Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

C orrection of the claw hallux and first metatarsal equinus deformity may be accomplished by transfer of the extensor hallucis longus tendon and arthrodesis of the hallux interphalangeal joint. Once the deformity of the forefoot is fixed (e.g., following a compartment syndrome), the extensor hallucis longus tendon can no longer dorsiflex the first metatarsal. Although C harcot-Marie- Tooth disease is often associated with a cavus foot, the transfer is not indicated when a planovalgus foot is present.

This neuropathic ulcer is stable. There is minimal drainage and no clinical findings to suggest an active infection. C ulture of the ulcer yields multiple nonpathogenic organisms and antibiotic therapy is not indicated. Treatment is initiated with either a total contact cast or a total contact walker boot.

Overplication of the medial capsule, overcorrection of the metatarsal osteotomy, and excessive lateral soft tissue release can lead to a hallux varus deformity. The most likely cause, however, is interference with the varus-valgus balance of the hallux as a result of a fibular sesamoidectomy.

Arthrodesis and resection arthroplasty of the hallux MP joint are indicated in the presence of arthritis of the hallux MP joint. A tendon transfer is preferred, and the extensor hallucis brevis tendon is an effective transfer. Use of the extensor hallucis longus tendon with arthrodesis of the hallux IP joint is indicated when there is a fixed deformity of the hallux IP joint.

Ankle arthrodesis must be used as a salvage procedure for failed management of the osteochondral lesion of the talus. Although osteoarticular autograft is a popular procedure, the results are variable and unpredictable, particularly in posteromedial lesions. Ankle arthroscopy with transarticular drilling is the most predictable procedure with expected satisfactory results in approximately
80% of patients.

This patient presents with a classic acute gout attack. Although the hallux is in severe valgus, it is unlikely that this is the cause of the joint pain. Note the swelling of the hallux and the shiny skin from the acute inflammation. These clinical findings are typical of gout. Intra-articular injection of steroids is effective treatment and can be combined with oral anti-inflammatory agents.

The appearance of the synovium is typical of pigmented villonodular synovitis. Staining of the synovium is characteristic. It is unlikely that a 43-year-old man will present with rheumatoid arthritis, although synovitis may appear similar. Recurrent ankle sprains cause a nonspecific synovitis that is not pigmented.

Fasciotomy of the foot is not indicated when pressures are less than 20 mm Hg. All of the alternatives are reasonable forms of treatment including application of an intermittent foot pump device that has been demonstrated to decrease compartment pressures of the foot. If pressures were more than 30 mm Hg, then a fasciotomy may be indicated.

Each of the alternatives presented is reasonable except for ankle arthroscopy because it has a limited role in the management of posttraumatic arthritis of the ankle. In this patient, there is a possibility to salvage the ankle before arthrodesis or joint replacement with an osteotomy of the tibia and or the fibula. Both have a definite role in management of ankle deformity and arthritis. A closing wedge osteotomy of the tibia was performed in this patient, and she remains asymptomatic 4 years later (Slide
3 and Slide 4).

When arthrodesis of the hallux MP joint is performed, it stabilizes the MP joint and continued flexion of the hallux with recurrent deformity occurs because the hallux interphalangel joint is not controlled with MP arthrodesis. All of the other procedures are satisfactory alternatives.

When a tarsal coalition becomes symptomatic in an adult, surgery becomes necessary. Initial immobilization may be attempted, although prolonged immobilization in an athlete is not ideal. Manipulation of the foot will exacerbate the pain, and therapy is not indicated. If arthrodesis of the hindfoot is performed for treatment of a calcaneonavicular coalition, then a triple arthrodesis is performed. Excision of the adult calcaneonavicular coalition is the preferred treatment.

This patient has typical symptoms of an interdigital neuroma, most likely involving the second web space. The likelihood of resolution of pain with nonsurgical treatment is good despite the duration of symptoms. Treatment can be initiated with a wide shoe, an orthotic arch support, or an injection of corticosteroid into the affected web space.

This patient has a malunion of the fibula that does not appear to be associated with ankle arthritis, despite the radiographic changes. The valgus tilt of the ankle joint is common with shortening of the fibula and does not imply arthritis. Therefore, arthrodesis and ankle replacement are not indicated. Lengthening osteotomy of the fibular combined with excision of the medial joint scar is ideal to realign the tibiotalar joint. Although ankle arthroscopy may be performed in conjunction with the fibular osteotomy, it is not sufficient treatment.

Although all of the above complications may occur following repair of an acute Achilles rupture, improper tensioning of the repair and stretching of the repair occur most commonly.
This is due to a number of factors including the position of the foot during the repair, incorrect tensioning of the repair, and premature unprotected dorsiflexion of the foot following surgery. When suturing the tendon ends, the sutures must be inserted correctly and not into the frayed tendon ends, which will lead to incorrect tension on the repair. It is preferable to position the foot in slight equinus during the repair.

Removal of the implant is necessary but will not be sufficient to alleviate pain from arthritis. In this obese patient, an arthrodesis is necessary. An extended hindfoot arthrodesis is only necessary when pain and arthritis are present in joints adjacent to the ankle. An ankle arthrodesis with interposition graft is sufficient.

The reported results following revision surgery following recurrence of symptoms after excision of an interdigital neuroma are poor. In a large series, Stamatis and Myerson reported less than a 50% good outcome following revision surgery.

The Weil osteotomy is a good procedure to correct deformity about the lesser metatarsophalangeal joint but is associated with potential complications, the most common of which is elevation of the second toe. As a result of shortening and plantar shifting of the metatarsal, the intrinsic muscles shift dorsally and can function as a dorsiflexor of the metatarsophalangeal joint.

An acute dislocation of the peroneal tendon must be repaired. The results of immobilization are not predictable and, in a professional athlete, the added potential for failure with nonoperative treatment must be considered. With a rupture of the
superior peroneal retinaculum likely to be the cause of the dislocation, the peroneal tendon should be repaired. When repair of an acute dislocation is performed, it should not be necessary to deepen the fibular groove.

The pain present in plantarflexion is common and associated with friction of the capsule against the dorsal osteophytes. This patient has noted only mild arthritis of the metatarsophalangeal joint. An arthrodesis is not a necessary treatment, although it is a reasonable alternative. Implant and interposition arthroplasty are alternatives for the treatment of arthritis of the metatarsophalangeal joint but preferably only when the condition is advanced.

Although some laxity may be present in this patient, it is impossible to determine whether this is present in the ankle or the subtalar joint based upon this clinical test. Simple inversion stress without simultaneously palpating the lateral shoulder of the
talus cannot indicate the presence or the type of instability. An anterior drawer that is positive and, in particular, is associated with a vacuum phenomenon in the anterolateral ankle is more diagnostic of ankle instability.

The extensor retinaculum is an important structure in maintaining and possibly augmenting the stability of the lateral ankle and subtalar joint. The inferior root of the extensor retinaculum inserts in the floor of the sinus tarsi, improving stability of the subtalar joint. This structure can be used to augment a repair of ankle instability.

This unstable ankle is associated with a complete disruption of the syndesmosis. With the information available, it is not likely that a high fibular fracture is present. One has to assume that the injury is limited to the syndesmosis. Although the deltoid ligament may be torn, one cannot determine this until the time of surgery. At surgery, if the mortise reduces well following insertion of screw(s), then the deltoid is left alone. If the talus does not reduce, then there may be deltoid tissue that needs to be removed before the reduction can be accomplished.

Ankle arthritis is rarely idiopathic. In the United States, the most common source of ankle arthritis is following trauma, usually of a major nature. Repetitive ankle injury, particularly when associated with recurrent instability and a varus or cavus foot, will likely lead to the development of ankle arthritis. Patients should be counseled that recurrent instability of the ankle, particularly when osteophytes are already present, frequently leads to arthritis.

This patient presents with a typical rupture of the anterior tibial tendon. She reports a drop foot, commonly perceived by the patient as a slapping sensation of the foot when attempting to lift the foot up as the heel contacts the ground. Note the slight extension of the hallux, indicating chronic overuse in an attempt to provide accessory dorsiflexion of the ankle.

This MRI presents the typical appearance of an anterior tibial tendon rupture. There is no continuity of the tendon distally, and the retracted tendon end has formed a scar palpable as a subcutaneous mass. The clinical history of the weakness associated with a drop foot gait is characteristic of the tendon rupture.

The calcaneus fracture is associated with subluxation of the subtalar joint, giving the appearance of injury to the talus and calcaneus. The true extent of the injury cannot be determined without a computed tomography scan; however, the question is not as to the outcome of treatment, but the ability to return this patient to his occupation. At 4 weeks following injury, while open reduction internal fixation of the fracture is possible, anatomic reduction may be difficult. The most likely means of returning this patient to work is with early arthrodesis, which should be combined with an open reduction internal fixation of the calcaneus.

The ideal position for arthrodesis of the hallux metatarsophalangeal joint is in 5° of valgus, 10° of dorsiflexion relative to the ground, and neutral rotation. Although the hallux is short and may be associated with painful metatarsalgia, the most likely cause of pain is abutment of the hallux against the shoe because it was fused in varus.

Resection of the lesser metatarsal heads is an operation that is commonly performed for patients with rheumatoid arthritis; however, this may also be performed for patients with debilitating metatarsalgia in the absence of systemic disease. C apsulotomy and tendon lengthening will not correct the alignment of the lesser toes or address the metatarsalgia. Revision of the resection arthroplasty will not address the metatarsalgia, and recurrent deformity of the hallux is likely. Shortening osteotomies of the metatarsal will decompress the joint, realign the toes, and decrease the metatarsalgia, particularly if performed in conjunction
with metatarsophalangeal arthrodesis. A lengthening bone block fusion is not necessary.

This patient has the typical features of Freibergâs osteochondrosis of the second metatarsal head. There is swelling present, which is not noted in association with a neuroma, even though the clinical findings may be similar. Synovitis is common but not associated with radiographic changes.

This patient has a flexible flatfoot deformity associated with a painful accessory navicular. No clinical or radiographic findings of a tarsal coalition are present. In addition to excision of the accessory navicular and advancement of the posterior tibial tendon, either a subtalar arthroerisis or an osteotomy of the calcaneus may be necessary.

The subtalar arthroerisis, as demonstrated in the radiograph, is used to control eversion of the subtalar joint during the foot flat phase of gait. A subtalar arthroerisis limits excessive eversion but does not restrict subtalar motion further. This procedure is indicated for a patient who has a flexible flatfoot deformity and can be used either as the sole or an adjunctive procedure for correction.

Although the anterior tibial muscle is weak, the cavus is the predominant deformity of this condition, caused by weakness of the peroneus brevis. The peroneus longus is functioning and is responsible for the plantarflexion of the first metatarsal.

The posterior tibial tendon transfer is a commonly performed surgery for correction of cavus foot deformity associated with weakness of the anterior tibial muscle and varying degrees of drop foot deformity. The removal of the force of the posterior tibial tendon adds to the correction of the deformity of the foot by balancing the absent peroneus brevis. Although the extensor hallucis longus can be used as a tendon transfer, it will not be the primary muscle used or sufficient to correct deformity.

The peroneus brevis is usually the first muscle to atrophy. Varying patterns of loss of the other muscles of the lower extremity include the anterior tibial and, in particular, the intrinsic foot muscles. Weakness in these muscles accounts for the cavus and the claw foot deformities noted in patients with hereditary sensory motor neuropathy.

This patient presents with an acute neuroarthropathy. The acute painless swelling, associated with warmth and absence of radiographic findings, is typical of the acute phase of a C harcot process. A short leg cast or a boot to immobilize the foot is ideal, and no weight bearing should be permitted until the acute phase of this neuroarthropathy has subsided.

This patient most likely has diabetes. Patients may present for the first time with an acute neuroarthropathy of the foot as a result of diabetes, even without a clinical history of the disease. Although the sedimentation rate will likely be elevated, it will not help in the diagnosis. Infection is not a likely consideration in this patient.

The indication for surgery is intractable deformity, which is refractory to all forms of bracing. By refractory, one implies that skin breakdown or imminent infection is present. If surgery were performed, then it would consist of a tibiotalocalcaneal arthrodesis. There are no indications for this surgery in this patient. Once the neuropathic process has reached a stable point, a deformity is not likely to progress.

In this age group, amputation of the second toe is a reasonable treatment. It is not possible to correct the second toe deformity without correction of the hallux, either by arthrodesis or arthroplasty at the metatarsophalangeal joint. The hallux is
asymptomatic, which is common in this age group, and the simplest treatment is to amputate the toe.

The cause of claw toe deformity is not idiopathic. C law toe deformity is a common deformity in adults, particularly in women as a result of lack of use of the intrinsic muscles of the foot, leading to an imbalance between the extrinsic and intrinsic muscles in the foot. As the intrinsic muscle atrophies, the long extensor and flexor tendons cause the deformity (as presented in this patient), with resulting metatarsalgia.

Although the long and short flexor tendons have some effect albeit indirect on the flexion of the metatarsophalangeal joint, the flexor that acts directly on the joint is the interosseous muscle. Intrinsic atrophy will lead to claw toe deformity.

Ambulatory treatment for a patient with diabetes is always the preferable treatment. In this patient, there is no evidence of infection. Unless drainage is purulent and the ulcer is in contact with bone, there should be minimal concern for infection. Reconstruction of a C harcot deformity of the midfoot is only indicated following repeated failure of nonoperative treatments.

Repair of a chronically torn deltoid ligament is not sufficient to correct this type of deformity. The ligament has degenerated, and the quality of the ligament is insufficient. Each of the other alternatives is reasonable either performed as the sole or adjunctive procedure.

This patient has a fixed deformity of the ankle, as well as the hindfoot. The subtalar joint has adapted to the varus position of the ankle but is stiff. Following the ankle arthrodesis, which has to be performed by bringing the ankle into a few degrees of varus, the forefoot will not be able to compensate for the fixed changes that have taken place in the hindfoot. To keep the forefoot plantigrade, a dorsal wedge osteotomy of the first metatarsal should be performed to keep the foot plantigrade.

Regardless of patient activities, desire for shoe wear, and age, the ankle must be fused in a standard position of neutral dorsiflexion and slight valgus. This is important because any deviation of this position, particularly in equinus, will increase the likelihood of arthritis in the talonavicular and subtalar joint.

This patient demonstrates the common finding of fixed forefoot varus associated with a flexible flatfoot deformity. It is likely that a gastrocnemius contracture is also present, but this is not always the case. Arthritis of the calcaneocuboid joint rarely occurs following a lengthening calcaneal osteotomy in an adult. C orrection of the forefoot varus is best accomplished with an opening wedge osteotomy of the medial cuneiform. Arthrodesis of the first tarsometatarsal joint may be performed in selected patients
with noted instability at this joint.

This patient most likely has an acute attack of gout. The prior episodes of foot pain and the sudden onset lasting 5 days for each bout is characteristic. The ankle is not a common location for gout (the most frequent site is the hallux metatarsophalangeal joint). The treatment should consist of injection of a corticosteroid into the joint and administration of appropriate oral anti-inflammatory medication.

The extensor hallucis longus or the extensor hallucis brevis (rarely the abductor hallucis) may be used as a tendon transfer for correction. Arthrodesis of the hallux interphalangeal joint may be performed for correction of a fixed claw deformity of the interphalangeal joint, usually in conjunction with a tendon transfer. Arthrodesis of the metatarsophalangeal joint is a reasonable alternative provided there is no fixed deformity of the interphalangeal joint present and when arthritis or fixed deformity of the metatarsophalangeal joint is present.

Important points to remember about Achilles tendon ruptures: A. Most common in middle-aged men
B. Often intermittent sports activity
C . Left more than right
D. Often the tendon is abnormal (degenerative) E. Mechanism
1/. Sudden forced plantarflexion
2/. Unexpected dorsiflexion
3/. Violent dorsiflexion of the plantar flexed foot
Factors which may make the patient more prone to rupture: A. Steroids
B. Fluoroquinolones

This meta-analysis showed:
Operative versus nonoperative (pooled rates):
Rerupture
Operative 3.5% (6/173) (relative risk 0.27) Nonoperative 12.6% (23/183)
Complications (adhesions, infection, disturbed sensibility)
Operative 34.1% (59/173) (relative risk 10.60) Nonoperative 2.7% (5/183)
Infection
Operative 4.0% (7/173) (relative risk 4.89) Nonoperative 0%