Rearfoot


Calcaneus


1.You suspect your patient has a cyst in his calcaneus, what radio-graphic views will you certainly order? Calcaneal axial and lateral view
 2.What is a Topaz (instrument)? Radiofrequency Coblation, microscopic damage increase BS via microtears, angiogenesis/healing. Used in plantar fasciitis surgical treatment.
3.What is a Dwyer? lateral closing base wedge of calcaneus to correct frontal plane deformity (varus)
4.What ligament holds in place a non-displaced calcaneal anterior process fracture? bifurcate ligament
 5.Person with calcaneal fx but before surgery notice parasthesia in both legs, what do you do first? check for vertebral spine fracture of  L5 lumbar spine
6.What is the treatment for a non-displaced calcaneal anterior process fracture? WB cast
7.What ligament prevents excessive STJ supination? cervical ligament
8.What is a Mondor’s sign? purple discoloration -hematoma that is formed and extending from heel
9.Which facet is involved in almost 90% of all intra-articular calcaneal fractures? posterior facet
10.How do you measure Bohler’s Angle? normal: 25-40 degrees. decreased with fracture.

Draw a line from the highest point of the posterior tuberosity to posterior facet. A line from  posterior facet to the highest point on the anterior  facet

11.The Angle of Gissane? >130 degrees indicates a fracture of the  subtalar joint
12.What is gold standard imaging for calcaneal fractures? CT scan, …..not an MRI
13.What does a calcaneal axial view show? lateral blow out of calcaneus, and varus/valgus position of calcaneus
14.what are the two most common associated injuries if there is an associated injury? lumbar fractures, talar fractures. And some fibular fracture or peroneal dislocation
15.The middle facet and posterior facets are separated by what two ligaments? 1. interosseous talocalcaneal ligament
2. cervical ligament
16.Is a calc. fracture more of a open or closed injury? closed fracture, but still have a 72% complication rate
17.Essex-Lopresti classification
  • Tounge type – fracture line extends posterior and transverse to posterior tuberosity
  • Joint Depression – fracture extends posterior and dorsal to posterior facet
18.Rowe Classification
  • Type 1A – Tuberosity fx
  • Type 1B – sustentaculum tali fx
  • Type 1c – anterior process fx
  • type 2A – avulsion fx of posterior superior calcaneus
  • Type 2B – avulsion fx of achilles attachment
  • Type 3 extra-articular fx of body of calcaneus
  • type 4 – intra-articular fx of body of calcaneus w/ joint depression
  • type 5 – comminuted intra-articular fx of body of calc w/joint depression
19.Sanders classification for CT view of calcaneal fractures
  • Type 1 – non displaced , multiple fractures
  • Type 2 – two part fractures.
    • A-lateral third, B- Central third, C-Medial third
  • Type 3 – three part fracture
  • type 4 – highly comminuted


Talus


1.What is the MOA for talar BODY fractures? hyperdorsiflexion
2.What is the MOA for lateral process talar fractures? snowboarding injuries due to hyper DF & inversion forces placed on ankle. Associated with peroneal tendon dislocation.
3.Canale radiograph view? Ankle in maximal equinus with foot pronated 15°
Beam directed 75° cephalad from horizontal.
4.Medial surface of talar body comma shaped facet, articulates w/ medial malleolus, attachment for deep teltoid ligament, through which courses the deltoid artery (if deltoid injured, worried about vascular perfusion)
5.Hawkins Classification
  1. NON-displaced fracture of the talar neck. AVN 0-13%
  2. Fracture with dislocation of the subtalar joint. AVN 20-50%
  3. Fracture with dislocation of the subtalar & ankle joints. AVN 80-90%
  4. Fracture with dislocation of the subtalar, ankle, & talonavicular joints. AVN >90%
6.Hawkins sign? Radiographic lucency of the talar dome seen in AP view seen at 6-8 weeks after a talar neck fracture. (its a good sign!)
7.How do you treat (AVN) avascular necrosis of talus? Core decompression and insert stem cells or PRP (platelate rich plasma). Blair fusion, or arhtrodesis of STJ.
8.Sneppen Classification for talar body fractures?
  • Type 1 – Talar dome lesion
  • Type 2 – Shear fracture of talar body
    • A) Corononal, B) Sagittal, C) Horizontal
  • Type 3 – Posterior tubercle fracture (Shepherd’s)
  • Type 4 – Lateral process fx
  • Group 5 – Crush injury, highly comminuted
9.What is a Shepherd’s fracture? How to diagnose clinically? Posterior lateral process fracture of the talus. Often misdiagnosed as Os trigonum. Clinically pain with plantarflexion or dorsiflexion of Big toe – FHL runs behind the talar process eliciting pain.
10.What are the advantages of anterior-to-posterior screw fixation? Advantages – direct visualization.

Disadvantage – difficult to place perpendicular, less strength, misalignment

11.Advantages/disadvantages of posterior-to-anterior? Advantages – stronger fixation, easy to perpendicular.

Disadvantage – indirect visualization, cartilage damage.

12.When do you do surgery on talar fractures? Displaced >2mm, size of fracture >10mm, comminuted
13.A 21 year old male sustianed injury to ankle while playing soccer. His foot was in downward position and felt a pop in back of ankle. what is most likely injury? Avulsion fracture of posterior talar process of talus. Not an os trigonum
14.Non-operative treatment of talar body fractures? non-displaced fractures, <2mm, place non weight bearing in cast for 6-8 weeks
15.Identify  each one: 

  1. Shepherds
  2. Cedell’s
  3. Snoboarder’s
  4. Foster’s
  5. Os trigonum
  1. Posterolateral talar process fracture
  2. Posteromedial talar process fracture
  3. lateral process fracture
  4. posteromedial and posterolateral fracture
  5. secondary ossicle
16.What percentage of articular cartilage make up the talus? 60%
17.What is the blood supply to the body of the talus? artery of tarsal canal (branch off the posterior tibial artery), anastomose with artery of sinus tarsi (branch off the peroneal artery), superior neck vessels (branches from anterior tibial artery)


Ankle Fracture


1.Spiral oblique fracture, with two screws under plate, what kind of plate to use? Neutralization plate
2.Ankle fracture, what do you address first? get back fibular length
3.In a popliteal block, what nerved is missed? Saphenous nerve
4.At what angle should syndesmotic screws be placed? They should be directed obliquely from back to front at an angle of 25-30 degrees starting posterolaterally and aiming anteromedially
5.What position do you want the foot when throwing syndesmotic screws? You want the foot in slight dorsiflexion because the syndesmosis is narrower in plantarflexion and throwing it while in plantarflexion could lead to over tightening
6.Aside from metallic screws, what are some other ways that syndesmotic injuries can be repaired? K wires, bioabsorbable implants, knotless suture with button fixation device
7.A patient feels numbness on his medial arch after surgery, what nerve is most likely damaged? Saphenous nerve
8.Danis-Weber Classification
  • Type A – infrasyndesmotic fracture of fibular (below syndesmosis)
  • Type B – transsyndesomitc fracture (at level of syndesmosis )
  • Type C – suprasyndesmotic fracture (above syndesmosis)
9.Lauge-Hansen Classification: 

SAD, SER

Supination- Adduction (SAD)

  • Stage 1 – transverse fx of fibular or rupture of lateral collateral ligaments
  • Stage 2 – vertical fracture of medial malleolus

Supination – External Rotation (SER)

  • Stage 1  – rupture AITFL or avulstion at insertion
  • Stage 2 – spiral fracture fibula (80% of ankle fractures)
  • Stage 3 – rupture PITFL
  • Stage 4 – avulstion of medial malleolus or rupture of deltoid ligament
PAB, PER Pronation – Abduction (PAB)

  • Stage 1 – transverse fracte of medial malleolus or rupture deltoid
  • Stage 2 – Rupture of AITFL
  • Stage 3 – short oblique fracture of fibula

Pronation – External Rotation (PER)

  • Stage 1 – transveerse fx of medial malleolus or rupture of deltoid ligament
  • Stage 2 – rupture of AITFL
  • Stage 3 – high fibular fracture (oblique or spiral
  • Stage 4 – rupture of PITFL
10.OTTAWA ankle rules? Ankle xrays are only required if the patient has :

  1. lateral malleolus pain near 6cm
  2. medial mallolar pain near 6cm
  3. pain base of fifth met
  4. pain navicular
  5. unable to walk more than 2 steps or inability to bear weight
11.In film radiographs what are the abnormals for the following:

  1. Medial clear space
  2. Tibiofibular overlap
  3. Tib-fib clear space
  4. Talocrural angle
  5. Shenton lines
  6. Dime sign
  7. Talar tilt
  1. >4mm indicates deltoid damag. 1mm shift of talus = 42% decrease tibtalar contact
  2. <10mm is damage to syndesmosis
  3. >5mm is damage to syndesmosis
  4. 83+/- 4 degrees is normal, increases with fibular shortening
  5. Disruption >2mm
  6. Disruption in dime sing >2mm
  7. Abnormal >2mm talar tilt
12.What is the research paper by Luage-Hansen based off on? the 1st word word is foot position (supination or pronation), and 2nd word is direction of talus (abduction, adduction, etc.). Classification was performed using cadaver feet, not based on real human fracture results
13.What is the Ramsey paper base on? That a 1mm shift of talus = 42% decrease tibtalar contact.
14.What is Destot fracture vs Pott’s fracture? Pott’s fracture – a bimalleolar ankle fracture. Destot fracture – a trimalleolar ankle fracture
15.Do you perform surgery on a hgih fibular facture ? (Maisonneuve fx) No. no plates or screws are needed unless its comminuted. the reason we don’t do surgery is to prevent injury of common peroneal nerve.
16.Why do you usually order a CT scan for ankle fractures? to determine complexity of fracture, help determine posterior malleolar fracture, and if any comminution seen.
17.What did the McDaniel paper talk about ankle fractures? if the posterior malleolar fracture is grater than >25% of articular surface, then you need to perform ORIF
18.Identify Each of the following:

  1. Tillaux-chaput fx
  2. Wagstaff fx
  3. Volkmann fx
  4. Bosworth fx
  5. Maisonneuve fx
  1. AITFL avulstion from anterolateral tibia
  2. AIRFL avulsion from anteromedial fibula
  3. PITFL avulsion from posterolateral tibia
  4. PITFL from posteriormedial fibula
  5. Weber C proximal fibular fracture occurs 10cm from fibular neck
19.Haraguchi classification for posterior malleolus fracture on CT scan
  • Type 1 – posterolateral oblique type (posterior malleolus fx)
  • Type 2 – medial extension type
  • Type 3 – small sheel type


Ankle Sprain


1.Patient has a history of ankle sprains and has a flexible flat foot? Evans osteotomy with Brostrom Gold procedure
2.Patient has an isolated ATFL chronic rupture, what procedure do you do? Brostrom for isolated. Lee, Christman snook, and Evans are for double ligament repairs
 3.Patient has a lateral ankle sprain with the foot dorsiflexed, what ligament is most likely affected? ATFL
 4.Patient has pain after plantarflexion and abducting his foot, what ligament is affected? Bifurcate ligament
5.Ankle scope, which nerve is most likely in danger of getting hurt? superficial peroneal (int. dorsal cutaneous is most common injury)
6.What are the lateral collateral ligaments? AITFL, CFL, PITFL
7.Deltoid ligaments? superficial – (3) Tibionavicular ligament, tibiocalcaneal ligament, superficial posterior tibiotalar ligament

Deep – (2) anterior tibotalar ligament, deep posterior tibiotalar ligament

8.Why are there bruises after a sprain? broken blood vessels from soft tissue stretching cause hemorrhage,  and inflammation leads to swelling causing nerves to be hyper reactive
9.Anterior drawer test? place the ankle in approximately 10-15° of plantar flexion, cup the palm and bring heel forward. >5mm is pahtalogic for injury
10.Talar tilt test? >10 degrees of inversion is pathalogic
11.What is the most common type of sprain? inversion or eversion? inversion, the anterior talofibular ligament is the most common 70-85% affected
12.What is a high ankle sprain? high syndesmotic sprain, caused by twisting of the foot, injury to ligaments above the ankle
13.What is the initial treatment? RICE – rest, ice, compression, elevate
14.How to treat with ankle immobilization? Air cast or CAM boot for 3 months
15.How recurrent are ankle sprains? 25-30% re-occurance in athletes who did not wear protective ankle gear.
16.What is the epidemiology? Most common in 19-25 year old males, however women over 30 years old have higher incidence.  U. S. military have 10x more ankle sprains than general pop.
17.If you have index of suspicion of fracture how can you check clinically? Ottowa rules, to see if u need xray
18. Dias (1979)classification system
  • Grade 1 – Partial Rupture CFL
  • Grade 2 – Complete Rupture ATFL
  • Grade 3 – Complete Rupture ATFL, CFL, ± PTFL
  • Grade 4 – All 3 Lateral Ligaments + Deltoid (Partial, Complete
19.Leach classification system
  •  Grade 1 – Partial/Complete ATFL Tear
  • Grade 2 – Partial/Complete ATFL + CFL Tear
  • Grade 3 – Partial/Complete ATFL + CFL + PTFL Tear
20.Dublin et al. (2016) classification system
  • Grade 1 – Microscopic Tearing of ATFL
  • Grade 2 – Microscopic Tearing of Larger Cross-Section Portion of ATFL
  • Grade 3 – Complete Rupture of ATFL; Microscopic or Complete Failure of CFL


Tendon

1.Patient has decreased Achilles tendon reflex, what nerves are affected? S1,S2
2.Described a gastroc-soleal equinus, what surgery is best?  TAL
3. Kuwada (1990) classification for achilles tendon rupture?
  • Type 1 – <50%, partial tear
  • Type 2 – complete tear, 3cm deficit
  • Type 3 – 3-6cm defect
  • Type 4 – >6cm defect
4.Describe Gastroc-soleus equinus Patient has limited ankle dorsiflexion at knee extended and flexed. <15 degrees ankle dorsiflexion
5.Conti Classification Stage Ia Tenosynovitis
1 or 2 fine longitudinal splits
Conti Stage Ib Narrower tendon signal with intramural degeneration
Conti Stage II A bulbous tendon in the diseased segment
Conti Stage IIIa Diffuse synovial swelling and prominent, uniform degeneration
Uniform degeneration with some intact tendon
Conti Stage IIIb Completely ruptured
Replaced with scar tissue in the gaped sections
6.What is a tendon anatomy composed of? 30% collagen, 2% elastin, 68% water.
7.Where does tendon get its blood supply? paratenon, tendon sheath, and bone attachment
8.What are the phases of tendon healing? Week 1 fibroblast proliferation, tendon callus. Week 2 increased vascularity. Week 3 collagen fiber produce new tendon fibers, can star passive ROM, Week 4 edema reduced, parallel tendon formation. Week 8 full maturation.
9.Gradding system for manula muscle testing
  • 5/5 strength- full resistance at end ROM
  • 4/5- some resistance, weak ROM
  • 3/5- able to move against gravity, no resistance
  • 2/5 – able to move with gravity removed
  • 1/5 – muscle twitch seen
  • 0/5- poor. no muscle contracture
10.Young tenosuspension anterior tibialis tendon reroute thorugh navicular while supinating foot
11.Kidner posterior tibial tendon advancement, excision of accessory navicular bone and re attachment of tendon
12.FDL tendon transfer removal of disease PT tendon, transect FDL at knot of Henry, insert FDL into navicular from plantar to dorsal.
13.STATT split tibialis anterior tibial tendon transfer. Split the AT tendon into half and reroute to cuboid or lateral cuneiform.
14.Hibbs EDL inserted to lateral cuneiform or 3rd met base, stumb sutured to EDB
15.Jones tenosuspension EHL transected at IPJ of hallux, rerouted thorugh medial to lateral hole in 1st metatarsal head. Includes fusion of IPJ
16.Girdlestone-Taylor reroute FDL into extensor expansion.


(TAR) Total ankle replacement


1.(1st)First generation TAR, what did it pertain? first total ankle implat by Lord & Marrotte (1970). A two part system with cement interface
2.Why did first generation failed? Required extensive bony resection leading to failure secondary to loosening, subsidence, and osteolysis
3.why used cement? for prosthesis fixation to tibial plafond
4.(2nd)Second generation TAR what did it pertain? Semi-constrianed, cementlsess, had biologic fixation, required less bone resection
5.What biologic fixation is used instead of cement? titanium porus plasma, hydroxyapatite coated spray. This allowed less frequent loosening.
6.(3rd)Third generation TAR? Three component, mobile fixation
7.What is the third component? mobile fixation of polyethylene is no attached to tibia or talus. STAR is the only FDA approved in US
8.STAR 3 component
9.Salto
10.INBONE
11.Agility LP
12.Zimmer Trabecular
13.Infinity
14.What is the TAR survival rate in 10 years? Mann et al – 90% in 84 cases, Wood et al – 80% in 200 cases, Kaplan 78% survival
15.What factors impact TAR outcomes? surgeon experience, preoperative alignment, arhtrosis etiology for each different TAR
16.Most common poor outcomes/ failures from TAR? polyethylene insert fracture, medial malleolar fracture, superficial skin infection, malalignment, impingement
17.Selecting the patient, what is criteria for a TAR? >60 yo, end stage anle arthritis secondary to degeneerative or inflammatory process, rearfoot valgus <10 degrees, well controlled diabetes, low activity level. Only 10% of population meet criteria
18.What is the learning curve for the surgeon? “it takes about 50 TAR for the surgeon to decrease compilation”. Complications of up to 60% seen in the first 25 TAR performed vs 20% seen after 50 TARs.
19.Contraindications to have a TAR performed? <50yo, poor compliance, heavy smoker, poor DM, ankle instability, >10 valgus heel, obese, poor bone.
20.Is there any concern for Gait after a TAR? ipsilateral arthritis of the hind and midfoot


Ankle Arthrodesis


1.Angles/position for ankle fusion? sagittal plane neutral 90 degrees, valgus 0-5 degrees, externally rotated 5-10 degrees
Triple Arthodesis Fusion of subtalar, calcaneocuboid, and talonavicular joints
 Triple Arthrodesis: Positioning  1. RF parallel to leg
2. 3-5 degrees STJ valgus
3. RF parallel to FF (Meary’s)
4. MT1 same level as MT5 head loaded – slight MTJ valgus, Foot abducted 10-15 degrees (MTJ pronated)
5. Foot 90 degrees to leg
Triple Arthrodesis: Postop course Cast – 10 weeks, about 6 weeks into CAM walker, serial XR until fusion noted


Classifications


Hawkin’s (1978) Classification
  1. NON-displaced fracture of the talar neck
  2. Fracture with dislocation of the subtalar joint
  3. Fracture with dislocation of the subtalar & ankle joints
  4. Fracture with dislocation of the subtalar, ankle, & talonavicular joints
Sneppen Classification (1974) for talar body fractures?
  • Type 1 – Talar dome lesion
  • Type 2 – Shear fracture of talar body
    • A) Corononal, B) Sagittal, C) Horizontal
  • Type 3 – Posterior tubercle fracture (Shepherd’s)
  • Type 4 – Lateral process fx
  • Group 5 – Crush injury, highly comminuted
Essex-Lopresti (1952) Classification
  • Tounge type – fracture line extends posterior and transverse to posterior tuberosity
  • Joint Depression – fracture extends posterior and dorsal to posterior facet
Rowe (1963) Classification of calcaneal fractures
  • Type 1A – Tuberosity fx
  • Type 1B – sustentaculum tali fx
  • Type 1c – anterior process fx
  • type 2A – avulsion fx of posterior superior calcaneus
  • Type 2B – avulsion fx of achilles attachment
  • Type 3 extra-articular fx of body of calcaneus
  • type 4 – intra-articular fx of body of calcaneus w/ joint depression
  • type 5 – comminuted intra-articular fx of body of calc w/joint depression
Sanders (1993) Classification of Calcaneal fractures
  • Type 1 – non displaced , multiple fractures
  • Type 2 – two part fractures.
    • A-lateral third, B- Central third, C-Medial third
  • Type 3 – three part fracture
  • type 4 – highly comminuted
Leach classification system
  •  Grade 1 – Partial/Complete ATFL Tear
  • Grade 2 – Partial/Complete ATFL + CFL Tear
  • Grade 3 – Partial/Complete ATFL + CFL + PTFL Tear
Dias (1979)classification system
  • Grade 1 – Partial Rupture CFL
  • Grade 2 – Complete Rupture ATFL
  • Grade 3 – Complete Rupture ATFL, CFL, ± PTFL
  • Grade 4 – All 3 Lateral Ligaments + Deltoid (Partial, Complete
Kuwada (1990) classification 
  • Type 1 – <50%, partial tear
  • Type 2 – complete tear, 3cm deficit
  • Type 3 – 3-6cm defect
  • Type 4 – >6cm defect
Berndt and Hardy (1959) classification 
  • Stage 1 – compression, bone contusion
  • Stage 2 – partial detachment of talar dome
  • Stage 3 – complete detached, non displaced osteochondral fracture
  • Stage 4 – complete detachement and displacement of soteochondral fracture