Documente Academic
Documente Profesional
Documente Cultură
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to
the site policies for rules on diseminating site content.
Ankle Fractures
Classifications
1. Lauge-Hansen
Cadaveric study which relates the fracture pattern to an injury mechanism
The first word in the designation refers to the foot's position at the time of injury; the second word
refers to the direction of the deforming force.
"eversion" is a misnomer; it more correctly should be "external" or "lateral" rotation
1 of 5
Pathology
Supination/adduction
Supination/eversion (external
rotation)
Pronation/abduction
Pronation/eversion
Pronation/Dorsiflexion (Pilon)
10/6/2007 10:49 AM
Ankle Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Pathology
Fibula # above level of syndesmosis - medial injury + tear of ITFL and interosseous
membrane
Maissoneuve's fracture
Spiral fracture of proximal fibula associated with very unstable ankle injury
Bosworth Fracture
A lesion described by Bosworth may be the cause of failure to reduce a posterior fracture-dislocation
of the ankle.
The distal end of the proximal fragment of the fibula may be displaced posterior to the tibia and locked
by the tibia's posterolateral ridge; the bone cannot be released
by manipulation because of the pull of the intact interosseous membrane.
In these cases the fibula is exposed, and a periosteal elevator is used to release the bone;
considerable force may be necessary. The fibular fracture then is fixed.
2 of 5
10/6/2007 10:49 AM
Ankle Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Bosworth
fracture with entrapment of fibular behind tibia. A, Anteroposterior view. B and C, Lateral views.
Rationale behind ORIF of ankle fractures
Tibiotalar congruency
Ramsey and Hamilton (JBJS (B) 1976)
showed that a 1mm lateral shift of the talus
in the ankle mortice reduces the contact
area by 42%
Posterior malleolus fracture >33% leads to
a significant loss of tibiotalar contact
DeSouza (JBJS (A) 1985) showed 90%
satisfactory results could be obtained even
if up to 2mm of lateral displacement was
present
Generally
Young ORIF if >1mm displacement
or >2 o talar tilt
Old can accept up to 2mm of
displacement
Always take into account the
ambulatory needs of the patient
and judge treatment accordingly
Surgical technique
Standard AO fixation
Interfragmentary screw and 1/3 tubular
neutralisation plate for fibula and lag screw
fixation for medial malleolus
Syndesmosis screw is required if fibula is
unstable at end of fixation (engage 3
cortices and ensure the ankle is at 90 o
when inserting screw, and that the screw is
not lagged) Screw needs to be removed
before weight bearing can be commenced
Alternative fixation for Type B fractures of
the fibula is the anti-glide plate which has
been shown to be biomechanically superior
to a lateral plate
Posterior malleolus fractures need to be fixed if there is > 25% of the articular surface involved. This is
often underestimated on lateral radiographs.
Post-operative management
In studies comparing the effect of early movement vs immobilisation and weight bearing vs non-weight
bearing, the conclusion is that there is no difference in the final result whichever regime is used.
3 of 5
10/6/2007 10:49 AM
Ankle Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Arthritis
Incidence increases with severity of injury
Degenerative changes in
10% of anatomically fixed
85% if not adequately reduced - changes apparent within 18 months
Klossner "Late results of operative and non-operative treatment of severe ankle fractures" Acta Chir
Scand Suppl. 293: 1-93, 1962
Prognosis
There is a reduction in the incidence of arthrosis in patients where an anatomical reduction has been
achieved (Phillips et al JBJS 67A: 67-78, 1985)
Prospective trial shows higher total ankle scores in those that are operatively treated- especially so in those
pts more than 50 yrs old
PILON / PLAFOND FRACTURES
(Pilon = Hammer / Plafond = Ceiling)
Reudi & Allgower Classification
(Ruedi TP, Allgower M: Clin Orthop 1979;138:105-110)
Type
Pathology
Undisplaced
II
III
Reudi
4 of 5
10/6/2007 10:49 AM
Ankle Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
5 of 5
10/6/2007 10:49 AM
Ankle Instability
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on diseminating site
content.
Ankle Instability
INVESTIGATIONS
NON-OPERATIVE TREATMENT
OPERATIVE TREATMENT
Non-Augmented
Augmented
Preferred Method
[Back To Top]
NON-OPERATIVE TREATMENT
[Back To Top]
Most patients with ankle instability will improve with non-operative rehabilitation.
Programme [ Orth Clin N Am.- Jan '94 ]
Phase 1: RICE (immobilze in POP for 2-3wks)
Phase 2: Strengthening of peroneal & dorsiflexor muscles, stretching of TA. Isometric exercises using furniture or rubber bands.
Phase 3: Proprioceptive training. W hen pain & swelling gone. = wobble board exercises. Progress thro functional activities- walking, running, figure-of-eight
running, hopping, jumping & cutting.
In severe strains protect ankle with pneumatic brace or taping for sports for 3-6mnths.
OPERATIVE TREATMENT
[Back To Top]
Prior to considerations for surgery, ensure that subtalar instability is not present
Indications:
Failed non-operative management
+ve anterior drawer & talar tilt tests clinically
stress x-rays
tibiotalar tilt > 20 deg.
anterior translation > 5mm.
Aims:
Restore functional stability.
Results:
A wide variety of reconstructive techniques have had a high degree of success.
Most authors report a good or excellent result in 80% to 85% of patients.
Techniques:
The methods of reconstruction fall into two general types: non-augmented and augmented .
Non-Augmented Methods:
[Back To Top]
Brostrom originally described this technique in 1966 [ Brostrom, L. Acta Chir. Scand. Vol 132. 1966. p 551-565. ]
Brostrom recommended a mid-substance repair of the free ends of the ligaments with fine continuous sutures.
Karlsson and associates modified this by shortening of the ligaments with reinsertion onto the fibula through drill-holes.
Gould and associates modified the Brostrom technique to include repair of the lateral talocalcaneal ligament and reinforcement of
the repair with suturing of the lateral extensor retinaculum to the distal aspect of the fibula. This modification is important in patients who have
excessive inversion and laxity of the subtalar joint. [ See Picture .]
1 of 4
10/6/2007 10:49 AM
Ankle Instability
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Advantages:
1.
2.
3.
4.
5.
Disadvantages:
1. Inability to achieve stability with only the weak & attenuated local tissues
2. Failure to reconstruct the calcaneofibular ligament adequately
3. Failure to address the relatively frequent problem of subtalar instability.
Augmented Methods
[Back To Top]
Watson-Jones
Peroneus
brevis
tendon is
anchored
to the
fibula,
limiting
inversion
of the
ankle and Evans tenodesis plus the graft is routed anteriorly through the talar neck to
anterior
reconstruct ATFL.
talar
translation
indirectly,
while also
limiting
motion of
the
subtalar
joint.
2 of 4
Peroneus brevis graft is brought through the fibula from ant. to post. to
reconstruct ATFL. It is then brought post. and inferiorly to the calcaneus
to reconstruct CFL.
10/6/2007 10:49 AM
Ankle Instability
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Longitudinal incision, running just posterior to the prominence of the lateral malleolus. This incision can be extended to allow
harvest of the peroneus brevis tendon if augmentation of the reconstruction is found to be necessary.
The anterior talofibular ligament and the calcaneofibular ligament are reconstructed.
The ligaments are divided just distal to their fibular attachments.
The joint is inspected and debrided as necessary.
Occasionally, one or both ligaments are avulsed from the fibula with a piece of bone. This so-called os subfibulare should be excised.
The bone at the anatomic attachment sites of the anterior talofibular and calcaneofibular ligaments is roughened, and the ligaments are reefed and
reattached to the fibula with the use of drill-holes. The repair is oversewn with the proximal stump of the ligament to reinforce the repair.
During the repair, the ankle is held in neutral and the foot is held in eversion.
Augmented reconstruction with Peroneus Brevis is added if:
The anterior talofibular ligament and the calcaneofibular ligament are so disrupted
and frayed that they cannot be repaired
Hypermobility of the subtalar joint
Previous failed reconstruction of the ankle.
Expose the peroneus brevis, while maintaining the integrity of the superior peroneal
retinaculum
Anterior third of the tendon is isolated distally and split from the distal position to the
musculoskeletal junction. This tendon portion is transected at its proximal aspect. A drill hole
is made through the distal fibula, and the split portion of the peroneus brevis is passed
through this hole. The tendon is tensioned with the foot in mild plantar flexion and eversion.
This augmentation procedure results in significant loss of eversion and inversion.
Post-operatively:
2 weeks NW Bing BK cast with the ankle in neutral and the foot in eversion.
At 2 weeks the patient is allowed to bear weight as tolerated.
6 weeks postop, range-of-motion exercises, progressive resistance exercises, and
proprioceptive exercises are begun.
At 3 months, full sports activities can be resumed with the ankle taped or braced. Most athletes should continue to use tape or a brace indefinitely during
sports activities, but bracing is not routine after 3 months for most work-related activities or activities of daily living.
Bibliography:
R.A. Marder; Instructional Course Lectures 1995, Volume 44:349
Jim Barries Foot & Ankle Hyperbook
TOP
3 of 4
10/6/2007 10:49 AM
Ankle Instability
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
4 of 4
10/6/2007 10:49 AM
Ankle Sprains
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on
diseminating site content.
Ankle Sprains
Functional Anatomy
Pathomechanics
Clinical
Investigations
Management
FUNCTIONAL ANATOMY
Lateral Ankle Ligaments
The lateral aspect of the ankle capsule is augmented by the anterior and posterior talofibular ligaments and the calcaneofibular ligament . Of
these three structures, the anterior talofibular and calcaneofibular ligaments are the most important clinically.
The anterior talofibular ligament
is a thickening of the ankle capsule
extends a relatively short distance from the anterior edge of the distal part of the fibula to the talar neck, anterior to its lateral articular facet.
The orientation of the anterior talofibular ligament depends on the position of the ankle joint:
In plantarflexion, it is parallel to the long axis of the foot
in dorsiflexion, it is aligned with the tibial and fibular shafts.
Strain in the anterior talofibular ligament is minimum in dorsiflexion and neutral, and it increases as the ankle is moved progressively through
plantarflexion. Inversion and internal rotation moments applied to the ankle increase the strain in this ligament.
The calcaneofibular ligament
A discrete, extra-articular, round ligament that spans the ankle and subtalar joints as it courses obliquely from the inferior tip of the distal part of
the fibula to insert posteriorly on the mid-lateral part of the calcaneus.
This ligament is extra-articular but it has an intimate connection to the overlying peroneal-tendon sheath.
1 of 4
10/6/2007 10:49 AM
Ankle Sprains
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Strain increases as the ankle is moved from plantarflexion to dorsiflexion, with the greatest strain occurring when an inversion moment is applied
with the ankle in dorsiflexion.
Because of its unique anatomic orientation, the calcaneofibular ligament also has a major role in the stabilization of the subtalar joint.
Deltoid Ligament
Consists of deep and superficial components.
The deep fibers connect the medial malleolus to the medial border of the talus, while the superficial portion has a broad, fan-shaped attachment
to the navicular, the sustentaculum tali, and the posterior part of the talus.
The deep portion resists external rotation of the talus
The superficial component resists abduction of the talus.
Distal Tibiofibular Syndesmosis
The ankle mortise is stabilized by:
the anterior and posterior tibiofibular ligaments
the inferior transverse ligament
the interosseous ligament
Strain increases in the anterior and posterior tibiofibular ligaments with dorsiflexion
Strain increases in the anterior tibiofibular ligament with external rotation of the talus
PATHOMECHANICS
[Back To Top]
Analysis of ankle stability under physiologic loading of the joint demonstrated that articular contact provides 100% of inversion stability and 30%
of rotational stability.{12} In reality, however, inversion ankle injuries usually occur during loading or unloading of the ankle.
Lateral Ankle Ligaments
Inversion injuries.
Injury of the anterior talofibular ligament occurs first, followed by a varying degree of injury of the calcaneofibular ligament.
Black and associates chose to describe injuries to it as single if one ligament was ruptured and as double if more than one ligament were
ruptured.
Singer and Jones classified injuries of the lateral ankle ligaments as stable or unstable and subdivided unstable injuries according to the degree
of the talar tilt and anterior drawer that is present under stress.
CLINICAL
[Back To Top]
Stress Tests
See Foot & Ankle Examination
It is difficult to be certain which ligament is being evaluated with each of the clinical tests.
The anterior drawer test [ Picture1 ][ Picture2 ]
can be performed with the patient either sitting or supine. W hen the patient is sitting, the knee should be flexed over the edge of a bench or table
and the ankle should be allowed to fall into equinus . The examiner then stabilizes the distal part of the leg with one hand and applies an anterior
force to the heel with the other hand, in an attempt to subluxate the talus anteriorly from beneath the tibia. This maneuver usually is not painful if
the patient has an acute injury.
The modified anterior drawer test can be used when the patient is supine . W ith the knee hyperflexed , the ankle in equinus , and the foot
fixed by one of the examiner's hands to the ground or table, a force is applied with the other hand on the anterior aspect of the distal part of the
leg, in an attempt to translate the tibia posteriorly .
The talar tilt test
is performed with the patient seated and with the ankle and foot unsupported in 10 degrees to 20 degrees of plantarflexion . The examiner
stabilizes the medial aspect of the distal part of the leg, just proximal to the medial malleolus, with one hand and applies an inversion force slowly
to the hindfoot with the other hand. The lateral aspect of the talus should be palpated during inversion of the hindfoot to determine if tilting is
occurring at the tibiotalar joint. Comparison with the normal ankle is helpful to detect any side-to-side difference. It has been noted that the talar
tilt test may be positive only if gross instability is present.
If the anterior drawer or talar tilt test suggests abnormal laxity or if pain, swelling, and muscle spasm are present to a degree that prevents
satisfactory clinical assessment, then stress radiographs are performed to measure laxity.
2 of 4
10/6/2007 10:49 AM
Ankle Sprains
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
INVESTIGATIONS
[Back To Top]
Stress Radiographs
anterior drawer test - > 3mm of anterior excursion = rupture of the anterior talofibular ligament. (measured as the shortest distance from the
posterior lip of the tibia to a constant point on the talar dome.)
talar tilt test - > 10deg. = complete rupture of both the anterior talofibular and the calcaneofibular ligaments.
Ankle Arthrography and Peroneal Tenography
Arthrography is useful for detection of tears of the lateral, medial, and syndesmotic ligaments of the ankle.
Peroneal tenography has proved to be more accurate in the diagnosis of disruption of the calcaneofibular ligament.
Magnetic Resonance Imaging
Can demonstrate accurately the normal and torn anterior talofibular and calcaneofibular ligaments
Major role in the evaluation of osteochondral lesions of the talus.
Arthroscopy
Useful in the treatment of certain conditions that may persist after an ankle injury, such as osteochondral defects of the talar dome, loose bodies,
painful ossicles within the ankle ligaments, and the hypertrophied inferior border of the anteroinferior tibiofibular ligament. However, arthroscopy
does not play a role in the diagnostic workup of an acute ankle injury.
MANAGEMENT
[Back To Top]
The results of early mobilisation are superior to early surgical repair of acute ankle ligament injuries. The literature shows clearly that excellent
results can be achieved in most patients with grade III lateral ankle ligamentous injuries by conservative treatment with a combination of
immobilization and early protected mobilisation
Possible exceptions:
high level athletes with an initial talar tilt on stress radiograph of >15 degrees
patients with significant disruption of both medial and lateral ligamentous structures
patients with bony avulsion.
Patients with residual functional instability after conservative treatment are best treated with an anatomical repair such as a modified Brostrom
technique.
See Ankle Instability
Bibliography:
Kaikkonen A, Kannus P, Jarvinen M. Surgery versus functional treatment in ankle ligament tears. A prospective study. Clin Orthop
1996;326:194-202.
R.A. Marder; Instructional Course Lectures 1995, Volume 44:349
[ Close Window ]
3 of 4
10/6/2007 10:49 AM
Ankle Sprains
4 of 4
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 10:49 AM
Arthritis in Children
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies
for rules on diseminating site content.
Arthritis in Children
Matt Smith, 2006
JUVENILE CHRONIC ARTHRITIS (JCA)
Approximately 1:1000 children will develop swelling of one or more joints persisting for more than 3 months with no specific
cause found. 50% of these will progress to JCA.
Aetiology - unknown
Diagnostic Criteria
Age under 16 at onset
Persistent arthritis in one or more joints for 6 weeks (minimum) to 3 months after other aetiologies have been ruled
out. E.g. infection, malignancy, blood dyscrasias, Reiter's, hypogammaglobulinaemia
Classification by onset (Schaller)
1. Systemic onset (Still's disease)
Age: usually under 5years but can be any age
Sex: <5yr female = male; >5yr female > male
Fever (high with spikes up to 40 C daily) plus one of the following
1.
2.
3.
4.
5.
Maculopapular rash
Iridocyclitis
RhF +ve
Cervical spine involvement
Pericarditis
Generalised lymphadenopathy
Hepatomegaly
Splenomegaly
Sites: knees, wrists, ankle, feet
2. Polyarticular onset
Age: any, even before age 1year!
Sex: female > male
5 or more joints involved in the first 3 months
Seronegative (RhFactor -ve)
Sites: knees (60%), wrists, hands
RhFactor +ve
Older children (9-10 years) with persistent activity and rapid joint destruction affecting mainly the hands and feet.
3. Pauciarticular (most common)
4 or less joints involved in the first 3 months
Type I
Younger onset <6yr, with females mainly affected. ANA +ve. Danger because of development of iridocyclitis. Presence
of ANA related to eye involvement.
Type II
Older onset 9yr+, with males mainly affected. Association with HLA-B27.
Lab tests
1 of 4
HB
WCC
ESR
RhF
ANA
Systemic
++
++
+ve
+ve
Polyarticular
-/+ve
30%+ve (in
those with
RhF+ve)
Pauciarticular
+ or -
-ve
10/6/2007 10:50 AM
Arthritis in Children
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Radiological changes
Early features limited to periarticular osteopenia
Late features occur after 6 months and include growth disturbance, chondrolysis, joint destruction and erosions.
These features are more common in the RhF +ve patients.
Prognosis
80% will eventually be able to lead normal functional lives.
Death can occasionally occur in the systemic onset group because of infection or the development of amyloidosis.
60% if seen within 1 year of onset will have normal function at 5 years compared with 25% of those seen after 1 year.
Functional outcome is related to joint contractures and destruction.
Poor prognostic factors
Onset < 1year
IgM (RhF) +ve
Eye involvement
Hip involvement leads to a greater functional deficit
Medical Management
Aim: to suppress activity and therefore prevent joint deformity
Multidisciplinary approach with rheumatologist, PT, OT, child psychologist etc
PT to help prevent joint contractures and keep healthy muscles working. Hydrotherapy affective.
OT for splints and orthoses
Drug treatment
NSAID's
- Ibuprofen, voltarol, naproxen etc.
- Aspirin used to be the drug of choice but dangerous with children under the age of 5 years because of the risk of
Reye's syndrome.
Disease modifying drugs
- Methotrexate: shown to be effective in polyarticular disease
- Gold, penicillamine, azathioprine etc.
Corticosteroids
- Systemic: the use of steroids does not affect the ultimate prognosis and there are many complications related to their
use, in particular growth disturbance, adrenal suppression etc.
- Intra-articular/tendon sheath: can be effective in controlling flare ups
Surgical treatment
Hip
- Soft tissue releases for contractures
- Total joint replacement
Knee
- Soft tissue releases for contractures
- Synovectomy
- Epiphyseal stapling
- Supra-condylar osteotomy
- Total joint replacement (rarely needed)
Foot and ankle
- Orthoses
- Triple fusion
Summary
Type
Joints
Features
Progression (%)
Systemic (Still's)
25
many
25
15
many
Mild fever
30
Polyarticular: RhF+ve
15
many
25
Pauciarticular I (F)
30
large
Iridocyclitis
15
Pauciarticular II (M)
15
large
Spondylitis, HLA-B27
15
Other arthritides
2 of 4
10/6/2007 10:50 AM
Arthritis in Children
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
FIGURE 121
Algorithm for evaluation of a child with joint pain and/or swelling. Chronic is considered <6 weeks. ANA, antinuclear antibody;
ASO, antistreptolysin-O; PPD, tuberculin skin test; PVNS, pigmented villonodular synovitis; ESR, erythrocyte sedimentation
rate; CRP, C-reactive protein.
3 of 4
10/6/2007 10:50 AM
Arthritis in Children
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
4 of 4
10/6/2007 10:50 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on
diseminating site content.
ANKLE ARTHRODESIS
SUBTALAR ARTHRODESIS
TALO-NAVICULAR
ARTHROSESIS
DOUBLE ARTHRODESIS
TRIPLE ARTHRODESIS
[Back To Top]
Indications:
posttraumatic arthritis
infection
paralytic conditions
salvage of failed total ankle arthroplasty.
Position:
neutral dorsiflexion to 10deg. equinus
5deg. valgus
7deg. external rotation (equal to opposite side)
Techniques:
Approaches:
Approach
Eponyms
Description
Anterior longitudinal
Blair, Morris,
Hand, Dunn
anterior longitudinal incision beginning 8 cm proximal to the ankle and ending at the medial cuneiform.
Dissect the interval between the extensor hallucis longus and extensor digitorum longus, and retract the
neurovascular bundle medially. Incise the capsule and periosteum in line with the skin incision.
see below
transverse incision extending from the talonavicular joint anteriorly to 1 cm below the lateral malleolus
10 cm longitudinal incision over the subcutaneous surface of the distal fibula, ending 1.3 cm distal to the
lateral malleolus. After subperiosteally exposing the fibula, osteotomize it 7.5 to 10 cm from its distal end
Anteromedial incision; Use an osteotome to remove a longitudinal wedge of bone about 10 cm long and 1 to
1.5 cm wide from the medial tibia including the inner third of the medial malleolus; also include the medial
side of the body of the talus.
allows for TA lengthening also.
Fixation Methods:
Charnley
Blair
Dowel technique
Technique (Charnley):
Transverse incision across the anterior aspect of the ankle, extending from 1 cm proximal to the tip of the medial malleolus to 1 cm proximal to the tip
of the lateral malleolus. Curve the incision distally at its middle so that subsequent sectioning of the extensor tendons is not directly beneath the skin
incision. Raise the skin and subcutaneous fat as a proximally based flap to expose the extensor tendons.
Between sutures, divide the tendons of the tibialis anterior, extensor hallucis longus, peroneus tertius, and extensor digitorum communis muscles.
Treat the extensor digitorum communis tendon as a unit, but do not include the peroneus tertius.
Divide and ligate the anterior tibial vessels, section the deep branch of the peroneal nerve, and incise the joint capsule transversely.
Subperiosteally expose the distal tibia and the medial and lateral malleoli.
Divide the deltoid and lateral ligaments of the ankle, then plantarflex the foot.
Partially divide the distal ends of the tibia and fibula with a power saw. Complete the bony division posteriorly with an osteotome.
Place the foot in the desired position and remove a section of bone about 6 mm thick from the superior surface of the talus.
Pass a heavy Steinmann pin through the open wound and through the anterior portion of the body of the talus so that its pull will counterbalance the
pull of the tendo calcaneus.
1 of 4
10/6/2007 10:51 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Compression arthrodesis of ankle. A, Distal pin should be inserted anterior to transverse axis of body of talus to counteract pull of tendo
calcaneus. B, If pin is inserted through or posterior to axis, force of tendo calcaneus will separate osseous surfaces anteriorly. C, Osseous
surfaces should not be flush anteriorly as shown; rather, talus should be displaced as far posteriorly as possible to preserve prominence of heel.
(Modified from Charnley J: J Bone Joint Surg 33-B:180, 1951.)
SUBTALAR ARTHRODESIS
[Back To Top]
TALO-NAVICULAR ARTHRODESIS
[Back To Top]
DOUBLE ARTHRODESIS
[Back To Top]
TRIPLE ARTHRODESIS
[Back To Top]
2 of 4
10/6/2007 10:51 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
talonavicular fusion will limit subtalar motion to about 9% so that there will only be about 2 deg of motion;
calcaneocuboid fusion decreases talonavicular motion down to 67% and subtalar motion down to 92%;
outcomes:
CL. Saltzman MD et al JBJS 1999, 67 feet in 57 patients who underwent triple arthrodesis were evaluated at an average of 25 and 44 years following
surgery; - indications for surgery: polio (55%), CMT (9%), spinal cord abnormalities (6%), CP (4%), Guillain-Barr' syndrome (1%); pseudarthrosis occurred in thirteen feet - 55 % of feet were painful at 44 years and all showed some degenerative changes; - despite the foot pain and
radiographic signs of degenerative changes, 95% of patients were satisfied with results of the procedure; - the authors note that the indications for
triple arthrodesis have change during the past few decades (less often for neuromuscular disorders and more often for severe degenerative arthritis or
severe flat foot), and note that the prevalence of pseudoarthrosis is less frequent;
RF Pell MD et al. Jan. 2000. Vol 82-A. p 47., the authors followed 183 triple arthrodeses procedure over an average of 5.7 years; - authors noted high
correlation between patient satisfaction and post-operative foot alignment; - 91% of patients indicated that they would have the procedure again, under
similar circumstances; - postoperative ankle arthritis (clinical and radiographic) was common but did not seem to affect patient satisfaction; - authors
noted that feet w/ post-traumatic changes (25) required the least correction where as the 22 feet w/ RA and the 70 feet w/ tibialis posterior rupture
needed the most correction; - average time to fusion was 10.7 weeks;
contra-indications:
contra-indicated in young children (less than 10-12 yrs) because the procedure limits foot growth
Ollier Incision:
begins over dorsolateral aspect of the talonavicular joint, - continue incision obliquely & inferoposteriorly to end about 1 inch inferior to lateral
malleolus; - superiorly expose long extensor tendons to toes and retract them medially, w/o opening their sheaths; - inferiorly expose the peroneal
tendons and retract them inferiorly; - divide origin of EDB muscle & retract it distally; - this exposes sinus tarsi;
NV bundle enters approx 1.5 cm medial & distal to anterior process of the calcaneus;
Continue dissection to cuboid and distal calcaneus thru deep portion of peroneus sheath;
Identify, posterior facet of the subtalar joint;
Identify the calcaneocuboid joint which is found just distal to the anterior beak of the calcaneous;
The talo-navicular joint lies superior and medial to calcaneocuboid joint;
Identify neck of the talus, and elevate the extensor tendons off the neck;
Procedure:
Incise the capsules of the talonavicular, calcaneocuboid, and subtalar joints circumferentially to obtain as much mobility as possible. If this release
allows the foot to be placed in a normal position, removal of large bony wedges is not required. If correction is impossible after soft tissue release,
appropriate bony wedges are removed
Identify the anterior articular process of the calcaneus, and excise it at the level of the floor of the sinus tarsi for better exposure of all joints. To make
this osteotomy, use an osteotome placed parallel to the plantar surface of the foot; preserve the bone for grafting.
Next, with an osteotome, remove the articular surfaces of the calcaneocuboid joint to expose cancellous bone. Remove an equal amount from both
bones unless wedge correction of a bony deformity is required.
Next remove the distal portion of the head of the talus with -inch and -inch straight and curved osteotomes. Remove only enough bone to
expose the cancellous bone of the talar head unless a medial wedge is required to correct a fixed deformity. A small lamina spreader can be inserted
for better exposure.
A second medial incision may be necessary to expose the most medial portion of the talonavicular joint. Beginning at tip of medial malleolus and in line
w/ medial border of foot, extending 6 to 7 cm toward great toe longitudinally & ending between anterior & posterior tibial tendons
Remove the proximal articular surface and subchondral bone of the navicular, and shape and roughen the surfaces for a snug fit with the talus. Excise
the articular surfaces of the sustentaculum tali and the anterior facet of the subtalar joint.
Now approach the subtalar joint and completely remove its articular surfaces. For better exposure of the posterior portion, use the small lamina
spreader to expose the subtalar joint. Remove appropriate wedges from this joint if necessary; otherwise, make the joint resections parallel to the
articular surfaces.
Cut the removed bone into small pieces to be used for bone grafting. Place most of the bone graft around the talonavicular joint and in the depth of the
sinus tarsi.
Smooth Steinmann pins, screws, staples or Kirschner wires may be used for internal fixation.
Obtain intraoperative roentgenograms to ensure correct positioning of the foot and the pins.
Close the muscle pedicle of the extensor digitorum brevis over the sinus tarsi to decrease the dead space. Close the wound over a suction drain, and
apply a well-padded, long leg cast with the knee in 45 degrees of flexion. If wires or pins are used for internal fixation, apply a short leg cast.
3 of 4
10/6/2007 10:51 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Bibliography:
Jim Barrie's Foot & Ankle Hyperbook
Campbell's Operative Orthopaedics
Orthopaedic Knowledge Update - Speciality Series - Foot & Ankle
Sponsored Links
www.ebimedical.com
[ Close Window ]
4 of 4
10/6/2007 10:51 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules on diseminating site content.
Indications
Portals
Technique
Complications
[Back To Top]
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6.
7.
8.
Chondral lesions
Osteoarthritis
Impingement exostosis
Meniscoid lesions of the ankle
Chronic lateral instability of the lateral collateral ligaments
Septic arthritis
Rheumatoid synovitis
Post-traumatic synovial impingement
[Back To Top]
A good joint distraction allows up to 5 to 10mm of joint opening. With increased joint opening there is less chance for operative complications and lessens the need for accessory portals.
Several positioning alternatives exist:
supine position
supine with the leg hanging dependent over the edge of the table
supine with a bolster under the hip to internally rotate the ankle into a neutral position.
Distraction methods may either be non-invasive or invasive:
Non-invasive methods applies force by traction onto the skin. A sterile commercially produced strap is applied with one loop at the heel and one loop over the dorsum of the midfoot. This strap is then
attached using a velcro strap to a sterile bar attached to the operative table. The velcro strap allows easy variation of distraction force during the case.
Invasive distraction involves pins placed proximal and distal to the joint. This can cause direct neurovascular injury & traction nerve injury.
Arthroscopic portals
[Back To Top]
1 of 3
10/6/2007 10:52 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Mark landmarks with marking pen: tibialis anterior tendon, dorsalis pedis artery, EHL, EDL, peroneal tendons.
Inject 50ml saline into the joint.
Use a 2.7mm arthroscope.
Systematic Examination:
Visualization from the anteromedial portal: - deltoid ligament; - medial malleolus; - medial gutter (medial talomalleolar joint); - talar dome (osteochondral lesions) - anterior gutter; - tibiofibular joint: synovitis, fibrocartilagenous protrusion; - posterior tib-fib ligament; - anterior tib-fib ligament; - anterior talofibular ligament (arising from the tip of the fibula);
Examination is made first of the central aspect of the tibio-talar joint, visualising the talus and the distal aspect of the tibia.
Plantarflexion of the foot allows the surgeon to pass the obturator over the talar dome into the posterior compartment allowing visualisation of the postero-medial and postero-lateral aspects of the joint.
The scope can then be rotated 180deg. allowing the surgeon to change the field of view and visualise the inferior aspect of the distal tibio-fibular joint proximally and intra-capsularly, as well as the talar
neck and anterior insertion of the capsule distally
Anterior 8 point system - from Stoller, MRI Arthroscopy & Anatomy of the Joints
Posterior 7 point system - from Stoller, MRI Arthroscopy & Anatomy of the Joints
[Back To Top]
2 of 3
10/6/2007 10:52 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Bibliography:
Ankle Arthroscopy by David Chia
Schneider et al. Arthroscopy of the ankle joint
Stoller - MRI, Arthroscopy & Surgical Anatomy of the Joints. Lipincott Williams.
[ Close Window ]
3 of 3
10/6/2007 10:52 AM
Bibliography
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Bibliography
The following Websites & Books were used in compiling the Orthoteer Summaries: ( Bold=
Essential)
Books:
Apley
Orthopaedic Knowledge Updates
Websites:
South Australian Orthopaedic Registrars' Notebook
Entrez-PubMed
University of Washington Radiology Webserver
Journals:
Current Orthopaedics
The Journal of Bone and Joint Surgery
BASIC SCIENCE
Sciences Basic to Orthopaedics - Sean Hughes & Ian McCarthy; WB
Saunders, 1998.
10/6/2007 10:52 AM
Bibliography
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 10:52 AM
1 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site
policies for rules on diseminating site content.
Range of Motion
Stability
Kinetics
Foot
Gait
Muscle Activity
Load Transmission
Subtalar Joint
Midtarsal Joints
TMTJ's
Fat Pads
Summary
10/6/2007 10:54 AM
2 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
In the horizontal plane, the ankle axis projects from anteromedial to posterolateral
10/6/2007 10:54 AM
3 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Ankle jt motion:
Mostly in sagittal plane
ROM varies widely, usu around 45o
10-20o dorsiflexion
25-35o plantarflexion
walking req's approx 10-15o dorsi & 15-20o plantar
Dorsiflexion of the ankle results in eversion of the foot, plantarflexion in inversion.
The axes of rotation change depending on whether the ankle is in dorsiflexion or plantarflexion. No true single joint axis
exists. These instant centers vary depending on the joint position, different individuals, direction of motion & weightbearing
status.
The distal fibula:
static buttress for the talus
the fibula bears one sixth of the weight transmitted downward from the knee during static weightbearing.
The distal fibula moves distally (average, 2.4 mm) when moving from nonweightbearing to weightbearing. (pulled
distally by the active
contraction of the flexors of the foot). This distal movement may increase ankle stability by deepening the mortise
and by tightening the interosseous membrane, thereby pulling the fibula medially.
Trochlea of the talus:
Wedge-shaped, with the mediolateral width greater anteriorly than posteriorly.
[Back To Top]
10/6/2007 10:54 AM
4 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Ankle stabilisers:
1.
2.
3.
4.
5.
6.
Shape of talus
interosseous membrane
Ant. & post. talofibular ligaments
calcaneofibular ligament
Deltoid ligament
Ankle joint capsule
Because the talus narrows posteriorly, in plantarflexion the tautness of the ligaments provide most of the stability.
Ankle Kinetics
[Back To Top]
Ankle has a larger weight-bearing surface area than the hip & knee joints. Therefore, lower loads per unit
area (stresses) can be transmitted. Also, a small amount of articular incongruity causes relatively larger stresses.
Thus the need for perfect anatomical articular reconstruction following fractures & the higher failure of ankle
arthroplasties.
Ankle free body diagram for calculating Joint Reaction Force (J in diagram):
The Ground reaction force (W) is known [BW x g]; The direction of the Achilles Tendon force (A) & W are known.
Therefore the magnitude of J & A can be calculated.
10/6/2007 10:54 AM
5 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
10/6/2007 10:54 AM
6 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
[Back To Top]
[Back To Top]
From heel strike to foot flat, the anterior compartment of the leg (tibialis anterior) contracts eccentrically, thus lengthening,
while the gastroc soleus is quiescent.
During foot flat the gastroc soleus complex is contracting eccentrically, and the anterior tibialis is quiet.
During heel rise the gastroc soleus complex contracts concentrically, and the tibialis anterior (anterior compartment) is
quiescent.
From heel strike to foot flat there is progressive eversion of the subtalar joint, which unlocks the transverse tarsal joint and
10/6/2007 10:54 AM
7 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Motion between talus and calcaneus consists of rotation about a single oblique axis.
Subtalar motion has been modeled as screw-like with calcaneal inversion (varus) & forward translation.
The axis of subtalar rotation passes in the plantar & lateral direction from the neck of the talus through the sinus tarsi to
the lateral wall of the calcaneus.
Subtalar rotation = ~45 degrees.
[Back To Top]
The midtarsal articulation consists of the calcaneocuboid joint and the talonavicular joint.
With varus / inversion of the hindfoot (subtalar joint), the midtarsal joints are not parallel, and this joint (Chopart's joint) is
locked. See Figure 8.
As the subtalar joint everts, these joints (Chopart's joint) become parallel and allow motion [see Figure 8] . This flexibility is
important during the heel strike and the subsequent stance phase of gait, when the hindfoot is in valgus; it allows
pronation of the foot, absorbing some of the energy from heel strike.
[Back To Top]
10/6/2007 10:54 AM
8 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
When the toes extend beyond 50deg. the MT fat pad is locked under the MT heads - occurs during toe-off.
Heel pad
To absorb the energy of the ground reaction force at heel strike, the skin and soft tissues are compartmentalized into a
unique shock-absorbing mechanism. Under the thick skin are slanted spiral chambers that contain adipose tissue
beneath the calcaneus. These chambers are so placed as to take their deep origin from the calcaneus and, passing
posteriorly and curving laterally, to attach to the skin. A second spiral system, located more superficial to the calcaneus,
converges on itself as it spirals laterally. The two systems represent a right-handed spiral that opens laterally beneath the
calcaneus and a second spiral that closes as it passes laterally, superficial to the first (Figure 9). The cushioning provided
by this system accounts for the ability of the resist repeated loads for long periods, as hiking.
10/6/2007 10:54 AM
9 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 10:54 AM
10 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
ankle = 15 plant (peak @ flat foot & toe off) to 10 dorsi (peak heel off)
Ground Reaction forces:
Newton's 3rd = + & opp force by ground to ody wt
Measured with force plate/platform
GRF mag & direction varies during stance phase
Ploting vectors of GRF during gait cycle gives the typical butterfly diagram (fig 42)
Plotting the vertical GRF against time for both feet gives double hump (fig 43)
First peak is due to deceleration of body mass at heel strike
Second peak is due to pushing off at toe off
[Back To Top]
All the metatarsal heads are in contact with the ground during stance.
50% of the load is borne by the MT heads & 50% by the heel. The load on the 1st MT head is twice that on each of the
other MT heads.
During the stance phase the center of load progresses forward along the foot rapidly to the great toe. As the foot
progresses to toe-off the load is transmitted mainly through the 2nd metatarsal head (since it is longer than the others).
10/6/2007 10:54 AM
11 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 10:54 AM
12 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 10:54 AM
13 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 10:54 AM
14 of 14
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 10:54 AM
1 of 1
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
[ Close Window ]
10/6/2007 10:54 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
The British Orthopaedic Foot Surgery Society recommends the following syllabus of study in
foot and ankle surgery for the FRCSOrth examination.
This syllabus has been recommended to the Intercollegiate Board in Orthopaedic Surgery. We
do not recommend at what stage of training any
particular part of the syllabus should be studied: this will depend on your clinical attachments
and your local training programme. Thorough knowledge of history taking and clinical
examination.
Investigation of foot problems including:
Plain radiological investigations.
Complex scanning including ultrasound, CT, MRI and
radioisotope bone scanning.
Invasive investigation such as arthrography.
Principles of gait analysis applied to the foot and ankle,
including foot pressure studies.
Swellings and Tumours about the foot and ankle.
Surgical approaches to the foot and ankle.
Reflex sympathetic dystrophy.
Principles of ankle arthroscopy.
Management of ingrown toenails.
Conservative management of the foot and ankle including:
The principles and use of orthoses
Shoe wear modifications
Appliances
Principles and variety of prostheses following amputation
Principal techniques of physiotherapy as applied to the foot and
ankle
The role of manipulation and injection techniques
TRAUMA
The classification, management and outcomes following injuries to the:
Ankle
Os calcis
Talus and peritalar soft tissues
Tarsal bones
Tarso-metatarsal joint
Forefoot and toes
Tendo Achilles injuries, recognition and treatment
Investigation and management of lateral ligament injuries of the ankle
10/6/2007 10:55 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Indications, techniques and outcomes of the surgical treatment of pain and deformity of
the first ray
Lesser toe and ray disorders and the investigation and treatment of metatarsalgia
The pathogenesis of deformities of the mid and hindfoot including congenital, post
traumatic, neurological and degenerative conditions
The principles of correction of deformities of the ankle, hindfoot and midfoot by soft
tissue and/or bony procedures such as fusion or osteotomy
The pathology, prevalence and classification of posterior tibial tendon ruptures and their
management
The diabetic foot, pathology, conservative treatment and surgical management
including neuropathic ulceration, Charcot deformities and amputations
The rheumatoid foot, pathology, conservative treatments and surgical management of
forefoot, hindfoot and ankle disease
[ Close Window ]
2 of 2
10/6/2007 10:55 AM
Bunionettes
1 of 1
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please
refer to the site policies for rules on diseminating site content.
Bunionettes
Classification
Type 1 - Enlargement of the 5th MT head
Type 2 - Lateral bowing of 5th MT
Type 3 - Widened 4-5 IMT angle
Surgical Treatment
If conservative treatment fails.
1. Chevron osteotomy for Type 1
'L' shaped capsule incision.
60deg. angle.
fix with K-wire.
2.
[ Close Window ]
10/6/2007 10:56 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please
refer to the site policies for rules on diseminating site content.
Calcaneal Fractures
Anatomy
Superior surface is divided into 3 articular facets:
Posterior - largest and convex on shape
Middle - on the sustentaculum tali, concave in shape
Anterior - often confluent with the middle facet, concave
Between the middle and the posterior facets lies the interosseous sulcus (calcaneal groove)
The anterior surface is saddle shaped, articulating with the cuboid bone
Principle functions of the calcaneum
1. To act as a lever arm for the gastrosoleus complex
2. To provide a foundation or vertical support for body weight
3. To provide support for and to maintain the lateral column of the foot
Any fracture that impairs one of these functions will significantly affect the patients gait if not corrected
or restored.
Associated injuries
Bilateral calcaneal fractures occur in 5 - 9% of patients
Compression fractures of the lumbar/dorsal spine occur in 10% patients with calcaneal fractures
Other injuries of the lower extremity occur in 26%, e.g. ankle, tibial fractures
Soft tissue injuries
Laterally the peroneal tendons can be subluxated or dislocated from the fibular sulcus
Medially the fracture fragments can injure or entrap the neurovascular bundle.
Flexor hallucis longus can interpose in fractures of the sustentaculum tali, trapping the
tendon.
Compartment syndrome develops in 10% of calcaneal fractures, with half of these
develop clawing of the lesser toes or other chronic problems such as stiffness and
neurovascular dysfunction. Fasciotomy should be carried out when pressure of
>40mmHg are encountered.
Classification
Extra-articular fractures
25-30% of all calcaneal fractures
Divided anatomically into:
Anterior process
Tuberosity (beak or avulsion)
More common in diabetics
Medial process
Sustentaculum tali
Body
Intra-articular fractures
1 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
2 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Lateral views will show Bohler's tuber angle and the crucial angle of Gissane clearly.
Bohler's angle - Normal = 20-40deg. (should compare to opp. side) - indicates
disruption of the posterior facet .
3 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
This is the investigation of choice. Coronal and axial views are needed.
Sanders classification
Type 1: undisplaced
Type 2: two parts (split)
Type 3: three parts (or split/depression)
Type 4: comminuted
Type 1 will do well with non-operative treatment, types 2 and 3 can be treated effectively with ORIF,
and type 4 defies operative reduction
Treatment
Extra-articular fractures
Admit for elevation, ice packs and compression bandaging.
4 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Commence vigorous exercises to regain subtalar and ankle movement once the swelling has begun
to subside.
If significant widening of the calcaneum exists some authors perform a closed manipulation (manual),
to decrease heel width and decrease the chance of late peroneal tendon irritation.
If Bohler's angle has been reduced by more than 10 o then calcaneal height can be restored by using
a transverse pin, applying traction and subsequently incorporating the pin in a POP cast for 4 weeks.
Prognosis
Virtually all patients with undisplaced extra-articular fractures have a good result, even if there is
displacement patients generally do well. Fracture union always occurs, and with early movement, joint
stiffness is a minimal long-term problem.
Intra-articular fractures
4 treatment options
1. Treatment without reduction
Compression dressing, elevation and ice packs
Early movement beginning at 24 hours
NWB mobilisation after the first week
Surgical shoe fitting at 14 days
PWB in the shoe after 6 weeks to FWB after 8 weeks
2. Closed reduction and fixation
This technique can be used in certain types of fracture, utilising a Steinman pin to
manoeuvre the fragment and then advance the pin to hold the fracture.
3. Open reduction and internal fixation
Using a lateral approach, the subtalar joint is reduced and held with reconstruction
plates.
Problems occurring with this treatment option include skin edge necrosis (8%) and
deep infection (2%).
4. Primary arthrodesis
Either isolated subtalar fusion or triple fusion, as there can be unrecognised damage
to the calcaneocuboid joint or talonavicular joint.
Prognosis
Lance (1964) reviewed 227 intra-articular fractures, only 55% of patients had good results, although
this was better than the group treated operatively.
Lindsay and Dewar reviewed 147 patients after 8 years, 76% of patients treated conservatively had
good results, with only 60% of patients treated with primary or late arthrodesis had good results.
Prognostic factors:
1. Degree of displacement of the posterior facet is the most important factor
2. Decreased tuber angle, with a persistent severe decrease (0 o or less) is associated with poor
long-term results.
3. Patient age, Essex-Lopresti recommended that patients over 50yr should not be treated as
aggressively as the results are worse.
4. Degree of comminution - 5-15% of intra-articular fractures are so comminuted that they are
not amenable to surgery and will have a poor outcome.
Premature weight bearing before 6weeks is related to redisplacement of the fracture fragments, and
weight bearing after surgery should be delayed to 12 weeks.
Other sources of persistent pain following calcaneal fractures
5 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
1. Subtalar joint
Secondary degenerative changes present as pain on weight bearing, which is aggravated by inversion
and eversion.
Subtalar arthrodesis alone may not control the symptoms, as unrecognised degenerative changes in
the calcaneocuboid or talonavicular joint will not be treated by a limited hind foot fusion.
2. Peroneal tendonitis
Stenosing tenovaginitis of the peroneal tendon sheath. Surgical decompression and rerouting of the
tendons can give relief.
3. Bone spur
Heel spur arising from a malunion can become painful, treated primarily with pressure relieving pads.
Surgical excision should only be undertaken as a last resort.
4. Calcaeocuboid OA
Treated with local steroid injections or a triple fusion should symptoms persist.
5. Nerve entrapment
Either from the healing fracture or from iatrogenic injury.
Cochrane Collaberative Review of Interventions in Calcaneal Fractures (from Cocharane
Musculoskeletal Reviews )
A substantive amendment to this systematic review was last made on 29 June 1999. Cochrane
reviews are regularly checked and updated if necessary.
Background: Fracture of the calcaneus (os calcis or heel bone) comprises one to two per cent of all
fractures.
Objectives: To identify and evaluate randomised trials of treatments for calcaneal fractures.
Search strategy: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and the
Cochrane Musculoskeletal Injuries Group Trials Register were searched. We checked reference lists
of relevant articles and contacted trialists and experts in the field. Date of the most recent search:
October 1998.
Selection criteria: Randomised and quasi-randomised trials comparing interventions for treating
patients with calcaneal fractures.
Data collection and analysis: Two reviewers independently assessed trial quality, using a 12 item
scale, and extracted data. Wherever appropriate and possible, results were pooled.
Main results:
Of the six relevant randomised trials identified, four were included, one excluded and one is ongoing.
All four included trials had methodological flaws.
Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative
management of displaced intra-articular fractures. Pooled results showed no apparent difference in
residual pain (24/40 versus 24/42; Peto odds ratio 0.90, 95% confidence interval 0.34 to 2.36), but a
lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45;
Peto odds ratio 0.30, 95% confidence interval 0.13 to 0.71), and was unable to wear the same shoes
as before (12/52 versus 24/54; Peto odds ratio 0.37, 95% confidence interval 0.17 to 0.84).
One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a
mean difference of 1.40 pain units on a visual analogue score (scale 0-10) (95% confidence interval
0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar
movement (mean difference 14.0 degrees, 95% confidence interval 3.2 to 24.6) at three months. On
average, patients in the impulse compression group returned to work three months earlier than those
in the control group.
Reviewers' conclusions:
Randomised trials of management of calcaneal fractures are few, small and generally of poor quality.
6 of 7
10/6/2007 10:57 AM
Calcaneal Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Even where there is some evidence of benefit of operative compared with non-operative treatment, it
remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems
best to wait for the results of one large ongoing trial on open reduction and internal fixation against
conservative treatment.
One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures
may be beneficial.
More large-scale, high quality randomised controlled trials are needed to confirm these results, and to
test other interventions in the treatment of calcaneal fractures.
TOP
[ Close Window ]
7 of 7
10/6/2007 10:57 AM
Compartment Syndrome
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Compartment Syndrome
INCIDENCE & AETIOLOGY
Compartment syndrome of the foot occurs in 10% of calcaneal fractures & 41%
of crush injuries.
PLANTAR COMPARTMENTS
the
9
DIAGNOSIS
HIGH INDEX OF SUSPICION
Unlike its counterpart in the leg or forearm, there are no classic signs in the foot. Pain on
passive stretch, dysesthesias, and diminished pulses are not consistent findings.
Tense swelling may be suggestive.
Pressure measurement of all major compartments is required. Absolute pressures >30mmHg
requires decompression, or less than 20mmHg below the diastolic blood pressure.
SURGICAL FASCIOTOMY
2 dorsal incisions over the medial aspect of the 2nd MT & lateral aspect of the
4th MT.
one 6cm medial incision - releasing the medial, calcaneal & lateral
compartments.
- medial approach:
can be used to decompress the medial and central compartments as well as the remaining foot
compartments; extends from a point below the medial malleolus (3 cm from the sole)to
10/6/2007 10:57 AM
Compartment Syndrome
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
proximal aspect of first metatarsal; once the neurovascular bundle has been retracted out of
the way, the fascia overlying the abduction hallucis and FDB is released; medial intermuscular
septum is opened longitudinally; the lateral plantar neurovascular bundle is found coursing over
the quadratus plantae (central compartment) as they course laterally; the remaining
compartments (central, lateral, intrinsic) are entered thru blunt dissection; the lateral
compartment is found by retracting the FDB out of the way;
- dorsal approach:
often the dorsal approach is not necessary unless there is concomitant metatarsal or Lisfranc
fractures; accomplished through 2 dorsal incisions centered just medial to the 2nd metatarsal
and just lateral to the 4th metatarsals (to maximize skin bridge); avoid injury to sensory nerves
and extensor tendons; superficial fascia is divided and interosseous are elevated off the
metatarsals to further decompress the compartments; bluntly dissect thru the central, medial,
and lateral compartments; separate medial incision may be needed to release the abductor;
fasciotomy incisions may be used for fracture fixation;
[ Close Window ]
10/6/2007 10:57 AM
Diabetic Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the
site policies for rules on diseminating site content.
Diabetic Foot
Prevalence
Neuropathy
PVD
Injury
Clinical
Investigations
Treatment
Charcot foot
[Back To Top]
[Back To Top]
[Back To Top]
Atherosclerosis appears earlier, progresses quicker and shows less male bias in diabetics.
Vessels in the lower limb most involved are distal superficial femoral, tibial and peroneal vessels.
There is controversy over how much small vessel disease there is. It has been assumed that there is
microangiopathy like that in the retina, but this is disputed.
It is possible that for the toes to become gangrenous even when ankle pressures normal.
2 Features of vascular disease in diabetes:
1. It occurs mainly distally, affecting popliteal arteries more than the iliac and femoral arteries
2. There is arterial wall calcification
Injury
[Back To Top]
Mechanical stress is the precipitator of ulceration in both the neuropathic and ischaemic foot.
In the ischaemic foot low pressures over a period of time may lead to necrosis. The most common sites
are the curve of the 1 st and 5 th metatarsal heads. The sole of the foot has a relatively good blood
supply and tends not to ulcerate early.
In the neuropathic foot ulceration precipitated by direct high pressure injury (unfelt) or gradually through
repetitive stress. Callosities develop under metatarsal heads and the heel. Subcutaneous tissue trapped
1 of 5
10/6/2007 10:58 AM
Diabetic Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
between bone and thick unpliable skin producing high shear forces, leading to sterile deep haematoma.
This deep' ulcer then tracks to the skin.
Clinical Assessment
[Back To Top]
[Back To Top]
Treatment
1. Prevention
2. DM control
3. Mx complications renal etc.
4. Eliminate infection
5. Optimise arterial inflow if ischaemic component
6. Local ulcer healing debridement, relief of pressure
Prevention of complications! Screening, pt education, good BM control, regular podiatrist.
Eliminate infection
Augmentin is a good broadspectrum antibiotic but not to be used on everyone with a positive
culture swab
Removal of infected bone
Drainage of abscesses
2 of 5
10/6/2007 10:58 AM
Diabetic Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Neuropathic ulcers
Healed by moderation of the causative mechanical forces
Options:
strict bedrest, expensive, risk of complications
non wt bearing on crutches
Total contact plaster cast: Below knee plaster cast with minimal padding, rocker for
walking, hole cut where ulcer is. Ulcer debrided and excess callus removed prior to
application. Changed weekly, then three weekly intervals
Ischaemic ulcers
Made worse by a total contact plaster
Arteriography will determine whether angioplasty, bypass surgery or amputation is necessary
Ulcers of mixed aetiology
Usually more one than the other, if it doesn't bleed, ischaemic, if it does, neuropathic
Prevention of further ulceration
Good diabetic control
Well fitting shoes with adequate cushioning, total contact insoles, 30 degree rocker sole to
prevent undue loading of metatarsal heads.
The role of surgery:
1. Debridement of infected ulcers, drainage of abscesses and excision of infected bone
2. Revascularisation of ischaemic foot
3. For fixed deformities - Correction or resection as in any foot , eg. Resection of distal
metatarsals (all) for prominent metatarsal heads.
4. Amputation (see notes on amputation ) - Digital, Ray, Symes if heel pad healthy, Below knee.
Charcot
3 of 5
[Back To Top]
10/6/2007 10:58 AM
Diabetic Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
A chronic painless degenerative process affecting the weight-bearing joints of the foot.
Rare complication of diabetes, only in 1 % of diabetics
Age - 5 th and 6 th decades in insulin dependent diabetics usually of more than 12 years duration
Aetiology
Repeated minor trauma in the neuropathic foot.
Spontaneous fractures, dislocations and subluxations can occur.
Autonomic neuropathy can increase blood flow leading to weakening of bone by
osteoporosis.
Can begin after acute trauma or even during bedrest.
Pathology
Swollen hot erythematous foot, some pain, may follow some minor trauma.
X-rays show healing fracture(s). Mimics infection!
Stage 2.
Coalescence
Stable but deformed shape to foot, can create pressure points for ulceration.
Stage 3.
May
span 2-3 years
Consolidation
4 of 5
10/6/2007 10:58 AM
Diabetic Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Updated by Naqui 1.05.05 using Orthoteers, Current Orth., Hyperbook & Miller.
Bibliography:
Klenerman - Current Orthopaedics 1996.
Jim Barrie - Foot & Ankle Hyperbook
[ Close Window ]
5 of 5
10/6/2007 10:58 AM
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Painful Heel
Painful Tarsus
Painful Forefoot
[Back To Top]
Children: Severs disease (apophysitis) usually male aged about 10 years with increased
density and fragmentation of the calcaneal apophysis
Raise heel and avoid strenuous activities, severe cases may require POP
Adolescents: Calcaneal knobs (often bilateral) usually female 15 - 20 years
Young Adults: Retrocalcaneal Bursitis (w/ Haglund's lump) above the Achilles tendon
insertion or plantar fasciitis (enthesopathies)
Older Adults:
1.
2.
3.
4.
5.
6.
Plantar fasciitis
Pagets may affect the calcaneum resulting in a chronic ache
Chronic bone infection (Brodies abscess with sclerotic margin)
Diabetes
Entrapment of medial calcaneal branch of posterior tibial nerve
Tarsal Tunnel Syndrome
Plantar Fasciitis:
Pain at the attachment of the plantar fascia to the medial tubercle of the
calcaneus. Treat with NSAIDs and orthosis, rarely needing release of plantar
fascia.
Painful Tarsus
[Back To Top]
Kohlers disease (osteochondritis of the navicular) usually children less than 5 years old
present with a painful limp and tender warm swelling over the navicular
Rest and strap for a few weeks results in relief and eventually normal looking navicular
Brailsfords disease similar to Kohlers but older women affected
The "overbone" In adults with high arches, ridge of bone on dorsal surfaces of the med
cunieform and 1st metatarsal- adjust shoes, bevel lump
Painful Forefoot
[Back To Top]
1. Metatarsalgia:
Symptom not a diagnosis and may be primary or secondary to other conditions
Primary metatarsalgia due to chronic imbalance in weight distribution between the toes and
metatarsal heads due to absent or ineffective muscle function
Secondary metatarsalgia caused by:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
10/6/2007 10:58 AM
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
TOP
[ Close Window ]
10/6/2007 10:58 AM
Freiberg's disease
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Freiberg's disease
Friebergs
Definition Osteochondritis of the 2nd metatarsal head
History Initially reported in 1914 by A.H. Freiberg as a series of 6.
Features:
Most commonly recognized in the 2nd decade
Thought to be secondary to a pressure effect as the second metatarsal is both the
longest and the least mobile.
Causes a painful synovitis with resultant loss of function.
Treatment:
Conservative:
Anti inflammatories
Activity modification
Metatarsal bars
Surgical
Dorsal closing wedge osteotomy
Alows debridement of the joint and rotation of the healthy plantar area
into the articulating position.
Joint Debridement and metatarsal head remodelling
1 of 4
10/6/2007 10:58 AM
Freiberg's disease
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Albert H. Freiberg, 1868-1940 Freiberg spent all his life in his birthplace, Cincinnati, apart from
a period of study in Germany and Austria. He established
himself as an orthopaedic surgeon in the city and played an
important part in the establishment of orthopaedic facilities
there. His influence on the development of American
orthopaedics was felt for two reasons: first, he was an active
medical author, one of the leaders of thought-he has been
called the philosopher of orthopaedic surgery. The second
reason for his eminence was his committeemanship; an
able, kindly speaker, he had the ability to turn discussions.
He is best remembered for describing flattening of the head
of the second metatarsal. It is interesting to note that he
considered that it was an injury. Since then opinion has
swung towards osteochondritis and back again; most
people would now agree that Freiberg was right.
In 1910-11 he was President of the American Orthopaedic
Association. It is ironic that Freiberg, whose name is
attached to the second metatarsal, should have just missed
working with Keller, who campaigned against damaging the
first metatarsal head, at the Walter Reed Hospital. Freiberg spent the war there and Keller
joined the staff after it was over.
Freiberg's original Description: Infraction of the Second Metatarsal Bone A TYPICAL
INJURY by Albert H. Freiberg, M.D., F.A.C.5., Cincinnati, Ohio, 1914 As a part of the general
symptom-complex of weak or so-called "flat foot" we very commonly encounter pain in the
2 of 4
10/6/2007 10:58 AM
Freiberg's disease
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
forefoot, in the region of the metatarsal heads. When seen as a paroxysmal affection
concerning the fourth metatarsal, in particular, we are dealing with the metatarsalgia of Morton.
Very frequently, however, we are consulted by patients because of pain in the heads of the
other metatarsals which is not of paroxysmal character but rather dependent upon the use of
the foot in weight-bearing. This may or may not be in the presence of other signs of yielding
and strain in the foot mechanism elsewhere than in the metatarsal region, but the dependence
of the pain purely upon the weight-bearing function will cause us to ascribe the symptom to
static incompetence of the foot. Under these circumstances we shall find that the most
common seat of the pain is the second metatarso-phalangeal joint instead of the fourth, as in
Morton's disease. The joint is usually tender to pressure and frequently somewhat thickened.
The well-known plantar callus is frequently seen; almost uniformly soin cases of long standing. I
have often found thickening of such degree in the second metatarso-phalangeal joint that I
have sought for organic change m the radiogram; always without finding it, however, until I
encountered Case i of the series which I am now reporting. In this case I felt justified in the
diagnosis of infraction of the distal end of the second metatarsal, a condition which I have thus
far failed to find described in literature.
During the past few years I have encountered six cases of in-fraction of the distal end of the
second metatarsal bone. I feel justified in speaking of it as a typical injury because in each of
my six cases not only was the same bone end involved, but the conditions under which the
patients presented themselves were very similar, as was also the character of the trauma which
produced the lesion.
Ten years ago the first patient in whom I recognised this lesion was referred to me by Dr. E. W.
Mitchell, of Cincinnati- The patient was a girl of sixteen. She had been suffering from pain in the
ball of the foot for about six months. The pain was precisely like that which we so often
encounter in the metatarso-phalangeal region in connection with static incompetence of the
foot. At the time I examined the patient she complained of pain in weight-bearing only. In
attempting any unusual exertion, as in walking considerable distances, she was compelled to
limp and the pain became severe.
The patient was quite sure that the condition dated from and was due to a game of tennis in
which she "stubbed" her foot. The pain was severe at the time; it was considered a sprain and
she was able to be about the next day. My examination disclosed a well formed and apparently
3 of 4
10/6/2007 10:58 AM
Freiberg's disease
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
strong foot. The metatarsophalangeal articulation of the second toe was thickened, on
palpation, and very tender to pressure. Passive movement of this joint was very painful and
accomplished by slight grating. The X-ray (Fig. x) showed quite clearly that the distal end of
the second metatarsal had been crushed in, causing the articular surface to lose its curved
outline. There was apparently a small loose body in the joint about two mm. in diameter.
The treatment consisted in applying a felt pad to the plantar surface of the foot by means of
adhesive plaster, so that its anterior end was placed just back of the injured joint. In this case I
also had a steel plate inserted between the layers of the sole of the boot in order to deprive the
foot of the motion in the metatarsophalangeal joints, in walking. I have not done this in my later
cases.
The patient was able to walk painlessly without the pad within six weeks and has had no further
trouble with this foot. The other foot has always been entirely normal.
I find it.unnecessary to report each of my cases in detail, as they have great similarity except as
noted below.
Three of my six cases have shown loose bodies in the radiogram, and grating upon
examination. In two of these three cases I was unable to give definite relief by mechanical
support alone and, therefore, removed the loose bodies by means of an arthrotomy from the
dorsal surface of the foot. This resulted in entire relief from discomfort and pain.
It is a curious fact that in two of the six cases, no injury whatever could be recalled by the
patients in spite of careful questioning on my part. In one of these cases operative removal of
small corpora libera was necessary. I have no doubt of the traumatic origin of these three
cases.
Two of my cases were women below middle age, but the remaining four wee girls under
eighteen years of age. In two of the six cases there was evidence of static incompetence of the
feet. I have no reason to believe that this stood in any particular relationship to the condition
which is here described.
Having observed six cases of this character in my own practice there would appear little doubt
that the condition which I have described is not extremely infrequent. It is very likely that the
similarity of symptoms to those of weak feet has caused it to be overlooked. While those cases
in which there are no loose bodies will be relieved by the use of the felt pad if sufficiently long
continued, the contrary will be true of the other cases. The cases with loose bodies will require
arthrotomy as a rule. As in my first case, this may be unnecessary where the bodies are very
few in number and very small.
It seems worthy of note that in my six cases only one foot has been the seat of this injury.
While it is common enough to see only one foot affected in cases of metatarsal pain from static
weakness, the contrary is the rule. This would seem, therefore, to be a point of some
diagnostic importance. Not a little interest attaches to the mechanism by which this injury to the
foot takes place. Under normal circumstances the second metatarsal bone is slightly longer
than the first. In the presence of a diminished power of toe flexion and especially of the great
toe, it is apparent that forcible impact of the ball of the foot against the ground not sufficiently
guarded by the flexor power of the toes will cause the distal end of the second metatarsal to
bear the brunt of the blow. It seems likely to me that we have here the explanation of the
mechanism of this injury.
[ Close Window ]
4 of 4
10/6/2007 10:58 AM
Hallux Rigidus
1 of 4
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please
refer to the site policies for rules on diseminating site content.
Hallux Rigidus
Definition
Stiff and painful first MTP joint associated with degenerate changes
Epidemiology
Most common condition affecting 1st MTP joint (Duvries 1959, Moberg 1979)
Affects 1 in 40 patients > 50 years old (Gould 1978)
May affect adolescents, possibly due to Osteochondritis dissecans of1st Metatarsal head if so
leads to more severe symptoms later
Females > males debatable
Positive Family history in 50%
Aetiology
Not known
osteochondral defect / osteochondritis dissecans definitely lead to hallux rigidus
Possible predisposing factors include : trauma / repetitive microtrauma / abnormal shape of
metatarsal head / long or short 1st metatarsals / tight intrinsics / pes planus
Clinical assessment
Pain on walking, relieved by rest
Stiffness in dorsiflexion
Plantar flexion may be present
Swelling synovitis / bunion / exostosis
Hallux valgus deformity can occur with hallux rigidus this is uncommon
Skin irritation over exostosis
Pain on flexion may be caused by stretching tight MTP joint capsule / EHL / inflamed synovium
May have positive Tinel sign because of compression of 1st webspace digital nerve from
osteophyte
Check neurovascular status of foot
Check midfoot / hind foot - sitting, standing and walking
Xray assessment
AP/Lateral weight bearing films
Sesamoid views may sometimes be useful
Look at shape of Metatarsal head
Reduced joint space may be deceiving if there is a gross flexion deformity
Subchondral sclerosis / Metatarsal head cysts / osteophytes 'dripping candle wax' on lateral
film / sesamoid hypertrophy
In young patients look for osteochondral defect
Lateral film evaluate for elevation of 1st metatarsal in relation to 2nd
Sesamoidal involvement is unusual
10/6/2007 10:59 AM
Hallux Rigidus
2 of 4
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Treatment
Non surgical treatment
Stiff insoles reduces excursion of MTP joint; but reduces room in the shoe, and can lead to
pain because dorsum of the toe is pushed against the top of the shoe
Insoles to correct hindfoot pronation / pes planus
Taping of the toe acts like a splint to reduce MTP excursion
Injection with steroid and local anaesthetic too many injections will accelerate degenerative
process
10/6/2007 10:59 AM
Hallux Rigidus
3 of 4
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Surgical treatments
Arthroscopy of 1st MTP joint for OCD / Ost Diss similar to knee
Dorsal cheilectomy - removal of 1/3 of articular surface of metatarsal head, not just the
osteophytes very good pain relief and restores some movement by removing the dorsal block
to extension. GOOD OPERATION
Moberg closing wedge osteotomy moves less worn part of the articular surface of the
metatarsal head to articulate with the proximal phalanx
Excision arthroplasty Kellers operation DO NOT DO THIS OPERATION leads to a floppy
cocked up toe, shortens the 1st ray and causes transfer metatarsalgia Patients are never
happy!
Replacement arthroplasty Silastic implants loosen and then need to be removed, leaving a
large area of bone loss ( effectively a 2 stage Kellers); Newer implants have only very short term
results. A multicentre study on the Moje Replacement is ongoing. Watch this space.
1st MTP joint fusion
Good pain relief
Shoe wear restriction
Must fuse in correct position
Complications malunion / non-union / prominent implants / infection / nerve & vessel damage /
failure of pain to resolve
10/6/2007 10:59 AM
Hallux Rigidus
4 of 4
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 10:59 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules
on diseminating site content.
Causes
Diagnosis
Surgical management of
Localised intractable plantar
keratoses
Surgical management of
Discrete callus beneath tibial
sesamoid
Surgical management of
Diffuse intractable plantar
keratoses
Conservative treatment
Soft corn
1. PLANTAR KERATOSES
Anatomic considerations
[Back To Top]
Transfer of load laterally from 1 st ray can occur in disorders of the 1 st ray such as hallux valgus or instability of first metatarsocuneiform
joint. This can cause callus formation under 2 nd and 3 rd metatarsal heads where the tarso metatarsal joints are quite rigid. The 4 th and
5 th TMT joints are quite flexible so rarely get callus formation due to transfer from the first ray
Postures of the foot that can precipitate callus formation are
Equinus deformity of ankle joint, causing increased forefoot loading
Cavus foot, generally reduced weight bearing area therefore more pressur
Flatfoot, if it produces a hallux valgus deformity, can cause callus over medial aspect of great toe at the IP joint
Varus forefoot, with lateral border more plantar flexed than medial border causes callus of lateral side of foot
Valgus deformity, opposite of above
Abnormal alignment of MTP joints, eg subluxation or dislocation, causes plantarward force on metatarsal head and callus
formation
Causes
[Back To Top]
Bony
Systemic disease
Rheumatoid arthritis
Psoriatic arthritis
Dermatological lesions
Wart
Seed corn
Hyperkeratotic skin disorde
1 of 4
10/6/2007 10:59 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Diagnosis
[Back To Top]
History
How long have they been there?
History of previous surgery/ trauma
PMH
What treatment has been attempted?
Examination
General overall picture of patient
Posture of foot and toes whilst standing
Range of motion of all joints
Neurovascular status
Look at characteristics of callus, a seed corn?, discrete plantar keratosis under fibular condyle of a metatarsal head? A diffuse
keratosis beneath a single metatarsal head, a diffuse callus under several metatarsal heads? Alocalised callus beneath the tibial
sesamoid?
Distinguish lesion from a wart- a wart will not necessarily be in a pressure area, on trimming, it will show multiple end arteries of
a punctate nature
Investigation
Weight bearing AP and lateral views and sesamoid views if indicated
Harris mat to determine pressure areas
Conservative Treatment
[Back To Top]
[Back To Top]
2 of 4
10/6/2007 10:59 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Or chevron osteotomy of distal metatarsal and dorsal displacement of metatarsal head,held with a k wire (Dreeben reported complete
relief of symptoms in 67 % of 45 patients)
Surgical management of callus beneath the tibial sesamoid
[Back To Top]
[Back To Top]
May be due to long metatarsal, Plantarflexed metatarsal, transfer lesion as a result of adjacent metatarsal osteotomy,
If offending metatarsal too long, shorten it to a line connecting two adjacent metatarsal, with an oblique metatarsal osteotomy
If due to a metatarsal being relatively plantarflexed and metatarsal is not long, a basal osteotomy with a dorsal closing wedge should be
used.
Only do metatarsal osteotomy if MTP joint is not contracted.
Distal Metatarsal Osteotomies
3 of 4
10/6/2007 10:59 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
4 of 4
10/6/2007 10:59 AM
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to
the site policies for rules on diseminating site content.
10/6/2007 10:59 AM
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
MTPJ soft tissue release and hammer toe correction (fusion or excision arthroplasty
of PIPJ)
DuVries metatarsal head arthroplasty
MTPJ dislocated:
Stainsby Procedure = 'V-Y' Dorsal incision (over MTPJ for single toe, web spce for
2 toes); Divide extensor tendon proximally; Remove prox. 3/4 of PP; Reduce Fat
Pad with McDonald under MT head; Suture distal extensor tendon end to flexor
tendon; K-wire through DIPJ-PIPJ-MTPJ. [Stainsby. Ann R Coll Surg Engl 1997
Jan;79(1):58-68]
Curly toes
Neutral at MTP, Flexed at PIP and DIP
-> flexor tenotomy of both FDL and FDB via an incision over proximal phalanx
Over-lapping 5th Toe
A common deformity, usually congenital. Dorsal and medial contracture of capsule and
PIP joint
Recommendation
flexible
flexible
flexible
fixed
dislocated
fixed
unstable
FDL transfer
mallet toe: DIPJ arthroplasty or terminalisation
[ Close Window ]
10/6/2007 10:59 AM
Lisfranc Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Lisfranc Fractures
The Lisfranc injury is named after the French surgeon Jacques Lisfranc, a field surgeon in
Napoleons army.
The original injury described by Lisfranc usually occurred when a soldier fell from his horse, but
his foot did not release from the stirrup
Mechanism
Direct: blow or crush
Indirect: e.g. windsurfer
RTAs are most common cause accounting for 30-60% of all cases
Crush injuries
Falls from ground level with or without twisting injuries
Falls form height
80% of these injuries occur in multiply injured patients
Classification
(Quenu & Kuss 1909)
Isolated: e.g. 1st ray displaced
while lateral 4 rays stay in
place
Homo-lateral: displacement:
i.e. all rays displace in the one
direction
Divergent: e.g. 1st ray goes
medial, the rest displace
laterally
X-rays
Up to 40% of injuries are
1 of 4
10/6/2007 11:00 AM
Lisfranc Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
overlooked on initial
radiographs
AP/Lateral and 30o oblique
There is a consistent
relationship between the
medial border of the 2nd and
4th metatarsals and the
medial edge of their
corresponding
Look for
Widening of
intermetatarsal space,
particularly the 2nd
metatarsal base
Lining up of
metatarsals with their
cuneiforms
Associated fractures
Treatment
"There is no place for conservative management of fracture and fracture dislocations of the
tarso- metatarsal joint complex". Myerson 1989 "the diagnosis and treatment of injuries to the
Lisfranc joint complex"
Fractures presenting with more than 2 mm of displacement and greater than 15o of
talometatarsal angulation require operative treatment. Young competitive athletes may require
anatomic reduction
Post op: Fixation must be rigid enough to prevent transverse plane & dorsoplantar motion of
tarsometatarsal joint and be maintained for at least 12-16 weeks
2 of 4
10/6/2007 11:00 AM
Lisfranc Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Prognosis
Whatever the severity of the initial injury the prognosis depends on an accurate reduction and
its maintenance
Lisfranc injuries without fracture have poor prognosis
Late midfoot collapse a common sequela
May occur from displacement in the saggital plane
Posttraumatic arthritis and planovalgus deformity are common and may occur in up to 50%
X-ray findings may not correlate with clinical findings
Symptomatic posttraumatic arthritis consider arthrodesis
Relationship between accuracy of reduction and outcome: Myerson et al Foot and Ankle 1986.
3 of 4
10/6/2007 11:00 AM
Lisfranc Fractures
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
4 of 4
10/6/2007 11:00 AM
Morton's Neuroma
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Morton's Neuroma
Aka: Morton's metatarsalgia / Morton's neuroma, (n.b. Morton described neither
he thought this was a problem in the 4th MTP joint. Betts described the "neuroma"
70 years later).
The "neuroma" consists of degenerative and fibrotic changes in - common digital
nerve near its bifurcation. However, there may be similar changes in adjacent
unaffected nerves and it is not known why one becomes symptomatic.
A number of causative factors have been suggested:
tethering of the 3rd space nerve by the anastomotic branch between
medial and lateral plantar nerves
traction on nerve by hindfoot valgus, interdigital bursitis or forced toe
dosiflexion in high-heeled shoes
The symptoms may be quite non-specific:
neuralgic pain in a toe and/or interdigital space
tingling of a toe
colour changes
-numb or "dead" toe
vague forefoot tingling
pain usually worse on walking and sometimes at night
relief on removing shoes
Symptoms -commonest in the 3rd interdigital space, then 2nd. Symptoms in 4th
space are rare and should make one doubt the diagnosis. Symptoms in the first
space are virtually unknown.
The condition may remain undiagnosed for many years.
Clinical assessment
Often strongly suspected within first minute of consultation. However - may be
arrived as part of the assessment of a more generalised metatarsalgia. In any
case, a full assessment of the foot should be carried out.
Ask about:
conditions which cause a peripheral neuropathy, especially diabetes and
chronic inflammatory disorders
trauma to foot
discomfort around ankle which may suggest tarsal tunnel syndrome
spinal problems, especially about any history of root entrapment
symptoms.
1 of 2
10/6/2007 11:01 AM
Morton's Neuroma
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
2 of 2
10/6/2007 11:01 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site
policies for rules on diseminating site content.
Examination
MR Classification
Treatment
Radiographs
XR Classification
OSTEOCHONDROSES
Sever's
Kohler's
Iselin's
Freiberg's
Clinical
Classification
Treatment
[Back To Top]
Aetiology:
Post-traumatic or idiopathic osteonecrosis
Anterolateral lesions:
may result from impaction of talus on fibula as the dorsiflexed ankle is forced into inversion
these lesions tend to be shallow
Posteromedial lesions:
may result from impaction of posteromedial talus on tibia, as plantarflexed ankle is forced into inversion & ER
these lesions are deeper and cup shaped
Examination:
[Back To Top]
palpate just posterior to the medial malleolus with the ankle dorsiflexed
Radiographs:
[Back To Top]
osteochondral # may be anterior or posterior to dome, requiring plantar or dorsiflexion of ankle to be visible on
mortise view
if radiographs are negative consider repeat radiographs in 2-4 weeks
Radiographic Classification: (Berndt and Harty)
[Back To Top]
Note: XR findings may or may not correlate w/ arthroscopic findings nor prognosis
I : small area of compression
II : partially detached osteochondral lesion
III : completely detached, non-displaced fragment
IV : detached and displaced fragment
Bone Scan: - a negative bone scan will r/o the diagnosis
CT or MR Scan: - offers more accurate staging of the lesion;
MR Staging: ( Hepple et al. Foot & Ankle International. 1999. 12:789-93 )
[Back To Top]
1 of 5
10/6/2007 11:02 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Non Operative Treatment: - no evidence that non wt bearing cast offers improved results over wt bearing casts; - no
evidence that patients need to be immobilized if they are kept non wt bearing
Operative Treatment: - Arthroscopy of the Ankle :
osteochondral lesions of the talus can be debrided, and loose bodies and small osteochondral fragments can be
removed
Kumai et al (JBJS(A) Sep 1999 ) noted:
Good clinical results w/ arthroscopy and K wire drilling of the OCD lesions in patients who were younger than 50
years
posteromedial lesions can be difficult to access
w/ large fragments ORIF may be required, w/ osteotomy of the medial malleolus being required for exposure; - ORIF
allows direct observation of the lesion and accurate repair.
Lahm et al. Arthroscopy . 2000;16:299-304 :
reported on the arthroscopic K-wire drilling of osteochondral lesions detected in the early stages via MRI imaging. A
clinical score system in which up to 100 points were given in the following categories: "pain," "stability-insecurity,"
"efficiency-pain-free walking distance," "gait," "differences in circumference," "range of motion," and "power."
42 patients, 22 had retrograde drilling, 13 with cancellous bone grafts, 4 refixations, and 3 curettages.
19 who had K-wire drilling, had a average score of 87%. In 3 patients, repeat surgery was necessary. Most of the
K-wire drilling was performed in patients with stage 1 lesions (cartilage intact, no definable fragment). Half of patients
with stage 2 lesions (cartilage breached but fragment intact) had drilling and half had cancellous grafts. Patients with
stage 3 lesions (cartilage breached, fragment still in situ) were treated with refixation and bone grafting. Removal of
the loose body and drilling of the crater were performed in patients with stage 4 lesions (loose body).
Results of K-wire drilling were not worse than those of cancellous bone grafts. Lesions can be detected earlier with
MRI of the lesion and treated successfully with retrograde drilling.
MRI is a useful tool for assessing the results of arthroscopic drilling & planning further treatment ( Higashiyama et al. Foot
Ankle Int 2000 Feb;21(2):127-33 )
OSTEOCHONDROSES OF THE FOOT & ANKLE
[Back To Top]
SEVER'S DISEASE
pain at Achilles tendon insertion
usually 8-12 years old
density + fragmentation of calcaneal apophysis - normal variant
symptomatic treatment
KOHLERS'S DISEASE
avascular necrosis of navicular
usually 4-8 years old
very rare
main differential diagnosis: infection
symptomatic treatment: will revascularise
may need cast during initial illness
long term prognosis good
ISELIN'S DISEASE
[Back To Top]
2 of 5
10/6/2007 11:02 AM
3 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
10/6/2007 11:02 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
# alone
surface contour altered
central portion depressed
loose body seperation
Flattening
Clinical features
[Back To Top]
pain in MTPJ
stiffness
swelling
sometimes large palpable osteophytes
Treatment
[Back To Top]
Non-surgical management
analgesia
orthosis
shoe adaptation
steroid injections into joint
Surgery
simple debridement and cheilectomy
metatarsal head osteotomy
excision arthroplasty
Freiberg's References:
Katcherian DA: Treatment of Freiberg's disease. Orthop Clin North Am 1994;25:69-81.
This is a detailed review of Freiberg's infraction and its treatment stages.
4 of 5
10/6/2007 11:02 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Kinnard P, Lirette R: Freiberg's disease and dorsiflexion osteotomy. J Bone Joint Surg 1991;73B:864-865.
Intra-articular dorsal wedge osteotomy through the distal metaphysis with sufficient bone removal to bring the healthy
plantar part of the metatarsal head into articulation with the phalanx was performed on 15 patients. Advanced disease was
present in nine patients. The authors reported that all of the patients were able to return to sports, although three had mild
discomfort after prolonged jogging. Although the authors observed about 2.5 mm of shortening, the technique appears to
restore congruity of the joint.
Smith TW, Stanley D, Rowley DI: Treatment of Freiberg's disease: A new operative technique. J Bone Joint Surg
1991;73B:129-130.
The authors discuss metatarsal shaft shortening (4 mm) in 15 patients (16 feet) and the application of a "T" plate. The plate
was removed after 12 months. Pain was relieved within 12 months (mean 5 to 7 months) in all but one patient. Swelling was
improved in four patients and stiffness was observed in seven of the 16 feet postoperatively. In four feet the toe did not
contact the ground in stance. Results were assessed as excellent in five patients; nine were pleased with the results.
Sproul J, Klaaren H, Mannarino F: Surgical treatment of Freiberg's infraction in athletes. Am J Sport Med
1993;21:381-384.
The authors reviewed 11 cases of Freiberg's infraction in athletes. All patients underwent debridement and all were reported
to have had improvement in symptoms with 80% normal range of motion. Nine of ten patients returned to presurgical sports
activities.
Bibliography:
Blackburn Foot & Ankle Hyperbook
Orthopaedic Knowledge Update Speciality Series - Foot & Ankle
[ Close Window ]
5 of 5
10/6/2007 11:02 AM
1 of 6
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the
site policies for rules on diseminating site content.
Neck
Body
Head
Lateral Tubercle
Lateral Process
Osteochondral
Talar dislocations
MIDTARSAL
INJURIES
TARSAL
DISLOCATIONS
MIDFOOT
FRACTURES
Navicular
Cuboid
METATARSAL
FRACTURES
5th Metatarsal
Fractures
SESAMOIDS
LISFRANC
INJURIES
TALAR FRACTURES
[Back To Top]
Pathology
Undisplaced
II
III
IV
AVN Non-union
Type I
Type II
Type III
Type IV
ORIF
10%
90%
Subtalar
Results
Arthrosis
2%
25%
8%
65%
10%
65%
(ankle
70%)
Hawkin's sign
Radiographic appearance on AP X-ray
At 6-8 weeks disuse osteopenia is seen as subchondral atrophy in the dome of the talus. This would not occur if
there was no blood supply. AVN risk 4%.
10/6/2007 11:02 AM
2 of 6
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
[Back To Top]
[Back To Top]
[Back To Top]
Non-operative
10/6/2007 11:02 AM
3 of 6
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Stage II
Non-operative
Stage III
Stage IV
[Back To Top]
[Back To Top]
[Back To Top]
10/6/2007 11:02 AM
4 of 6
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
[Back To Top]
1. Navicular
A. Tuberosity #
Symptomatic treatment, but if displaced > 5mm then ORIF as non-union is likely
B. Body #
Classification (Sangeorzan)
Type 1
Type 2
Type 3
Treatment:
Undisplaced # NWB cast for 6 weeks
All displaced, comminuted or fracture dislocations should be treated surgically
ORIF with K-wires or screws bone grafting for depressed areas
Stress #
Seen in track athletes
Management
Cessation of training for 6-8 weeks with restricted weight bearing
Delayed union or non-union can occur which may require intervention
10/6/2007 11:02 AM
5 of 6
2. Cuboid #
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
[Back To Top]
Undisplaced:
Weight bearing as tolerated
Can use wooden shoe or weight bearing cast
Displaced
1 st metatarsal #
ORIF as only minor malalignment can lead to transfer lesions
nd
2 - 4 th metatarsal #
If no sagittal plane angulation deformity present then treat as for undisplaced #
If sagittal angulation present ORIF with longitudinal K-wires
5 th metatarsal #
[Back To Top]
Jones fracture:
described by Sir Robert Jones in 1902, after he sustained a 5th MT fracture.
typically 1.5cm distal to the base of the 5th MT.
Dameron, Lawrence & Botte have described three separate fracture zones
Majority can be treated conservatively but if symptomatic non-union develops then ORIF may be indicated
particularly in athletes
Non-union or delayed union more likely in Zone 3
Hypertrophic - longitudinal compression screw
Atrophic - tricortical bone graft + longitudinal compression screw
SESAMOID FRACTURES
[Back To Top]
10/6/2007 11:02 AM
6 of 6
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Sponsored Links
www.biometeurope.com
www.ebimedical.com
[ Close Window ]
10/6/2007 11:02 AM
1 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to
the site policies for rules on diseminating site content.
10/6/2007 11:03 AM
2 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Chronic fracture of the os perineum, with or without peroneus longus tendonopathy or tear
Peroneal tendonopathy or tear at the level of the inferior peroneal retinaculum, often of a stenosing type
Peroneal tendon tears
10/6/2007 11:03 AM
3 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Clinical features
Patients with peroneal tendon problems usually present with pain, swelling and sometimes clicking or
popping on the posterolateral aspect of the ankle or the lateral aspect of the hindfoot. Those with longus
tears may localise the pain to the entry to the cuboid tunnel (POPS) or occasionally under the midfoot.
There may be a history of an ankle sprain especially with brevis tears.
Examination will demonstrate
tenderness over the tendon typically behind the malleolus with brevis
tears and at the entry to the cuboid tunnel or at the IPR with longus tears.
Getting the patient to actively rotate the foot may produce obvious tendon prolapse onto the lateral
aspect of the malleolus. With lesser degrees of instability there may be no obvious prolapse but the
brevis tendon may be felt to slide laterally, usually in eversion. A brevis tendon which becomes
prominent laterally often has a longitudinal tear.
Resisted contraction of each tendon may reproduce thepatients pain.
Active movement may produce a grating or creaking sensation over the tendons.
There may be varying amounts of synovial swelling. Pes cavus suggests a longus tear.
Imaging
Plain radiography is not usually very helpful. Oblique views of an acutely injured ankle may show an
avulsion fragment lying lateral to the lateral malleolus this represents a flake of bone avulsed with the SPR.
ultrasound can show the tendons well and demonstrate tears. assess the ankle ligaments.
MR also enables assessment of the depth of the peroneal groove and will demonstrate
intra-articular problems in the ankle such as osteochondral injuries. Tendonopathy shows as enlargement,
high signal or a flame shape to the tendon. Tears show as multipart or chevron-shaped tendons, and part
or all of the tendon may be subluxed laterally.
There have been no comparative studies of the accuracy or utility of ultrasound and MR.
10/6/2007 11:03 AM
4 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Non-surgical treatment
Simple analgesics or NSAIDs may be used for pain and synovitis.
Physical modalities such as ice, ultrasound or interferential therapy may be used to settle acute symptoms.
An ankle brace may be useful in the acute situation or occasionally pallliatively.
Patients with flexible cavus deformities and a longus tear may benefit from orthotics.
Try non-surgical treatment for patients without overt instability, but would generally advise the correction of
SPR instability as primary treatment.
Surgery
Peroneal tendon tears
Debridement and suture of longitudinal tears, with tubulisation of the remaining
tendon. Krause et al (1998) recommended repair for tears of peroneus brevis where more than 50% of the
tendon was intact, but where there was less than 50% tendon remaining they excised the abnormal
segment and attached the ends to the peroneus longus.
Where there is a complete tear with discontinuity of the tendon ends repair without tension is usually
impossible except in the acute setting, and the ends of the tendon should be sutured to the adjacent
tendon.
complete tears of both tendons preclude this, and a tendon transfer is required flexor digitorum longus
transfer has been reported in two patients by Borton et al (1998)
Peroneus longus tears at the os peroneum may be debrided and repaired. A fragmented os peroneum is
usually excised. Occasionally a defect in the tendon needs to be bridged with a tendon graft (plantaris).
Peroneus brevis tears often have associated SPR laxity and this should be repaired at the same time as the
tendon (see below). Stenosing tenosynovitis of peroneus longus may require release of the IPR and/or
reduction of the peroneal tubercle.
Van Dijk (1998) described endoscopic debridement and suture of the peroneal tendons. There have been
no comparative studies with open surgery.
Superior peroneal retinaculum laxity
Many different types of operation have been described to correct SPR laxity:
Sliding bone graft to the lateral edge of the groove
Deepening of the groove by removing underlying cancellous bone and depressing the cortical floor of the
groove
Bankhart-type repair of the type-2 retinacular lesion
Rotational osteotomy of the distal fibula
Various forms of retinacular tightening or re-insertion
Obviously, these are not all mutually exclusive. Our standard stabilisation procedure is a Bankhart-type
repair. The retinaculum is opened longitudinally, close to where the attachment to the fibular groove should
be. The bare area on the lateral malleolus is freshened and one or two suture anchors inserted close to the
edge of the groove. The avulsed tissue sleeve is reattached to these and the retinaculum plicated, usually
also onto the suture anchor(s). If the groove is shallow, a posterior trapdoor is elevated and cancellous
bone removed from the posterior part of the lateral malleolus to allow the floor of the groove to be lowered
and the edges of the trapdoor evened. Debridement and repair or tenodesis of tendon tears is usually
required.
All reports of stabilisation are small, usually 10-20 patients. Overall, about 85-90% of patients get
satisfactory functional results, and some have returned to top-level sport. The rate of recurrent instability is
5-10%. Other complications include neuromas, infection and lateral ankle pain. Symptomatic ankle
instability can be corrected through the same incision, usually with a Brostrom-Gould procedure.
10/6/2007 11:03 AM
5 of 5
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 11:03 AM
Rheumatoid Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies for rules
on diseminating site content.
Rheumatoid Foot
STAGES
CLINICAL
TREATMENT
ANKLE
HINDFOOT
FOREFOOT
TENDONS
OTHER TISSUES
INTRODUCTION
70-90% of rheumatoids have foot involvement
15% present initially with foot complaints.
STAGES
[Back To Top]
Stage 1 - synovitis
Stage 2 - Joint erosion & tendon dysfunction
Stage 3 - Progressive deformities
CLINICAL
[Back To Top]
[Back To Top]
Conservative
1. Medications
2. Footwear - shoes should not be made to correct the deformity, but rather be adjusted to it.
Surgery
Pre-op precautions:
Check the positions of the knees & hips (should correct these first for ankle & hindfoot problems)
Skin condition
Medications - methotrexate & corticosteroids may need to be stopped.
ANKLE JOINT
[Back To Top]
Arthroscopic Synovectomy
useful for cases of marked synovitis & minimal articular damage
Supramalleolar Osteotomy
for stiff hindfoot in equino-varus.
1 of 3
10/6/2007 11:04 AM
Rheumatoid Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Ankle Arthrodesis
Operation of choice in most cases.
Arthroscopic arthrodesis if there is minimal osteoporosis & destruction.
Intramedullary nail through heel
Dowel arthrodesis.
If there is gross deformity will need more correction / resection & external fixator.
Ankle Arthroplasty
Indication = severe destruction with a stiff, non-deformed hindfoot (or triple arthrodesis)
2 main types = 1. semi-constrained (Mayo) and 2. LCS prosthesis.
Failures were awful & complication rates high.
This may be improving with newer designs (eg. STAR prosthesis).
Note requirements for a joint replacement prosthesis are:
1.
2.
3.
4.
5.
6.
7.
More detail on Ankle Replacement see Maitrise Orthopaedics and Mr Peter Wood's Website
star
[Back To Top]
[Back To Top]
90% of RA pts have forefoot involved. 15% present with forefoot pain.
MTP's loose competence, then toes sublux dorsally and dislocate " pulling plantar fat distally and anteriorly.
Also get IP hyperextension and HV.
OPTIONS
1. Synovectomy of MTPJs - best synovectomy is excision arthroplasty.
2. Metatarsal oblique osteotomies (Helal)
3. Excision of MT heads plus prox. third of PP's (Hoffman type procedure)
2 of 3
10/6/2007 11:04 AM
Rheumatoid Foot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
4. 'Pobble' amputation - amputation of all the lesser toes at the MTPJs - only for severe deformity & pain.
5. HV " Keller's or silastic implant (not good), arthrodesis prob. Best
6. Forefoot reconstruction: provide stable medial post by arthrodesis of 1 st MTP. Also reduce plantar fat pad back
down " HOFFMAN procedure removing MT heads.
Also see Lesser Toes Summary
TENDONS
[Back To Top]
Tibialis Posterior tendon rupture causes planovalgus collapse. May have Tarsal tunnel syndrome also.
Peroneal Muscle spasm can occur.
OTHER STRUCTURES
[Back To Top]
1. Neuropathic joints
2. Tarsal Tunnel Syndrome
3. Rheumatoid nodules (indicative of aggressive disease)
4. Rheumatoid ulcers
5. Stress fractures
Sponsored Links
www.ebimedical.com
[ Close Window ]
3 of 3
10/6/2007 11:04 AM
Rheumatoid Forefoot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Rheumatoid Forefoot
Tim Williams, 2006
90% of RA pts have forefoot involved. ( = Hand incidence!)
15% of RA pts initially present with forefoot pain.
Pathology
MTPJ Synovitis & Pannus destruction
IPJ's usually Spared
Deformities
2nd-5th MTPJ Synovitis ? Capsular laxity ? P1 Dorsal subluxation / dislocation ?
Prominent MT Heads as fat pad drawn distally ? METATARSALGIA & PLANTAR
KERATOSES
Subsequent Intrinsic / extrinsic muscle imbalance ? CLAW TOE & DORSAL CORNS
1st MTPJ Synovitis combined with loss of lateral support from lesser toes ? HALLUX
VALGUS & BUNION
Larsen Staging (Acta Orthop 1977)
Stage I: No bony deformity. Discomfort and synovitis without significant joint space narrowing.
Stage II: Early involvement without fixed deformity. Minimal erosive changes.
Stage III: Soft tissue deformity. No significant joint erosive changes.
Stage IV: Articular destruction. Severe hallux valgus, dislocation of the lesser MTP joints with
fixed hammer toe or claw toe deformities, pes planovalgus (flatfoot), and hindfoot arthroses.
TREATMENT OPTIONS
Multidisciplinary Approach
Non - Operative
Medical Optimisation (Rheumatologists & G.P.)
NSAIDS, Steroids, DMD's, anti-TNF etc..
Orthotics
Large Toe Box Shoes
Metatarsal Pads / Bars
Total Contact Insoles
Rocker Bottom Shoes
Physiotherapy - Try to maintain movement
Operative
1. Lesser MTPJ Surgery - Decompress the Joint to allow relocation
Synovectomy
1 of 3
10/6/2007 11:04 AM
Rheumatoid Forefoot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
4. Amputation
Through MTPJ - Salvage Surgery
Recent papers
Arthrodesis versus Mayo resection: the management of the first metatarsophalangeal
joint in reconstruction of the rheumatoid forefoot.
Grondal L, Brostrom E, Wretenberg P, Stark A. - Stockholm
JBJS Br. 2006 Jul;88(7):914-9.
31 patients prospectively randomised to either fusion or Mayo resection as part
of forefoot reconstruction. No significant differences between outcome for both
groups at mean 6 years.
Metatarsal head resection in the rheumatoid foot: 5-year follow-up with and without
resection of the first metatarsal head.
Hulse N, Thomas AM - Birmingham
J Foot Ankle Surg. 2006 Mar-Apr;45(2):107-12.
2 of 3
10/6/2007 11:04 AM
Rheumatoid Forefoot
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Retrospective study of 45 feet. 16 had only lesser MT excision and 29 had 1st 5th Mt head excision. 7 /16 ( 47%) of 1st group had revision excision of 1st MT
head
Further Reading
The pathological anatomy of claw and hammer toes . MS Myerson 1989 JBJS(Am).
Long-Term Results of the Modified Hoffman Procedure in the Rheumatoid Forefoot. S.
Thomas, Kinninmonth, and C. Senthil Kumar, JBJS(Am). 2005;87:748-752
http://dr.barouk.free.fr/anglais.htm - Scarf & Weil Osteotomies - surgical videos and
techniques.
Rheumatoid Forefoot Reconstruction. A Long-Term Follow-up Study . M.J. Coughlin
JBJS (Am) , Mar 2000; 82: 322 - 41.
Acknowledgements
The Cooke Book - Mr. P. Cooke, Oxford.
Forefoot Reconstruction - L.S. Barouk (Springer Publications)
Surgery of the Foot & Ankle - Coughlin & Mann (Mosby)
[ Close Window ]
3 of 3
10/6/2007 11:04 AM
Sesamoids
1 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please
refer to the site policies for rules on diseminating site content.
Sesamoids
Embryology
Anatomy
Biomechanics
Imaging
Turf Toe
Stress fractures
Infection
Arthrosis
Embryology
Fractures
[Back To Top]
[Back To Top]
Central ridge, crista divides the under surface/trochlear surface of the 1 st MTP joint, divides
the two sesamoids
Medial and lateral metatarsaosesamoid ligaments and medial and lateral
phalangosesamoid ligaments and intersesamoid ligaments are stabilisers
The sesamoids are embedded in the plantar plate in the plantar plate with attached to prox
phalanx inferiorly by insertions of medial and lateral heads of flexor hallucis
The fibular sesamoid also attached to adductor hallucis, and intermetatarsal ligament
The tibial sesamoid is attached to abductor hallucis
Biomechanics
[Back To Top]
[Back To Top]
AP standing xray
10/6/2007 11:05 AM
Sesamoids
2 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Standing lateral
Oblique views
axial view shows relationship of sesamoids to crista (sesamoid skyline view with toes
dorsiflexed)
[Back To Top]
Mechanisms of injury - forced dorsiflexion and abduction, direct trauma, sudden loading of
1 st MTP joint fragments
To differentiate from partite sesamoids, look for a sharp line, dorsiflexion views may show
increase in separation of fragments. CT scan may help.
Treatmentbelow knee cast for 3 weeks, followed by a metatarsal bar. Pain may persist for 4-6 months.
If symptomatic nonunion, or chronic pain, consider excision of sesamoid or fragments, through
medial , dorsal or plantar incision.
If both sesamoids- avoid resection as a cock up deformity can occur due to loss of function of
flexor hallucis brevis
10/6/2007 11:05 AM
Sesamoids
3 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[Back To Top]
Exaggerated dorsiflexion with valgus/ varus strain of MTP joint, described by Bowers and
Martin 1976
More common since artificial sports surfaces
Can range from sprains of the sesamoid complex to ruptures of the complex causing
proximal or distal migration of the sesamoid bones to sesamoid complex to a fracture of the
sesamoid and dislocation
Usually treated with below knee cast, but may need operative reduction and repair through
medial approach
Stress fractures
[Back To Top]
[Back To Top]
Treat with excision, if both sesamoids need to be removed a delayed fusion of the 1 st MTP joint
can be performed to avoid a cock up deformity
Arthrosis of metatarsosesamoid joint
[Back To Top]
Occurs secondary to malalignment, such as hallux valgus. Can also occur in hallux rigidus
and inflammatory arthropathies such as R.A. and gout.
As splaying of the first metatarsal occurs, the intermetatarsal ligament holds the sesamoid
complex laterally.
Symptoms more subtle than in sesamoiditis, with aching pain in plantar aspect of the foot
rather than focal pain
Usually no point tenderness on examination, but motion and compression elicits pain,
crepitus may be present
If squeezing the 1 st and 5 th metatarsals together allows correction of splaying between the
1 st and second MTs, then it is likely that only a minimal soft tissue release (of the adductor
hallucis and superficial and deep parts of intermetatarsal ligaments) will be necessary. If the
squeeze test does not reduce the sesamoids, release of the lateral sesamoid ligament will
be necessary.
Try and avoid excision of the sesamoids.
[ Close Window ]
10/6/2007 11:05 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
Anatomy
Anatomy
Aetiology
Pathology
Clinical
Investigations
Treatment
[Back To Top]
The sinus tarsi is an anatomical space bounded by the talus and calcaneum, the
talocalcaneonavicular joint anteriorly and posterior facet of the subtalar joint posteriorly. It is
medially continuous with the much narrower tarsal canal.
The sinus tarsi contains the cervical ligament and the three roots of the inferior extensor
retinaculum.
The tarsal canal contains the interosseous talocalcaneal ligament and the deep and
intermediate roots of the inferior extensor retinaculum.
Both the sinus and the canal contain blood vessels - which are important for the nutrition of the
talus - and nerves. The extensor digitorum brevis and bifurcate ligament lie anterior to the sinus
tarsi.
Aetiology
[Back To Top]
The term "sinus tarsi syndrome" was first applied in O'Connor in 1958 to a syndrome of
post-traumatic lateral hindfoot pain and instability which was relieved by the injection of local
anaesthetic into the sinus tarsi.
The cause of pain has been postulated to be vascular engorgement or nerve irritation, both
due to fibrosis.
Frey et al suggests (on the basis of arthroscopic examination) that sinus tarsi syndrome is an
inaccurate diagnosis & there is usually an underlying abnormality:
interosseous talocalcaneal ligament tears
subtalar instability
osteochondral injuries of the subtalar joint
arthrofibrosis of the subtalar joint
degenerative disease of the subtalar joint
fibrous tarsal coalition
chronic inflammatory changes in the sinus tarsi connective tissues
Pathology
[Back To Top]
Pathological examination of tissue removed from patients with sinus tarsi syndrome include
chronic inflammatory changes, fat necrosis, fibrosis and synovial cysts.
Clinical
1 of 2
[Back To Top]
10/6/2007 11:05 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Tenderness over the sinus tarsi, which is relieved by local anaesthetic injection
Pain may be exacerbated by varus tilting of the heel (unlike the pain of lateral impingement
which is worse on valgus tilting of the heel) or walking on uneven ground.
A feeling of subtalar opening may be felt on the varus tilt test .
Abnormalities in the ankle are common: up to 50% have ankle instability and/or anterolateral
synovitis.
Investigations
[Back To Top]
Plain radiographs are generally normal, although degenerative arthritis of the subtalar joint may
be seen.
Stress views of the subtalar joint (lateral or Broden views) may show instability
Subtalar arthrography may show obliteration of the anterior micro-recess but sensitivity is not
very high.
MR shows inflammatory and fibrotic changes well. The interosseous talocalcaneal ligament
may be shown to be torn but some observers find that non-specific changes make this difficult
to visualise. MR also shows damage to the subtalar joint and surrounding structures.
Treatment
[Back To Top]
[ Close Window ]
2 of 2
10/6/2007 11:05 AM
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
10/6/2007 11:05 AM
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 11:05 AM
1 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
10/6/2007 11:06 AM
2 of 2
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 11:06 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer
to the site policies for rules on diseminating site content.
The tarsal tunnel is formed by the flexor retinaculum behind and distal to the medial malleolus
Contents from ant. to post.: (Tom Dick ANd Harry)
Tibialis Posterior Tendon
Flexor Digitorum Longus tendon
Posterior Tibial artery
Posterior Tibial Nerve
Flexor Hallucis Longus tendon
Posterior tibial nerve
is a branch of the sciatic nerve
enters the deep posterior compartment of the leg between the two heads of the gastrocnemius.
It passes deep to the soleus and travels distally between it and the posterior tibialis muscle.
3 terminal branches in the tarsal tunnel
medial plantar nerve - Sensation to the plantar-medial aspect of the foot from the great toe
to the medial half of the 4th toe. Motor to the abductor hallucis, flexor brevi & the 1st
lumbrical.
lateral plantar nerve - Sensation to the 4th & 5th rays & toes. Motor to ADQ, the interossei,
adductor hallucis, 2nd to 5th lumbricals.
the calcaneal branch - can be of a variable origin. Provides sensation to the heel pad.
Aetiology:
1.
2.
3.
4.
5.
6.
1 of 3
10/6/2007 11:06 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Examination:
Insidious onset of symptoms in the sensory distribution of the involved nerves
Pain radiates along the plantar side of the foot
Paresthesias, & atrophy of foot intrinsics
+ve Tinel sign behind medial malleolus
Manual compression for 30 sec. may reproduce symptoms
Investigations:
Nerve Conduction Studies can be useful - sensory conduction studies are more sensitive than motor
studies.
MRI - 88% of Tarsal Tunnel Syndrome has shown an abnormality on MR scans.
Differential Diagnoses:
stress fractures (identified on 45 deg medial oblique view)
inflammatory arthritides
plantar fasciitis
PID.
Treatment:
Depends on the aetiology
Rheumatoid synovitis responds well to rest & NSAIDs.
Space occupying lesions respond well to surgical decompression.
Steroid injections are a useful temporizing measure.
Surgery:
Curved incision that follows the
nerve posterior to the medial
malleolus.
The flexor retinaculum is divided
from proximal to distal, down to
the abductor hallucis fascia.
[Picture]
The calcaneal branch or
branches are protected as they
extend posteriorly
The medial and lateral plantar
nerves are followed and freed
beneath the abductor hallucis.
The deep fascia of the abductor
hallucis should be divided if it is
tight.
Deep Peroneal Nerve Entrapment /
ANTERIOR TARSAL TUNNEL
SYNDROME
Aetiology:
Can occur as the nerve passes under
the inferior extensor retinaculum.
Other causes include:
compression against dorsal osteophytes on the tarsal bones
shoe wear that is tight over the dorsum of the foot.
2 of 3
10/6/2007 11:06 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Patients complain of aching over the dorsum of the foot with numbness or pain in the first webspace.
If the lateral branch of the nerve is involved, the extensor brevis will show signs of atrophy.
Medial branch entrapment causes a sensory deficit in the first webspace.
Nonsurgical treatment involves shoe modifications & NSAIDs or steroid injection.
Surgery is indicated for persistent symptoms and is directed toward decompression of the nerve by the
release of the tight retinaculum and the removal of any osteophytes.
Superficial Peroneal Nerve Entrapment
The Superficial Peroneal nerve passes through the fascia about 10 cm above the ankle to become
subcutaneous. It branches into the medial & intermediate dorsal cutaneous nerves just proximal to the
ankle which supply sensation over the dorsum of the foot except for the first webspace.
Entrapment may occur where the nerve passes through the fascia of the lateral compartment.
[ Close Window ]
3 of 3
10/6/2007 11:06 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site
policies for rules on diseminating site content.
Nomenclature
Aetiology
Treatment
Tendon Pain
References
Rupture
[Back To Top]
Achilles tendinopathy represents a common and debilitating spectrum of conditions. These range from acute
Achilles tendon pain, to chronic painful Achilles tendinosis, to rupture of the tendon. Symptoms from the Achilles
tendon result in prolonged periods of absence from work and sporting activity. The incidence of rupture is
increasing in the Western World. Despite this fact, there are large areas of Achilles tendon pathology that are
poorly understood and most therapeutic interventions are controversial.
Nomenclature
[Back To Top]
The term 'tendinitis' should be reserved for acute Achilles tendon pain, usually as a result of trauma. This
may have an inflammatory component. It is usually self-limiting and responds to analgesia and modified
activity.
'Tendinosis' is the term used for chronic degenerative change within the tendon. There does not appear to
be a major inflammatory component to these changes. The condition is common and often asymptomatic.
Those patients who have pain are often resistant to treatment.
'Tendinopathy' is probably the safest term for all tendon pathology as it does not imply an aetiology
Aetiology
[Back To Top]
In the normal tendon the collagen fibres are arranged in a linear fashion with a characteristic crimp. The tenocytes
are 'squashed' into oval shapes between the fibres.
In tendinosis the fibre alignment and structure becomes less well defined and eventually is lost. The tenocytes
become more round. The number of tenocytes may decrease (or in cases of painful tendinopathy increase.)
Fig 1. Normal tendon and tendinosis
The aetiology of tendinosis is not fully understood. Repetitive micro-trauma affects all tendons and usually leads to a
reparative process. In the Achilles tendon the repair process may fail leading to progressive tendinosis. Why does
the process fail?
There appears to be a hypovascular area of the tendon 2 to 6 cm proximal to the insertion into the calcaneus. (The
major blood supply of the tendon is through its mesotenon, with the richest supply anteriorly).
1 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
With increasing age this blood supply has been shown to reduce further.
Reduced blood supply appears to be at least partly responsible in some cases. However, there are several reports
that suggest that painful tendinosis is actually characterized by increased vascularity.
The most recent research suggests that tendinosis is linked to a failure of the regulation of the enzymes
(metaloproteinases in particular) that breakdown the tendon matrix.
There are several factors that appear to accelerate the development of tendinopathy:
Drugs such as steroids and quinolone antibiotics (such as ciprofloxacin)
Repeated trauma due to over-training, the wrong footwear (functional over-pronation) and dysfunction of
the triceps surae.
Connective tissue disorders
Rupture
[Back To Top]
History
The most common mechanism for TA rupture is pushing off with the weight-bearing forefoot while extending the
knee (eccentric contraction of the calf muscles). The same effect can also be created by a sudden unexpected
dorsiflexion of the ankle as in a fall from a height.
The patient describes a sudden pain (like being hit from behind), but is usually able to weight-bear. This may explain
why late presentation is common c 40%.
Diagnosis
The easiest way to assess the Achilles tendon is with the patient kneeling on a chair facing away from you.
Acute ruptures are characterized by a palpable tendon defect
And a negative calf-squeeze test (Simmonds squeeze test in the UK = Thompson test in USA).
Plus an inability to do a toe-raise on the affected side
85% of tendon ruptures occur in the mid-portion of the tendon; 10% at the musculo-tendinous junction (these
respond well to non-operative treatment) and 5% at the insertion (these are usually treated surgically and often
require augmentation)
Late presentation ruptures may be difficult to assess. Tendon lengthening, as measured by dorsiflexion of the ankle,
may be a useful surrogate sign. NB compare to the other side.
In equivocal cases dynamic ultrasound is by far the best investigation.
Treatment
[Back To Top]
Re-rupture at 1yr
Other complications (mostly
wound related)
Other factors
Operative
3.5%
Non-operative
12.5%
34%
3%
Operative technique:
Open or percutaneous repair
Open repair has a high complication rate, but in more recent papers these are much less frequent than has been
reported in earlier articles. This may be due to a better understanding of the soft-tissues or more aggressive post-op
rehab regimes.
Percutaneous repair has been shown to reduce the wound complication rate, but there is a relatively high risk of
sural nerve damage. The results of accelerated rehabilitation following percutaneous repair have not yet been
evaluated.
2 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
There is little evidence (actually, none) that mechanically stronger suture techniques produce better results than
more traditional Kessler and Bunnel techniques. Nor is there much evidence to support the use of non-absorbable
sutures
There is no evidence that primary reinforcement (with any material) in otherwise uncomplicated cases produces
betters results than simple primary suture
6 to 8 weeks of protected mobilization is all that is required.
The knee does not need to be included in the cast / orthosis, (knee position does not affect the tension in the repair
when the foot is in equinus and immobilisation of the articular cartilage of the knee is detrimental).
Open repair:
With the patient in the prone position, make a posteromedial longitudinal incision; make it about 1 cm medial to the
tendon and end it just proximal to where the shoe counter strikes the heel. Carry the incision sharply through the
skin, subcutaneous tissues, and tendon sheath.
Reflect the tendon sheath with the subcutaneous tissue, minimizing subcutaneous dissection.
Approximate the ruptured ends of tendon with a tension suture, using a modified Kessler stitch through the stump
2.5 cm from the rupture depending on the degree of tendinosis.
Plantar flex the foot to approximate the ends of the tendon before tying the tension suture.
Percutaneous Repair:
3 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
1. Webb &
Banister
( JBJS Br. 1999
Sep;81(5):877-80
)
Can be done
under local
anaesthesia (with
adrenaline)
3 posterior
transverse
incisions - the
middle one at the
level of the
rupture & the
other two 5cm
prox. & distal.
Make the
proximal incision
slightly medial (to
avoid the sural
nerve).
Repair as per
diagram - No. 1
Nylon suture on
curved needle.
Post-op:
- 2wks in BK cast
in plantarflexion
- 2wks
mid-position
- 2wks neutral
FWBing
- 4wks heel raise.
How will I rehabilitate the patient?
Fig. A traditional cast versus an orthotic for this patient with bilateral ruptures?
4 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
5 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Rehabilitation guide:
Average return to full sporting activity is still in the region of 6 to 9 months warn the patients!
8 weeks - normal walking, physiotherapy concentrates on proprioception and gait correction
12 weeks - resistance exercises begin, low impact (cycling and swimming preferred)
4 months - jogging
6-9 months - normal sports.
Neglected Rupture of the TA:
Treatment depends on the patient's physiological age, activity level, and amount of functional impairment. Surgery
6 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
is generally indicated but the risks are high. Some patients do manage to walk without an Achilles tendon but stairs
are very difficult
Options:
V-Y advancement of the aponeurosis over the gastrocnemius
TA tendon turn-down flap of proximal tendon/aponeurosis
Artificial tendon substitutes
If there is extensive tendinosis or gross wasting of the triceps surae (any injury over 2 months old will have
this) then seriously consider an FHL transfer.
Tendon Pain
[Back To Top]
[Back To Top]
Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon. JBJS 1991; 73-A:
1507-1525.
Astrom M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathological findings. Clin
Orthop 1995;316:151-64.
7 of 8
10/6/2007 11:07 AM
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Riley G. The pathogenesis of tendinopathy. A molecular perspective. Rheumatology 2004; 43: 131-142.
Surgical interventions for treating acute Achilles tendon ruptures. Kahn R et al. Cochrane Database Syst Rev.
2004;(3):CD003674.
Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon--a prospective
randomized controlled study. Foot Ankle Int. 2001 Jul;22(7):559-68.
Tashjian RZ, Hur J, Sullivan RJ, Campbell JT, DiGiovanni CW. Flexor hallucis longus transfer for repair of chronic
achilles tendinopathy. Foot Ankle Int. 2003 Sep;24(9):673-6.
Gravare Silbernagel K, Thomee R, Karlsson J. Eccentric overload training for patients with chronic Achilles tendon
pain - a randomised controlled study with reliability testing of the evaluation methods. Scand J Med Sci Sports
2001; 11: 197-206.
Alfredson H, Ohberg L. Neovascularisation in chronic painful patellar tendinosis -promising results after sclerosing
neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc. 2005
Mar;13(2):74-80
[ Close Window ]
8 of 8
10/6/2007 11:07 AM
1 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved.
Please refer to the site policies for rules on diseminating site content.
[Picture]
J. M. Webb, G. C. Bannister
From Southmead Hospital, Bristol, England; J Bone Joint Surg [Br] 1999;81-B:877-80.
Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible
complications with the wound, but the sural nerve may be damaged. We describe a new
technique which minimises the risk of injury to this nerve.
The repair is carried out using three midline stab incisions over the posterior aspect of the
tendon. A No. 1 nylon suture on a 90 mm cutting needle approximates the tendon with two box
stitches. The procedure can be carried out under local anaesthesia.
We reviewed 27 patients who had a percutaneous repair at a median interval of 35 months
after the injury. They returned to work at four weeks and to sport at 16. One developed a minor
wound infection and another complex regional pain syndrome type II. There were no injuries to
the sural nerve or late reruptures. This technique is simple to undertake and has a low rate of
complications.
10/6/2007 11:08 AM
2 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
synthesis confirmed the in vivo results that were obtained. The decrease in proteoglycan
anabolism seemed to be a direct effect of pefloxacin on tissue metabolism rather than a
consequence of the low concentration of sulfate. Pefloxacin treatment for several days induced
oxidative damage of type I collagen, with the alterations being identical to those observed in the
experimental tendinous ischemia and reperfusion model. Oxidative damage was prevented by
coadministration of N-acetylcysteine (150 mg/kg) to the mice. These results provide the first
experimental evidence of a pefloxacin-induced oxidative stress in the Achilles tendon that
altered proteoglycan anabolism and oxidized collagen.
The effect of knee and ankle position on displacement of Achilles tendon ruptures in a
cadaveric model. Implications for nonoperative management.
Sekiya JK, Evensen KE, Jebson PJ, Kuhn JE
Am J Sports Med 1999 Sep-Oct;27(5):632-5
Section of Orthopaedic Surgery, The University of Michigan Medical Center, Ann Arbor, USA.
Using a cadaveric model, we evaluated the effect of knee and ankle position on the
displacement of the severed ends of an Achilles tendon transected at three different points. In
six cadaveric legs the Achilles tendon was severed transversely, then marked with radiopaque
wire suture. The distance between the wire markers was measured on radiographs taken in
different positions of ankle and knee flexion. Ankle plantar flexion had a statistically significant
effect on decreasing the gap between the severed ends of the Achilles tendon. This effect was
clinically significant as, on average, the tendon edges were separated more than 20 mm when
the ankle was in the neutral position and were apposed when the ankle was in 60 degrees of
plantar flexion. With the ankle fixed in 60 degrees of plantar flexion, knee position had no
significant effect on the displacement of the severed ends of the Achilles tendon. Overall, the
effect of knee flexion was neither statistically significant nor clinically significant, as the increase
in displacement of the severed ends of the Achilles tendon was only 3 mm from 0 degrees to
120 degrees of knee flexion. These results suggest that the nonoperative treatment of Achilles
tendon ruptures requires immobilization in maximal ankle plantar flexion, and that
immobilization of the knee may not be necessary to achieve tendon-edge apposition.
The effect of knee and ankle position on displacement of Achilles tendon ruptures in a
cadaveric model. Implications for nonoperative management.
Sekiya JK, Evensen KE, Jebson PJ, Kuhn JE
Am J Sports Med 1999 Sep-Oct;27(5):632-5
Section of Orthopaedic Surgery, The University of Michigan Medical Center, Ann Arbor, USA.
Using a cadaveric model, we evaluated the effect of knee and ankle position on the
displacement of the severed ends of an Achilles tendon transected at three different points. In
six cadaveric legs the Achilles tendon was severed transversely, then marked with radiopaque
wire suture. The distance between the wire markers was measured on radiographs taken in
different positions of ankle and knee flexion. Ankle plantar flexion had a statistically significant
effect on decreasing the gap between the severed ends of the Achilles tendon. This effect was
clinically significant as, on average, the tendon edges were separated more than 20 mm when
the ankle was in the neutral position and were apposed when the ankle was in 60 degrees of
plantar flexion. With the ankle fixed in 60 degrees of plantar flexion, knee position had no
significant effect on the displacement of the severed ends of the Achilles tendon. Overall, the
effect of knee flexion was neither statistically significant nor clinically significant, as the increase
in displacement of the severed ends of the Achilles tendon was only 3 mm from 0 degrees to
120 degrees of knee flexion. These results suggest that the nonoperative treatment of Achilles
tendon ruptures requires immobilization in maximal ankle plantar flexion, and that
immobilization of the knee may not be necessary to achieve tendon-edge apposition.
10/6/2007 11:08 AM
3 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Sixty patients with acute rupture of the Achilles tendon were included in a prospective study
and assigned randomly for operative treatment using a 4-string suture with either a new mobile
cast (30) or a rigid below-knee cast (30). All patients were evaluated clinically for 1 year after
surgery. During surgery, a radiographic monitor was placed in the Achilles tendon above and
beneath the site of rupture. Radiographic evaluation of tendon behavior during healing was
also performed on all patients for 1 year. Major complications were 1 rerupture in the mobile
cast group and 2 reruptures and 1 infection in the rigid cast group. There were fewer minor
complications in the mobile cast group. More patients in the mobile cast group resumed sports
activities at the same level as before the rupture than in the rigid cast group. They also had
better recovery of normal ankle movement plus faster and better recovery of plantar flexion
strength. Fewer patients in the mobile cast group had calf atrophy, and fewer had problems 1
year after the accident. Furthermore, patients treated with the mobile cast had a statistically
significant shorter sick leave. Radiographic evaluation of the tendon monitor showed
significantly less elongation of the tendon 1 year after rupture for patients in the mobile cast
group. Operative treatment with a 4-string suture and use of a postoperative mobile cast
proved safe and convenient and preferable to treatment with the traditional rigid below-knee
cast.
Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of
ground-reaction forces and temporal data.
McComis GP, Nawoczenski DA, DeHaven KE, University of Rochester Medical Center and
Ithaca College Department of Physical Therapy, New York 14623, USA.
gmccomis@fullnet.com
J Bone Joint Surg Am 1997 Dec;79(12):1799-808
Fifteen patients who had sustained a rupture of the Achilles tendon were managed
non-operatively with use of a functional bracing protocol, and clinical and functional
performance measures were assessed after a mean duration of follow-up of thirty-one
months (range, twenty-four to forty-five months). An age and gender-matched group of fifteen
subjects was assessed to provide normative data for the comparison of side-to-side
differences. Numerical scores were generated on the basis of subjective responses to a
questionnaire, clinical measurements of the range of motion of the ankle and the
circumference of the calf, and the results of the Thompson squeeze test and a single-limb
heel-rise test. A 100-point scoring system was used to categorize the outcome as excellent,
good, fair, or poor. In addition, ground-reaction forces and temporal data were assessed
during functional dynamic activities that included walking, a single-limb power hop, and a
thirty-second single-limb heel-rise endurance test. The result was graded as excellent for
three patients, good for nine, fair for two, and poor for one. An increase in passive
dorsiflexion of the treated ankle was the only clinical measure that was significantly different
10/6/2007 11:08 AM
4 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
between the groups (p = 0.02). This increase in dorsiflexion was positively correlated with
vertical force output between the mid-stance and terminal-stance phases of gait (r = 0.40, p =
0.05). With the numbers available, we could detect no significant differences between the
groups with regard to the kinetic or temporal variables that were measured during functional
dynamic activities. Patients who generated less peak vertical force and vertical height during
the single-limb power-hop test tended to have poorer clinical scores. We believe that
non-operative functional bracing may prove to be a viable alternative to operative
intervention or use of a plaster cast for the treatment of acute ruptures of the Achilles tendon.
The goals of treatment are to prevent the musculoskeletal changes that are associated with
immobilization, to reduce the time needed for rehabilitation, and to facilitate an early return to
work and to preinjury activities.
Early motion of the ankle after operative treatment of a rupture of the Achilles tendon.
A prospective, randomized clinical and radiographic study.
Mortensen HM, Skov O, Jensen PE; Department of Orthopaedics, Odense University
Hospital, Denmark. niels.mortensen@dadlnet.dk
J Bone Joint Surg Am 1999 Jul;81(7):983-90
BACKGROUND: Different regimens of early motion of the ankle after operative treatment of a
ruptured Achilles tendon have been suggested since the late 1980s. However, as far as we
know, no controlled studies comparing these regimens with conventional immobilization in a
cast have been reported. METHODS: In a prospective study, seventy-one patients who had
an acute rupture of the Achilles tendon were randomized to either conventional postoperative
management with a cast for eight weeks or early restricted motion of the ankle in a
below-the-knee brace for six weeks. The brace was modified with an elastic band on the
posterior surface, in a manner similar to the principle of Kleinert traction. Metal markers were
placed in the tendon, and the separation between them was measured on serial radiographs
during the first twelve weeks postoperatively. The patients were assessed clinically when the
cast or brace was removed, at twelve weeks postoperatively, and at a median of sixteen
months postoperatively. RESULTS: The separation between the markers at twelve weeks
postoperatively was nearly identical in the two groups, with a median separation of 11.5
millimeters (range, zero to thirty-three millimeters) in the patients managed with early motion
of the ankle and nine millimeters (range, one to forty-one millimeters) in the patients managed
with a cast. The separation was primarily correlated with the initial tautness of the repair (r[S]
= 0.45). No patient had excessive lengthening of the tendon. The patients managed with
early motion had a smaller initial loss in the range of motion, and they returned to work and
sports activities sooner than those managed with a cast. Furthermore, there were fewer
visible adhesions between the repaired tendon and the skin in the patients managed with
early motion, and these patients were subjectively more satisfied with the overall result. The
patients in both groups recovered a median of 89 percent of strength of plantar flexion
compared with that of the noninjured limb, as measured with an isometric strain-gauge at 15
degrees of dorsiflexion. The heel-rise index was similar for both groups: 0.88 for the patients
managed with early motion and 0.89 for those managed with a cast. CONCLUSIONS: Early
restricted motion appears to shorten the time needed for rehabilitation. There were no
complications related to early motion in these patients. However, early unloaded exercises
did not prevent muscle atrophy.
10/6/2007 11:08 AM
5 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
partial rupture. In tendons with a false negative result histopathological changes were mild
and a tendency towards a better clinical outcome was noted in the sonographic cases.
Assessment of the paratenon was unreliable with both methods. Ultrasonography and MRI
give similar information and may have their greatest potential as prognostic instruments.
10/6/2007 11:08 AM
6 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
on and in seven of them the final result was satisfactory. The conclusion of this study is that
partial Achilles tendon ruptures are often difficult to treat and only two out of three patients
can be expected to obtain satisfactory results after surgical treatment.
10/6/2007 11:08 AM
7 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
of the bursa also were fibrocartilaginous. On the anterior wall, fibrocartilage replaced the
calcaneal periosteum; on the posterior wall, there was a sesamoid fibrocartilage in the deep
part of the tendon. When the tuberosity was not prominent, the bursal fibrocartilages were
absent. Histopathological features were observed in 31 entheses. Bone spurs extended from
the calcaneus into the tendon and probably formed by endochondral ossification of enthesial
fibrocartilage. Longitudinal fissures were splits in the fibrocartilage along the lines of the
endotenon, and small transverse tears occurred at the tendon-bone junction. Longitudinal
fissures showed evidence of repair; they were filled with amorphous material and surrounded
by clusters of cells. In the bursal walls, calcification or degradation, or both, were observed in
37 specimens and usually involved both sesamoid and periosteal fibrocartilages. These
fibrocartilages could therefore be implicated in retrocalcaneal bursitis.
Surgical management of Achilles tendon overuse injuries. A long-term follow-up study.
Schepsis AA, Wagner C, Leach RE; Department of Orthopaedic Surgery, Boston University
Medical Center/University Hospital, Massachusetts.
Am J Sports Med 1994 Sep-Oct;22(5):611-9
We studied 79 cases of surgically treated Achilles tendon overuse injuries in 66 patients.
Fifty-three (80%) of these patients were competitive or serious recreational runners operated
on between 1978 and 1991. There were 49 men and 17 women with a mean age of 33 years
(range, 17 to 59). The cases were divided into surgical subgroups based on their site of
primary symptoms and abnormalities: paratenonitis (23), tendinosis (partial rupture or
degeneration) (15), retrocalcaneal bursitis (24), insertional tendinitis (7), and combined
abnormalities (10). Followup included a comprehensive patient questionnaire and office
examination. There were 79% satisfactory (51% excellent, 28% good) and 21%
unsatisfactory (17% fair, 4% poor) results. The percentages of satisfactory results in the
paratenonitis group (87%) were best and those in the tendinosis group were the worst (67%).
Satisfactory results were obtained in 75% of the patients with retrocalcaneal bursitis and 86%
with insertional tendinitis. Seven of the 45 cases with longer than 5-year followup with initially
satisfactory results deteriorated with time and required reoperation (16%). Of these, 4 were in
the tendinosis group, 2 had retrocalcaneal bursitis, and 1 had paratenonitis. One of the 34
patients followed less than 5 years required reoperation.
Eccentric exercise in chronic tendinitis.
Stanish WD, Rubinovich RM, Curwin S
Clin Orthop 1986 Jul;(208):65-8
Chronic tendinitis, particularly of the Achilles tendon, frequently outwits traditional programs
of therapy including surgery and/or prolonged immobilization. A hypothesis proposes that
disruption of the tendon, micro or macro, occurs under specific conditions of eccentric
loading. In order for the healing tendon to be adequately rehabilitated, the treatment program
must include specific eccentric strength rebuilding exercises.
Operative management of Haglund's deformity in the nonathlete: a retrospective
study.
Sammarco GJ, Taylor AL; University of Cincinnati Medical Center, Ohio, USA.
Foot Ankle Int 1998 Nov;19(11):724-9
Haglund's deformity, or "pump bump," is a common cause of posterior heel pain.
Management of the condition usually consists of nonoperative therapy. This study presents a
retrospective study of 65 cases (53 patients), with symptomatic Haglund's deformity in
nonathletes (13 male and 40 female), who presented during a 4-year period (1989-1994).
Sixty-five percent (39 heels) of these patients failed to respond to nonoperative therapy for
an average of 62 weeks, (range, 4-260 weeks). This group of patients went on to operative
treatment. Surgical management consisted of excision of the posterior calcaneal tuberosity
through a medial longitudinal incision with debridement, reattachment of the Achilles tendon
using bone anchors, and 4 weeks of postoperative immobilization. Thirty-nine patients (74%)
were contacted for follow-up. The average follow-up period for these patients was 155
weeks, (range, 92-335 weeks). There were 50% excellent results, 47% good results, 3% fair
results (1 patient), and no poor results. The Maryland Foot Score for operated heels was an
average of 67/100 preoperative and an average of 92/100 postoperative. On unoperated
heels the score was an average of 81/100 at first evaluation and an average of 86/100 at
final evaluation. Complications included one recurrence of painful prominence, one wound
infection, and one incisional neuroma. The outcome of these cases demonstrated that in
10/6/2007 11:08 AM
8 of 8
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
those patients who fail nonoperative treatment, surgical treatment of Haglund's deformity
produces a predictably good surgical result when performed using the technique described.
[ Close Window ]
10/6/2007 11:08 AM
Tendon Disorders
1 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Printout from Orthoteers.com website, member id 1969. 2007 All rights reserved. Please refer to the site policies
for rules on diseminating site content.
Tendon Disorders
TIBIALIS POSTERIOR INSUFFICIENCY
Adapted from the Foot & Ankle Hyperbook
Commonest cause of adult acquired flat foot
Tears occur in the hypovascular zone 3-5 cm proximal to insertion
Causes
trauma
chronic flat foot
inflammatory arthropathy
degenerative tendonopathy
Myerson described two groups:
younger patients aged 30-40 with inflammatory arthropathy
older, typically female patients 50-60 years old with degenerative tears
Complaints
post-malleolar pain
arch pain + aching
progressive flat foot
forefoot problems: progressive hallux valgus, metatarsalgia, lesser toe deformities
rarely, tarsal tunnel syndrome
Examination
gait
planovalgus foot
heel remains in valgus on double foot tiptoe standing
post-malleolar tenderness/swelling with no palpable tendon on resisted plantar flexion/inversion
single foot tiptoe test: cannot stand on tiptoe on single foot if tibialis posterior not functioning
tight TA in hindfoot neutral
hindfoot/forefoot malalignment and its degree of correctability
Differential diagnosis
longstanding flat foot made symptomatic, usually by minor trauma
sequelae of other injuries
joint instability or destruction due to inflammatory arthritis
neuropathic foot collapse
Imaging
Standing hindfoot alignment view: shows where the valgus is
Standing lateral foot both show talonavicular
Standing AP forefoot and talometatarsal alignment
MR: best technique for assessing tendons
The first three are known in Blackburn as a "deformity series" (they are also employed in other generalised foot deformities such
as pes cavus). They also demonstrate joint alignment and degeneration.
Pathology: staging systems
Classification after Johnson (1989), indicating findings and treatment
Tendon condition
Stage I
Stage II
Stage III
peritendonitis/
elongation
elongation
degeneration
10/6/2007 11:08 AM
Tendon Disorders
2 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
Hindfoot
mobile, normal
mobile, valgus
mobile, fixed
Pain
medial, focal
mild weakness
marked weakness
marked weakness
normal
positive
positive
Pathology
synovitis/
degeneration
degeneration
subtalar arthrodesis
degeneration
conservative/
Treatment
debridement
Dereymaeker and Wouters extended the classification at both ends to produce five stages:
Tendon condition
Stage I
Stage II
Stage III
Stage IV
Stage V
Biomechanical
predisposition
Peritendonitis/
Elongation/
Disrupted
Disrupted
degeneration
rupture
Hindfoot
Mobile
Mobile
Mobile
Fixed
Fixed
Forefoot-hindfoot
Normal
Normal
Valgus
Valgus
Valgus
None/after activity
Mild/moderate
Moderate/
Sinus tarsi
Ankle
severe
Arthritic
alignment
Pain
10/6/2007 11:08 AM
Tendon Disorders
3 of 3
http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a...
[ Close Window ]
10/6/2007 11:08 AM