivity of 96% and specificity of 98% in detecting RSD. A normal scan does not exclude the diagnosis of RSD. The result of the bone scan is based on the RSD phase Stage 1: (Early 0 to 8-20 weeks) Increase flow and blood pool activity in the affected extremity. Increased activity, particularly in a periarticular distribution is noted on delayed images. Stage 2: (Mid 2 to 6 months, possibly up to 1 year) Flow and blood pool abnormalities begin to normalize, but increased activity on delayed images persists. Stage 3: (Late Over 6 -12 months) Flow and blood pool activity can be normal or decreased (in about 1/3 of patients) in the involved extremity. Normal or decreased activity is commonly seen on delayed images, however, persistent increased delayed activity (3rd phase) has been reported in up to 40% of pts. Decreased flow in advanced RSD may be related to disuse, which is a common feature of post-hemiplegic RSD.

Diseases What is Haglund’s Disease? Osteochondrosis of accessory navicular Describe Malignant Hyperthermia A side effect of general anesthesia includes tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity and hyperthermia Treatment of Malignant Hyperthermia? Dantrolene (for muscle relaxation) 2.5mg/kg IV x1, then 1 mg/kg rapid IV push q6° until symptoms subside or until max dose of 10mg/kg Treatment of cutaneous larva migrans Promethia under occlusion For diabetics, who gets diabetic ketoacidosis and who gets diabetic coma? Ketoacidosis-IDDM Coma-NIDDM Treatment for Lyme disease Doxycycline 100 mg po qd or Rocephin 1g IV qd


DOC for necrotizing fasciitis? Primaxin 250-1000 IV q6-8° (most commonly 500 mg IV q8°) What is Kohler’s disease? Avascular necrosis of navicular bone in children Triad for Reiters Arthritis Conjunctivitis Urethritis (Pneumonic-can’t see, can’t pee, can’t climb a tree) What is another name for Paget’s disease? What is it? Osteitis deformans- abnormal bony architect caused by increased osteoblast and increase osteoclast. More common in elderly What are the stages of Paget’s? 1. Osteolytic 2. Mixed osteolytic and osteoblastic 3. Late What is Felty’s syndrome? Splenomegaly Neutropenia Rheumatoid arthritis What is mycosis fungoids? A cutaneous t-cell lymphoma that presents as an erythematous eczematoid or psoriasiform plaque tumor What is erythrasma? Superficial infection, asymptomatic, intertriginous (interdigital). Cause: corneybacterium minutissumum What is erysipelas? Superficial type of cellulitis involving lymphatics. Margin of lesion is raised and sharpley demarcated What is ecthyma? How is it treated? MC cause Staph Aureus and Strep pyogenes. Superficial infection extending into dermis characterized by crust erosion and ulcers. Treatment is Dicloxacillin What is psoriasis? Hereditary disorder mc presentation in chronic scaling papules and plaques in areas of body related to repeated minor trauma. Koebner phenomenon and Auspitz sign are


present. Also present are nail pitting, beau’s lines, oil spot, subangual hyperkeratosis discoloration and destruction. What is lichen planus? Acute or chronic inflammatory dermatosis involving skin or mucous membranes characterized by flat top violaceous, shiny pruritic papules. Usually on flexor aspects of wrist and forearms. Histologically it has saw tooth acanthosis. Nails thinning, ridges and onycholysis Dermatologic presentation of Rheumatoid?

1. Rheumatoid nodules over pressure points 2. nail fold infarcts, splinter hemorrhage 3. leucocytoclastic angiitis 4. dry eyes 5. skin looks like wet tissue paper

What is cellulitis? Acute spreading infection of dermal and subcutaneous tissues MC cause group A strep or staph aureus Red hot tender skin Phases of Charcot?

1. acute or developmental 2. coalescence 3. reconstruction

Miscellaneous Drugs What can cause ‘Gray Baby Syndrome’? Chloramphenicol What is chloramphenicol? An antimicrobial Which is the longer acting steroid, phosphate or acetate Acetate-crystallizes, only use every 3-4 months What is diazepam? Trade name is Valium, a benzodiazepam, an anxiolytic/hypnotic/anticonvulsant How to reverse diazepam? Flumazenil (Romazicon) for benzodiezepam reversal 0.2 mg IV over 15 seconds, then 0.2 mg IV prn over 1 minute up to 1 gram total Common complication with steroid injection Post injection flare give ice


How are glococorticoids broken down? Liver, excreted in urine Function of Biguanide Antihyperglycemic (not hypoglycemic) What is Trental’s generic name? Pentoxifylline Rx fro sleeplessness BE HARD B-Benadryl E-Estazolam H-Halicon A-Ambien R-Restoril D-Dalmane Most commonly used are Benadryl 25 mg po qhs or Ambien 5 mg po qhs What drugs leave a metallic taste in the mouth? Flagyl Lamasil Who does Lamasil work? Inhibits ergosterol synthesis What do you give with a Tylenol overdose? N-Acetylcyteine (muco mist)

MISC What do you always ask with a break in the skin? Tetanus status Signs of hypoglycemia Nervousness, tachycardia etc MC gram negative for dog bite? DF-2 What is the most accepted theory about clubfoot? Germ plasma defect-malposition of head and neck in talus What should the Hct and Hemoglobin be for elective surgery Hemoglobin 10 gm/dl or greater Hct 30 % or higher


What part of the brain regulates the body’s temperature? Hypothalamus MC inflammatory arthritis in men over 30? Gout MC time for post operative Myocardial infarction? Day 3 What are the bugs of bite wounds Human-eikenella corroden Dog/cat-pasturella multicida Another name for menopausal lipoma? Juxtamalleolar lipoma How to culture osteomyelitis? 1. Take one from middle of infection of bone 2. Take proximal cut-healthy bone at the edge of the remaining bone (to make sure you took out enough bone. For a culture, how do you grow ghonorrhea? Chocolate/blood agar Treatment for gonorrhea? Ceftriaxone What type of bacteria is gonorrhea? Gram negative dipplococci Most common cancers that metastasize to foot (bone?) LEAD KETTLE (PB for lead) P-prostate B-brain K-kidney T-thyroid L-lung Where is Regranex made? Puerto Rico (I was really asked this once) What is Regranex essentially? PDGF-1 (platelet derived growth factors)


Clinical Podiatry

Describe the anterior drawer test (I have seen variations of this) 5-8 mm drawer rupture of ATF 10-15 mm drawer rupture of ATF + CF >15 mm drawer rupture of ATF, CF + PTF Describe the talar tilt test >10 degrees indicitive of rupture of CFL Describe the stress inversion test 5° inversion ATF 10-30 ATF + CF What is Hooke’s law? For a material under load, strain is proportional to stress What is Young’s modulous? After a load is removed, the material will spring back to its original shape, the resulting slope represents the stiffness of a material or Young’s modulous What is the Silverskiold test? For gastroc equinus Dorsiflex the ankle with knee strait and then with the knee bent. If the dorsiflexion of the ankle with the knee strait displays equinus, then it is due to the gastroc. muscle. Describe the 3 hammertoes Flexor stabalization-pronated foot, late stance MC Flexor substitution-supinated, high arch foot, late stance Extensor substitution-anterior cavus, ankle equinous, swing phase What is Simon’s rule of 15? For clubfoot, children <3 years talo-nav subluxation If T-C angle is <15°, talo-1st met angle is >15° What to do if patient has edema with a cast If it goes down in am gravity edema normal If it does not go down in am abnormal Clinical test for fracture? Point tenderness over fracture site What is Mulder’s sign? For Morton’s neuroma


Silent palpable click when you move met heads together and up and down How do you treat calcaneovalgus? Manipulation Serial casting for 3-6 months-plantarflex, Forefoot adduction, Rearfoot neutral Followed by ganley splints Surgery Lengthen or resect tight soft tissues Arthrodesis What type of acid is phenol and the %? Carbolic acid, 89% 5 malignant bone tumors of the foot? Ewings Osteosarcoma Chondrosarcoma Fibrosarcoma Periosteal sarcoma Name benign bone tumors of foot FOG MACHINE F-fibrous displasia O-osteochondroma G-Giant cell tumor M-Myeloma A-aneurysmal bone cyst C-chondroblastoma, chondromyxoid fibroma, clear cell H-hemangioma I-infection N-non-ossifying fibroma E-Eosinophillic granuloma, Enchondroma, epidermoid inclusion cyst S-solitary bone cyst What are the 3 components of clubfoot? What is the order of correction? FF adductus, RF varus, ankle equinus Correct the FF and RF together first, then the ankle equinus Tests for lateral collateral ligament pathology 1. ATF- anterior drawer test Push pull late stress radiograph 2. Calcaneofibular-stress inversion mortise radiograph

3. Ankle arthrogram, peroneal tenography What is Q angle? The angle between the axis of the femur and the line between patella and tibial tuberosity


What do you do for anesthesia if pt is allergic to all local anesthetic and you’re doing a nail avulsion? Saline block (pressure induced block) Pressure cuff Benadryl block (blocks histamine release)


Trauma Note-Also see the section on Classifications Name the fractures Pott’s bimalleolar fx Cotton’s trimalleolar fx Bosworth’s lat melleolar fx with ankle displacement Maisonnueve proximal fibular fx Volkman’s posterior tibial malleolar fx Tillaux avulsion fx of the ant lat tibia Wagstaff avulsion fx of the ant med fibula Shepard's fx of post lat process Cedell's fx of post med process Foster's entire posterior process What is Lauge-Hansen type V? Pronation dorsiflexion Stage 1-verticle fx of tip of tibial malleolus 2-fx of ant tibial lip 3-spramalleolar fib fx 4-transverse fx of post tibial, level with prox aspect of ant tib fx % of fractures of tarsus that involve the calcaneus? 60% Of these fractures, how many ivolve the involve the joint? 75% MC complication of fracture

1. Delayed union 2. Non-union 3. Pseudoarthrodesis 4. OA/AVN

MC cause of non-healing for a bone fracture Improper immobilization What is Rosenthal’s classification? For nail trauma. Classification is based on level of injury and direction Level- Zone 1-distal to bony phalanx Zone 2-distal to lunula Zone 3-proximal to distal end of lunula Direction


Dorsal (oblique) Transverse Plantar (oblique) Axial (tibial or fibular oblique) Central (gouge) What is Sneppen’s classifcation? For talar body fractures What is a high fibular fracture called? What is the mechanism of action? Massoneuve fracture Pronation external rotation What is the most common locations of talar dome lesions and their mechanisms of injury? DIAL A PIMP Dorsiflex inversion anterio lateral lesion Plantarflex Inversion medial posterior What are classifications for talar dome lesion Bernt-Hardy Fallot and Wy Name the appropriate classification (See classification section for more info.) Ankle fracture Lauge-Hansen Phalangeal/nail Rosenthal Anterior process calcaneal fracture Degan Lis Franc Jt Quenu and Kuss, Hardcastle Talar body Sneppen 1st Metatarsophalngeal Jahss Frostbite Orr and Fainer, Washburn Calcaneous Rowe, Essex and Lopresti, Sanders Physeal ankle fx Dias and Tachdjian Talar dome Bernt-Harty, Fallot and Wy Achilles rupture Kuwada TP based on MRI findings Conti Talar neck Hawkins Navicular Watson Jones Epiphyseal fx Salter-Harris Pilon fracture (distal metaphysis of tibia) Ruedi and Allgower Ankle sprains O’Donoghue, Leach, Rasmussen,

Dias and Tachdjian, New Dias 5th met base Stewart Open fracture Gustillo Non-unions Weber and Cech


What do you test clinically test via Toe Test of Jack? Foster’s Fx (fx of entire posterior process) What is a Stida process? Enlarged Os trigonum What is Mandor's Sign? A hematoma in sole that is pathognmonic of calc. fx. What is Hoffa's Sign? An upward & forward displacement of tuberosity which relaxs Achilles & decreases plantar flexion What is the mechanism of injury (MOI) to the ankle with a transverse fibular fracture? The foot is supinated with adduction motion. Lauge-Hansen SAD What is the MOI to the ankle with a verticle tibial fx? The foot is supinated with adduction motion. Lauge-Hansen SAD What is the MOI to the ankle with a oblique fx to fibula on AP and transverse fibular fx on lat? Foot is pronated with an abduction motion. Lauge-Hansen PAB What is the MOI to the ankle with a fibular spiral fibular fx? Foot is supinated with external rotation. Lauge-Hansen SER What is a Maissonueve Fx and how is it caused? A fibular oblique fracture about the mortise jt. It is caused by the foot being pronated with external rotation. What is a Thurston-Holland sign It is when the epiphysis is separated from the physis with the fracture extending into the metaphysis. It makes a triangular fracture fragment. What is a Flag sign? It is also called a Thurston-Holland sign. It is when the epiphysis is separated from the physis with the fracture extending into the metaphysis. It makes a triangular fracture fragment What is a Hawkins sign? It is a subcondral radiolucency under the talar body on an ankle AP. This means that that the talus does not have an AVN


Between week 6-8 an AP of the ankle reveals the presence or abscense of subchondral atrophy. Subchondral atrophy is indicative of vascularity of the talar body thereby excluding the diagnosis of AVN.


Labs and Pt Management What orders should you order for an inhouse pt for surgery? Labs-cbc with diff, pt/ptt/inr, sma-7 X-rays OR in AM Anesthesia to see pt npo after midnight Chest x-ray, ECG (if necessary) (You might also have to call for medical clearance of the patient) What other factors does one have to be concerned with when getting the patient ready for surgery? If the patient is taking steroids, insulin, anticoagulants or anything else that might put the patient at risk. Note: it is usually best to clear any non-routine orders with the patient’s primary service.

CBC with Diff What is in a CBC? WBC (white blood cell count), hemoglobin, hematocrit and platelets. Normal lab values of CBC? Note: every lab has different lab values. WBC 5000 to 10,000 Hemoglobin For males is 14-18 g/dl For females is 12-16 g/dl Hematocrit For males is 40-54% For females is 37-47% Platelets 150,000 –450,000 When dealing with an infection, what do you expect to happen to the WBC count after surgery? Eventually it should go down, but in post-op days 1-2 the WBC may go up a point or two. This is believe to be because surgery stirs up the body’s reaction to the infection. It is a common occurrence. What to do if WBC is over 10 First, decide if the patient has an infection or not. 1. If the patient has an infection, then the antibiotics and the possible incision and drainage (I&D) should eventually decrease the WBC count. 2. If non-infected pt, then you must find out the cause. Is then is the patient taking corticosteroids? Is the increase acute or chronic? Is there a combination of medical condition causing this? Notify your attending/senior resident (as always).


What to do if platelets are low (under 150,000-350,000/mL)? Notify your attending/senior resident Can transfuse platelets, but it is not commonly done. What should the Hct and Hemoglobin be for surgery? Hemoglobin 10 gm/dl or greater Hct 30 % or higher What to do if the Hemoglobin/Hematocrit if below 10/30? Notify your attending/senior resident Can give patient packed red blood cells (PRBC) What is the condition called? Anemia.

SMA-7 What is in a sma-7? Sodium, potassium, chloride, carbon dioxide, BUN (blood urea nitrogen), creatinine, glucose What is in a sma-12? Sodium, potassium, chloride, carbon dioxide, BUN (blood urea nitrogen), creatinine, glucose plus calcium, cholesterol, phosphatase (alkaline), transaminases (alanine and aspartate) What are the normal values of a sma-7? Note values change with different labs Na+ 134-149 meq/l Potassium 3.2-5.2 meq/l Chloride 94-110 mmol Carbon dioxide 19-32 mmol/l Bun 6-26 mg/dl Creatinine 0.4-1.59 mg/dl Glucose 56-124 mg/dl What does Na+, K+, Cl and CO tell you? Nutritional status. These are your electrolytes What to do if Na+ is low? Give NSS or regular salt. What should your K+ levels be? For K+, if pt is on digoxin worry if the K+ level is around 3, if not worry if below 2.8. This condition is called hypokalemia. The K+ should be below 5.2. If it is above that the condition is called hyperkalemia.


What to do if K+ is too low? Notify your attending and the anesthesiologist Give K rider (potassium chloride supplement), also give potassium food in diet i.e., banana What to do with an elevated K+ (Hyperkalemia)? With a K+ over 5.2 meq/L, 1st get ECG. 2nd manage the hyperkalemia Calcium gluconate 10% give 10 ml over 2-5 minutes Sodium bicarbonate 7.5%, give 1 ampule IV over 5 minutes Manage the glucose and insulin What does bun and creat tell you? Kidney function What to do if creatinine is high? Consult renal if creat is over 1.5 for a couple of results. Note creat may be increased after muscle loss or breakdown. Which is more important-Bun or creat? Why? Creat is more important because bun is influenced by hydration state. In other words, if bun is high but creat is normal, then the patient is most likely dehydrated and rehydration (i.e. NSS at 80 cc per hour) should correct the bun. However, if bun and creat are both high, then the patient most likely has kidney damage.

PT/PTT/INR What does PT/PTT/INR tell you? The coaguable state of the patient If one of these is high, it means that the patient will take longer to stop bleeding or it is harder for the pt to develop a blood clot. It only takes blockage of one of the pathways to anticoagulate the patient. What causes the PTT to be high? Heparin What is the normal value for PTT? 10.1-13.1 seconds Which pathway does PTT check? Intrinsic


Which pathway does PT check? Extrinsic What can cause the PT/INR to be high? Coumadin (most likely) Malnutrition Alcoholism Antibiotics Metabolic disorders What does INR stand for and why was it developed? International Normalized Ratio. The INR was developed because there are different ways to determine the PT and thus there are different lab values of normal and abnormal. INR was developed to take all off the different PT’s and make it into a set of lab values (the INR) that would be constant regardless of the method to develop the PT. What are the INR values? Normal=1 Intense anticoagulation=2-3 High intensity=2.5-3 What do you want the INR to be for most surgeries? Under 1.4 What to do if the INR is over 1.4? Tell your attending/senior resident Transfuse Fresh Frozen Plasma (FFP). Under normal circumstances, one unit of FFP should decrease the INR 0.2, however, this is not a hard rule. Two units of FFP will take approximately 6 hours to work. Rember to order a STAT INR after the transfusion. 10 mg of Vit. K is an option, but it will only bring it the INR a small bit and it takes over 24 hours to work. When is it ok to have an INR higher than 1.4? 1. The risk of surgery outweighs the risk of excessive bleeding (i.e. If it is an emergency surgery and you have anesthesia’s ok) 2. With a patient with PVD and you are doing a debridement or amputation. I have seen debridements with an INR at 1.6. Note: if the patient has PVD, make sure you have Vascular Surgery’s OK for surgery. In this case it is acceptable for the patient to bleed a little extra-that is what we are hoping. If you do surgery on a patient that has a high INR, what to you want to watch? The hemoglobin and Hematocrit. Make sure the patient is not anemic. If the Hemoglobin goes below 8 or the Hematocrit goes below 24, think about transfusing with prbc’s.


When to discontinue aspirin before surgery? 7 days When to d/c the coumadin before surgery? 3-5 days When to d/c the heparin before surgery? 24 hours before surgery, but I have seen it as low as 8 hours. When to d/c a heparin drip before surgery? 2-3 hours. What is the dosing of Enoxaprin? Enoxaprin (Lovenox) is 30 mg Q12 hours 7-10 days after surgery. If renal impaired, order 30 mg once a day. What is the dosing of Coumadin? 4-5 mg daily PO for one week, then get INR. Aim for an INR around 2.2 What to do if the patient is low on platelets? Order a ‘six pack of platelets’ which is ‘six pooled platelets concentration’. Mind you, if I do this I consult a hematologist. How to counteract Heparin? Protamine Sulfate one mg per 100 units of Heparin

Note, also see page 26 for more one anti-coagulation


Surgery

Fixation Devices AO internal fixation principles (2002)

1. Anatomic articular reduction, adequate shaft reduction 2. Stable/biologic fixation 3. Preservation of blood supply 4. Early ROM

Note: in 1958 the AO principles were:

1. Anatomic reduction 2. Rigid internal fixation 3. Preservation of blood supply 4. Early ROM

Describe mini fragment screws Sizes 1.5, 2.0, 2.7-all fully threaded and all cortical How much of a screw do you want to show past the far cortex? 1-½ threads What is the screwdriver handle made out of? Pressed linen Difference between cortical and cancellous screw

1. Cortical has smaller pitch 2. Cortical has smaller rake angle 3. Cortical has smaller difference between thread diameter and core diameter

What are the steps to inserting a fully threaded screw? Predrill the length of the bone Overdrill near cortex Countersink Measure Tap Insert What is the purpose of tapping? Gives a path for the screw threads Why do you countersink a screw? Stress risers Soft tissue irritation Even compression from screw head (land)


Describe a malleolar screw For fixation of medial malleolus, partially threaded, same thread profile and pitch as cortical screw, trephedine self-cutting tip Why do you use a fluted tip screw? Self-tapping

What are the screw sizes? What are their predrill sizes? What are their overdrill & countersink sizes?

Mini Fragment Sizes 1.5 2.0 2.7 ***All are fully threaded Predrill 1.1 1.5 2.0 Countersink 1.5 2.0 2.7 Overdrill 1.5 2.0 2.7

Small Fragment Sizes 3.5 4.0 fully threaded 4.0 partially threaded Predrill 2.5 2.5 2.5 Overdrill 3.5 4.0 4.0 Countersink 3.5 4.0 4.0

Large Fragment Sizes 4.5 4.5 malleolar 6.5 partially threaded 6.5 fully threaded Predrill 3.2 3.2 3.2 3.2 Overdrill 4.5 4.5 6.5 6.5 Countersink 4.5 4.5 6.5 6.5 What sizes are in the Synthes modular hand screw system? Screws sizes of 1.0, 1.3, 1.5, 2.0, 2.4, 2.7 What are the canulated screw sizes? For Synthes 3.0, 4.0 For Smith & Nephew 4.0 & 6.5, 5.5 and 7.0 What are the steps for inserting a 4.0 canulated screw? Insert 1.3 mm guide pin to appropriate distance Measure Ream near cortex with 4.0 canulated cortex reamer (optional)


Ream with 2.7 canulated screw reamer-stop approx 5 mm from far cortex (for soft bone this is unnecessary)

Tap (unnecessary with self tapping screws) Countersink Insert screw What is a Herbert screw? Headless, can insert through articular cartilage. Threaded portion proximal and distal, smooth in-between. Prox tighter pitch for compression. For met osteotomies, Aikins. What is a Reese screw? Headless, to create compression through arthrodesis. Prox part clockwise threads. Distal part counterclockwise. Smooth in between What are the K-wire sizes and their width in millimeters? Sizes .028 .035 .045 .062 Millimeters 0.6 0.9 1.2 1.6 Why did I ask you a question about K-wires in a screw set section? Because K-wires can be used for the pre-drills if the situation arises (the predrill is missing or it dropped on the floor). The .062 can be used for the 1.5 predrill (for the 2.0 screw) The .045 can be used for the 1.1 predrill (for the 1.5 screw) What are the K wire sizes and their appropriate caps? .028 .035 .045 .062 yellow blue white green (young boys wear green) Size of Steinman pins Every one from 5/64 to 12/64 except for 11/64 For a download of the Smith and Nephew catalog go to http://www.smithnephew.com/Downloads/71180472.pdf

Suture and Absorbable fixation devices What is orthofix? Polyglycolic acid (same as dexon)(dexon=orthofix) What is orthosorb? PDS (PDS=orthosorb) In terms of fixation, what is the time difference between absorbable and non-absorbable? Absorbable gets absorbed within one year.


How long before PDS loses strength? When absorbed? Loses strength-4-6 weeks Absorbed 3-6 months What are the two sutures that are the least reactive to tissue? Stainless steel (least reactive) Prolene Should you use vicryl with an infection? Not if you can avoid it vicryl is too reactive How long does it take vicryl to absorb? 80% absorbed in 21 days

Arthroscopy Name a few indications for ankle scope Synovitis Chondromalacia Osteochondral lesion/fracture Impingenent lesion Erosion Name some scope techniques Scanning-side to side, up and down Pistoning-in and out Rotation-360° What is the light intensities for arthroscopes Tungsten 2900 kelvins Metal halide lamps 5800 kelvins Xenon 6000 kelvin What are the cameras for a scope? Saticon-good for low light, not submersible for sterility CCD integrated-circuit camera-needs more light, less bulk Who first describe arthroscopy? Takagi First podiatrist to describe a podiatric use for arthroscopy? Heller and Vogel in 1982 Name 3 surgical treatments for plantar fasciitis? Endoscopic plantar fasciotomy (EPF)


Durvies Griffith MC complication of EPF Lateral column instability calcaneal-cuboid joint pain

1st Ray Surgery MC indication for lapidus? Hypermobile 1st ray Order of lateral release for a McBride?

1. Extensor hood 2. AdH tendon 3. fibular sesmoid ligament 4. lateral collateral ligament 5. FHB 6. fibular sesmoid excision (if performing)

Purpose of an implant? To maintain space between bony surfaces Difference between a Vogler and Kalish and a Youngswick? Vogler-offset V (apex at metaphyseal-diaphyseal joint) Kalish-Austin with angles of approx 55° for screw fixation Youngswick-Austin with a slice taken dorsally to allow the capital fragment to PF Correction of PASA Reverdin Peabody Biangular Austin Offset V with swivel Correction of DASA Proximal Aikin Correction for hallux abductus interphalangeous Distal Aikin

Plastic Surgery What is an anti-tension line? S shaped or zigzagged


What is the order of wound graft closure? 1. direct closure 2. graft 3. local flap 4. distant flap

To close a lesion properly, what must the length vs. the width be? 3:1 length X width How long for orthofix to lose strength/absorb? Loses strength in 6-12 weeks Resorbs in 1-3 years

White and Black Toe Post-Op Causes of a white toe post surgery Arterial in nature, usually acute Signs-pain, pale, pareshesia, pulselessness Treatment of white toe?

1. avoid nicotine 2. d/c ice and elevation 3. put foot in dependent position 4. loosen bandages 5. rotate k-wire 6. proximal warm compresses 7. local nerve block proximally 8. nitroglycerine paste proximally 9. consult vascular surgery

What are causes of a blue toe? Either from poor arterial inflow or sluggish venous outflow If… Blue toe due to sluggish venous outflow toe is warm and will blanch with pressure

1. inspect dressing, loosen/change if needed 2. d/c ice (not elevation) 3. avoid dependency 4. don’t attempt to increase vascular perfusion 5. consult vascular surgery

blue toe due to arterial insufficiency toe is cold and doesn’t blanch with pressure (Treat like white toe)

1. inspect dressing, loosen/change if needed 2. rotate/remove K-wire 3. d/c ice and elevation 4. avoid nicotine and caffeine


5. heat to popliteal fossa or anterior groin 6. thermostat controlled heat lamp, not to exceed 90° F 7. vasodilators

a. oral-niacin, nifedipine, cyclospasmol b. nitroglycerine paste

What to do if you drop the capitol fragment on the floor? 1. rinse with saline 2. bacitacin soak for 15 minutes 3. rinse with saline 4. bacitracin soak for 15 minutes 5. rinse with saline 6. document and tell patient

Rearfoot Surgery

What is the Valente procedure An STJ block using a polyethylene plug with screw threads. Allows just 4-5° of STJ pronation afterwards What is Mondor’s sign? Ecchymosis in the rearfoot the goes to the sole of the foot. Indicative of calcaneal fx. Name 3 treatments of Haglund’s deformity? Keck and Kelly Duvries Foller and Phillip Dickerson Treatment for Equinous (tendon)

1. Stretching/exercises 2. Nightsplints 3. Gastroc recession

A. Vulpius B. Strayer C. Baker D. McGlammary and Fulp

4. Tendoachilles lengthening A. open/closed z B. Hauser C. White D. Hoke E. Sglarto F. Stewart


Name a surgical procedure for pes planus in each of the planes Transverse Evans C-C distraction arthrodesis Kidner Sagital Lowman Miller Cotton Young Hoke Cobb Frontal Chambers Gleich Baker-Hill Lord Dwyer Koutsoganis What is a Keck and Kelly procedure? For Haglund’s deformity with cavus foot with high calcaneal inclination angle. Remove wedge from posterior-superior aspect of calcaneous. The posterior superior prominence is moved anteriorly. What is arthroesis? An operation to limit joint mobility (i.e. MBA plug in sinus tarsi) What order do you resect and what order do you fixate the joints in a triple arthrodesis? Resection-1. midtarsal joints (T-N, CCJ)

2. subtalar joints (T-C) Fixation-opposite order

1. subtalar joints 2. midtarsal joints

Types of fixation in a triple arthrodesis MC- 6.5 mm-7.0 mm interfragmental compression screws Others-blount staples, pneumatic staple designed by 3M company How does a bone stimulator work? Piezoelectric principle-side under compression makes a negative charge that leads to bone growth. Therefore, put a cathode in non-union and its negative charge will stimulate growth.

Etc. What is in antibiotic beads? Polymethylmethalcralate with antibiotic (usually use gentamycin because it is heat stable, good diffusion coefficient, small surface area, a lot of research has been done on it. Tobramycin is also used)


For surgery, what can you not give to a patient if they have an egg shell injury? Propophol (diprovan) What is a Blair and Humbrey knife? A knife for skin graft. Contraindications to a tourniquet? Open fracture of a leg Severe crushing injury Severe hypertension Skin grafts in pt where bleeding must be distinguished Compromised vascular circulation or arterial graft DM-(not absolute contra-indicaton) Sickle cell dx Infection What ABI is inadequate for healing in diabetics <.6 What is needed to heal digital wounds? 30 mmHg What is the lag time for osteomyelitis on an x-ray? 10-14 days What is the direction of the cut for reverse Wilson of the 5th toe? Distal lat to proximal medial 1st to describe arthrodesis? Soule Name the order of hammertoe surgery 1.PIPJ tendon capsule-dorsal collaterals capsule-plantar arthroplasty 2. MPJ hood tendon capsule plantar plate 3. PIPJ arthrodesis *do Kelikian push up in between each step to determine if the next step is needed.


Drug of Choice

Introduction Much of the information in this section is also found in the Antibiotics section.

However, in this section, the emphasis is on the clinical presentation or the test results and how to proceed from there. I believe this would be useful because often the decision on choosing a drug is based on the gram stain or clinical presentation.

Obviously, thanks to Dr. Joseph, DPM for much of this information. -Brett

Common Bugs, Drugs and Alternatives What is catalase positive, gram positive cocci in clusters? Staph Aureus Drug of choice for staph? Keflex for PO, Ancef for IV Alternative for staph? Clindamycin, Levoquin, Vanco, Azithromycin, Dicloxacillin, Naphcillin Alternative for staph if PCN all? Clindamycin, Levoquin, Azithromycin, Vanco What if the cultures and sensitivities (C&S) come back and the bug is resistant to the above antibiotics? It is MRSA (methacillin resistant staph aureus) DOC for MRSA? Vancomycin for IV, Bactrim (if sensitive) or Linezolid for PO Alternative for MRSA? Synercid or Linezolid What is a gram positive cocci, single, paired or chained? Strep. DOC for Strep? PCN (or more commonly Keflex for podiatry) for PO, Ancef for IV Alternative for Strep? Clindamycin, Levoquin, Vanco


Alternative for Strep if PCN all? Clindamycin, Levoquin, Vanco DOC for VRE? Linezolid (IV or PO) or Dalfopristin-Quinupristin (Synercid) What is small, polarly flagellated, gram negative rod with pili? Pseudomonas aeruginosa DOC for Psuedomonas Aeruginosa? Cipro Alternatives for Psuedomonas Aeruginosa? 3rd gen cephalosporin, aztreonam, bactrim How do you expect Psuedomonas to present? Blue-green pus and a grape like sweet odor? What is a gram negative, anaerobic rod? Bacteroides Fragilis. DOC for bacteroides (anaerobes) for the diabetic foot? Unasyn, Augmentin, Timentin, Zosyn Alternatives for bacteroides (anaerobes) for the diabetic foot if PCN allergy? Clindamycin/Cipro, Primaxin, Flagyl DOC for enterococcus? Amoxicillin PO or Vancomycin IV Alternatives for enterococcus? Augmentin, Linezolid DOC for Lyme disease (Borrelia)? Rocephin, Doxycycline Alternative for Lyme diseas? Amoxicillin


DOC for Diptheroids? Vanco What is gram negative diplococcus, oxidase positive? Neisseria gonorrhoeae DOC for N. Gonorrhoeae? PCN (if susceptible), although a 3rd generation cephalosporin such as ceftriaxone (Rocephin) appears to be the DOC What is anaerobic, spore forming, large gram positive rod? Clostridium perfringens What are the two soft tissue clinical manifestations caused by Clostridium? 1. anaerobic cellulitis 2. myonecrosis (gas gangrene) Why is gas gangrene a surgical emergency? Because it progresses rapidly to shock and renal failure. Fatal in 30% of untreated cases.

Less Common (To Podiatry) Bugs, Drugs and Alternatives What is a gram negative short rod? E Coli DOC for E. Coli? Keflex or Ancef Alternative for E. Coli if PCN all? Cipro or Levaquin DOC for proteus? Keflex or Ampicillin Alternative for proteus if PCN allergic? Cipro or Levaquin DOC for E/C/S/M group? Quinolone (Cipro/Levaquin)


Alternatives for the E/C/S/M group? 3rd gen ceph, aztreonam, bactrim DOC for Aeromonas? Cipro Alternative for Aeromonas? Bactrim DOC for Xanthamonas? Bactrim Alternative for Xanthomas? Ceftazidime DOC for P. Cepacia? Bactrim Alternative for P. Cepacia? Ceftazidime

Miscellaneous What is the drug of choice (DOC) for a diabetic with a PCN allergy? Clindamycin DOC for severe limb threatening infection? Primaxin DOC for bite wounds? Augmentin What is B-hemolytic and coagulase positive staph? Staph Aureus What is gram positive, catalase negative? Strep What has blue-green pus and a grape like sweet odor? Psuedomonas aeruginosa Which type of step causes impetigo, cellulitis and erysipelas? Group A strep


What is the difference between cellulitis and erysipelas? Cellulitis is if the lesion is confined, erysipelas applies if the lesion spreads most likely through lymphatics What is gram positive, anaerobic filamentous bacterium? Actimomyces What are the organisms most likely to cause gas in tissues? (Nemonic BECK-SP) Bacteroids Escherichia Clostridium Klebsiella Serratia Peptostreptococcus


Gout How to treat acute and chronic gout? Acute-colchicine NSAIDS-indomethacin Corticosteroids ACTH Chronic-colchicine (prophylactically) Allopurinol Uricosurics (probenecid sulfinpyrazole) Stages of Gout?

1. Asymptomatic Hyperuricemia 2. acute gouty arthritis 3. intercritical gout 4. chronic gouty tophaceous gout

Can you use Allopurinol, Probenicid or Sulfinpyrazole for acute gout? No, because they may cause a initial hyperuremia. How do you test for gout? Uric Acid level (normal is under 7 mg/dL) Aspirate the joint and send to pathology What is a positive test for gout in pathology? Monosodium urate crystals are needle shaped and display a negative birefringence under a polarizing light microscope. For gout, how do you tell if someone is an overproducer or underexcreter? Take a 24 hour uninalysis Which is more common-to be an underexcretor or an overproducer? Underexcreter make up approx 90% MC inflammatory arthritis in men over 30? Gout What medication to give a patient with gout if the pt is an overproducer or underexcretor? Pneumonic-OverAchieving, UnderPaid Overproducer allopurinol Underexcreter probenecid What is a martini sign? For gout histo shows glucophage engulfing crystal (looks like martini and olive)


What to send speciment in if you suspect gout? One in formaldahyde (dissolves gout, but is the usual medium for sending most speciments) One in alcohol (does not dissolve gouty tophi) Dosing of colchicines? There are two tablet forms-0.5mg and 0.6 mg Both are one tablet po q2° until the gout pain is gone or until pt develops the gastrointestinal side effects Daily max dose of colchicines? Po 8mg, IV 4 mg


Case Study 1 A 23 yo pt presents in the Emergency Department with foot trauma.

1. What do you do first? Get a quick history and check neurovascular study.

2. Results

History-pt has his foot run over at work. The patient states that his foot is 10/10 pain, toes feel cold and numb. NV check-You check his pulses and they are present, his toes feel cold, he can not feel you touching the toes, his toes are changing color (purple or white) and he cannot move his toes. What is going on?

Compartment syndrome

3. What do you do next? Remove dressings casts etc. If compartment syndrome persists, prepare pt for surgery-this is a surgical emergency. Compartment syndrome is a clinical diagnosis, according to The AO principals course. It is better to get the patient up to surgery than it is to find an instrument to measure the pressure. Preparation for surgery-call your attending and senior residents, x-rays, labs, npo, anesthesia to see patient, consent.

What is compartment syndrome? A condition with increased tissue in a limited space compartment which compromises the circulation and function of the tissues. It can lead to ischemia of the tissues. What are some of the causes of compartment syndrome? Fractures, crush injuries, prolonged limb compression and postischemic swelling. In a sense, any injury can cause compartment syndrome. What are the signs of compartment syndrome? Pain out of proportion (most important) Paresthesia Pallor Pulses present Poiklothermia (cold) Paralysis What are some forms of measuring pressure? Wick catheter, slit catheter, needle technique, continuous infusion technique But as stated before, this should be a clinical diagnosis.


What is the treatment? Fasciotomy of the compartment. In the leg surgical access should be made to access all four compartments. To do a leg fasciotomy, make one incision medial to Tibia and one lateral. From the Medial incision, open the superficial and deep posterior compartments. From the lateral incision, open the anterior and lateral compartments. What are some absolute indications for a fasciotomy? Motor and sensory loss Tissue pressure above 35 mmHg Pain out of control


Case study 2 A patient who you prescribed pain medication has wheels, hives, itching and trouble breathing after taking the medication. What is most likely going on? Anaphylaxis What is anaphylaxis? A rapid, generalized immunolgically mediated events that occur after exposure to foreign antigen substances in previously sensitized persons. This syndrome can affect any organ in the body, but most commonly it affects pulmonary, circulatory, cutaneous, neurologic, and GI. What causes anaphylaxis? It is the interaction of a foreign antigen with specific IgE antibodies found on tissue mast cells and peripheral blood basophils. Their release of histamine and other mediators cause smooth muscle spasm, brochospasm, mucosal edema and inflammation, and increased capillary permeability. Clinical symptoms of anaphylaxis Common (mild)-uticaria, weakness, dizziness, flushing, angioedema, congestion and sneezing More severe-upper respiratory tract obstruction, hypotension, vascular collapse, GI distress, cardiovascular arrhythmias and arrest. What is the difference between anaphylaxis and anaphylactoid reaction? They present the same clinically, but anaphylactoid reaction is not mediated by IgE antibody and not necessarily requiring previous exposure to inciting substance. What is the best way to prevent anaphylaxis? History and elimination and avoidance of offending substances. How do you treat anaphylaxis? 1. First thing is to stop the offending agent and other possible agents. If that means to d/c all meds, then do it. 2. If the patient is having life threatening problems like the case above, get them to an emergency department if they are at home. Get the right people involved (attendings, senior residents etc.) 3. Treat the symptoms. Airway-bronchospasm Initial therapy-epinephrine 0.5 ml of 1:1000 dilution (0.5mg) subq every 10-20 min Oxygen 40-100 percent


Metaproterenol 0.3 ml (5% solution) in 2.5 ml of saline in a nebulizer, 2-3 puffs every 3-4 hours

Second therapy Amiophylline loading dose 6mg/kg IV over 30 min period. Maintenance 0.3 –0.9 mg/kg/hr IV (for bronchospasm) Corticosteroids 250 mg of hydrocortisone or 50 mg of methylprednisone IV q6° for 2-4 doses (bronchospasm)

Cardiovascular reactions-(hypotension) Initial therapy-IV fluids 1 L q20-30 min as needed. Maintain systolic BP >80-100mmHg

Epinephrine 1mg in 1:1000 dilution in 500ml of D5W IV at a rate of .25-2.5 ml/min

Secondary therapy-Norepinephrine 4mg in 1L of D5W IV at 0.5-3ml/min Antihistamines (as above) Cutaneous reaction- Initial therapy-epinephrine 0.5 ml of 1:1000 dilution (0.5mg) subq every 10-20 min Secondary therapy-Antihistamines hydroxyzine (atarax or vistaril) or

diphenhydramine (benadryl) 25-50 mg IM or PO q6-8° prn 4.Document offending agents and educate patient for future avoidance.


NSAIDS What pathway do NSAIDS work on? COX (I gave you an easy one to start) What are the selective COX-2 inhibitors Celebrex (celecoxib), Vioxx (rofecoxib), Bextra (valdecoxib) What are the NSAIDS with the least nephrotoxicity? COX-2’s, Relafen, Lodine What effects do NSAIDS have on asthma? NSAIDS can increase the symptoms of asthma. What NSAIDS are safest for someone with asthma? Diclofenac, Ketoprofen What NSAIDS do not inhibit platelet aggregation? COX-2 inhibitors Which treat collagen vascular disease? Ibuprofen, tolmentin, sulindac Which NSAIDS are non-renal clearance? Indomethacin, and sulindac What effects can NSAIDS have on cardiovascular? Can increase blood pressure and cause vasoconstriction. What NSAIDS have the least effect on cardiovascular? Diclofenac, Ketoprofen What NSAIDS do not decrease the chance of a DVT post-surgery? COX-2 inhibitors (because they do not inhibit platelet aggregation) What are the most hepatotoxic? Ibuprofen, naprosyn, aleve, diclofenac. Indications for Vioxx? Osteoarthritis, rheumatoid arthritis, menstrual cramps Most common side effect for NSAIDS? GI disturbance (except with cox-2 inhibitors)


What is the only IV NSAID? Ketorolac tromethamine (Toradol) Does giving NSAIDS IV decrease the GI disturbances? No, because NSAIDS still inhibits COX-1. COX-1 has cyptoprotective agents What to give with an Indomethacin overdose? Benadryl (decreases serotonin and histamine release) What is in arthrotec? Misoprostol and diclofenac (an NSAID with protection for the stomach, pretty much a dinosaur after the cox-2 inhibitors came) What is the anti-inflammatory dose of ibuprofen? 1200-3200mg/day in divided doses What NSAIDS work on both the lipooxygenase and cyclooxygense pathway? Ketoprofen and diclofenac What is the difference between cataflam and voltaren? Cataflam is diclofenac K+ and immediate release Voltaren is diclofenac Na+ and delayed release What are the only Pro-drugs (for NSAIDS)? Nabumentone and Sulindac What is the only nonacidic NSAID? Nabumentone Which NSAIDS have fewer pulmonary problems? Ketoprofen and diclofenac Which NSAIDS only have anti-inflammatory effects? Indomethacin, tolmentin sodium Do NSAIDS decrease joint destruction? No, they only decrease inflammation What NSAID causes irreversible inhibition of platelet aggregation? Aspirin What are some once a day NSAIDS? Rofecoxib (Vioxx), celebrex (celecoxib), piroxicam (feldene), oxaprozin (daypro), nabumentone (relafen), bextra (valdecoxib) plus others


What are the three mechanisms of action for most NSAIDS? Analgesic, Antipyretic, Anti-inflammatory Which NSAID is often given during surgery or immediately post-op to decrease pain and inflammation? Ketorolac (Toradol) 30mg or 60 mg IV What drugs do NSAIDS interact with and what are the effects? Coumadin-increases action of coumadin Sulfonylureas-increases action of sulfonylurea Corticosteroids-increases GI risk Antiepileptic meds-increases antiepileptic toxicity Antihypertensive meds-antagonizes antihypertensive meds Digoxin-increases digoxin’s effects Methotrexate-decreases methotrexate’s clearance Lithium-decreases lithium’s clearance Probenecid-increases concentration of NSAIDS


Classifications Author’s note: Although all of the classifications are important, the ones in bold, capitalized and underlined (i.e. LAUGE-HANSEN) are the most common or most used ones.

ANKLE FRACTURES

LAUGE-HANSEN CLASSFICATION: -based on a two word system 1st word=position of foot w/respect to the leg 2nd word=motion that causes fx pattern (where talus moves w/respect to the tibia and fibula) *=hallmark SUPPINATION-ADDUCTION -remember adduction=inversion Stage 1:*transverse fx of fibula OR rupture of lateral collaterals Stage 2:*vertical fx of medial malleolus -NO tib-fib diastasis PRONATION-ABDUCTION -remember abduction=eversion Stage 1: transverse avulsion fx of medial malleolus OR rupture deltoid ligament Stage 2: rupture of ant+/-post distal tib-fib ligaments Stage 3: *short fibular fx (oblique on AP, trans. on lateral) SUPINATION-EVERSION (*most common) -also called SER -eversion=external rotation -medial axis is medial malleolus Stage 1: anterior tib fib ligament disruption OR one of the following tib-fib ligament avulsions: Tillaux-Chaput: tibia Wagstaffe: fibula Stage 2: *spiral oblique fx fibula Stage 3: rupture of post tib-fib lig OR Volkmann's fx (avulsion of tibia from post tib-fib.) Stage 4: transverse fx med. malleolus OR ruptured deltoid PRONATION-EVERSION -also called PER (eversion=ext. rot) -talus ext. Rotated around lat malleolar axis


Stage 1: rupture deltoid OR transverse avulsion of med mal. Stage 2: ant tib-fib lig. Disruption Chaput fx-tears interosseous lig with it Stage 3:* high fibular fx tears interosseous membrane Stage 4: Posterior tib-fib lig OR Volkmann's fx. Pronation-Dorsiflexion (Arch. Surgery #67: 813-820, 1953) Used to describe pilon fracture Stage I: Medial malleolar fx (oblique or transverse) or deltoid ligament rupture. Stage II: Fracture of the anterior lip of the tibial plafond. Stage III: Fibular fracture above the level of the syndesmosis. Stage IV: Transverse fracture of the distal part of the tibia at the same level as the proximal margin of the large tibial fracture. DANIS WEBER condensed Describes fractures of fibula · Type A: Transverse avulsion fx. below the level of the ankle jt.

(corresponds with Lauge-Hansen SAD) · Type B: Spiral or oblique fx at the level of the ankle joint

(corresponds with Lauge-Hansen SER and PAB) · Type C: Fx above the level of the ankle joint a.k.a. Maissoneuve fx.

(corresponds with Lauge-Hansen PER) DANIS-WEBER (Ortho Clinics of NA 661, 1980) - Based on location of fx of fibula. Corresponds w/Lauge-Hansen.

Type A: Transverse avulsion fx of fibula below the level of ankle mortise MOI-supination-adduction TX: k-wire w/ tension band for fibular fx. 2 interfrag screws for the med

malleolus. Type B: At Level of ankle mortise

MOI-pronation-abduction OR SER TX: interfrag screws &/or plate. repair ATFL

Type C: Above level of ankle mortise MOI-PER TX: interfrag screws & plate OR just a plate. repair ATF & interoseous memb. w/ transfixation screw.

PILON FRACTURE

RUEDI & ALLGOWER condensed Pilon Fractures -distal tibial metaphyseal fx

Type 1-no displaced fragments of tibia Type 2-intraarticular fx of tibia but not comminuted Type 3-comminuted & disruption of articular surface of tibial


Ruedi and Allgower (Clin. Orthop. #138: 105-110, 1979) Type 1: Mild displacement and no comminution without major disruption of ankle jt. Type 2: Moderate displacement & no comminution with significant dislocation of the ankle joint. Type 3: "Explosion Fracture", Severe comminution and displacement of the distal tibial metaphysis femoral distractor -will bring tibia out to length before fixation if-type 3 fix tibia 1st 40-80% failure of ankle fusion Lauge-Hansen (Lauge-Hansen Pronation-DF describes a pilon fracture) Pronation-Dorsiflexion (Arch. Surgery #67: 813-820, 1953) · Stage I: Medial malleolar fracture (oblique or transverse) or deltoid ligament rupture. · Stage II: Fracture of the anterior lip of the tibial plafond. · Stage III: Fibular fracture above the level of the syndesmosis. · Stage IV: Transverse fracture of the distal part of the tibia at the same level as the proximal margin of the large tibial fracture.

Medial malleolar Fractures, Avulsion Muller · Type A: Avulsion of the tip of the medial malleolus, horizontal orientation · Type B: Avulsion fracture at the level of the ankle joint, horizontal orientation · Type C: Oblique fracture · Type D: Vertical fracture

Fibular Avulsion Fractures Pankovich; Wagstaffe-LeFort Fracture (Clinics Ortho Rel. Res. 143: 138, 1979) · Type 1: Avulsion fracture maintaining attachment to both the anterior talofibular and anterior-inferior tib-fib ligaments · Type 2: Avulsion fracture associated with an oblique fracture of the fibula originating distal to the anterior-inferior tib-fib ligament. Spiral fracture of the fibula with a proximal fibular spike and a transverse fracture associated with the avulsion fragment. · Type 3: Avulsion fracture of the anterior tibial tubercle followed by a type 2 AO System (Ankle Fractures) · Type A: extra-articular · Type B: partially articular · Type C: completely articular


· All 3 can involve: A. No comminution or impaction in the articular or metaphyseal surface B. impaction involving the supra-articular metaphysis C. Comminution and impaction involving the articular surface with metaphyseal impaction Destot System · Subgroup I: Posterior marginal fracture of the tibia · Subgroup II: Anterior marginal fracture of the tibia · Subgroup III: Explosion fracture of the tibia · Subgroup IV: Supra-articular fracture of the tibia with extension into the ankle joint Kellam and Waddell (Journal of Trauma, #19: 593-601, 1979) · Type A: Rotational pattern consisting of 2 or more large tibial articular fragments, minimal or no anterior cortical comminution, and a transverse or short oblique fibular fracture at the level of the tibial plafond. · Type B: Compressive fracture pattern with multiple tibial fragments with marked anterior tibial cortical comminution. Maale and Seligson (Orthopedics #3: 517-521, 1980) Modification of Ruedi and Allgower · Type 1: Distal tibial compression fracture · Type 2: External rotatory fracture with a large posterior fragment · Type 3: Spiral fracture extending from the articular surface into the metaphysis Ovadia and Beals (JBJS 68A: 543-551, 1986); modified the Ruedi and Allgower Type II classification · Type I: Non-displaced articular fracture resulting from rotational forces · Type II: Minimally displaced fracture resulting from articular forces · Type III: Displaced articular fracture with several large fragments due to compressive forces · Type IV: Displaced articular fracture with multiple fragments including a large metaphyseal fragment resulting from compressive forces. · Type V: Severe comminution due to compressive forces Mast System (Clinics of Ortho 230: 68-82, 1988) · Type I: Malleolar fracture with significant axial load at the time of the injury producing a large posterior fragment · Type II: Spiral extension fracture · Type III: Central compressive injury divided into A, B and C


ACHILLES TENDON RUPTURE KUWADA · Type 1: Partial Tear <50%, Treat with casting (foot plantarflexed) · Type 2: Complete tear with <3cm defect after debridement. Treat with end-to-end attachment · Type 3: Complete tear with 3-6cm defect after debridement. Treat with end-to end attachment and tendon flap. · Type 4: Complete tear >6cm defect after debridement. Treat with end-to-end, recession, or graft.

Radioopaque lesions of the Achilles Tendon Morris and Giacopelli (Journal Foot Surgery, 1990) · Type I: Opacities at the Achilles insertion. Calcification in within the tendon and remains partially attached to the calcaneus. · Type II: Opacities 1-3cm proximal to the insertion. Lesions separate from the calcaneus. · Type IIIA: Lesions > 3cm proximal to the insertion. Partial tendon calcification. · Type IIIB: Lesions > 3cm proximal to the insertion. Total tendon involvement.

Lateral Ankle Trauma Note: you should learn one of the classifications in this section, but it really doesn’t matter which one. Leach- Lateral Ankle · 1st Degree: Rupture of the ATF · 2nd Degree: Rupture of the ATF and CF · 3rd Degree: Rupture of the ATF, CF, and PTF O’Donoghue-condensed: Grade I: partial ATF tear Grade II: complete ATF tear Grade III: complete ATF & CFL tear O'Donoghue –expanded (Northwest Medicine, October 1958, p1277) · Grade 1: Partial tear of ATF, mild tenderness and swelling.

No loss of function or instability. Pt can walk, play · Grade 2: Complete tear of ATF, moderate pain and swelling with ecchymosis Some loss of function and moderate instability. Pt limps after injury · Grade 3: Complete tear of ATF and CFL, severe pain, swelling, and ecchymosis Unable to bear weight and severe instability. Pt cannot walk after injury


Dias ( Journal of Trauma, 19: 266-269, 1979) · Grade I: Partial rupture of the CFL · Grade II: Rupture of the ATF · Grade III: Complete rupture of the ATF, CF, and/or PTF · Grade IV: Rupture of all lateral collateral ligaments and partial failure of the deltoid ligament

TALAR DOME FRACTURES BERNT AND HARDY-condensed Stage 1-compression of talar dome without displacement. Stage 2-osteochondral lesion of talar dome, partially detached Stage 3-osteochondral lesion of talar dome completely detached but not displaced. Stage 4-osteochondral lesion of talar dome, displaced BERNT AND HARDY(JBJS 41A: 988-1020, 1959) Mechanism: DIAL A PIMP · Stage 1: Osteochondral compression of the talar dome.

TX: conservative · Stage 2: Partially detached, non-displaced osteochondral fracture. TX: conservative · Stage 3: Fully detached, non-displaced osteochondral fracture. TX (medial lesion)-conservative TX (lateral lesion)-Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production. · Stage 4: Displaced osteochondral fracture. TX: Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production. * Mechanism of Injury: DIAL A PIMP or DIAL-A-PIMPER 1. DIAL-Dorsiflexion and Inversion leads to Anterior-Lateral lesion:. Wafer-shaped lesion, assoc. w/trauma 2. PIMPER-Plantarflexion and Inversion with External Rotation. Posterior-Medial lesion: small, deep, round cup-shaped fragment, 80% not** assoc. w/trauma Treatments * TX: Stage 1, 2, and medial 3: NWB Short leg cast for 6-12 wks TX: Lateral stage 3 and 4: Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production.


TALAR NECK FRACTURES

HAWKINS-Talar neck fx condensed

Type 1: Vertical fx. of talar neck. Nondisplaced Type 2: Vertical fx. of talar neck, STJ dislocation/subluxation Type 3: Vertical fx. of talar neck, STJ and ankle dislocation/subluxation Type 4: Vertical fx. of talar neck, STJ and ankle and TN dislocation/subluxation

HAWKINS(JBJS 60A: 143-156, 1978); Modified by Canele and Kelly MOI - hyperdorsiflexion of the foot on the leg

Type 1: Vertical fracture of the talar neck without displacement. Disruption of 1 blood vessel (12% risk of AVN) TX: BK cast immobilization for 8-12 weeks, NWB for 6-8 wks. - Need to see trabeculation across the fracture site to start weightbearing.

Type II-Displaced fracture of the talar neck with subluxation of the STJ (ankle jt remains aligned) Disruption of 2 blood vessels (42% risk of AVN) TX: 1. Trial of closed reduction by pushing backwards on a plantarflexed foot while pulling forward on the distal tibia.. If this is successful, percutaneous pinning is performed. If successful, cast in equinus for 4 wks with subsequent casting bringing the foot out of equinus. Total casting time - 3 mos of NWB casting. 2. If after one unsuccessful attempt at closed reduction, ORIF is indicated. Avoid multiple attempts at closed reduction. Longitudinal anteromedial incision along the neck of the talus, just medial to the TA. 6.5mm canulated cancellous screws. Use titanium screw to facilitate the later use of MRI to monitor the progress of osteonecrosis.

Type 3: Vertical fracture of the neck of the talus, dislocation of the STJ, and dislocation of the Talus from the ankle joint.

Disruption of 3 blood vessels (91% risk of AVN). TX: ORIF important not to dissect off the deep fibers of the deltoid ligament which may remain attached to the talar body (osteotomize the medial malleolus rather than reflect the deltoid) -25% of these are open

Type 4: Vertical fracture of the neck of the talus, with dislocation of the talus

from the STJ, ankle joint and the talonavicular joint. Disruption of 3 blood vessels (91% risk of AVN).

TX: ORIF (seen in one patient - this modification was attributed to Canale and Kelly JbJs 1978)

-osteonecrosis is the most common complication associated with this injury


10% incidence of calcaneal fractures assoc. with talar neck fractures 19-28% incidence of medial malleolar fractures assoc with talar neck fractures X-rays - place ankle in maximum equinus, place foot on a cassette pronated 15 deg, x-ray tube is directed cephalad at a 75 deg angle from the horizontal. This will give the best view of the talar neck. Sclerotic (apparent increase in density) Surrounding bones become osteopoaotic due to disuse & acute hyperemia (Aviator's Astragulus)1952 Jbjs Cohart -is hyperdorsiflex of foot by rubber bar in airplane impact Rates of Osteonecrosis -type I - 0-13% -type II - 20-50% -type III, IV - 83-100% Hawkin's sign - between week 6-8 an AP of the ankle reveals the presence or absence of subchondral atrophy. Subchondral atrophy is indicative of vascularity of the talar body thereby excluding the diagnosis of AVN. MRI can define the presence and the extent of osteonecrosis in the body of the talus as early as 3 weeks. Up to 36 months are required for complete creeping substitution of the body after union has occurred. Ideally you want to protect the patient from WB until complete revascularization occurs - Patellar Tendon Bracing is an excellent adjunct to partially relieve the load on the talar dome once WB is initiated. If the talar dome collapses - Blair Fusion - excise the avascular talar body and place a sliding corticocancellous graft from the anterior distal tibia into the residual, viable talar head and neck

Talus - Body Fractures SNEPPEN condensed · Type 1: Compressive fracture of the talar dome usually involves the medial or lateral aspect · Type 2: Shearing fracture of the talar body 2A: Coronal shearing force 2B: Sagittal shearing force 2C: Horizontal shearing force


· Type 3: Fracture of the posterior tubercle · Type 4: Fracture of the lateral process · Type 5: Crush fracture SNEPPEN CLASSIFICATION (Acta. Ortho. Scand. 45: 307, 1974)

Type I -Transchondral or compression fracture of the talar dome (including osteochondritis of the talus)

Type II Coronal, sagital, or horizontal shearing fracture involving the entire

body 2A: Coronal shearing force

2B: Sagittal shearing force 2C: Horizontal shearing force -MOA unknown but thought to be forced dorsiflexion with the foot locked, combined with axial compression -Fractures displaced > 2-3 mm @ trochlear surface should undergo ORIF -75% incidence of OA of STJ accompanies these injuries

Type III-Fracture of the posterior tubercle of the talus Shepard's FX= post lat tubercle FX. Do not confuse with Os trigonum a.k.a. Intern's FX. -MOA 1) hyperplantarflexion, or 2) avulsion of posterior talofibular ligament -Sometimes confused with os trigonum can do a bone scan to differentiate -TX-short leg NWB cast with foot in mild equinus. If pain persists - excise fragment

Type IV-Fracture of the lateral process of the talus -MOA dorsiflexion with inversion -A.k.a. "snowborder's ankle" -Tx-6wks of NWB cast immobilization in slight equinus. Large fragments can be internally fixated.

Type V-Crush fracture of the talar body -Poor prognosis -Primary arthrodesis after 2-3 weeks due to risk of soft tissue envelope if performed immediately Studies show 23% of open talar fractures went on to Osteomyelitis and may result in future talectomy Boyd and Knight (South. Med. J. 35: 160, 1942) · Type 1: Coronal or Sagittal shear fractures

1A: Non-displaced 1B: Fracture with displacement at the talo-crural joint 1C: Type 1B with displacement of the STJ


1D: Fracture with total displacement of the talar body · Type 2: Horizontal shear fracture 2A: Non-displaced 2B: Displaced

Lateral Talar Process Hawkins-Lateral Process (JBJS 47A: 1170, 1965) · Type 1: Simple fracture of the lateral process that extends from the talofibular articular surface down to the posterior talocalcaneal articular surface of the STJ. · Type 2: Comminuted fracture of the lateral process that involves both the fibular and posterior calcaneal articular surfaces of the talus and the entire lateral process · Type 3: Chip fracture of the anterior and inferior portion of the posterior articular process of the talus

Posterior Lateral Talar Process Fracture Dobas and Watson (Arch. Pod. Med. Foot Surg. 3: 17, 1976) · Stage 1: Normal posterior lateral process; no clinical significance · Stage 2: Enlarged posterior lateral process · Stage 3: Non-fused os trigonum · Stage 4: Synchondratic union of the os trigonum to the talus McGougall (JBJS 37B: 257-265, 1955) · Stage 1: A line of cleavage occurs at the impingement point · Stage 2: Posterior lateral process begins to separate from the main body of the

talus · Stage 3: Complete separation of the posterior lateral process from the talar body

Calcaneal Fractures ROWE condensed: Type I: A-fx of medial tubercle B-fx of sustentaculm tali C-fx of anterior process Type II: A-beak FX B-avulsion off Achilles insertion Type III: Oblique FX not involving STJ Type IV: Fractures involving STJ Type V: Central depression FX of STJ w/comminution Note, Rowe is usually used for extra-articular fractures. Intra-articular fractures: Rowe IV and V are usually replaced by Essex and Lopresti.


ESSEX-LOPRESTI condensed Type I: tongue fx (vertical fx line) Type II: joint depression fx (horizontal fx line) ROWE (JAMA 184: 98-101, 1963)

Type 1: A. Fracture of the medial tuberosity due to inverted or everted foot

TX: Non-displaced: CR and BK WB cast for 6 weeks. Displaced: ORIF

B. Fracture of the sustentaculum tali due to twist on a supinated foot TX: Non-displaced: CR and BK cast for 6 weeks

Displaced: ORIF C. Fracture of the anterior tubercle due to plantarflexion on a supinated ft.

Most common type I and most common in females. TX: CR and BK WB cast for 6 weeks. If symptoms persist excise the fragment.

Type 2: A. Beak fracture without Achilles insertion involvement TX: NWB BK cast for 6 weeks in plantarflexed position B. Avulsion fracture of the Achilles tendon TX: ORIF or attempt percutaneous pinning

Type 3: A. Fracture of the body without STJ involvement. Most common extra-articular. TX: NWB AK cast with knee flexed if non-displaced.

Displaced: ORIF Type 4: Fracture of the body with STJ involvement. Type 5: Comminution of the body of the calcaneus.

ESSEX-LOPRESSTI (Br. J. Surg 39: 395-419, 1952)

Type 1: Tongue type fracture with a primary fracture line running superior to inferior with a secondary fracture line exiting the posterior aspect of the calcaneus.

Type 2: Joint depression fracture with a primary fracture line running superior to inferior with a secondary fracture line surrounding the STJ.

** 75% of all calcaneal fractures are intra-articular. TX of Intra-articular Fractures Essex-Lopresti Technique: A percutaneous pinning technique using a Steinmann pin introduced into the tuberosity. The tongue fragment in reduced and the pin is placed into the anterior calcaneus or cuboid. No cast is required and motion is performed immediately. The pin is removed in 8-10 weeks at WB is begun. Indicated for Sanders 2C (87% success rate). - Closed Reduction: Used if <2mm displacement.


- ORIF a) Incisional Approaches Medial Approach: Burdeaux Combined Approach: Stephenson Extended Lateral Approach: Benirschke b) Procedure: Goal is to restore the STJ and C-C articulation Need to perform the surgery within 6-8 hours of the injury otherwise it has to wait until the swelling is reduced. Reduction is performed by placing a Steinmann pin through the tuberosity fragment to restore the STJ posterior facet. Once aligned, the tuberosity fragment is fixated to the constant fragment (sustentaculum fragment). Various plates can then be used to act as a buttress. Before arthrodesis is performed, CR or ORIF should be attempted. DEGAN (JBJS 64: 519, 1982) · Type I: Non-displaced fracture of the anterior process tip · Type II: Displaced fracture of the anterior process not involving the articular surface (extra-articular) · Type III: Displaced fracture of the anterior process involving the articular surface (intra-articular of calcaneal-cuboid jt) SANDERS (used for CT evaluation from coronal & axial CT) (Clinics of Ortho 290: 87-95, 1993) -classified by # of pieces -use letter & number * lines A and B divide the inferior portion of the talus’s posterior facet into 3 equal portions. Line C is used to separate the medial and posterior facets. A: lateral, B: midline, C: medial I: non-displaced, non-intra-articular fx.

Any number of fx lines. All non-displaced fractures no matter how many fragment

II: 2 pieces of posterior facet One fx line. 2 part fractures of the posterior facet. Use 1 letter (2A, 2B, and 2C)

III: 3 pieces of posterior facet Two fx lines. 3 part fracture of posterior facet. Use 2 letters (3AB, 3AC, & 3BC)

IV: 3 pieces of posterior facet + sustentaculum fragment Three fx lines. 4 part fracture with high degree of comminution

Anterior Process of the Calcaneous Fx. Hannover (Clinics of Ortho 290: 76-86, 1993) CT scan evaluation based on the fragments involved and the number of joint fractures · 5 Fragments:

1. Sustentaculum


2. Tuberosity 3. STJ 4. Anterior process 5. Anterior STJ fragment

***Most common is the 5 fragment/2 joint fracture

NAVICULAR FRACTURES WATSON-JONES condensed

Type 1 Tuberosity fx (Nutcracker Syn.)- severely displaced fx. & compression fx. of cubiod &/or calcaneus

Type 2 Dorsal Lip fx Type 3 Body 3A Fx. of body without displacement 3B Fx. of body with displacement

Type 4 Stress Fx. WATSON-JONES(Fracture and Joint Injuries, Watson and Jones, 5th ed., p1200) · Type I: Fracture of the navicular tuberosity-usually an avulsion fx

-24% of navicular fxs. Nutcracker Syndrome: severely displaced fracture and compression fracture of the cuboid and/or calcaneus. MOI:1)forceful eversion w/medial avulsion of the pt off of the tuberosity. 2)direct blow to the tuber.

*need to D/D OTE vs. true fx, thus take B/L films:LO#1 TX: BK cast with partial WB x 4 weeks · Type II: Fracture of the dorsal lip. Most common. TX: BK cast with partial WB x 4-6 weeks · Type III: Fracture through the body of the navicular: IIIA: without displacement TX: BK walking cast x 6-8 weeks IIIB: with displacement TX: ORIF and BK NWB cast for 6-8 weeks · Type IV: Stress fracture of the navicular If non-displaced, BK NWB cast for 4-6 weeks. If displaced, ORIF followed by BK NWB 6-8 weeks.

Accessory Navicular-Os Tibials Externum Geist-(1914) First described by Bahin 1605

Type1 sesamoid in tendon Type2 articulating os center (Sella-Clin Ortho-86, Foot&Ankle-87)

2A synchondrosis acute angle 2B synchondrosis obtuse angle


Type3 fused accessory os center

Navicular Classifications Wilson- chip/comminuted/crush Watson Jones- tubersoity, dorsal lip,& transverse DePalma- dorsal lip, avulsion, tuberosity & Fx dislocation Rockwood & Green- body Fx w/ & w/o dislocation, chip, tuberosity Goldman- chip, tuberosity, body, displaced, osteochondral Fx

STJ DISLOCATIONS Buckingham · Type 1: Medial STJ dislocation (FF goes medially and Talar head moves laterally) · Type 2: Lateral STJ dislocation · Type 3: Anterior and posterior STJ dislocation

TARSAL COALITIONS DOWNEY (JAPMA 81: 187-197, 1991) Juvenile (Osseous Immature)

Type I: Extra-articular coalition A: No secondary arthritis TX: Badgley procedure B: Secondary arthritis TX: Resection, Triple

Type II: Intra-articular A: No secondary arthritis TX: Resection, Isolated arthrodesis, Triple B: Secondary arthritis TX: Triple Adult (Osseous Mature)

Type I: Extra-articular A: No secondary arthritis TX: Resection, Triple B: Secondary arthritis TX: Triple

Type II: Intra-articular


A: No secondary arthritis TX: Isolated, Triple B: Secondary arthritis TX: Triple

CHOPART FRACTURES Main and Jowett (JBJS 57B: 89, 1975) · Classification is based on the direction of the deforming force and the resulting displacement 1. Medial Force · Type A: Flake fracture of the dorsal talus OR navicular and of the lateral calcaneus OR cuboid · Type B: Medial displacement of the forefoot with medial disassociation of the T-N and C-C joints · Type C: Forefoot rotates medially around the interosseous talocalcaneal ligament, with T-N disassociation and the C-C joint intact 2. Longitudinal Force · Type A: Maximally plantarflexed ankle giving a characteristic pattern of through and through navicular compression fracture:

A1: Force through the 1st ray: Crushes the medial 3rd with the tuberosity displaced medially A2: Force through the 2nd ray: Crushes the middle 3rd with the middle

3rd and tuberosity displaced medially A3: Force through the 3rd ray: Crushes the lateral 3rd with the medial

2/3rds and tuberosity displaced medially · Type B: Submaximally plantarflexed ankle resulting in a dorsal displacement of the superior navicular and the crush of the inferior portion on the ? 3. Lateral Forces · Type A: Forefoot forced into valgus with a resulting fracture of the navicular tuberosity OR dorsal talus and a compression fracture of the C-C joint (Nutcracker Fracture) · Type B: T-N joint displaces laterally with comminution of the C-C joint 4. Plantar Forces · Type A: Avulsion fracture of the dorsal navicular OR talus and the anterior process · Type B: Impaction fracture of the inferior C-C joint


Lis Franc's Dislocation Hardcastle Quenu & Kuss Type A Convergent Homolateral Type B1 & B2 Isolateral Type C1 & C2 Divergent QUENU AND KUSS (Rev. Chir. 39: 281-336, 720-91, 1093-134, 1909)

Convergent homolateral 1-5 mets sublux laterally

All 5 metatarsals are displaced in the transverse plane laterally Isolateral

1st met sublux med or 2-5 mets sublux laterally 1 or 2 metatarsals are displaced in the transverse plane laterally

Divergent 1st met sublux med & 2-5 sublux laterally

Displacement is in both the sagital and transverse plane HARDCASTLE (JBJS 64B: 349, 1982)

Type A Total Incongruity A1-Lateral A2-Dorsoplantar plane

Type B Partial Incongruity B1 Partial medial displacement

1st met med displaced &/or in combination with 2,3,4 mets B2 Partial lateral displacement

lat displacement of 2-4 one or more lesser mets Type C Divergent

Divergent: 1st metatarsal is displaced medially and lesser mets laterally C1-Partial incongruity 1st met med displaced & any combination of 2,3,4 mets displaced lat C2-Total displacement 1st met med displaced & mets 2-5 displaced laterally TREATMENT OPTIONS: 1.cast immobilization=sprains 3-5 weeks. 2.closed reduction & percutaneous pinning. 3.ORIF REDUCING SEQUENCE: 1. 2nd met on middle cuneiform. once stabilized lesser mets will follow.


2. next stabilize 1st met, then lat mets. POST OP CARE: BK casting for 6 to 12 weeks. initial NWB 6-8 weeks partial WB approx 6 weeks. begin ambulation in stiff soled shoe. PT ASAP. accommodative orthotics. COMPLICATIONS: MAJORITY-post DJD SERIOUS-circulatory compromise Myerson (Foot and Ankle 6(5): 225, 1986) · Type A: Total displacement in any plane or direction · Type B1: Medial Displacement of 1st met · Type B2: Lateral Displacement affecting 1 or more lesser mets · Type C1: Partial displacement of 1st met medially and lesser mets laterally · Type C2: Total displacement with a divergent pattern with total incongruity

PT Rupture Classifications MUELLER I. direct injury II. pathologic rupture(RA) III. idiopathic IV. functional abnormality

MRI Rupture Stages CONTI

I. 1-2 fine, longitudinal tears II. intramural degeneration, variable diameter III. diffuse swelling

Peroneal tendon subluxations Eckert Grade 1 - retinaculum & periosteum separated from fibro-cartilaginous lip Grade 2 - fibrous lip elevated along w/ retinaculum Grade 3 - thin fragment of bone elevated along w/ fibrous lip


FOREFOOT FRACTURES

5 TH METATARSAL FRACTURES

STEWART CLASSIFICATION-condensed

• Type 1: True Jones fx. Extra-articular fx of metaphysis, (approx 1 cm from the joint)

• Type 2: Intra-articular fx of 5th met base. • Type 3: Avulsion fx. of styloid process (5th met base) • Type 4: Comminuted intrarticular fx of 5th met base. • Type 5: Partial avulsion of epiphysis in children

STWEART1960 Clin Ortho(5th Met fx) Stewart described only the first 4 types · Type 1: True Jones Fracture at the metaphysis of the 5th met base approx 1 cm from the articular cartilage. Either transverse or oblique fracture. (This is due to rotation of the forefoot with the base of the 5th met remaining fixed; not seen with inversion ankle sprains). This type of injury has a high propensity for non-union. (Sir Robert Jones 1902- 4 fxs including his own) MOI-internal rotation, PF ankle and adduction of forefoot TX: Non-displaced, BK NWB cast x 4-6 weeks. If displaced, ORIF. · Type 2: intra-articular fracture of the base 5th met into 5th met-cuneiform jt. MOI- Shear force. Resulting from contraction of the peroneus brevis. TX: If non-reducible, ORIF. If reducible, BK NWB cast for 4-6 weeks. · Type 3: Avulsion of the base of the 5th (styloid process). AKA Tennis Fx. MC 5th met fx. MOI-contraction of PB with DF of ankle TX: If reducible, BK NWB cast for 4-6 weeks. If non-reducible, ORIF (possibly tension band wiring). · Type 4: Comminuted intra-articular fracture of the base of the 5th. MOI-crush TX: BK NWB cast for 4-6 weeks. If severely displaced, bone grafting and ORIF. · Type 5: Partial avulsion fracture of the epiphysis (located in a longitudinal direction) in children. Risk of Iselin's AVN. AKA Salter-Harris type 1 TX: BK NWB cast 4-6 weeks. REVIEW ARTICLE - Lawrence F&A '93 Confusion of 3 fx.'s 1) Jones fx. 2) diaphyseal stress fx. 3) tuberosity avulsion fx. Shereff F&A '91 Spalteholtz tech. of 5th blood supply/ nutrient art. prox & med 1/3 med shaft


On X-ray it heals med. to lat. FIXATION; tension band wire, low profile plate, screws, cross k-wires, 4.5 malleolar screw COMPLICATIONS; sural nerve entrap apophysis fused at 9-12 Torg et al JBJS 1984 Torg · Type 1: Acute Jones fracture · Type 2: Delayed union of a Jones fracture or diaphyseal stress fracture · Type 3: Non-union of a Jones fracture or a diaphyseal stress fracture Champman · Type IA: Jones fracture · Type IB: Displaced Jones fracture with possible comminution · Type II: Delayed or non-union of a Jones fracture · Type IIIA: Avulsion fracture of the styloid · Type IIIB: Intra-articular fracture of the styloid

Metatarsal Head \ FRIEBERG’S INFRARCTION Type 1 - met head dies but heals by replacement: articular surface preserved Type 2- head collapses but articular surface remains: Peripheral osteophytes (dorsal) Type 3 - head collapses with articular cartilage loosening: joint is destroyed Type 4 - multiple heads involved

1st Met Dislocation JAHASS condensed Type1 Dorsal dislocation of prox phalanx & sesamoids with intersesamoid lig intact Type2 Dorsal dislocation of prox phalanx & sesamoids with rupture of intersesamoid lig 2A no sesamoid fx. 2B transverse fx of a sesamoid JAHSS (Foot and Ankle 1: 15, 1980) *Secondary to extreme dorsiflexion · Type 1: Dorsal dislocation of Proximal phalanx and sesamoids with the intersesamoidal ligament intact (Requires ORIF)


· Type 2A: Dorsal dislocation of proximal phalanx and sesamoids and rupture of the intersesamoidal ligament. TX: CR and Reece shoe or BK walking cast. · Type 2B: Dorsal dislocation of proximal phalanx and sesamoids and rupture of the intersesamoidal ligament and fracture of one sesamoid. TX: CR and followed by Reece shoe or BK NWB cast or excision of the fractured sesamoid.

Nail injuries ROSENTHAL -(Ortho Clinics of NA 14(4): 695, Oct, 1983) Zone 1 Distal to phalanx Zone 2 Distal to lunula Atasoy=plantar V-Y advance Kutler=bi-axial V-Y advance Zone 3 Proximal to the distal end of lunula (TX. amputation) If nail bed is lacerated = open fx.

Physeal Injuries: SALTER-HARRIS I. fx through physis Same II. physis/metaphysis Above III. physis/epiphysis Lower IV. epiphysis/metaphysis Through Epiphysis V. crush injury Real Bad

SALTER-HARRIS CLASSIFICATION OF FRACTURE Site: epiphyseal, metaphysis, diaphysis. Extent: complete vs. non-complete Configuration: transverse>oblique>spiral>communited Position: rotated ,angulated distracted, impacted overiding, lateral shift Environment: open vs. closed

SALTER-HARRIS (Skeletal Radiology 6: 237-253, 1981) Describes physeal injuries · Type 1: Complete transverse separation of the epiphysis from the metaphysis through the physis. Epiphysis separates from the metaphysis without any bone fragments-germ cells remain with epiphysis

-shearing force-seen in pathologic fractures -common in infants


-reduction not necessary. -growth is not disturbed, unless associated aseptic necrosis and premature closure of the physis.

TX: CR if seen within 7 days of the injury, followed by 3-4 weeks of casting. · Type 2: Epiphysis is separated from the physis with the fracture extending into the metaphysis (Thurston-Holland sign)

TX: CR if seen within 7 days of the injury, followed by 3-4 weeks of casing. · Type 3: Partial separation of the physis with an intra-articular break into the epiphysis (Tillaux fragment) · Type 4: Intra-articular fracture extending from the epiphysis into the metaphysis. · Type 5: Impaction of the epiphysis into the physis and metaphysis resulting in comminution. TX of 3,4, and 5: Should attempt to close reduce, but usually requires the anatomic reduction of the physis. Fixation should be kept within the metaphysis. Rang · Type 6: Perichondral injuries produced by a shearing force resulting in a cup-shaped fragment of epiphyseal, physeal, and metaphyseal bone with possible degloving (tear of the 'ring of Lacroix') Ogden · Type 7: Intra-epiphyseal fracture that does not involve the physis · Type 8: Transverse fracture of the metaphysis only · Type 9: Diaphyseal growth injury resulting in periosteal elevation and possible degloving of the periosteum. Peterson (J Pediatric Ortho 14: 439, 1994) · Type 1: Transverse fracture of the metaphysis with extension to the physis by way of longitudinal compression (15.5%). · Type 2: Separation of part of the physis with a part of the metaphysis attached (Thurston-Holland sign). Salter-Harris type 2 (53.6%). · Type 3: Separation of the epiphysis from the diaphysis through the physis. S-H type 1 (13.2%). · Type 4: Separation of a portion of the physis with extension of a fracture into the joint. S-H type 3 (10.9%). · Type 5: Fracture involving the metaphysis, physis, and epiphysis. S-H type 4 (6.5%). · Type 6: Fracture involving a missing portion of the physis. Often caused by open fractures, lawn mower injuries, farm machinery, or other power equipment.


Poland · Type 1: Separation of the epiphysis from the metaphysis · Type 2: Partial separation of the epiphysis from the metaphysis with fracture of the diaphysis (Thurston-Holland sign) · Type 3: Partial separation of epiphysis from the metaphysis with a fracture of the epiphysis. · Type 4: Complete separation of the epiphysis from metaphysis with a fracture of the epiphysis. Weber · Type A: Extra-articular A1: Separation of the epiphysis and metaphysis A2: Fragments in the epiphysis or metaphysis · Type B: Intra-articular B1: Within the physis extending into the epiphysis B2: Through the epiphysis, physis, and metaphysis.

OPEN FRACTURES GUSTILO & ANDERSON condensed Type 1- wound <1cm & clean inside-outside wound Type 2- wound >1cm & no extensive soft tissue damage Type 3- extensive skin, soft tissue, muscle, & neurovasc. damage 3A-adequate tissue coverage -high energy 3B-periosteal stripping, -massive comminution 3C-arterial injury GUSTILO AND ANDERSON (JBJS 58A: 453, 1976) · Type I: Open fracture with a wound < 1cm. and clean. Simple, transverse or short oblique fx with little comminution. No crush involved. · Type II: Open fracture with a laceration > 1cm. without extensive soft tissue damage, slight or moderate crushing injury, moderately comminuted fx, moderate contamination. · Type III: Open fracture with extensive soft tissue damage > 5cm wound, high degree of contamination, severe comminution, assoc. with high velocity injury. Special types include: gunshot, farm injuries, arterial injuries, and motor vehicle accidents

IIIA: Adequate soft tissue coverage IIIB: Extensive soft tissue loss/damage with periosteal stripping, requires local or

free flap.


IIIC: Any open fracture associated with arterial injury requiring repair. Type lllC is assoc. with amputation rate of 25-90%. Absolute indications for primary amputation:

HALLUX LIMITUS REGNAULD(The Foot, 1986) Grade 1- functional hallux limitus, dorsal spurring sesmoids intact with no-disease assoc. with them

no jt. dx. Arthrosis, <40° dorsiflexion and <20° plantarflexion, joint enlargement, but joint space narrowing.

Grade 2- broad flat met head, narrow jt. space, structural elevatus, sesmoid hypertrophy,

osteochondral defects in the met head, significant spurring. Pain at rest, 75% decrease in total ROM, joint space hypertrophy, -An example is an osteochondral defect surrounded by chondromalascia

Grade 3- severe loss of jt. space, extensive peri-articular spurs, extensive 1st met-sesmoid dx.,

osteochondral defect with jt mice present -must have collapse of the jt.--bone on bone. Ankylosis, articular hypertrophy, FDL contracture, hypertrophy of sesamoids, osteophytes.

MODIFIED REGNAULD/OLOFF (ACFAS, 1994) · Stage 1: Functional Hallux Limitus - Limited dorsiflexion with weightbearing, but normal with non-weightbearing, NO DJD changes on x-ray, NO pain on end ROM. · Stage 2: Joint Adaptation - Pain on end ROM, Flattening of met head, small dorsal exostosis. · Stage 3: Joint Deterioration - Crepitus on ROM, non-uniform joint space narrowing, subchondral sclerosis and cyst, osteophytes, severe flattening of met head. · Stage 4: Ankylosis - Obliteration of the joint space, osteophyte fragmentation, ROM minimal to none. Drago, Oloff, and Jacobs (JFAS, 1984) · Grade 1: Pre-hallux limitus; Metatarsus primus elevatus, subluxed proximal phalanx, and pain on end ROM. · Grade 2: Flattening of metatarsal head, osteochondral lesion, pain on end ROM.


· Grade 3: Severe flattening of the met head, osteophytes, dorsal exostosis, pain on full ROM. · Grade 4: Obliteration on joint space, joint mites, <10° ROM (may be asymptomatic if ankylosed. Hanft (JFAS, 1993) · Grade I: Metatarsus primus elevatus, mild dorsal exostosis, and sclerosis around MPJ. · Grade II: Grade I, flattening of met head, joint space narrowing, dorsal and lateral osteophyte. · Grade IIB: Grade II, and DJD findings (osteophytes, subchondral sclerosis and cyst) · Grade III: Grade II and severe flattening, sesamoid hypertrophy. · Grade IIIB: Grade III and DJD findings Ktavitz, Laporta, Lauton 1994 :

1- zero to mild flattening of the head 2- minimal narrowing, 3a- dorsal spurring, cysts with irregular narrowing, 3b- minimal space, loose bodies, large dorsal flag 4- no space, sesmoid fusion, large exostosis formation

Posterior Tibial Tendon Dysfunction

JOHNOSON AND STROM STAGES I. medial foot and ankle pain, and normal tendon length with mild degeneration II. supple flat foot, too many toes sign, attenuation or PT rupture, increased talar 1st met angle, abducted forefoot, uncovering of talar head III. rigid flat foot, calcaneal fixed valgus, dc stj ROM (complete PT rupture) IV. valgus tilt of talus/ankle mortise leads to lateral tibiltalar degeneration Wilson (JBJS 54B: 677, 1972) · Inversion Injury Stage 1: 4 lesser mets move laterally; divergent diastasis Stage 2: Stage 1 and the 1st met moves dorsolateral with other mets · Eversion Injury Stage 1: Medial dislocation of the 1st met Stage 2: Lesser 4 mets dislocate dorsolateral; divergent diastasis


Ulcerations WAGNER (Foot and Ankle 2: 64-122, 1981) · Grade 0: No open lesions in the skin. Bony prominence and structural deformity present. · Grade 1: Superficial ulcer without penetration to the deep layers. · Grade 2: Deep ulcer penetrating to tendon, bone, joint capsule, or ligament. · Grade 3: Grade 2 depth with the presence of infection. · Grade 4: Gangrene of the forefoot · Grade 5: Gangrene of the entire foot

Wound, Ostomy and Continence Nurses Society (formerly I.A.E.T.) in their Standards of Care 1987 This classification is often used in the hospitals Stage 1-Nonblanchable erythema of intact skin Stage 2-Partial thickness loss of skin involving epidermis, dermis or both. Ulcer is superficial and presents clinically as an abrasion, blister or shallow crater Stage 3-Full-thickness tissue loss involving damage to or necrosis of subcutaneous tissue that many extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4-Full thickness tissue loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g. tendon, joint capsule) Undermining and sinus tracts also may be associated. USAHSC (Journal of Foot and Ankle Surgery 35: 528-531, 1996) · Grade 0: Pre or Post ulcerative lesion completely epithelialized · Grade 1: Superficial wound not involving tendon, capsule, or bone · Grade 2: Wound penetrating to tendon or capsule · Grade 3: Wound penetrating to bone or joint Within each grade there are 4 subtypes: A: non-ischemic, clean wound B: infected wound C: ischemic wound D: infected and ischemic wound

DIABETIC FOOT ULCERS Meade and Mueller (Med Times 96: 154-169, 1968) · Type 1: Dorsal foot phlegmon (non-localizing, cellulitic, infectious process) · Type 2: Deep plantar space infection · Type 3: Mal perforans neuropathic foot ulcers (subclassed by Wagner and USATHC)


MALIGNANT MELANOMA Clarks (Cancer Res 29: 705-727, 1969) · Based on the histological level of invasion · Level 1: Located in the epidermis or epidermal-dermal junction · Level 2: Located in the papillary dermis · Level 3: Located in the papillary to reticular dermis · Level 4: Located down into the reticular dermis · Level 5: Located within the subcutaneous tissue Breslow's (Ann Surg. 172: 902-908, 1970) · Based in the thickness of the melanoma · Level 1: < .75mm (99% cure) · Level 2: .76-1.5mm · Level 3: 1.51-4.0mm · Level 4: > 4.0mm

Non-Union Of Fracture WEBER AND CECH Hypervascular (Hypertrophic)90% 1. Elephant foot 2. Horse Hoof 3. Oligotrophic Avascular (Atrophic)10% 1. Torsion Wedge 2. Comminuted 3. Defect 4. Atrophic

PERONEAL SUBLUXATIONS EKERT AND DAVIS (JBJS 58A: 670, 1976) · Grade 1: Retinaculum ruptures from the cartilaginous lip and lateral malleolus · Grade 2: Distal edge of the fibrous lip is elevated with the retinaculum · Grade 3: Thin fragment of bone is avulsed from the deep surface of the peroneal retinaculum and deep fascia


PVD CLASSIFICATION MEDICARE CLASS A: A1-nontraumatic amputation of foot or integral portion thereof CLASS B B1-absent PT pulse B2-advanced trophic changes such as (3 required) 2a-hair growth dec. Or absent 2b-nail changes (thickened) 2c-pigmentary changes 2d-skin texture(thin, shiney) 2e-skin color (rubor, redness) B3-absent dorsalis pedis pulse CLASS C C1-claudication C2-temperature changes(cold feet) C3-edema C4-parathesias C5-burning

Soft Tissue Injury Tscheme and Gotzen Grade 0-Little or no soft tissue inj. Grade 1-Significant abrasion or contusion. Grade 2-Deep contaminated abrasion with local contusional damage to skin or muscle. Grade 3-Extensive contusion or crushing of skin or destruct. of muscle, also includes subq. avulsions, decompen

Posterior Tibial Malleolar Fx Volkmans · Type A: Large intra-articular fracture (>25% of surface area) with displacement · Type B: Small intra-articular fracture (<25%) with impaction · Type C: Small fracture with minimal impaction and articular damage · Type D: Avulsion of the posterior-inferior tib-fib ligament without articular involvement


Polydactyly Blauth & Olason Radiographic and morphological presentation of the deformity. Describes the position of the duplication in both the longitudinal and transverse planes. 1. Longitudinal Type: describes degree of duplication of the ray from distal to proximal, with a division into 5 types: 1. Distal phalanx 2. Middle phalanx 3. Proximal phalanx 4. Metatarsal 5. Tarsal 2. Transverse Type: indicates which rays are involved in the duplication, classification in roman numerals starting with the 1st ray and ending with the 5th ray. Roman numerals starting with the 1st ray and ending with the 5th ray.

Charcot Sanders & Freykberg 1) ipj & phalanx, mpj & metatarsals 2) tmj (Lis Franc's) 3) nc & tn cc 4) ankle 5) calcaneous

Classifications of Osteomyelitis:

Waldvogel Hematogenous: Spread via the Blood, starts inside the bone and works out

towards the cortex. SEEN MOST COMMONLY IN THE METAPHYSEAL REGION OF CHILDREN with open plates

Direct Extension: secondary to trauma or sx, affects periosteum 1st, then cortex and marrow. Proteolytic enzymes destroy Sharpey's fibers

Contiguous: Spread of infected soft tissue to underlying bone Vascular Insufficiency--> PVD

Cierny and Mader

Anatomic Type 1. Medullary


2. Superficial 3. Localized 4. Diffuse

Physiologic Type A-Host: Good immune system and delivery

Normal immune response Normal Metabolic Reserve Good Vascular Supply

B- Host: Compromised locally or systemically Metabolic Compromise Nutritional Compromise IMMUNOLOGIC Compromise Impaired Vascularity Systemic Illness

C-Host: No treatment because treatment is worse then the disease Minimal Disability High Morbidity Poor Prognosis for Cure

Buckholz (Journal of Foot Surgery 26(1): 17, 1987 supplement) · Type 1: Wound induced osteomyelitis 1A: Open fracture with complete incontinuity 1B: Penetrating wound of injury 1C: Post-op infections · Type 2: Mechanogenic osteomyelitis 2A: Implants and internal fixation 2B: Contact instability as bone-to-bone appositional movement · Type 3: Physeal osteomyelitis · Type 4: Ischemic limb disease · Type 5: Combination osteomyelitis, types 1-4 as acute bone infections · Type 6: Osteitis with septic arthritis · Type 7: Chronic osteomyelitis


Name that Surgery Author’s note: Since the names of surgeries come up on residency interviews and different boards, here is an incomplete list of surgeries with some indications and a brief description of the procedures. –Brett Akin Indication: for large DASA proximal Akin Long proximal phalanx central Akin High Hallux interphalangeal angle distal Akin Procedure: Medially based Wedge osteotomy of proximal phalanx Austin If you don’t know this one, stop reading this and find a paper bag to cover your head in shame. Baja Project Indications: For Clubfoot Procedure: Cuboid decancellation procedure Laterally based wedge of bone removed from cuboid and lateral cuneiform Baker Indications: For Achilles tendon lengthening Procedure: Tongue in groove with the tongue distal, facing upward Baker and Hill Indications: For pes planus, medial column repair Procedure: Wedge shaped graft into posterior facet Bankart Indications: For Met Adductus, ages 8 and above Procedure: Excise cuboid Brostrom-Gould Indications: For lateral ankle instability Procedure:

1. Incise capsule 2-3 mm distal to lat malleolus, tighten capsule 2. Mobilize extensor retinaculum, pull over capsule and suture

Brostrom-Gould Indications: Lateral Ankle stability. Procedure: Tightening of lateral ankle capsule (with ATF), CFL and the lateral portion of the extensor retinaculum Brown Indications: For Met Adductus, ages 2-6


Procedure: 1. Transfer TP into Nav 2. Medial capsulotomy of nav-cun jt

Chambers Indications: For pes planus, medial column repair Procedure:

1. TAL 2. Bone graft under sinus tarsi (similar to arthroesis)

Chiappara Indications: For pes planus Procedure: 1. A Silver (Opening wedge calc osteotomy from lateral side) with TP advancement 2. TA tenodesis to TP Chielectomy Indications: For Hallux Limitus Procedure: Remove portion of bone of the dorsal part of 1st met Chielectomy Indiacation: Hallux limitus Procedure: removal of dorsal bump of 1st met head and prox phalanx base Chondrotomy by Johnson Indications: For Met Adductus ages 6-8 Procedure:

1. Resect 2.5 mm lateral based wedge (apex medially) of cartilaginous of mets 2-5, enlarge bases medially

2. use lateral base wedge osteotomy distal to epiphysis of 1st 3. lengthen AbH

Christman Shook Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: Split PB thru lat malleolus (ant to post) thru calc and sutured to other ½ of PB Cobb Indications: For pes planus, medial column repair Procedure: Hemi section of TA left intact to insertion, augments TP Cormick and Blount Indications: For Met Adductus, ages 8 and above Procedure:

1. Arthrodesis of 1st met-cun 2. Osteotomy of 2-4


Cotton Indications: For pes planus, medial column repair Procedure: Opening wedge osteotomy of medial cuneiform Drato Indications: Large 1st IMA, abnormal PASA, valgus rotation of the 1st met Procedure: Derotational osteotomy of 1st met head Dwyer For cavus foot: Lateral wedge resection of calcaneous. Allows the calc to go into valgus For pes planus: Medial wedge resection of calc. Calc will go into a more varus position. Dwyer Indications: For Clubfoot Procedure: Opening wedge medial calcaneal osteotomy Elmslie Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: Tensor Fascia Lata thru cal, thru lat malleolus, thru talus back thru lat malleolus and back thru calc. Evans Indications: For lateral ankle instability, reinforces ATFL Procedure: PB detatched prox, PB thru lat mallolus and attached to lat malleolus (similar to Nilsone). Prox PB attached to PL Evans Indications: For pes planus Procedure: Lateral wedge of graft inserted into calc roughly 1 cm from C-C jt Evans-For Clubfoot Indications: For Clubfoot Procedure: Shorten lateral column by calc-cuboid fusion Fowler Indications: For Clubfoot Procedure: Autogenous bone graft into medial cuneiform Fowler Indications: For Met Adductus, ages 8 and above Procedure: Opening wedge osteotomy of medial cuneiform Gartland Berman Indications: For Met Adductus, most popular osseous procedure, ages 8 and above Procedure: Osteotomies of 1-5


Gerbert Indication: Tailor’s bunion Procedure: Oblique wedge osteotomy at 5th met base Ghali Indications: For Met Adductus, ages 2-6 Procedure:

1. Anterior medial release of nav-cun and 1st met-cun 2. Division of TA at medial aspect of med cun

Gleich Indications: For pes planus Procedure: Oblique calc osteotomy displaced anteriorly Hambly Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: Split PL into talus (or attached to it) thru lat malleolus (ant to post) thru calc and attached to other ½ of PL Heyman, Herndon and Strong Indications: For Met adductus, ages 2-6 Procedure: Cut ligaments and capsule of tarso-met ligaments 1-5 Don’t cut lat 1/3 of plantar ligament Hibbs Indications: To Decrease MTPJ buckling, increase DF Procedure:

1. EHL is detached at the met heads and attached to the lateral cuneiform or 3rd met 2. Distal stubs of EHL is attached to EDB at met head area

Hoke’s Indications: For Achilles tendon lengthening Procedure: Triple tenotomy of Achilles tendon, cut the proximal and distal ½ medially, the middle ½ is cut laterally Hoke Indications: For pes planus, medial column repair Procedure:

1. TAL 2. Fusion of Nav to medial and intermediate cuneiform

Hohman Indication: HAV (reverse Hohman is for tailor’s bunion) Procedure: Through and through transverse osteotomy at the neck Jones


Indications: For cock-up hallux, weak TA, enhance DF Procedure:

1. EHL is detached and inserted into 1st met head via a medial to lateral drill hole 2. IPJ fusion 3. Stump of EHL is attached to EHB

Juvara Indications: For HAV Procedure: Oblique CBWO Kalish Indications: For HAV Procedure: An Austin with long dorsal arm for screw fixation Kelikian Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: Use of plantaris tendon. From calc, into lat malleolus (post to anterior) thru talus neck, back out and thru lat malleolus (ant to post), back into calc and then sutured on itself. Did you get all of that? Kessell Bonney Indication: Hallux limitus Procedure: removal of Dorsiflexory wedge of bone from prox phalanx Kidner Indications: For pes planus, medial column repair Procedure: Remove bump of Nav, reattach TP more plantarly Koutsogianis Indications: For pes planus Procedure: Medial displacement osteotomy of calc Lambrindi Indication: Hallux limitus Procedure: PF osteotomy of 1st met base Lange Indications: For Met Adductus, ages 2-6 Procedure: Capsulotomy of 1st met-cun, followed by serial casting Lee Indications: For lateral ankle instability, reinforces ATFL Procedure: PB detatched prox, thru lateral malleolus (post to ant) and sutured upon itself. Prox PB attached to PL Leprid


Indications: For Met Adductus, ages 8 and above Procedure:

1. 3 incision technique 2. Oblique adductory wedge osteotomy of 5th 3. Osteotomies of 2-4 from dorsal distal plantar prox, parallel to weight bearing

surface 4. Oblique osteotomy of 1st met

Lichtblau Indications: For Clubfoot Procedure: Resection of lateral base bone from calc (shortens lateral column) Lichtblau Indications: For Met Adductus, ages 2-6 Procedure: Sectioning of spastic AbH Lindholm Indications: For TAL ruptures Procedure: Two flaps from proximal TAL reflected distally Logroscino Indications: For HAV and increased DASA Procedure: CBWO and Reverdin Loison Indications: For HAV Procedure: Transverse CBWO Lord Indications: pes planus Procedure: A Gleich (Oblique calc osteotomy) displaced anteriorly, medially & inferiorly Lowman Indications: For pes planus, medial column repair Procedure: 1. TAL 2. Talo-nav wedge arthrodesis 3. Reroute TA under Nav and suture into spring ligament 4. Tenodesis of medial arch by taking slip of TA and reflect downward (leave its insertion to the calc still intact) Lund Indications: For Clubfoot Procedure: Talectomy Lynn


Indications: For TAL ruptures Procedure: End to end attachment McGlammary Modification A modification of Baker’s technique Indications: For Achilles tendon lengthening Procedure: Tongue in groove with the tongue distal, facing downward Mercado Indication: Tailor’s bunion Procedure: Oblique wedge osteotomy at 5th met neck Miller Indications: For pes planus, medial column repair Procedure:

1. TAL 2. Fusion of Nav to medial cuneiform to first met 3. Advance the medial soft tissues

Murphy Indications: For spastic equinus Procedure: Anterior transfer of TA into calc. Modification is to route under FHL. Nilsone Indications: For lateral ankle instability Procedure: PB detatched prox, PB thru lat mallolus and attached to lat malleolus. Prox PB attached to PL Oats Procedure Indications: For posterior medial talar osteochondral lesion. Procedure: Take plug of bone with articular cartilage from knee and through a trans-tibial approach insert it into the talus PBTT (Peroneus Brevis Tendon Transfer) Indications: for type 1 vertical talus and severe pes valgoplanus Detatch PB and reroute dorsally to talar neck. I have also seen it described as transferred to lateral cuneiform or 3rd met Peabody Indication: Large PASA Procedure: A Reverdin done in the 1st met neck Peabody-Muro Indications: For Met Adductus, ages 8 and above Procedure:


1. Excise bases of mets 2-4 2. Osteotomy of 5 3. Mobilize 1st met-cun

PLTT (Peroneus Longus Tendon Transfer) Indications: For drop foot, anterior muscle weakness, flexible cavus Procedure:

1. Cut PL near PB insertion site, suture distal PL to PB 2. 2. Reroute PL dorsally to 3rd cuneiform

Reverdin Indications: A bunionectomy for increased PASA Reverdin Indication: Large PASA Procedure: Head procedure of 1st met Reverdin Green Indication: Large PASA Procedure: Head procedure of 1st met, saves sesamoids Reverdin Laird Indication: Large PASA and IMA Procedure: Head procedure of 1st met Scarf Indications: For HAV Procedure: A ‘Z’ type osteotomy in the shaft of 1st met Seeburger Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: Hemisection of PL. From talus, into lat malleolus into calc. Selakovich Indications: For pes planus, medial column repair Procedure: 1. Osteotomy and grafting of sustentaculum tali 2. Tightening of medial structures 3. Re-route ½ of TA into Nav Selakovich Indications: For pes planus, medial column repair Procedure: 1. Osteotomy and grafting of sustentaculum tali 2. Tightening of medial structures 3. Re-route ½ of TA into Nav


Silver Indications: For pes planus Procedure: Opening wedge calc osteotomy from lateral side (often this is called an Opening Wedge Dwyer) Silverskiold Indications: For Achilles tendon lengthening Procedure: Resection of the Gastroc heads at their attachment to the femoral condyles and reinserted into the proximal tibial area. Makes a 3-jt muscle into a 2-jt muscle. Silver and Simon Procedure: Neurectomy with reinsertion of Gastroc to proximal tibial Sliding ‘Z’ lengthening Indications: For Achilles tendon lengthening Procedure: Most commonly, this ‘Z’ is in the frontal plane. DF foot will cause the ends of the tendon to separate from each other. Stamm CBWO and Keller STATT (Split Tibialis Anterior Tendon Transfer) Indications: Increase true ankle DF, decrease long extensor swing phase, decrease adductovarus FF Procedure: ½ of TA is detached and rerouted and inserted into peroneus tertius or (if the peroneus tertius is not present) to the cuboid. (Essentially it’s the same as a TATT to the peroneus tertius but only ½ of the tendon is used.) Steytler & VanDerWalt Indications: For Met Adductus, ages 8 and above Procedure: ‘V’ osteotomy of all mets Stoffel Procedure: Neurectomy for spastic Gastroc equinus Strayer Indications: For Achilles tendon lengthening Procedure: Distal recession with the complete cutting of the aponeurosis. The proximal portion is sutured to the deeper soleus Tachdjian-Grice Indications: For Met Adductus, ages 8 and above Procedure:

1. Extra-articular arthrodesis for rearfoot


2. Soft tissue release of forefoot

TATT (Tibialis Anterior Tendon Transfer) Indications: To decrease forefoot supinatory twist, increase true ankle DF Procedure: TA is detached and rerouted and inserted into lateral cuneiform or 3rd met. I have also heard this procedure described as a transfer into the peroneus tertius or the cuboid if the peroneus tertius is not present. However, I heard that it is better to do a STATT than transfer the TA into the peroneus tertius because there are less complications. Thompson Indications: For Met Adductus with hallux varus, ages 2-6 Procedure: resect AbH Trethowan Indications: For HAV Procedure: Opening base wedge osteotomy TPTT (Tibialis posterior tendon transfer) Indications: For Drop Foot, eliminate flexor substitution Procedure: TP is detached at its insertion to nav, re-routed thru the interosseous membrane of the tibia and fibula, brought anteriorly and then inserted into the lateral cuneiform Valenti Indications: For Hallux limitus Procedure: Involves taking the dorsal section of the 1st met and prox phalanx to increase ROM Vogler Indications: For HAV Procedure: Offset ‘V’ bunionectomy. The ‘V’ is made in the neck of the 1st met Volpius and Stoffel Indications: For Gastroc Equinus repair Procedure: Distal resection of Gastroc aponeuresis by using an inverted ‘V’. Don’t suture to Soleus. Waterman osteotomy Indication: Hallux limitus Procedure: Removal of wedge of bone from 1st met head to DF capital fragment Watson Jones Indications: For lateral ankle instability, reinforces ATFL


Procedure: PB detatched prox, thru lateral malleolus into talus back thru lat malleolus and sutured upon itself Weinstock Indications: For HAV Procedure: Cresentic osteotomy Whinfield Indications: For lateral ankle instability, reinforces ATFL and CFL Procedure: PB detatched prox, PB left attached to its insertion, brought thru lat malleolus (ant to post) and inserted into calc. White Indications: For Achilles tendon lengthening Procedure: Tenotomy of anterior 2/3 of distal of TA, the medial proximal 2/3 of the TA. This resects the gastroc due to its twisting before it’s insertion Wilson Indication: HAV (reverse Hohman is for tailor’s bunion) Procedure: Oblique through and through osteotomy at the neck Yancey Indication: Tailor’s bunion Procedure: Oblique wedge osteotomy at 5th met midshaft Young Indications: For pes planus, medial column repair Procedure:

1. TAL 2. TA thru keyhole in nav (do not detach TA)

Youngswick Indications: For HAV with a DF 1st met Procedure: An Austin Bunionectomy but an extra slice taken out dorsally to allow the head to drop down plantarly


Normal Jt’s ROM

1st Ray/Bunion Evaluation

Normal 1st met length a.k.a. 1st met protrusion angle 2mm shorter than 2nd met Roughly equal to 3rd met Hallux abductus angle Normal 15° DASA (distal articular set angle) Normal 7.5° PASA (proximal articular set angle) Normal 7.5° IMA (intermetatarsal angle) Normal 8-12° Head procedure <16° Base procedure >16° If hypermobile 1st ray do Lapidus procedure Hallux interphalangeal angle Normal >10° Met adductus angle Normal 15° Tibial sesmoid position Normal 1-3 ROM 1st mpj 65-75° 1st met-medial cuneiform angle Normal 22° 1st ray ROM 10°


Rearfoot angles STJ axis direction STJ goes thru 1st ray in neutral 2nd ray in supination Medial to 1st ray in pronation STJ axis of motion 16° from sagital plane 42° from transverse plane STJ ROM From neutral 2/3 motion in inversion (20°) and 1/3 in eversion (10°) Bohler’s angle Angle formed by: Anterior process to top of calcaneal posterior facet Top of calc process to highest point of calc tuberosity Normal 25-40° Changed with calcaneal fracture Glissane’s angle Angle formed by: The angle of the ant and middle facets trabecular patterns Trabecular patterns of posterior facet Normal is 120-140° Changed with calcaneal fracture Toyger’s Angle Line drawn down the posterior aspect. Normal: This should be a strait line (180°) Decreases with Achilles rupture

Ankle Dorsiflexion/plantarflexion Dorsiflexion 10-20° Plantarflexion 20-40°

Femur Angle of inclination 1yr 146° 4 years 137° Adult 120-136°, avg 127° Angle of declination (anteversion angle) of femur 1 yr 39° 10yr 24° Adult 6°


Tibia Tibial torsion Birth no twist 6 yrs 13-18° Adult 18-23° Tibial varum/valgum Compare distal 1/3 of tibia to ground Birth 5-10° varum >2yrs 2-3° valgum

Talus Talus: Long axis of head and neck with long axis of the body This straitens out when one gets older Birth 130-140° Adult 150-165° Talar head and neck Plantar flexed 25-30° Medially aligned 15° on body Angle of talar torsion Head is laterally rotated on the body Fetus 18-20° Childhood 30° Adult 40° Note, this motion brings the supinated foot in embryo down to a more pronated adult position Talar declination angle 21° Increase in pronation Decreased in supination Talus-1st met angle Normal is 0-10° Can increase with either pronation or supination Supination will cause the axis of the talus to go dorsal to 1st met Pronation will cause the axis of the talus to go plantar to 1st met Cyma line On lateral view there is a line formed by talus and calc. Normal: anterior S Supination will move this relationship posteriorly


Pronation will move it anteriorly

Metatarsals/MPJ Metatarsal length Longest 2>3>5>4>1 shortest Metatarsal protrusion Longest 2>3>1>4>5 shortest Lesser MPJ’s Flexion/extension Flexion 30-40° Extension 50-60° Metatarsal declination angle Normal 21° Metatarsal Abductus angle Normal 0-15°

5th Ray angles 5th ray IMA Normal 4-5° Pathologic >9° Lateral deviation angle of 5th met head a.k.a. lateral bowing angle of 5th met Normal 0-3° Pathologic >7°

Splay foot Splayfoot IMA over 12° for 1st and 2nd mets, and IMA over 8° for 4th and 5th mets

Calcaneus Calcaneal inclination angle Normal 21° Pronated <21° Supinated >21° Fowler and Phillips angle Angle from the posterior calcaneus and the anterior portion of the calc Normal >75°


Total angle of Vega Fowler and Phillips angle plus calcaneal inclination angle Normal 90° Calcaneal Cuboid Abduction Normal 0-5° Increased with pronation Talocalcaneal joint On DP view Normal 21° Decreased with supination Increased with pronation Talo-Navicular joint Normal 75° Decreased coverage with pronation Possibly increased with supination Forefoot abductus Normal 8° (0-15°)

Joint ROM of lower extremity

Hip Flexion/extension-strait knee Normal flexion 90-100° Normal extension 10-20° Flexion-bent knee Normal flexion 120-130° Rotation of Hip

Adults Children Internal rotation 35-40° 20-25° External rotation 35-40° 45-50° Abduction/adduction of Hip Abduction 24-60°, avg 36° Adduction <30°


Knee Knee Flexion/extension Flexion 130-150° Extension 5-10° Knee Rotation Medial rotation 40° Lateral rotation 40° Knee Valgum/Varus (bow knee, knock knee) Birth 15-20° genu varum 2-4 yrs strait 4-6 years 5-15° genu valgum 6-12 years strait 12-14 years 5-10° genu valgum > 14 years strait


Special Surgery Section

This section that follows is based on my notes on how to do a select few rearfoot and ankle cases from both my residency years and my years practicing. Basically, the outlines are a combination of McGlamry’s, Coughlin’s and Kitoaka that I used to prepare for the cases. Obviously, my notes are only one of many ways to do the cases.

I have included my notes here as a quick outline reference. As always, it is up to the reader to go to the original sources to learn the material.

-Brett


Achilles Tendon Rupture Mostly 30-50 yr old men-weekend warriors Usually midsubstance of tendon, although avulsions and myotendinous junction ruptures are possible Clinically-they can PF because of TP, but can’t do a one legged heel raise

-Positive Thompson test -May have palpable gap, although this may be occluded by edema after 24 hours.

Indications: younger people do better with sx Older, non-active people better with conservative. Pre-operative Jones compression dressing with mild PF foot Surgery Pt prone, general or spinal, thigh tourn. 1. Incision is to the medial aspect of the Achilles tendon from just above the myotendinous junction to insertion on calcaneus. Incision is down to paratendon. Careful not to create flaps because this is a very avascular area. Plantaris is medial Sural nerve is perforates the Achilles tendon centrally at the myotendinous junction and then courses laterally. At times it runs with the Lesser Saphenous V. 2. Incise the paratendon. The paratendon should be opened as part of the full thickness flap. Get good exposure to tendon For Mid-Tendon ruptures 3. Irrigate, debride the mop-top ends of tendon. 4. Reapproximate using Bunnel, Kessler or Krackow type of suture (pg 314-317 Kitaoka) using 3-0 Dacron (non-absorbable polyester) suture. 5. Reinforce site with 1.0 Vicryl in circumferential stitch. Irrigate. 6. Close paratendon (3.0 Vicryl), subq then skin For tears at the myotendinous junction (Hard to suture into muscle) 3. Reverse Lindholm’s technique: rather than inverted strips of tendon being raised from proximal to distal, go distal to proximal 4. Weave inverted tendon into place. 5. (As with midtendon repair) suture with Bunnel, Kessler or Krackow technique. Reinforce with Vicryl circumferential suture


6. Close For avulsion ruptures 3. Extend incision distally past insertion of Achilles onto calcaneus. 4. Debride calcaneus of fibrous tissue, debride down to cancellous bone. Make drill 2 drill holes longitudinally. 5. Put suture (3.0 Dacron) in tendon (i.e. half a Kessler) bring suture through drill holes and tie over itself. 6. Close Post op 1. Jones compression dressing for 7-10 days 2. NWB BK cast for 2-3 wks

Cast in 20 degrees PF for avulsion and mid-tendon rupture Cast in neutral for myotendinous ruptures

3. Remove cast, have pt put his foot on a footrest for 15-20 minutes to gently allow the foot to go to neutral or close. Cast in this position. WB BK cast for 2-4 wks. Can use brace here instead. Can start passive ROM 4. Put in shoe with 1-inch heel lift. Can start aggressive walking at 10 weeks. 5. Return to sports at 14-16 weeks after surgery. Note: Pt may not be able to get to full DF for 3-6 months. Conservative Treatment 1. PF cast for 2wks NWB 2. Increase DF (but still PF) for 2 more wks. NWB 3. At 4 weeks, if can cast in neutral, pt can WB 4. At 8 wks. d/c cast and use removable cast or stirrup for 4 more wks. A 2-2.5 cm heel lift can be put in shoe. Start passive ROM 5. At 12 wks. start active exercises in regular shoe (may use ¼-1/2 inch heel lift)


Ankle Arthroscopy Ports Anterior-medial port is medial to TA, lateral to saphenous v. and n. Anterior-lateral port is lateral to Peroneus Tertius, medial to intermediate dorsal cutaneous n. Anterior-central port is just lateral to FHL; medial to DP and deep peroneal n., medial dorsal cutaneous n. crosses over FDL at this level and may be lateral. Due to all of potential complications, this port is usually contra-indicated Posterior-Lateral port is lateral to Achilles tendon 1-2 cm distal to anterior ports Posterior-medial port is medial to Achilles tendon. In the area are the FHL, FDL, posterior tibia nerve and artery, and the calcaneal artery. Due to all of potential complications, this port is usually contra-indicated Posterior central port is also called trans-Achilles and it is thru the Achilles. This is usually contraindicated. Most commonly used are ant-med, ant-lat and post-lateral. Always remember to do a good irrigation. Often, this may be enough. Use 2.7 or 4.5 scope Insertion of scope Mark anatomic landmarks-medial and lateral malleolus, superficial peroneal n., TA and Peroneus Tertius (if present, if not EDL) For Anterior-medial and Anterior Lateral ports 1. Find the joint, insert 18 gauge needle into joint. Fill joint with 20cc of NSS 2. Incise the skin only. Blunt dissect down to capsule. 3. Insert canula and blunt obturator. Insert scope 4. With direct vision of scope, insert 18 gauge needle into lateral port, find the needle with the port. Careful of superficial peroneal n. 5. Incise skin only, blunt dissect, use obturator to make port. For Posterior-Lateral Port 1. Go lateral to Achilles tendon approx 1-2 cm distal to anterior port levels. This will be just distal to posterior syndesmotic ligament. 2. Cannula is used for dedicated inflow Joint examination Look for anterior joint synovitis-shave with 2.9 or 3.5 shaver.


If anterior exostosis, - 1. Reflect the capsule by putting the shaver against the osteophyte and lifting the

capsule off the osteophyte 2. Use 4mm burr from ant-lat port while viewing from ant-medial port. Can use rongeaur or osteotome. 3. Switch portals and do lateral portion. 4. Can use intra-op radiographs

If anterior medial exostosis at tip of medial malleolus. Make secondary port approx 1-2 cm medially and slightly distal to ant-medial port


Author’s Note: These articles on Ankle Fractures are based on my notes from my personal experiences, the texts I have previously referenced and from my lectures from the AO course in Davos, Switzerland. The first thing they stated at the AO Course in Fracture Management was that they used the Webber Classification and not the Lauge-Hansen system because the Lauge-Hansen was too complicated. Therefore, the surgical choices are broken down by the Webber Classification. However, you still want to learn the Lauge-Hansen system because that is what you will most likely be quizzed/tested. -Brett

Webber A Surgical Choices Screw Placement

Patient is supine with bump under hip, thigh tourniquet

Screw Fixation 1. Incision-Small incision at tip of lateral malleolus

a. Expose tip of malleolus by splitting calcaneofibular ligament longitudinally

b. Avoiding tilting lateral malleolus toward the talus 2. Insertion point for meduallary fixation is at lateral surface of malleolar tip

–4.0mm cancellous screw or malleolar screw is inserted into proximal medial cortex of fibula above the fracture site -

– Insertion of a long screw (4.0 mm) across the fracture line into the meduallary canal of the proximal fragment; -

3. Avoid rotation or displacement of distal fragment as screw is inserted –K-wire can be added as temporary fixation

Note: Since the medullary device (screw) is straight, the lateral malleolus may be inadvertently tilted toward the talus: - this will result in narrowing of ankle Mortise & reduced motion

4. Close


Webber A Surgical Choices Tension Band wiring

Patient is supine with bump under hip, thigh tourniquet

Tension Band Wire 1. Skin incision-vertical, parallel to w/ long axis of tibia directly over lateral

malleolus a. A strait incision is often used because it can be extended. Try to avoid J

shaped incision b/c they cannot be extended 2. Dissect sharply down to bone. If undermining is necessary, do it just over

periosteum 3. With a periosteal elevator or 15 blade, elevate the periosteum for a distance of 2-3

mm from the fracture lines a. Remember, be good to the soft tissues

4. Curette and irrigate fracture fragments to remove all hematoma. 5. Inspect joint 6. Reduce fracture with towel clip on fx fragment and guide it in with periosteal

elevator 7. Insert two .045 or .062 k-wires. Insert from distal to proximal from tip of lateral

malleolus across the fracture line. Insert at right angles to the fracture (this is pretty vertical). Be careful not to violate the joint.

8. 20 gauge wire is then passed thru transverse drill hole above fx site & placed in a figure of 8 fashion around bent tips of protruding K wires;

9. Close


Ankle Fracture-Webber B Fixation with 2 lag screws Posterior anti-glide plate

Lateral plate and lag screw

Webber B Fracture at the joint line Corresponds with PAB or SER Lateral Malleolar Fx-Anatomy PB and PL posterior to fibula Superficial Peroneal N anterior/medial to fibula Sural N. and Short Saphenous V. is post and plantar to fibula FHL is post + mainly muscular at this level -proximally incision is btwn peroneous tertius (anteriorly) and peroneous longus and peroneous brevis (posteriorly) Generally safe with an incision over fracture site on the fibula All with incision over fracture site.

Webber B-Fixation With 2 lag Screws Fixation with 2 Lag Screws

When to use Fixation with 2 Lag Screws If fibular fx is spiral (2x diameter of bone), not comminuted, and is not osteoporotic, then sufficient fixation can be achieved w/ only two lag screws. Advantages: - allows for a smaller incision the hardware is not prominent and usually does not have to be removed; will not interfere w/ syndesmotic screws (if they are needed); Fixation with 2 lag screws- Procedure

1) Incision is made slightly anterior to midline of fibula Not too much layer dissection. Incision is mostly just down to bone

2) Clean up wound edges 3) Restore fibular length, Hold with reduction clamps, check w/ C-arm 4) Insert two 3.5 screws (or 2.7 if small patient) from anterior to post using AO

lag techniques 5) C-arm to confirm position 6) Close


Webber B

Lateral Plate and Anterior-to-Post Lag Screw (Most common surgical approach for Webber B fibular fracture)

Ideally, you want to cross five cortices of fixation proximally and distally. Distally, if using a buttress plate, only unicortical screws are used and most likely only three cortices will be fixated. Lateral Plate and Lag Screw Pt is Supine with lateral bean bag/bump Thigh tourniquet 1. Incision is directly over fibula over fx site. May make incision slight anterior to midline. (If posterior malleolus fracture is present, then make it posterior)

Do not do too much dissection, mainly incision is down to periosteum (preserve soft tissues). Any undermining should be done at the periosteum level. 2. Elevate periosteum 2-3 mm from the fracture line. The full anterior and posterior portions of the fracture line must be exposed. 3. Curette and irrigate fracture fragments and hematoma. 4. Explore talus for any osteochondral defects. 5. Reposition fracture (increase deformity, distract, reposition) use towel clip and periosteal elevator 6. Hold fx in anatomical position w/bone forceps 7. Re-asses anatomical position -can use bone forceps, lobster claw, K-wire across fx to stabilize fx -can use post spike of fx as guide -C-arm for verification of position 8. Insert lag screw (3.5mm cortical) anterior to post and aimed inferiorly Screws must engage posterior cortex, but should not extend so far as to puncture peroneal tendon sheath 9. Apply one third semi-tubular plate laterally Bend to appropriate contour of fibula. Distal fibula laterally deviates

3 proximally (3.5 mm cortical screws) 2-3 distally 4.0 cancellous, run these screws short don’t protrude fibular-talar jt

10. C-arm to check position 11. Close


Webber B Posterior Antiglide Plate

Advantages

• Achieves strong fixation even in osteoporotic bone • Hardware generally does not cause symptoms or wound necrosis; - • Does not interfere w/ syndesmotic screw insertion if necessary • Distal screws obtain better purchase, b/c they engage a thicker part of distal fibula • Engage 2 cortices without risk of joint penetration • Biomechanically this construct is stronger than lateral plate fixation, especially in

osteoporotic bone • Loss of fixation is rare due to the stability of the construct • In elderly patients, posterior plate position may be fixation of choice, since it is

biomechanically stronger • Posterior plate provides better fixation w/ posterior comminution • Essentially no risk of intra-articular screw insertion • Less risk of wound slough than with direct lateral approach • Essentially no risk of symptomatic palpable screws • Posterior incision allows access to the posterior malleolus, when direct fixation is

required

Disadvantages • Technically more challenging • May irritate peroneal tendons in minority of patients, but this often spontaneously

resolves in 4-8 weeks • Peroneal tendon subluxation-should not be a problem is the tendon sheath is left

intact

Posterior Antiglide Plate Procedure

1. Pt is Supine with lateral bean bag/bump 2. Incision is made along the most posterior border of the fibula at fracture level

-The plate often lies slightly posterior laterally (rather than directly post), thus the incision will be away from the plate

-Incision is carried down to peroneals, but does not violate the peroneal sheath. ---Incision proceeds over the lateral edge of peroneals. Peroneals are usually retracted posteriorly

3. Some of proximal retinaculum may need to be released to expose distal fibula. Clear periosteum off fibula

4. Fx reduction- ideally, anatomic should be achieved prior to plate application; - -Reduction can be held with a single K wire or lag screw


-Apply lag screw from anterior to posterior so not interfere w/ plate application

5. Plate application - one-third tubular plate is applied to posterior surface of the fibula;

- 4 hole plate-classically - 6 hole plate-more recently - B/c posterior surface of fibula is straight; contouring of the plate is usually not necessary - Due to the lateral bow of fibula, the plate may have to be placed posterolaterally

6. Proximal screw insertion: - -1st 3.5 mm cortical screw is placed proximally, thru the plate, 2 mm above posterior fx line -If an anatomic reduction is achieved, the proximal screw can be tightened down If an anatomic reduction has not been achieved, then do not fully tighten the screw Plate helps prevent proximal gliding of the distal fragment

7. If anatomical alignment is not achieved: Apply bone clamps to both fx fragments + distract out to length. Apply slight internal rotation to distal fragment;

- At this point proximal screw is tightened down 8. Remaining proximal 3.5 mm cortical screws are inserted 9. Lag screw: - lag screw is then inserted posterior to anterior thru the first plate

hole which is distal to the posterior fx line; -The screw must be angle slightly proximally in order to be perpendicular to the fx site

-Remember to remove initial lag screw (inserted anterior to posterior) if used -Lag screws improve fx reduction but do not significantly improve antiglide

strength -B/c the post cortex is thin, lag screw must be inserted thru plate (which serves as

solid posterior cortex) -OK to leave screw slightly long b/c screw is directed away from the peroneal

tendons, -if possible, a second lag screw can be inserted using the same technique

10. Insert distal screws: - technically the more distal screws are not necessary, but 4.0 mm cancellous screws may be inserted at the surgeon's discretion;

because there is no risk of joint penetration, longer screws can be used to get a better hold on bone

11. Close


Medial Malleolar Fractures

3 options 2 Lag Screw Medial Plate Tension Band Wiring All supine, all with thigh tourniquet Medial Malleolar Fractures

Two Screw Fixation either open or percutaneous (two stab incision procedure) Lag Screws: True lag screws are used to counteract and neutralize a tension

failure on the medial side. Note: I prefer to do an open procedure over a stab incision because with a fracture of the medial malleolus, there usually is some soft tissue in-between the fracture fragments

Two Screw Stab Incision-Procedure Most common procedure for medial malleolus fracture, however I do all mine open.

1. Two stab incisions at tip of medial malleolus 2. Blunt dissect 3. K-wire from distal tip across fracture line at right angles into proximal section.

Aim somewhat vertically to avoid the ankle joint. C-Arm to check position. 4. Insert two 4.0 mm cancellous partially threaded cannulated screw. C-Arm to

check position 5. Close


Med Malleolar Fracture-Open Procedures For plate insertion For two screw insertion with better visualization Comminuted fractures Difficulty in Reduction

Med Malleolar Fx-Open Procedure For Screw Fixation or Plate Insertion

1. Skin incision-vertical, parallel to w/ long axis of tibia directly over medial

malleolus a. A strait incision is often used because it can be extended. Try to avoid J

shaped incision b/c they cannot be extended 2. Dissection sharply down to bone. If undermining is necessary, do it just over

periosteum 3. With a periosteal elevator or 15 blade, elevate the periosteum for a distance of 2-3

mm from the fracture lines a. Remember, be good to the soft tissues

4. Curette and irrigate fracture fragments to remove all hematoma. 5. Inspect joint 6. Reduce fracture with towel clip on fx fragment and guide it in with periosteal

elevator 7. Stabilize with 2 k-wires from canulated screw set. Insert from distal to

proximal from tip of malleolus across the fx. Insert at right angles to the fracture (this is pretty vertical). Be careful not to violate the joint.

8. Insert two 4.0 mm cancellous bone screws. Cannulated screws may be used. If not cannulated, remove k-wire and insert screw in k-wire hole

a. If using a plate, insert with 3.5 mm cancellous screws. Run the proximal screws short so they don’t violate the ankle joint.

b. Other options: 1/3 semi-tubular, DCP, T, Clover Leaf 9. Close

Note: For a "push off" (shear) fracture, the purpose of the plate is to provide an anti-glide or a buttressing effect.


Med Malleolar Fx-Open Procedure Tension Band Wiring of Medial Malleolus

This can be used for the very small medial malleolar fragments or comminuted Studies differ onto effectiveness of tension band Tension bands are rarely used now for medial malleolus If you always place two screws you are going to comminute a few med malleoli and

you’ll to be very unhappy. Then you will need this tension band technique for salvage.

Also, patients hate these wires. Anytime you do a tension band wire and leave a wire long (in an area where there is movement) patients will hate you a lot.

Tension Band Wiring-Procedure Patient Supine with thigh tourniquet

1. Skin incision-vertical, parallel to w/ long axis of tibia directly over medial malleolus

b. A strait incision is often used because it can be extended. Try to avoid J shaped incision b/c they cannot be extended

2. Dissect sharply down to bone. If undermining is necessary, do it just over periosteum

3. With a periosteal elevator or 15 blade, elevate the periosteum for a distance of 2-3 mm from the fracture lines

a. Remember, be good to the soft tissues 4. Curette and irrigate fracture fragments to remove all hematoma. 5. Inspect joint 6. Reduce fracture with towel clip on fx fragment and guide it in with periosteal

elevator 7. Two parallel K wires (0.045 inch or .062) are inserted at distal end of fibula and

engage the proximal medial cortex above fracture site; 8. 20 gauge wire is then passed thru transverse drill hole above fx site & placed in a

figure of 8 fashion around bent tips of protruding K wires; 9. Let your first year close


Ankle Fracture Posterior Malleolar Fracture

When to do an ORIF? – When >25% of posterior articular surface is involved as seen on lat view – Fracture is displaced >2 mm – There is posterior subluxation of talus – If fracutre prevents reduction of tibia

Posterior Malleolar Fx-Procedure Use a posterior lateral approach (similar to the one used for a fibular antiglide plate) with patient lateral or prone

1. Incision is at posterior border of fibula, if fibula needs to be reduced, do that first. Hold with temporary fixation. According to Coughlin--Do the definitive fixation of fibula after the post malleolus b/c of lack of exposure after fibula is fixated. However, I have seen the fibula fixated first and then the post malleolus was addressed 2. Bluntly dissect between the PB/PL and the FHL (muscular at this level) to the

posterior surface of the tibia. Must get exposure of entire fracture fragment 3. Reduce fracture. The fracture reduction is determined by palpation and visualization of extra-articular fracture line and c-arm. Cannot directly visualize the intra-articular jt b/c talus is in the way.

a. Note: reduction of fibular fracture most likely will reduce the posterior malleolus b/c of firm attachment of post tibiofibular ligament.

b. If difficulty reducing fracture, DF foot may give slack to ligaments and posterior capsule

4. Hold reduction with large reduction clamp 5. Insert 2 K-wires to the fragment in place (for 4.0 mm partially threaded

cancellous lag cannulated screws) 6. Insert screws posterior to anterior

a. Insert at right angles to the fracture 7. Alternate fixation: stab incision anteriorly, insert 4.0 mm cortical screw anterior

to posterior 8. C-arm for position 9. Let your 1st year close 10. Postop-NWB until union is solid, this may take up until 3-4 months


Ankle Fracture Syndesmotic Fixation

Syndesmosis separations are unstable and should be stabilized. Remember the AO principle of Stable fixation if non-articular Indications for Syndesmotic Fixation Irreparable medial joint injury w/ disruption of syndesmosis High fibular (Webber C) fx >15 cm above the jt line Medial ligament injury, syndesmotic disruption, talar shift w/o fracture of fibula Widening of the tibiofibular "clear space" (arrows) as a result of disruption of the

syndesmosis. The clear space is normally < 5 mm wide. Injury Patterns Isolated Syndesmotic injury with fibular fracture Syndesmotic injury with medial injury

Choices of Syndesmotic Screws 4.5 mm screw (most common) x2 3.5 mm screws in smaller patients Bioabsorbable fixation (polylevolactic acid) Fibrowire

Proper level-Syndesmotic Screw Screws should be parallel to joint line 1 cm prox to syndesmosis or 4 cm prox to ankle jt.

– If too low, can pass thru distal tib-fib articulation causing pain – If too high, may cause tip of fibula toe outward

Insertion of Syndesmotic Screw Thigh tourniquet, general anesthesia

1. It is best to stabilize the fibular fracture before the syndesmosis. Use a plate on the fibula. Fibula should be reduced posteriorly into the tibial sulcus. The syndesmosis should be reduced before the screw(s) are inserted.

2. Dorsiflex foot 5 degrees 3. Stab incision on fibula (use C arm to find correct level- 1 cm proximal to

syndesmosis and/or 4 cm prox to ankle jt.) 4. Insertion of screw (4.5 mm cortical fully threaded)


a. Because fibula is posterior to tibia, aim screw thru posterior-lateral fibula to anterior-medial tibia at an angle of 25-30 degrees anteriorly. Perpendicular to long axis of bones, parallel to the ankle joint.

b. Engage 3 cortices, hopefully 4 c. Do not lag! Do not overtighten!

Screws generally will not loosen or break if the ankle does not dorsiflex past neutral. Patients are allowed to weightbear after 6 weeks in a short leg cast or walking boot. Routine removal of screw 8-12 weeks after surgery.


Ankle Fusion Tibial-Talar Arthrodesis

Ideal position

Ankle neutral (no DF or PF) 5° valgus External rotation equal to opposite limb

Procedure Pt prone, with sandbag Thigh tourniquet Lateral Approach

1. Incision is on the fibula, starting about 10cm proximal to tip and extends to base of 4th met.

a. Avoid sural and intermediate dorsal cut nerve 2. Create skin flaps 3. Strip periosteum from fibula bone anteriorly and posteriorly

a. Incision is carried down to expose post facet of STJ and sinus tarsi 4. With periosteal elevator, strip the tibia, ankle jt, and prox talar neck going from

lat to med a. Do not dissect talar neck except for prox portion. Do not want to strip off

the blood supply to talus 5. Osteotomize the fibula about 2cm prox from the ankle jt. Bevel the cut so that

you don’t have a sharp edge. Remove distal portion of fibula a. Reflect peroneal tendons posteriorly

6. Make incision thru deep fascia at post tibia. With a periosteal elevator, strip the soft tissues off the tibia

a. This can be visualized after fibula is removed 7. The initial cut in the tibia is with the short wide blade, and completed with a

deep wide blade. a. Cut is perpendicular to long axis of bone b. Remove as little bone as possible c. Stop cut where the curve for the medial malleolus

Medial approach

1. Incision: 4 cm incision over the anteromedial aspect of the medial malleolus and swung slightly inferior so that the medial tip of med malleolus can be exposed

2. Strip soft tissue anteriorly a. Do as little damage to deltoid ligament as possible.

3. See that the cut in the tibia is not complete. With a 10 size osteotome, cut along the medial malleolus while freeing up the intial cut

Lateral incision

1. With a broad osteotome, wedge out the tibial cut by gently levering


2. In the talus, cut 3 to 4 mm from the superior surface 3. Check alignment, remove more bone if needed. 4. Fixation

a. Temporary fix with .062 k-wire b. Check position relative to patella c. Place two 3.2 drill bits, one in sinus tarsi and one just above lateral process d. Check position e. Insert two 6.5 mm screws from lat distal to prox medial.

i. Be sure to engage medial cortex of tibia ii. If soft bone, use washer

5. Check rigidity of arthrodesis site 6. Can put 3rd screw thru medial incision

? Fixation of fibula 4.0 mm cancellous or 4.5mm Closure

1. Drain is inserted 2. Deep closure, etc. 3. Marcaine block 4. Compression dressing.

Post op Leave post op dressing in place for 10-12 days, change and remove stitches Put pt in BK cast, NWB Do not use removable cast because they do not provide enough support 6wks, x-ray. If healing appears to begin, then BK WB cast At 12 wks, if satisfactory healing, can WB Average time for fusion is 14 wks Average shortening is 9mm


Ankle Fusion Tibial Calcaneal Arthrodesis

Patient is supine, with bump under ipsilateral hip Lateral Approach (similar to lateral approach in Tibiotalar arthrodesis)

1. Incision: 10 cm proximal to tip of lateral malleous across the tip of the lateral malleolus and towards the 4th metatarsal base.

a. Watch out for sural nerve and superficial peroneal nerve 2. Strip the periosteum from the anteroposterior aspect of the fibula, the lateral aspect of the

talus and the calcaneus 3. The distal portion of the fibula is removed approximately 1.5 cm above the level of the

distal tibia 4. Dissect over the anterior portion of the tibia to the medial malleolus. 5. An incision is made over the posterior aspect of the tibia and the pereosteal elevator is

passed along the back of the tibia to the level of the calcaneus. Now the entire lateral aspect of the ankle joint and talus is exposed

6. Using a saw, make a cut of the talar neck, from lateral to medial. Make the cut just distal to the dorsal articular cartilage of the talus

7. Remove the talus body. Now can visualize the calcaneal articular surface 8. Remove the articular cartilage of the tibia perpendicular to the long axis of the tibia.

Remove as little bone as possible. Start approximately 2mm above the cartilage. 9. With the foot in plantargrade position, remove the dorsal aspect of the calcaneus. This is

to create a flat surface for the arthrodesis. a. This includes the posterior and middle facets but leaves the sinus tarsi intact b. Do not violate the calcaneal cuboid joint or the anterior process of the calcaneus

Medial approach 1. Start over the anteromedial aspect of the joint and is carried distally past the tip of the

medial malleolus for about 2 cm to the talonavicular joint 2. Strip the periosteum from the medial malleolus (the portion uncut from the osteotomy) 3. Remove this portion of the medial malleolus, usually by osteotome.

a. Careful of the neurovascular bundle at the posterior medial portion of tibia

Allignment 5 degrees of dorsiflexion and 5 degrees of valgus

1. If necessary, remove bone from tibia or calcaneus to achieve it 2. The fusion site should be posterior enough for normal posterior curvature of the heel.

Make cut in anterior aspect of the tibia parallel to the cut made in the talar neck. 3. Drill surfaces of arthrodesis sites

Internal Fixation Use .062 k wires for temporary fixation


Check alignment 1. 7.0 or 7.3 cannulated screws. Go from calcaneus posteriorly to anterior portion of tibia.

If possible, do two screws a. The screws are more plantar than in a subtalar arthrodesis, even if this means you

are on a weightbearing surface b. Can throw a third screw from tibia to calcaneus posterior to anterior or apply a

blade plate 2. Fixate the talus to tibia with two 4.0 screws 3. Check alignment with C-arm. Close.


Arthrosurface 1st Met Implant

Step 1 Drill Guides, match w/ Articular Component Step 2 Cannulated Pin, Drills Step 3 Tap Step 4 Driver Step 5 Tap Cleaner Step 6 Trial Cap Step 7 Centering Shaft Step 8 Contact Probes Size is usually 15

1. Dissect down and expose 1st met. 2. Use Drill Guide to locate the axis normal to the articular surface and central to

defect. 3. Confirm Articular Component Diameter by matching it to the Drill Guide 4. Place Guide Pin thru the Drill Guide into bone

a. Make sure its central to defect. b. It is very important to verify that Drill Guide is seated on the curved

surface such that four points of contact are established on the articular surface. A normal axis and correct Articular Component diameter are necessary for proper implant fit.

5. Place Cannulated Drill over Guide Pin and Drill until the proximal shoulder of Drill is flush to the articular surface.

6. Tap hole to etched depth mark on tap. If nec. Insert bone cement into pilot hole 7. Place Driver onto the Taper Post over the guide pin and advance until the line on

the Driver is flush with the height of the original articular cartilage level. 8. Remove guide pin. 9. Clean taper in Taper Post with Taper Cleaner. 10. Place Trial Cap into taper post to confirm correct depth of Taper post.

a. The peak height of the trial cap must be flush or slightly below the existing articular cartilage surface to avoid the articular component from being place above the surface of the defect.

i. Adjust depth using the driver to rotate the taper post. 11. Place Centering Shaft into Taper Post. 12. Place Contact Probe over Centering Shaft and rotate around Centering Shaft.

Read contact probe to obtain offsets at four indexing points. a. Superior/inferior and medial/lateral b. Select appropriate Articular Component using Sizing Card.

13. Remove Centering Shaft and replace with Guide Pin. Advance Circle Cutter back and forth. Don’t bend guide pin. Score articular cartilage down to subchondral bone.

14. Choose appropriate Reamer. Drill Surface Reamer over Guide Pin until it contacts the top surface of Taper Post.


15. Remove guide pin. Clean Taper in Taper Post. 16. Place the Sizing Trial into the defect

a. Should be congruent with the edge of the surrounding articular surface. 17. Check suction device. Place articular component on implant holder and insert

into taper of taper post. 18. Tap with Impactor to seat Articular Component.


Brostrom-Gould repair Indications Chronic ankle instability that hasn’t responded to conservative TX Pro level athlete Contraindications Fixed virus heel type (need to correct w/ Dwyer) People over 200-25-lbs (use an Evans repair with PB) Peroneal weakness (i.e. CMT)

Procedure Pt supine with bump, thigh tourn, bump under foot

1. Curvilenear Incision over anterior border of fibula, stop at Peroneal tendons. a. Careful of sural n., intermediate dorsal cutaneous n., Peroneal tendons b. Probably will ligate lesser saphenous branch of n.

2. Dissect down to capsule; Incise capsule 2-3 mm from fibula (leave cuff for later attachment)

3. Find the CFL by reflecting the Peroneals, Incise CFL 4. Put foot in neutral DF and slight eversion 5. Resect necessary capsule, re-approximate using 2-0 absorbable suture starting

with the CFL and then ATFL. 6. Test for full range of DF and PF 7. Identify extensor retinaculum (should be distal)

a. (The extensor retinaculum fibers run perpendicular to AFT and CFL). b. Extend incision if necessary.

8. Mobilize the extensor retinaculum. Pull over the repaired capsule and attach to tip of fibula using 2-0 chromic cat gut (absorbable).

9. Check again for ROM and stability. 10. Close.

Post op Post splint 3-5 days BK walking cast for 3-4 weeks Air type stirrup for additional month with ROM exercises


Calcaneal Slide Osteotomy Can slide medially for flatfoot, or laterally for ankle instability Supine position, thigh tourniquet, bump hip

1. Incision: 1 cm posterior to fibula and 2 cm proximal to superior aspect of calcaneous (behind peroneal tendons and anterior to Achilles tendon). Stay posterior to peroneal tendons. Ends at junction of plantar and lateral skin at level of peroneal sulcus.

2. Sharp dissection down to bone, careful of peroneal tendons and sural nerve. 3. Bone cut: perpendicular to calcaneous. From the midpoint of tuberosity to 1 cm

past the plantar weight bearing portion of the calcaneous. ***Careful about cutting too far medial because your nerves and arteries are over there.

a. Score your cut first b. Get a wider, longer blade than usual. c. May have to finish with osteotome.

4. Displace tuberosity: a. If laterally so that midaxis of tibia is slightly medial to the midpoint of the

calcaneous. The lateral wall of calc should be just lateral to the lateral malleolus.

b. If medially, displace approx 1 cm. c. Can displace with an osteotome or lamina spreader without teeth.

5. If needed, can use a Dwyer wedge for added valgus. A Dwyer wedge is generally 1 cm laterally.

6. Fixation: angled plate, one (or two) 6.0 or 7.0 partially threaded cannulated screws, or two 4.0 partially threaded screws.

a. For the screws: insert just off the heel pad posteriorly (about 1.5 cm above plantar surface). If sliding medially, insert screw just laterally. If sliding laterally, insert just medially.

b. C-Arm for position. 7. Marcaine post-op block 8. Close. Compression dressing and splint.

Post op Posterior splint in OR Cast after 1st visit for 5 weeks. Removable cast: range of motion exercises until osteotomy site is healed.


Delayed Repair of Achilles Tendon History-pt’s complain of weakness in PF Clinical: At time of rupture, pt feels as if struck in the back of the calf.

If pt has progressive degenerative changes to Achilles tendon, insidious onset Tendon tends to be thicker as if progressively gets longer Often rupture is not palpable Conservative-heel lifts, lace up shoes, MAFO, braces These won’t restore normal push off Indications for Sx-to restore normal pushoff power 3 areas of rupture-at tendon 2-6 cm from insertion at myotendinous jct calcaneal avulsion Take x-rays and MRI if >3cm defect & > 3 mo. end to end suture (as in acute Achilles rupture) Surgery Pt prone, general or spinal, thigh tourn. Pt can be supine for more medial I For mid-tendon tear

1. Posterior medial incision over Achilles from just above myotendinous jct to past calcaneal insertion. Make full thickness incision to paratendon

2. Incise paratendon, reflect with full thickness flap 3. Irrigate, clean up mop handle like edges.

If > 3 cm

4. Kessel, Bunnel or Krackow type of suture with 3.0 Dacron 5. Reinforce ends circumferentially with 3.0 Vicryl

If gap is approx 3cm inverted v-y advancement is done

4. Do the inverted v-y: leaving the underlying muscle attached to the paratendon. 5. Advance the distal flap distally 6. Then close the defect via Kessel, Bunnel Krackow with 3.0 Dacron 7. Reinforce ends circumferentially with 3.0 Vicryl


If much greater than 3cm, do a v-y advancement, close end to end, then reinforce w/ FHL (The inverted v-y will be have to be done at an acute angle and will make the tendon very thin. This is why you have to reinforce with the EHL.) Pt is supine, general or spinal with thigh tourn. FHL transfer part

1. Incision is on medial border of midfoot, from the navicular to head of first met, just above the level of the abductor muscle. (Approx where the plantar skin meets the regular skin)

2. Dissect down to the layer of the AbH fascia. Reflect the muscle downward. Retract with a Weitlander.

3. FHB is reflected plantarly and the FHB is released from its origin. 4. Identify the FHL (medial) and FDL. These are usually covered by fatty layer.

By flexing the IPJ of the hallux, the FHL can be identified. 5. Section the FHL as distally as possible; generally at midshaft of 1st met. 6. Tag proximal part of FHL. Suture distal FHL to FDL with the toes in the

neutral position.

Posterior Medial Incision 7. Posterior medial incision over Achilles from just above myotendinous jct to past

calcaneal insertion. Make full thickness incision to paratendon 8. Incise paratendon, reflect with full thickness flap 9. Irrigate, clean up mop handle like edges. 10. Incise the fascia overlying the FHL. By pulling on the suture from the FHL, you

can identify the muscle. 11. Retract the tendon thru posterior medial incision. 12. Make transverse drill hole into posterior calcaneus just distal to insertion of

calcaneus halfway from medial to lateral. 13. Second drill hole goes from prox to distal to intercept the holes in calc. A large

towel clip is used to connect the two holes. 14. A suture passer is inserted in the distal medial hole upward. The FHL is attached

to it and the FHL tendon is passed from prox to distal-medial. 15. The FHL is then woven into the Achilles tendon from distal to prox and

repeated to use the full length of FHL tendon. 16. The tendon is secured using #1 Dacron. 17. Repair paratendon, then close in layers.

Post op -Jones dressing and plaster splints with foot in 15° PF until first visit (7-10 days) -BK cast with foot in 15° PF for 4 weeks -Put foot on footrest with hip flexed, allow foot to passively go to neutral. Cast foot in neutral with BK walking cast or removable cast walker for 4 weeks. -At 8 wks post-op, strength training and ROM exercises. Pt remains in removable cast walker until the 10° of DF and 4/5 PF strength is achieved. -Half-inch heel lift is added to shoe. Home exercises are performed at this period. Athletic activity is restricted for 6 months.


Evans Calcaneal Osteotomy PT supine, thigh tourniquet Mark out tendons and CC jt. before surgery

1. Get bone graft in saline and starting to reconstitute. 2. Incision-oblique over distal half of calcaneous (cut will be 1-1.5 cm from CC jt) 3. Dissect to bone. Careful of Intermediate Dorsal Cutaneous Nerve (Dorsal) Sural

N and Peroneal Tendons (Plantar) 4. Expose to osteotomy site 1-1.5 cm from CC jt 5. Free up EDB 6. Pass a probe thru the anterior and middle facets. 7. Make cut with sagital saw parallel to CC jt, aimed slightly distal to emerge in-

between the anterior and middle facets. Don’t go too far medially or you may damage vital soft tissues medially. Can use osteotome to finish the medial cut

8. Lamina spreader is put in place of the osteotomy site. 9. The osteotomy site is opened by loading the fifth met and putting foot in

adduction. Load until the hind foot valgus is corrected as well as the forefoot varus.

10. Insert bone graft. Bone graft is probably going to be twice as wide on the outside as the medial side. Most likely the graft will be about 1cm in width at the widest side. Don’t forget to keep the cortical sides with the other cortical sides.

11. Can fixate with staple, or screw. Screw is placed distal dorsal to proximal plantar. Very often no fixation is used.

Post op-NWB BK cast. For adults 6-8 weeks, for adolescents 5-6 weeks.


Excision of Calcification of Achilles Tendon Thigh tourniquet Have Miteck anchor or other kind of anchor in room Procedure: 1. Incision: from the superior-medial of the Achilles tendon (can go 1 cm medial to tendon and 3-4 cm proximal to spur or tuberosity) inferior lateral (2-3 cm distal to spur or tuberosity), with the horizontal part over the spur. Note: can go the other direction which may keep away from sural nerve 2. Dissect in layers, tag paratenon 3. Incise Achilles Tendon longitudinally (Lateral ½ = Medial ½)

Keeps distal attachments of Achilles, if possible 4. Reflect Achilles Tendon side to side, remove any intra-tendon calcification 5. Deepen incision-remove retrocalcaneal bursa Release any paratenons fibrosing or scaring -expose any Posterior calcaneal exostosis Can resect calcaneal exostosos with an osteotome 6. Repair Achilles Tendon with 2.0 vicryl in running suture 7. Close Post op: 3-6 weeks non-weightbearing in cast (if necessary) 3-6 weeks in a weighbearing boot If total resection of Achilles Tendon must be performed, then remove all boney prominences and treat it like a Ruptured Achilles Tendon. Can do drill holes and use non-absorbable suture ie fibrowire Can use a mitech or other form of anchor


Fibular Derotational and Lengthening Osteotomy

General 1.Tramatic displacement of talus is associated with displacement of lat malleolus 2.Malalignment is characterized by distal fibular shortening, lateral shift or malrotation 3. Increases pressure in mid-lateral and posterolateral quadrants of the talar dome 4. Goal of Fibular Derotational and Lengthening Osteotomy is to restore the sensitive weight-bearing area to normal anatomic relationship Radiographs (Can also use CT and MRI) Abnormalities of talar position is seen on x-rays. Check for (compared to other side)

1. Widening of medial joint space 2. Talar tilt 3. Fibular shortening

Check for DJD If no DJD- Fibular Derotational and Lengthening Osteotomy If severe DJD-ankle arthrodesis Contra-indications Infection Neuropathy Mortise View-check for:

1. Equidistant and parallel joint space with no medial widening 2. Shelton’s line of the ankle

a. A dense subchondral supporting bone creates a radiographic line that can be followed over the syndesmotic space from tibia to fibula (Kitoaka pg. 501). This should be even and continuous between the two bones

3. Unbroken curve between the lateral part of the articular surface of the talus and the distal fibular recess

4. Talar tilt. a. This should be parallel or within 3° of parallel

5. Abnormal seating of fibula in the incisura fibularis of the tibia. (Pg. 501) a. Normal is less than 6mm as measure 1 cm above tibial plafond b. If internal fibular rotation-increase in this measurement c. If external rotation of fibula-measurement is normal or decreased. This

is more common Surgical choices Oblique osteotomy-can only gain 3-5 mm in length Transverse osteotomy of fibula, iliac bone graft, plate, syndesmotic screws into plate


Ilizarov method Insertion of wires Place wire with the frame already built. Make stab incision Blunt dissection Wire is inserted via safe tract via clamp Remember to pulse the drill to avoid over heating. Use a wet Raytech to keep wire cool. Positioning Proximal: 2 fingers between the frame and the tibia Distally: 3 fingers. This position allows for swelling Frame should be 2-3 cm from the surface of the ground to allow for WB.

Tibial wire insertions Break the tibia into 6 segments (1st being most proximal and probably out of our scope of practice) At the 2nd segment:

Put half pin perpendicular to subq surface of tibia (pretty much the general rule for insertion of half pin at the tibia.)

For the wire, try to engage the widest portion of the tibia. This means insert the wire slightly oblique to the transverse plane of the tibia, thus exiting a little more anterior medial when compared to plane of tibia. 3rd and 4th segment

Similar to 2nd segment 5th segment

Wire is inserted almost perpendicular to frontal plane of tibia. Note, often the tibial wires will be parallel so that the frame can be slid both medial and lat. 6th segment Wire options:

Directly medial to lat More anterior lat to post medial Thru fibula and into tibia


MBA Implant Procedure New McGlammry p 910 Thigh tourniquet Position patient so heel is resting over edge of bed Axis: distal lateral prox medial. Aim at superior to the tibialis post tendon and anterior and slightly inferior to medial malleolus.

Procedure 1. Incision over sinus tarsi 2. Blunt dissect to sinus tarsi 3. Insert guide pin so it abuts the anterior aspect of the body of talus. Advance pin

until it tents the skin medially- Aim at superior to the tibialis post tendon and anterior and slightly inferior to medial malleolus. Can C arm here, or at any step

4. The torpedo shaped probe is inserted until it tents the skin. Make incision. Proper insertion of probe should cause the distal aspect of the probe to exit just superior to the tibialis post tendon and anterior and slightly inferior to medial malleolus.

5. Rotate probe clockwise and counterclockwise to dialate the tarsal cannal. 6. The guide pin is then placed within sinus tarsi. 7. Most often the 8 and 10 mm implants will be used. Use the sizers, and the sizer

should allow 2-4 degrees of subtalar eversion. Choose a size. 8. Next, use the trial implant of the above size. Check range of motion, and clinical

correction are assessed. Use radiographs at this point. 9. Now use actual implant on screw driver with nose cone. Apply over guide pin.

Screw in clockwise. Insert no more than 1 cm medial to calcaneal wall and no more than ½ way across talus

10. Once inserted, the implant should be resting on floor of sinus tarsi. Take x-ray 11. When satisfied, remove guide pin and inserter. Irrigate with NSS. Re-valuate

motion, close in layers. Post op-wb in cast for 2 weeks, gradual return to shoe gear.


Murphy’s Procedure Indication: For spastic equinus Procedure

1. 5 cm incision in made slightly medial to midline of Achilles tendon 2. Dissect down to deep fascia and paratendon. Incise and tag the paratendon. Do

not dissect in layers b/c this will lead to soft tissue necrosis 3. Detach TAL from its insertion to the calcaneus

a. If child, careful not to disturb the calcaneal apophysitis 4. Reroute the TAL under the FHL (if desired) 5. Divide the fat over the calcaneus, then resect a ½ cm wedge of bone from

calcaneus just posterior to posterior facet 6. From that wedge, make two drill holes, one exiting medially, one exiting laterally 7. Use a Bunnell type of suture to the distal end of the TAL. Can use either

absorbable (1.0 Vicryl or Dexon) or non-absorbable (1.0 Ethibond or Tevdek) 8. One of the loose end strands bring out the medial drill hole. Bring one of the end

strands laterally. 9. With the foot in neutral, guide the tendon into the wedge and tie the sutures over

the dorsal surface of the calcaneus, anterior to TAL 10. Close, cast in AK cast with knee slightly flexed, foot in neutral


ORIF Calcaneus Indications Injuries that would do poorly without sx, such as severely displaced intra-articular, widening of heel, horizontally oriented talus, severe soft tissue injury, and high-energy mechanism. Contraindications Severely comminuted Impaired vascularity Infection Severe neuropathy Essex Lopresti Primary fracture line runs from anterior-lateral to posterior-medial thru the Subtalar Jt. (mostly thru the posterior facet). As the primary fracture line progresses, this will lead to lateral wall blowout and decrease in calcaneal height. Both of Essex Lopresti types start with the primary fracture line. Type one-vertical force will lead to tongue type Type two-more horizontal force will lead to joint depression

Surgery Lateral decubitous position, thigh tourniquet. General order or reduction-

1. Anterior process 2. Medial wall 3. Posterior facet 4. Lateral wall.

Procedure 1. Incision-curved behind the lateral malleolus. The proximal portion is halfway

between the anterior portion of the Achilles and the peroneal tendons. The line progresses distally, around the lateral malleolus, and then runs parallel to the bottom of the foot, ending up roughly at the C-C Jt.

a. Watch out for the sural n and the peroneal tendons. 2. Sharply dissect down to bone, create a flap with the calcaneal-fibular ligament

and the peroneals and flap that anterior-superiorly 3. Insert two .062 k-wires into the talus to hold this flap up. Bend k-wires upwards. 4. Expose STJ, remove hematoma and small fracture fragments via irrigation and

rongeur. 5. Identify the fracture lines in the anterior calcaneus that extend medially.

Determine if the fracture line progresses to the calcaneal-cuboid joint.


6. The anterior process is typically elevated. Therefore the anterior process needs to be retracted plantarward. Use a Langenbeck retractor or lamina spreader between the talus and the anterior process. Fix with K-wire.

7. Identify the fracture line progressing from anterior-lateral to post-medial (the

primary fracture lines), separating the posterior facets from the anterior and middle facets.

8. The posterior facet is usually plantarflexed. With the use of a periosteal elevator, lift up the posterior facet. Hold with k-wire directed from the anterior process laterally to the posterior facet medially.

9. The lateral part of the posterior facet is retracted laterally or removed. This allows visualization of the medial posterior facet.

10. A 4.0 Schantz pin is inserted into the tuberosity fragment from posterior to anterior (in other words, from the back of the heel into the posterior tuberosity). This is used as a lever to reduce the fragment plantarly, medially and into slight valgus.

11. When the medial wall of the tuberosity lines up with the medial wall of the facet fragment, it is held with two .062 k-wires. The k-wires are entered from the posterior aspect of the tuberosity and are directed to the sustentaculum tali (be careful not to damage the articular cartilage). Probably need c-arm for this.

12. After the anterior process and the medial wall are reduced, the posterior facet is

reduced. Match the lateral fragment to the medial fragment. Insert .062 k-wires into the anterior and posterior margins.

13. Get intra-op x-rays. If alignment is good, insert a 2.7 cortical lag screw below the subchondral surface.

14. Reconstruct the lateral wall if necessary. Insert a plate. Bend the plate, but keep

the frontal plane portion of it strait. a. Best bone for plate is subchondral bone deep to the C-C joint, the

subchonral bone near Achilles tendon insertion, and the dense bone of the sustentaculum tali.

b. May need to fill in deficit with bone chips, Grafton or other bone substitute

15. Add drain and close.

Post op-depends on how much damage. If minimal displacement, then do 6-8 weeks ROM exercises and non-weight bearing. If severe displacement-could be >12 weeks ROM exercises and NWB.

Complications-relatively common. Infection, delayed wound healing, sural nerve, tibial nerve problems (more likely from injury rather than surgery.)


ORIF Talar Neck Fractures ORIF should be done even if Hawkins type II was closed reduced because this type of fracture will inevitably develop an equinus contracture that happens with prolonged casting in PF Talar neck fracture without dislocation Supine with bump under ipsilateral hip. Have c-arm ready.

1. Anterior-medial incision-made from anterior aspect of the medial malleolus to the dorsal aspect of the navicular tuberosity. Dissect carefully down, go dorsal to TP tendon. Don’t disrupt the deltoid ligament because this might disrupt some of the vasculature to the talus.

2. Remove hematoma. Don’t dissect the soft tissues off of the talus dorsally and plantarly because this might disrupt the blood supply to talus neck.

3. Anterior-Lateral incision-starting from anterior margin of lateral malleolus to the base of the 3rd or 4th met. This allows confirmation of the reduction of the talar neck. It also permits removal of foreign bodies.

4. Incise inferior retinaculum. 5. Retract EDL and peroneus tertius. Retract the EDB dorsally. 6. Remove all fragments. Probe STJ blindly for fragments. 7. Reduce the fracture. Careful not to have communution or reduce into varus

position. 8. Insert two 2.5 mm titanium screws (can be used with MRI). Do not lag!

Lagging a screw might send the talus into varus. If Talar Neck Fracture is Displaced as in Hawkins Type III-STJ and ankle Jt.

1. Anterior medial incision-extend the incision over the medial malleolus and the distal aspect of the tibia.

2. Go into space between tibia and Achilles. There is the body of the talus. 3. A femoral distractor may be needed. Put pins in tibia and calcaneus. 4. Manually place body of talus back into mortise.

a. If the talus will not return to the mortise, a medial malleolar osteotomy will have to be done.

For medial malleolar osteotomy

1. Identify ankle Jt. for tibia. 2. Make two retrograde 2.5 mm drill holes in the medial malleolus across the

osteotomy site.


3. Release the anterior portion of the capsule off the deltoid ligament as well as a portion of the TP sheath. Protect the TP ligament.

4. Incise the periosteum about 5-10 mm superior to the ankle joint. 5. With oscillating saw, cut the transverse portion, then the two vertical portions. 6. Reflect the medial malleolus distally. Don’t damage the deltoid ligament. 7. Manually place Talus back into its place.

Anterior Lateral incision-as above. Fix medial malleolus with two 4.0 mm cancellous titanium screws.

Post op Post split or boot. Do not do ROM exercises until wound healing is done. NWB for 8-12 weeks until trabeculae cross the fracture. Complications AVN Arthrofibrosis, malunion, non-union, skin necrosis


Osteochondral Lesions of the Talus-Surgery Surgery for stages 3 lateral lesion and stage 4 Conservative tx for stage 1, 2, and medial stage 3 Surgery Pt supine, thigh tourn. General or spinal. 1. Get scope ports. 2. Use 2.7 mm scope, both 30 and 70 degrees. Examine the joint. 3. With a probe, evaluate the articular cartilage, whether there is a loose bone fragment beneath articular surface and the extent of the lesion over talar dome. 4.Type of surgery is dependent on type of osteochondral defect. -Acute fx is usually anterior lateral, more substantial bone base and better for internal fixation -Chronic posterior medial lesion is more likely to have fragmented necrotic bone and poor articular cartilage. These lesions must be removed. -In young patients without skeletal maturity, if intact articular cartilage, then simple drilling may be enough. For drilling, use .062 k-wire to depth of 1 to 1.5 cm. For post medial lesion Old method was to use trans-tibial approach. New method is to use a guide and go thru sinus tarsi into posterior medial portion For articular cartilage that is fragmented, loose and necrotic (For post-medial lesions, use post lateral port for 70-degree scope) 1. Use probe to lift cartilage 2. Remove cartilage with forceps 3. Use angled cervical curette to debride lesion to healthy, bleeding bone. Stopping the inflow will demonstrate bleeding. 4a. If good bleeding, just remove all remaining bone fragments 4b. If not good bleeding, drill as previously described. Bone grafting If cartilage is good and intact, but either there is a viable bone fragment or there is only edema of the underlying cancellous bone. Insert in the trans-talar approach (like drilling thru subtalar.) Oats Procedure For posterior medial talar osteochondral lesion. Take plug of bone with articular cartilage from knee and through a trans-tibial approach insert it into the talus


Peroneal Brevis Tendon Repair and Reconstruction

Non-operative management-BK cast in neutral to slight inversion for 6 weeks. Associated with 30-40% rate of redislocation. Surgery Pt supine, sandbag under hip or lateral decubitous. Thigh tourniquet

1. Incision-curvilinear, approx 5-7 cm behind the fibula, inline with the peroneal tendons. Half of incision above malleolus, half below.

2. Full thickness flaps, identify superior peroneal retinaculum 3. Inspect peroneal tendons for subluxations, partial or complete tears and

tenosynovitis 4. Retract PL anteriorly to visualize PB and often reveals a central split and

subluxation over posterior ridge of fibula a. If PB tear is found and degenerative tissue is <50% of tendon debride

degenerative tissue. Then tubularize the remaining tissue using a running, absorbable suture.

b. If peroneus tertius or low-lying muscle belly is present excise it. c. If lateral ligament instability use Brostrom or Chrisman Snook d. If PB tear is >50% then resect the whole tendon (not sure about this

personally) and attach to PL. 5. Inspect floor of peroneal groove. If too shallow make larger groove (pg 303) 6. Use rongeur to prepare fresh-bleeding fibular bed, then reattach the Superior

Peroneal Retinaculum through drill holes in lateral ridge. Go from deep thru holes to dorsal. Suture the rest of superior peroneal retinaculum with pants over vest style.

Post op- NWB splint for 1 week BK walking cast for 4-6 weeks


Posterior Tibial Tendon Repair-Substitution

Stages- I-Normal length with tendonitis or peritendonitis II-PT is elongated, but RF is still flexible III-PT is elongated, RF rigid Always try conservative first-rest, arch supports, PT, oral anti-inflamatories, immobilization with cast or brace Steroid injections are contraindicated. For stage I-debridement, repair For stage II-FDL transfer For stage III-(fixed deformity) triple arthrodesis It’s usually worse than you thought. Surgical Technique ***Almost always done with an osseous procedure

1. Incision-10 cm proximal to tip of tibial malleolus and 1 cm posterior down behind the medial malleolus to the navicular tuberosity’s plantar portion. (Follows the TP tendon)

2. At the upper end of the incision, the deep fascia is incised and the TP is exposed. The TP lies very close to the posterior margin. Trace the tendon distally to its insertion while leaving a 2 cm pulley just posterior to medial malleolus at the level of the tibial plafond.

3. Determine the length of the TP tendon. If TP is normal length, it’s stage I then do tendon debridement, tenosynovectomy and sheath resections are done and close wound.

4. If tendon is elongated, it’s stage II and FDL transfer is needed. 5. For debridement of tendon:

a. If fraying-smooth edges leaving major portion of tendon intact b. If bulbous enlargement just tip of medial malleolus-an ellipse is removed

from bulb and tendon is sutured burying the knot c. If longitudinal split exists-clear inner side of tendon of scars and

approximate scars 6. Tenosynovectomy-the outer portion of the tendon sheath distal to the pulley is

removed to prevent a possible reformation of stenotic tendon sheath 7. Inspect tendon for area of tear. Proximal to the region involved, the tendon will

be dull and white if the tear is old. Sometimes there is a transverse tear. 8. Transfer of the FDL: detach FDL distal to the crossover area of FDL and FHL.

Cut the FDL under direct vision. a. Optional suturing of distal end of FDL to FHL


9. Tag FDL with strong, non-absorbable suture in zigzag suture 10. Identify tuberosity of NAV and expose the inferior and superior surfaces of the

tuberosity 11. With 0.25 or 0.375 inch drill bit, a drill hole is done from superior to inferior.

The drill hole should come out inferior to the main surface of the PT 12. Leave FDL in its own sheath. Bring FDL into NAV drill hole from inferior to

superior. Pull through as tightly as possible with foot PF and supinated. 13. Suture the FDL with its non-absorbable suture into the capsule dorsally.

Reinforce the tendon by suturing the inferior portion of FDL (under NAV) into the TP tendon.

14. Assess the proximal TP muscle. Often the muscle will become fibrotic and stiff after a TP dysfunction. Test the muscle by pulling on the proximal portion of the tendon. If the there is some elasticity (the muscle still has some function)-then do a side-to-side suturing of FDL to TP with non-absorbable sutures, buried knot. If the muscle is stiff, don’t suture the two muscles together.

15. Optional advancement of the spring ligament and the TN capsule Alternative method: TP tendon repair with side-to-side suturing. Limitations-cannot restore significant flatfoot deformity to normal alignment, but it should relieve pain and improve function 1. Identify and resect the diseased section of the TP tendon. Suture tendon ends

together with non-absorbable suture 2. Then do a side-to-side repair with the FDL with non-absorbable suture.

Postop Without FDL transfer- Jones compression cast with foot in PF and inversion for 1-2 days BK WB cast for 3 weeks Post op shoe and gradually move into shoe. May take months

With FDL transfer Jones compression cast with foot in PF and inversion for 1-2 days NWB BK with foot in adduction and inversion for 3 wks. Remove sutures, NWB BK with foot in neutral for 3 more weeks Progress to WB as tolerated, PT


Posterior Tibial Tendon Transfer Thigh tourniquet, Pt prone 4 incisions- One at TP insertion site One at middle distal 1/3 of leg, medial to tibial crest One at middle distal 1/3 of leg, 1 cm lateral to tibial crest One at lateral cuneiform/3rd met insertion site Procedure

1. Incision at TP insertion on navicular 2. Release the TP from its insertion on navicular

1. 2nd incision at middle distal 1/3 of leg, medial to tibial crest. Pull TP up through

this incision. 2. 3rd incision at middle distal 1/3 of leg, 1 cm lateral to tibial crest. 3. Separate tibialis anterior from the tibia 4. Expose interosseous membrane and make window in interosseous membrane 5. Compress the posterior muscle mass. This will expose the TP 6. Gently pull TP from medial incision thru window in interosseous membrane with

blunt curved Kelly forceps and moist sponges a. Careful of NV bundle which lies under TP b. Often there is muscle fibers attached distally from the window gently

pull them free

1. 4th incision over lateral cuneiform or 3rd met 2. Insert tendon passer, Bozeman forceps or uterine packing forceps into insertion

site and retrograde up extensor sheath, grab TP and retrograde 3. Fixate to lateral cuneiform with foot in neutral position


Split TA Tendon Transfer (STATT) /Tibialis Anterior Tendon Transfer

(TATT)

STATT Pt prone Thigh tourniquet 3 incisions for STATT One over TA insertion of medial cuneiform/1st met One over anterior surface of leg just proximal to transverse crutiate lig. One over peroneous tertius insertion. Note, if the Peroneous Tertius is not present, the tendon can be inserted to cuboid or sutured to the PB For split TA tendon transfer

1. Split the tendon with umbilical tape with a tendon passer in leg incision thru to TA insertion.

2. Cut the lateral ½ of the TA tendon and retrograde that thru to the proximal window.

3. Insert to peroneous tertius tendon

TATT 3 incisions for TATT One over TA insertion of medial cuneiform/1st met One over anterior surface of leg just proximal to transverse crutiate lig. One over lateral cuneiform For TA tendon transfer

1. Tendon is separated from its insertion 2. Tendon is drawn up thru insertion onto leg incision 3. With a tendon passer, bring tendon up thru peroneous tertius sheath (same as the

EDL tendon sheath. a. Be sure to be under extensor retinaculum

4. insert TA into lateral cuneiform via hole and button


Note: usually with TA tendon transfer, the third incision is over the lateral cuneiform/3rd met and the TA is transferred to this bone. However it is possible to transfer the TA all the way to the peroneus tertius tendon.


Subtalar Arthrodesis Pt prone, Thigh tourniquet Surgery

1. Lateral incision is over sinus tarsi from tip of lateral malleolus to 4th met base. 2. Free the EDB from its attachment to calcaneous 3. Incise the fatty plug longitudinally 4. Retract the peroneals plantarly 5. W/ lamina spreader, spread the sinus tarsi 6. Remove articular cartilage with rasp, curette, osteotome or rongeur

Preserve the shape and contour of the bones Careful not to violate the tibiotalar jt. Make stab incision, Put in guide wire in calcaneous Put heel in 5-10° of valgus

7. After heel in 5-10° valgus, advance wire into talus, x-ray, advance 7.0 mm cancellous screw with 16 mm thread length

a. Test strength of fusion 8. Optional 2nd screw thru same incision 9. If not stable, remove hardware and insert a screw thru talar neck into calcaneous.

If bone graft is needed, you can take part of the anterior process of calcaneous. Can also use Grafton. Post op. First 48° Jones compression dressing with splint Then BK cast NWB for 6 wks (remove stitches at 3 wks) BK WB cast for 4-5 wks until radiographic evidence of healing. Then rehab w/ or w/o PT


Talo-Navicular Fusion Good results in low activity patients High demand patients should probably add a C-C fusion (double arthrodesis) Indications

• Main-primary arthrosis secondary to trauma or rheumatoid arthritis • If instability secondary to PT dysfunction, or collapse of T-N joint from rupture of

spring ligament, isolated T-N fusion is indicated (but Coughlin usually does triple)

Procedure Position of foot- 5° valgus T-N jt in neutral Forefoot 0-5° varus Pt supine, thigh tourniquet 1- Incision-just distal to medial malleolus to 1 cm beyond the navicular-cuneiform jt, curved slightly dorsal (especially if large dorsal osteophyte is present) 2- strip joint capsule with periosteal elevator or sharp osteotome 3- Remove osteophytes with rongeur or osteotome 4- Identify articular surfaces, remove with curette or osteotome Can use towel clip in medial navicular for exposure Visualization can be improved with lamina spreader if bone is hard Hard to see laterally, but this must be exposed and debrided 5- joint surfaces are heavily feathered and foot is manipulated into anatomic alignment 6- Hold calcaneus in one hand,

Place STJ in 5° valgus, Manipulate midtarsal jt into a few degrees abduction Forefoot into a plantigrade position that is perpendicular to long axis of tibia

Forefoot should not have a residual of more than 7-10° varus or valgus Internal fixation-can use two 4.0 or 4.5 mm canulated cancellous screws. For large person, can use 7.0 mm screw. If bone is soft, can use multiple staples 7-hold foot in corrected alignment, drive guide pin into navicular starting at navicular-cuneiform joint and drill obliquely across navicular into head and neck of talus 8-check alignment of foot, c-arm, 9- add second guide wire, c-arm 10- Overdrill navicular, insert 40 to 50 mm long threaded cancellous screw. Screw threads must pass the intended fusion site. If soft bone, use washer. C-arm 11- check stability of foot


12- If bone is soft or the fusion is not stable, use staples. This is also useful if there is a fracture of the navicular 13- close, marcaine for post-op block 14- compressive dressing with two splints Post-op NWB for at least 6 weeks Add cast on 1st visit After sutures are removed, put pt in short leg removable cast. After 6 weeks, and x-rays look good, pt can ambulate with short leg cast. 3 months after surgery, if x-rays ok, pt can d/c the short leg cast Complications- 1. Nonunion rate is higher than in C-C jt or STJ probably because of inadequate exposure to joint. Also because Nav is avascular If non-union, can 2. Flatfoot-from placing the STJ in too much valgus and forefoot in too much abduction. Correct in triple Items needed for surgery Thigh tourniquet, pt supine C-arm Periosteal elevator, osteotome, curette Possible sagital saw Wire driver Towel clip Lamina spreader 4.0, 4.5 or 7.0 canulated cancellous screw (probably 40-50 mm) Possible washers Possible staples 3.0, 4.0 vicryl, 5.0 monocryl or 4.0 prolene Splints for stirrup/post split


Tarsal Tunnel Release Most often occurs in the fibro-osseous tunnel (bound by lacinate ligament), most often at the distal edge of the ligament. Division of nerve of medial and plantar nerve occur deep to lacinate ligament in 93% of people, and proximal in the other 7% The nerve is in the third channel (Tom, Dick and A Very Nervous Harry.) Need peanuts, posterior splint, and Penrose drain. Thigh tourniquet, deflate before closure. Don’t eschmark the foot, just elevate it.

1. Incision-10 cm proximal to the tip of the medial malleolus and 2cm posterior to the tibia. After the medial malleolus, gently curve plantar to the level of the talonavicular joint (plantar to tn joint). This should be about the midpoint of the abductor hallucis

McGlamry-2cm proximal to superior edge of lacinate ligament and gently curving to the proximal margin of the abductor hallucis.

2. With hemostats, blunt dissect the SubQ. A moistened 4x4 can be used.

When in the SubQ, be careful of the medial branch of the nerve as it punctures the lacinate ligament.

3. When at the lacinate ligament, feel for the pulse of the Posterior Tibial Artery. Also palpate for the ligaments of the posterior tibial and flexor digitorum longus. The flexor Hallucis Longus (4th compartment) can be palpated by moving the big toe.

4. From proximal to distal, make incision of the roof of the third canal. May want

to use hemostats and split them, or may use groove channeler.

5. Isolate the Tibial Nerve and all 3 branches (medial and lateral plantar nerve, and the calcaneal branch) of its branches from all tissues.

Remove any neoplasm. Be careful Move varicose veins. Ligate veins if necessary, but make sure that you aren’t ligating an artery.

6. Follow nerve distally through the abductor canal. Section the abductor canal

stricture.


7. Go proximal and follow nerve upwards.

8. Deflate tourniquet. Closure- don’t reapproxiamte the lacinate ligament (McGlamry says only partially reapporoximated) and the subq and skin are closed. If a lot of ooze, then use a drain.

9. Marcaine at end

10. Below the knee compression dressing is applied. No weightbearing or partial

weight bearing for two weeks. Begin DF and PF of ankle after 2 weeks.


Tibial Periarticular Fx Reduction &

Fixation Indications Pilon or Tibial Plafond fractures Articular displacement of >2mm, Unacceptable axial alignment Open fractures Neurovascular injury due to fracture Pre-operative planning Check NV, compartment syndrome, soft tissue injury Radiographs-AP, Lat, MO Whole tibial shaft Foot radiographs CT can be useful Surgical Procedure Staged surgery-first part immediate once the patient has stabilized (usually 12-18 hours) with ORIF of fibula and external fixator for tibia. Kitaoka recommends EBI or Orthofix 1st Stage

1. Fibular incision-slightly posterior-laterally to increase the width of the skin bridge with the later anterior incisions.

2. Do not do calcaneal skeletal traction- (even with a Bohler-Braun frame) this pulls patient out of bed and displaces foot posteriorly

3. Fix Fibula fracture 4. Apply Ex-Fix onto tibia

When the soft tissue edema has subsided (usually 10-21 days), open reduction and internal fixation can be performed 2nd Stage Pt supine, thigh tourniquet Take frame off tibia but don’t remove the pins. Have circulator sterilize the frame. This may be used later in the case for distraction. Anterior-medial incision

1. Locate the fracture fragment. If the fragment is anterior-medial: incision begins just lateral to the medial crest of tibial shaft. Extend the incision distally across the ankle joint, staying just medial to tibialis anterior


2. Identify the anterior tibia tendon sheath. Once identified, create a full thickness flap by incision the tendon sheath and the extensor retinaculum. Bring this incision down to bone/joint down to the periosteum. Do not strip the periosteum or remove any fat unnecessarily

3. Identify fracture ends, debride and irrigate. Remove all clots 4. Reduce the fracture. This incision works well with a medial pilon plate

Anterior Midline Incision Use this incision when the fracture is a pure anterior crush injury. This injury gives good exposure and will allow for easy placement of low profile anterior tibial plate

1. Incision is made between the TA and the EDL a. Identify the Superficial peroneal nerve, the artery and the deep peroneal

nerve. Retract all of this laterally Anterior-Lateral Incision Use this with large lateral fragments, such as the Tillaux-Chaput avulsions. Careful with this incision because it may jeopardize the skin from the fibular incision. This is why you usually use a posterior lateral incision for the fibula.

1. Incision starts proximal to the ankle joint and slightly medial to Chaput’s tubercle and extends distally in a strait line toward the base of the 3rd and 4th mets.

a. Superficial peroneal nerve is protected 2. Incise through the superior and inferior extensor retinaculum 3. Mobilize the peroneus tertius and EDL, the deep peroneal nerve and the anterior

tibial/DP artery 4. Distally the EDB is seen and can be retracted laterally or detached 5. Protect the lateral branch of deep peroneal nerve and the lateral tarsal artery

Technical Pearls and Pitfalls Joint surface should be reconstituted first b/c anatomical malallignment is not acceptable. The ankle will accept some axial mallallignment, but not articular. Shaft reconstruction is performed second Reconstruct the joint with isolated lag screws followed by neutralization plate of the metaphyseal-diaphyseal component Joint surface needs to be anatomic reconstructed. If there are centrally depressed pieces, the perimeter fragments need to be retracted and the central ones need to be elevated Fixation-

1. Fix the jigsaw puzzle, then use reduction clamps followed by 1.6 mm k-wire 2. Canulated screws are rarely used 3. If a piece is small, a bioabsorbable pin can be used 4. Once the screws are in place, a cancellous graft can be used 5. Apply plate. Options are

a. Medial pilon plates for rotational and varus valgus injuries b. Anterior pilon plate for anterior crush plates. Note Dr Lutz states to

always use an anterior plate.


c. Supplemental washer plates may be needed. I.e. spider washer plate Closure Small drain, close etc. Pitfalls Doing definitive surgery too soon b/c fracture patterns are not clear with all of that soft tissue swelling Unstable EX-FIX Failure to stabilize the fibula Post Op Post op Jones dressing and splint 1 wk change to compression stocking and removable boot. Start ROM. Pt is to wear the boot at all times, even sleeping or the patient may develop equinus deformity Start formal PT about 4-6 weeks, only after the wounds have healed Weightbearing at 3 months if radiographic evidence Outcome is based on the fracture at presentation Complications Infection, wound complications, malunions Post-traumatic complications at 1-2 years


Triple Arthrodesis Pt prone, Thigh tourniquet, may need bump. Tourniquet can be kept up for 2 hours. Deflate for 15 minutes if necessary and re-inflate Might want pain pump May want to do a 23 hour admit Need 6.5 and 4.0 canulated screw sets Position for fusion: 0 degrees dorsiflexion 5 degrees valgus (calcaneus) 0-5 degrees abduction of midtarsal joint

Approx 15 degrees external rotation (should match other side) Eliminate forefoot varus I- Lateral incision

1. Incision over sinus tarsi from fibular malleolus to base of 4th met. a. Avoid superficial peroneal nerve and peroneal tendons

2. Reflect EDB distally off calcaneous 3. Protect peroneal tendons. Longitudinally incise sinus tarsi fat plug 4. Find bifurcate ligament this will show you the entry point to debride the

talonavicular and naviculocuboid joints 5. Spread with lamina spreader 6. Mobilizing the soft tissues is necessary for reducing the pes plano valgus

articulation. Note: it is unusual to remove more than 3 to 5 mm of bone to correct a deformity.

II- Calcaneal-Cuboid Joint

1. From the above incision, reflect down to the Calcaneal-Cuboid Jt. 2. Distract with a Hohman spreader 3. Reflect the soft tissues 4. Find the bifurcate ligament and resect it. 5. Resect the soft tissues of the Talonavicular jt and Naviculocuneiform Jt.

III- Dorsal medial incision

1. Incision is 2 cm distal to medial malleolus 1 cm distal of the navicular-cuneiform joint.

2. Resect the soft tissues and then the cartilage If, after all the soft tissues are released, the deformity can be corrected minimally resect the articular cartilage. IV-Resect joints

1. Resect T-N jt, then C-C jt and then the T-C jt. 2. use curette for T-N and T-C joint. Can use two osteotomes for C-C joint and pry

out.


3. use K-wire to drill holes in joints

IV- Fixation-order TC, then TN then CC. See above for fixation position

1. Talo-Calcaneal fixation: From talar neck, aimed posterior-laterally, a 6.5 mm partially threaded cancellous screw.

a. Calcaneus should be in 5 degrees evertion. b. Avoid placing the screw too far into posteriorly into the talar neck because

it will cause ankle impingement. c. Can go from the calcaneous to talus. In this case, go posterior and as

plantar without having the screw be on the plantar surface of the foot. Use a canulated 6.5 screw and aim toward the talar neck. Use C-arm to confirm position

2. Talo-Navicular fusion: a. The midtarsal joint should be 5 degrees abduction b. A 4.0 canulated screw (or 4.5 cortical screw) is placed from the navicular

to talus. Screw should be less than 40 mm. Use C-arm to confirm position c. Some literature says to use 2 screws.

3. Calcaneo-Cuboid jt a. The midtarsal joint should be 5 degrees abduction b. C-C jt is fixated with a 4.0 canulated screw (or 4.5 cortical screw) placed

from calcaneous to cuboid. Screw should be less than 40mm. Use C-arm to confirm position

c. Some literature says to use 2 screws. Can go from cuboid to calcaneus Note: can use staples for C-C jt or T-N jt. V- Closure

1. EDB is closed over lateral side of wound 2. Close capsule, then subq, then skin 3. Pain pump or post-operative block.

Post-op If drain is put in, pull it next day. Coughlin: change cast 10-14 days after surgery and remove sutures Non-weightbearing for 6 weeks with cam or cast and ace

If satisfactory union is occurring, then wb with cam walker for 6 weeks After 12 weeks, ok to wb to tolerance

McGlamry- nwb or 8 weeks After 10-12 weeks, progressive physical therapy and partial wb After 3 months, graduation to full wb.


Special Studies

Bone Scan What must you d/c before and A-gram? Glucophage b/c the pt may develop metabolic acidosis What are the phases of bone scan?

1. Immediate, early, flow or angiogram (it goes by all of these names) 2. Pool 3. Delayed 4. 4th phase

What is the 4th phase of a bone scan used for? PVD When are the phases of the bone scan done? Immediate 2-3 seconds Pool 2-3 minutes Delayed 2-3 hours 4th phase next day What do each of the phases of the bone scan test? 1st phase-blood flow 2nd phase-soft tissue 3rd phase-bone activity 4th phase-for bone uptake for pt with PVD What normally lights up on a bone scan? Epiphysis of growing child Fracture Tips of scapula Bladder Sternum Intercostals (ribs) ½ life of technetium 99? 6 hours What if bone scan lights up in stages 1 and 2 but not 3? Cellulitis most likely Name a way to test between Charcot disease and osteomyelitis? Ceretec scan (tagged wbc test) or an Indium 111.


What does Gallium 67 test for? Acute inflammation and infection. How long does it take for a Gallium 67 to work? Test takes 2-3 days. Why would you use a Technetium scan with a Gallium scan? Use chart below Acute osteo Chronic osteo Septic Arth. Tech 99

Phase 1 + +/- +++ Phase 2 ++ + +++ Phase 3 +++ +++ +/-

Gallium positive focal uptake negative positive focal Indium 111 positive negative positive Fracture Acute cellulites Charcot Tech 99

Phase 1 +++ +++ +/- Phase 2 +++ ++ +/- Phase 3 +++ + +++ Phase 4 ++/+++

Gallium negative positive diffuse negative Indium 111 negative positive negative What does Indium 111 tag? WBC’s What is Indium 111’s use? Highly sensitive and specific for acute soft tissue and osseous infections.

MRI What causes increased signal intensity on MRI T1? Fat What causes increased signal intensity on MRI T2? F.I.I.T.-Fluid, infection, inflammation, tumor For MRI, what are the main indications for STIR imaging? It is useful for evaluation of edema in high lipid regions, such as bone marrow. It is also useful for evaluating cartilage.


What is fat saturation used for? Evaluation of fat. (C’mon, that’s obvious.) What is Gradient Echo also known as? Steady State Magnetization What is Gradient Echo used for? Joint imaging. What are two uses for Gadolinium?

1. Intravenously: it will be quickly distributed into the extra-cellular fluid. It will be distributed to places with increased vascularity, such as neoplasms and inflammation. Cellulitis and walls of abscesses will enhance, but the pus will not.

2. Intra-articular: tests cartilage integrity. What will a stress fracture show up as on MRI? T1-linear zone of decreased signal intensity surrounded by a less defined area of SI T2- linear zone of decreased signal intensity surrounded by an increased SI due to the edema STIR-increased SI because fatty bone marrow is suppressed. How will osteomyelitis show up as on MRI? T1-break in the cortex, decreased signal in the bone marrow. T2-break in the cortex, increased signal in bone marrow. How will AVN show up on MRI? T1 and T2-decreased signal intensities STIR and long T2-double rim sign. Inner margin will show and increased SI (this represents the granulation tissue.) Outer margin will show decreased SI (this shows mineralization). What does MRA stand for? Magnetic Resonance Angiography What is MRA used for in the LE? PVD, DVT, neoplasm and anatomic studies.

CT Scan What are the 3 planes of a CT scan? Coronal, Axial and Sagital Which of the three CT planes is computer reconstructed? Sagital


What does the coronal plane of a CT scan represent? Frontal plane Memory peg 1st vowel in coronal and frontal is the “o” What does the axial plane represent? Transverse plane Memory peg 1st vowel in transverse and axial is the “a”

Misc. What are some tests for sickle cell anemia? Microscope and observe Hemoglobin electrophoresis How man phases in a Ceretec scan? One What does HMPAO stand for? Hexylmethy propylene amine oxime (a Cerotec scan) What does MDP stand for? Methyldiphosphate


The Social Interview.

For some people, the social interview is harder than the academic interview. In my opinion, the reason that it is harder is because people don’t prepare for the social interview. After sitting through two years of interviews, I am amazed at how some people don’t seem ready for the social interview. With that in mind, I have put down some hints and some sample questions. Many of these ideas are from my past as a salesperson in a job interview. Essentially that is what you are-a person selling themselves for a job. Hint #1-Look and dress appropriate.

For men, a pressed shirt, tie and a dark suit. I would wear either a white or blue shirt, but that is not a hard and fast rule. For women, wear a conservative suit. Both men and women’s hair should be neat and combed.

When you sit in the chair, sit back in the chair with good posture. Your hands should be in your lap (when you are not talking with them). Keep your feet flat on the floor (for men). Women can cross their legs. Do not lean your arms on the table in front of you-you are not at your desk at home. Hint #2-Proper salutations

When you enter the room, sit in the chair and give proper greeting. Make sure to make eye contact with everyone in the room.

When you leave, it is appropriate to only shake hands with the director unless the other members of the room offer to shake their hands. Thank the interviewers for their time. Hint #3-Do your homework At the end of many interviews, the host will ask the interviewee if he or she has any questions. In my opinion, you should not. You should have done your homework by this point. Why would you spend your money and time to interview at a place that you have no information, other than what is in the caspar book? To ask questions in the interview that should have been asked in a visit makes you look unprepared and uninterested. By the time of your interview, you should have all your questions about the program answered. You have had months to visit the program. If physically visiting the program was out of the question (i.e. you are applying to a program that is a airplane ride away) then a phone call to one of the residents will work. During that phone call, get your questions answered. Be prepared and have a good list of questions for the resident. If any questions do arise after the visit/phone call then it is perfectly acceptable to call or re-page the resident. A good response to the question “Do you have any questions about our program?” is “No Sir or Ma’m, all of my questions were thoroughly answered by Dr So-and-So on my visit. I feel as if I have a good understanding on the opportunities of your program.”


Hint #4-Ask for the program I know some people feel that by showing up for the program they are essentially stating that they want the program. I still feel that one should go the extra yard and ask for the program. I do not mean to suck up to the program, but state to the interviewers that you want the program in a mature and professional manor. By asking for the program or stating that you want the program it shows the program that you want to be there and that this is not a practice interview. I know personally if there are two women who I want to date and one expresses an interest in me and one is indifferent, I will always choose the one who expresses an interest. Proof? Of all the interviews I have been a part of, only four people asked for the program (over a three year span) and all four people got the program. Hint #5-Act enthusiastic. Honestly, I can’t believe I have to put this one in here, but I see too many people act like they just took a sleeping pill. If you cannot get excited about an interview, then nothing can excite you. Hint #6-Act like someone you would want to work with. Continuing on #5, act like a mature, responsible adult. One gets picked for a program because the program feels that you will represent the program well and that you will be a good person to work with. The interview is your opportunity to show this. Hint #7-Remember you are in an interview. Hint #8-Prepare for the social interview. Go over some of the sample social questions, and formulate a couple of answers for them, if possible. Go over these answers with fellow classmate, a resident you are working with, your mother, anyone. Just be prepared as best as you can, and practice, practice, practice. Hint #9-Good Posture. Sit up, do not slouch and keep your hands comfortably on your lap. Look relaxed but professional. Do not lean on the desk. Remember, you are in an interview, not on your couch watching TV Hint #10 Have Fun I am serious, have fun in your social interview. This will show the program you are applying to that you are a good person to work with and you can handle the stress of the interviews.

Sample Social Questions Tell us about yourself-

Keep this one short. Three sentences (i.e. who you are, what you are and what you like to do). Keep this to the point and under 15 seconds.

Who is your hero? (Obviously, besides “Jazzy” Jeff Lehrman, DPM)


Why did you pick podiatry? Why should we take you over the other applicants? What do you know about our program? What did you learn on your externships? What was your favorite externship and why? (Springfield because of Jen “Mulley” Mullendore, DPM and Melissa “MaBell” Baily, DPM.) Did you visit? If yes-what did you learn about our program? If not-why didn’t you visit our program? Tell us about some of the current events. What was the last book you read? Tell us a joke. (Might want to keep this clean) I’ll tell my joke here… Sherlock Holmes and Doc Watson were camping. They went to sleep and were sleeping soundly until Sherlock Holmes woke up Watson. Sherlock said “Watson, Look up. What do you see?” Watson looked up at the sky and saw millions and millions of stars and the moon. Realizing that The Sherlock Holmes asked him the question, Watson wanted to give an impressive answer.

Watson thought about it for a second and answered “From a Theological point of view, it shows how vast and powerful God is and how insignificant we are when compared to God.

From a astronomical point of view, I see the Milky Way and many different constellations to the North.

From a Holographic point of view, I see that clouds are coming from the East and we may have a chance of rain tomorrow.

From a Astreological point of view, I see that the moon is in Jupiter and if you are a Scorpio, you are going to have a good day tomorrow.”

Watson then asked, “Why, what do you see, Sherlock?” Sherlock took a drag on his pipe and replied “Someone stole our tent”.

What do you do in your free time? (Please don’t tell me you read Podiatry articles or anything else like that) Be prepared to answer a question about one of your lower grades. Who was your favorite resident? Who was your least favorite resident? (Only Michelle Hinze is allowed to say I am her least favorite resident)


What is your favorite color? If you can be any animal, what would it be? Who was your favorite clinician at school and why? Who is your mentor? Who is our director? (Don’t screw this one up)



Documents

Crozer-Keystone Ex Tern Ship Manual