Diabetic Infection 12/16/13 2:29 PMGet Homework/Assignment Done

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Infection- minimal number of viral particles necessary to establish disease states:

106 Bone infection 105 Soft tissue infection 102 Infection of soft tissue or bone + foreign body Allows differentiation b/w colonization & infection

-Subjective

CC: foul smelling ulcer for 3 days etc… NLDOCAT “Systemic” signs of infection N/C/V/D/F/SOB “Local” signs of infection calor, dolar, rubor, tumor, pain 5 Questions to ask:

1) Trauma?2) Previous amputations of infections?3) Recent glucose/HgA1C?4) NPO status- looking ahead for surgical debridement?5) Tetanus status?

-PMH co-morbidities associated with disease-FH parents alive/cause of death-PSH foot & ankle, CABG, Vascular surg-Meds dosage & frequency

Add up all insulin types and divide by 4-Allergies type of rxn (true rxn or not)-Social working? how long & how much of drug? Housing?

-ROS General, Eyes, Lungs, Pv, Neuro, Musc

Now the whole thing:o HEENT, Resp, Cardio, GI/GU, Musc, Skin, Neuro, Lymph

-Objective Vitals Temp/HR/RR/BP & Height/weight

o SIRS (need at least 2 of below criteria) Temp (96.8 or 100.4) HR (>90) & RR (>20) WBC (<4k or >12K or 10% bands)

o Septicemia bacteremia + fever, chills, nausea etc…

Lower Extremity focused o Vasc: doppler, CFT, edema

ABI: >1.2= calcification (monkebergs sclerosis) < 0.45= inadequate for healing in diabetics

TcPo2: need to be > 30mmHg for adequate healingo Neuro: protective & vibratory sensation

Prop & Vib posterior column Light touch & pain/temp anterior lateral

o Derm: Depth, Diameter, Drainage, Odor, Base, Border PROBE TO BONE??

Grayson- 89% PPI for OM Lavery- 98% NPI for OM

*Wagner: 0= pre-ulcer, 1= superficial, 2= deep to bone, 3= deep to bone + abscess/infection

UT : 0= normal, 1= superficial, 2= tendon, 3= bone A= Normal , B= Infected, B= Ischemic, D= both

PEDIS : (Perfusion Extent Depth Infection Sensation) 1= uninfected 2= (Mild) > 2 manifestations of inflam

Erythema/cellulitis < 2 cm around ulcer 3= (Mod) Erythema/cellulitis > 2 cm around ulcer,

streaking lymp, abscess, gangrene 4= (Severe) + N/C/V/D/F/SOB/Confusion

o Musc: boney prominences ? Foot type, Previous amputations, Strength

-What to order1) Imaging:

X-rays o Gas= emergency

Get more PROXIMAL films BECKS+ (Bacteroides, E. coli, clostridium, klebsiella,

stap/strep, peptococcus, peptostrepto co OM (may take 10-14 days/ need 30-50% resorption)

Acute = soft tissue swelling, periosteal rxn, lytic changes, cortical destruction

Chronic = sequestrum, involucrum, cloca, brodie’s MRI

o No contrast if Poor renal function o T1= low signalo T2/Stir= high signal in cortex/medullary bone

Bone Scan o Increased uptake in all 4 phases o Charcot vs. “Acute” OM

Charcot has more diffuse “periarticular” uptake on phase 3

Ceretec (Tech-HMPAO) sensitive & specific “safer” Only shows ACUTE infections Determines if hotspot is in or out of bone

Indium-111 Oxime done in 24hrs Better for CHRONIC infections

2) CBC w/ diff: Hemoglobin (12-18) **Transfuse if < 8 Hematocrit (35-55%) **Transfuse if < 24

o 1 unit PRBC = increase Hg by 1 & Hct by 2o 1 unit Whole blood = increase Hg 2 & Hct 4

Platelets (100-450) ** No surgery if < 100

WBC (<4,000 or >12,000) **Absolute Neutrophil Count shift to left with bands & segments

o Left shift= neutrophils + bands > 803) BMP

Sodium (hypernaturemia- dehydration, Na overload, vol overload) Glucose- healing potential haulted if >150-175 mg/dL Creatinine- kidney function measuring GFR

4) Hba1C (add 30 mg/dl each increase inn HbA1c) HbA1c of 5%= 100 mg/dL HbA1c of 6%= 130 mg/dL

5) Coag’s PT (10-16) PTT (25-35) INR (1) **Need < 1.6 for surgery

o 1 unit FFP decreases INR by 0.26) Inflammatory markers

ESR (0-20 mm/hr) NOT SPECFIC o Kaleta- if > 70 suspect OM

CRP (0-0.8 mg/L) more closely follows the severity of ds7) Albumin (3.5-5 g/L)

Pre-albumin (19-36 mg/dL) **shorter half life

8) EKG/CXR/HCG EKG Males > 40 & Females >50 going to surgery CXR smoking history HCG women < 50 yrs

9) Culture (always get AFTER debridement) Gram stains

o G(+) : stains purple (Teichoic acids, lacks outer-membrane) Cocci: Staph (cat + “cluster”) & Strep (cat – “chains”)

S. aureus (coagulase +) Rods: clostridrum, bacillus, etc..

o G(-) : stains pink (Endotoxin in outer-membrane) Cocci: Neisseria (oxidase + diplococci) Rods: Pseudomonas (oxidase + lactose non-ferm)

Aerobic, Anaerobic, Fungal, Acid-fast Culture & Sensitivity Blood culture (3 diff locations 10 min apart)

10) Non-invasive studies Doppler: want biphasic Segmental pressures: > 10 mmHg drop indicates occlusion ABI: need > 0.45 (Wagner) TcPo2: need > 30 mmhg (Wyss, Harrington & Burgess, JBJS)

o Will be decreased from edematous states

-Decision making Admit or home

o Make “Outpatient” if : Local infection that can be controlled w/ PO Abx Benign medical conditions

o Make “Inpatient” if : Systemic infection requiring IV Abx Needed surgical intervention Immunocompromised (Dm, PVD, HIV, RA, Elderly,

Steriod) Admit (ADCVANDLIMAX)

Antibiotics/Meds o Creatinine clearance (140-age) x weight (kg) (x 0.85 in women) / 72 x serum Cr

o Vanc (1g q12 IV) & Zoysn (4.5 g q6 IV) Adjust vanc according to trough levels

o PCN Allergy (Clinda 600 mg q6 IV) & (Cipro 400 mg q12 IV)o PCN & Quin allergy Clinda & Aztreonam (1 g q8 IV)o Sliding scale of insulin

Once glucose is 200mg/dL then give 2 units, and 2 more units each 50 increase of glucose

Surgery (make NPO)

o Beside I&D (localized, neuropathic, etc..) Irrigation w/ local debridement Wet to dry dressing (dakins, betadine, saline) Cultures & tissue biopsy

o OR I&D (tracks or probes, abscess, gas in tissue) Debridement, Drainage, Decompression

Remove all tendons in the way Pulse lavage at least 3 liters (DAB vs. TAB) Deep cultures & Tissue biopsy

Clean margins with bone resection procedure Antibiotic beads (PMMA)

Commonly used antibiotics include: gentamycin, tobramycin, and vancomycin

Packed open and eventual DPC Chronic OM

Sequesterum is non-viable and a nidus for infections so it must be removed

o TMA Incisions:

Fishmouth w/ adequate plantar flap Tennis racquet for lesser met amp

Preserve only P. brevis & PT Adjunct TAL

DVT 12/16/13 2:29 PM

-IntroductionDVT clot formed in deep venous system of LE

PE “detached” thrombus from LE that travels to arteries of lung Risk Factors (I AM CLOTTED)

o Inactivity, A fib/Age, MI, Coag state, Longevity of surgery, Obesity, Tobacco use, Trauma, Estrogen, DVT history

Common locations o 20% of calf emboli will become thigh embolio 1/5th of PE come from calf

-Clinical Diagnosing: Clinically : red, hot, swollen, painful calf - edema is the most reliable

sign of DVT (compare suspected calf to the contralateral side) Homan’s test DF foot elicits pain in calf Pratt’s sign calf compression elicits pain

-Diagnostic Tests: Non-invasive

o Duplex Doppler : lack of venous compression indicates DVT Can have color flow imaging to enhance sensitivity Allows to determine direction of blood flow and the

amount of reduction in lumen diameter Grady-Bensmetal JBJS, 1994 : duplex ultrasound has the

PPV of 7/9

o Impedence plethysmography measures small changes in electrical resistance of the

chest, calf or other regions of the body. These measurements reflect blood volume changes,

and can indirectly indicate the presence or absence of venous thrombosis

o MRI provide visual images of your veins and may show if you have a clot

o D-dimer detect fragments produced by clot lysis high sensitivity may be useful for excluding the

diagnosis of acute DVT, particularly when the pre-test probability for the disease is low

Invasive o Contrast venography

Gold standard for detecting DVT Disadvantages contrast agent can cause reactions

such as urticaria, angioedema, bronchospasm, cv collapse or injury to kidney

Creatinine > 2.0 mg/d is relative contraindication

-Diagnosing PE PE COD: Right-sided heart failure

o Increased right ventricular wall causes underfilling of left ventricle provoking myocardial ischemia compromising coronary artery perfusion leading to circulatory collapse.

Clinically: sudden onset of chest pain, dyspnea, hemoptysis, tachycardia Pt may be febrile, hypotensive and cyantic

o Triad CP, Dyspnea, Hemoptysis Diagnosis:

o 1) Blood gasses: PaO2 < 80 mmHg o 2) Chest x-ray: 50% are normal; a normal or near normal

chest x-ray in a dyspenic patient suggests PTE. Abnormalities include : focal oligemia (Westermark’s

sign), a peripheral wedge shaped density above diaphragm (Hamptom’s hump) or enlarged right descending pulm artery

o 3) Ventilation- Perfusion Scan (V/Q Scan) **A mismatch demonstrating an area of ventilation but

NO perfusion suggests PE Ventilation : inhalation of xenon 133 Perfusion : T99 labeled albumin V/Q mismatch : acute PE, previous PE, centrally located

cancer, radiationo 4) Pulmonary angiography

Definitive test, indicated if V/Q scan is inconclusive Diagnostic signs : intraluminal filling defect, abrupt

vessel cutoff, loss of side branches-Prophylactic Measures:

Non-pharmacologic o Compression stockings o SCDs prevents stasis due to increased venous return

Pharmacologic o Heparin

Pre-op 5,000 units SQ q2h Post-op 5,000 units SQ q8-qh

-Treatment Heparin IV

o MOA Binds & accelerates Anti-thrombin 3 which potentiates the inhibition of coag factors 10a and 2a““works in blood”

o Loading dose : 10,000 -15,000u or 80u/kg o Maintenance dose : start with 1,000 u/hr (18u/kg/hr)

o MONITOR PTT DAILY (goal 60-90 seconds) Titrate to 1.5-2 x normal (30ish x 2= 60)

o Reversal Protamine sulfate 1 mg protamine pre 100 u heparin

o LMWH (Lovenox) More predictable efficacy and lower incidence of

adverse effects such as HIT, patients can inject LMWH themselves at home

Therapeutic 30 mg SQ BID (for 7-10 days) Prophylactic 1 mg/kg SQ (for 7-10 days)

Coumadin o MOA interfere with the synthesis of Vit. K clotting factors 2,

7, 9, 10, and Protein S & C “works in the liver”o Start after heparin is therapeutico Commonly 2.5 mg qd o MONITOR PT DAILY (1-1.15 x normal/INR 2 -3)

Titrate to 1-1.15 x normal (1.2 ish x 2= 17)o Reversal Vit. K or FFP

Thrombolytic (Urokinase, Streptokinase, tPA)o MOA aid in conversion of plasminogen to “Plasmin” which

cleaves thrombin & fibrin clots (+) PT & PTTo Must be initiated w/in 24-48 hrso Loading dose 250,000 Units infused over 30 mino Dosage/Duration 100,000 Units/hr for 72 hr

Surgical o Greenfield filter placed in IVC below renal veinso Embolectomy

Hallux Limitus & Rigidus 12/16/13 2:29 PM-Introduction

Normal 70 DF & 30 PF Limitus decrease in ROM “limited dorsiflexion” < 20 degrees Rigidus Absent ROM due to “ankylosis” <10 degrees

o Presence of bony ankylosis & sesamoid immobilization Classification

o Functional Dorsi decreased ONLY when loaded (Stage 1)o Structural Dorsi decreased BOTH loaded & unloadedo Primary long 1st metatarsalo Secondary DJD, trauma, arthritis

Etiology o Long/short 1st, MPE, Trauma, Hypermobility, Arthritis

Clinical findings :o Dorsal bunion w/ tenderness on dorsiflexiono Apropulsive gait w/ early off & abductory twist

Radio findings :o Joint space narrow w/ loose bodieso Squared/flattened met heado Subchondral scerlosiso Met primus elevatus

-Classification Systems (Drago, Oloff, Regnauld)

Regnauld o Stage 1

Joint enlargement w/ mild spurring Functional Hallux Limit

o Stage 2 Narrowing of joint space Flattening met head with dorsal exostosis

o Stage 3 Severe loss of joint space w/ crepitus on ROM Joint mice w/ extensive spurring & DJD

o Stage 4 Complete bony ankylosis “obliteration of joint”

-Conservative treatment (Stages 1 & 2) Activity modification & PT Orthotics (rocker bottom, morton’s extension, 1st ray cut out) NSAIDs (PO) or Corticosteriod (injection

-Surgical treatment (Stages 3 & 4) Joint Preservation (> 50% of cartilage) “CCBWY”

1) Cheilectomy resection of dorsal exostosis

2) Cotton opening wedge osteotomy 3) Bonney & Kessel dorsal wedge of phalanx base4) Waterman dorsal wedge of met base5) Youngswick plantarflexory osteotomy

Joint Destruction (< 50& of cartilage) “K FILM”1) Keller resection 1/3 proximal phalanx base2) Implant (total vs. hemi) function as spacer3) Fusion “Mckeever” 15 dorsiflexed & 10 abducted4) Mayo/Stone Mayo (artic surface) & Stone (1/4th met head)5) Lapidus TMT joint fusion

-Post-Op Management Orthotic + padding PT with passive ROM exercises Serial radiographs

Bunion case 12/16/13 2:29 PM-Introduction:

Goals (RED CAR):o Reduction of abnormal osseous angleso Establish congruous 1st MPJo Decrease medial eminence o Control correction of factors that lead to deformity o Align sesamoids back to proper position o Restoration of 1st MPJ weight bearing function

Etiology o Primary hypermobile/long 1st or pronation o Secondary trauma, RA, pes planus, gout

Pathology o Progressive disorder with these factors affecting :

Hyperpronation unlock MTJ loss P. longus 1st ray instable retrograde buckle adductor advantage ligament instability arthritic changes

o Stages : 1- lateral displacement of prox phalanx 2- HAV where 1st abuts 2nd digit 3- increase IM angle 4- subluxed hallux w/ overriding digits

Anatomy o 4 articular surfaces

o 9 ligaments (2 collateral, 4 sesamoidal, Intersesamoidal, DTIML, Capsule)

o FHL only tendon that DOESN’T attach to MPJ capsuleo Square met head is most stable

-Radiography In the area of patient’s presenting complaint I see:

o AP view 1) (Mild or Severe) soft tissue swelling2) (Mild or Severe) HAV deformity at level of MPJ defined by (mild or mod) increases in:

IM angle (8-12°) HAI angle (< 10°) HA angle ( 15°)

3) PASA & DASA (normal, deviated, subluxed) Positional (P +D < HA) “subluxed/deviated joint” Structural (P + D = HA) “congruous joint”

4) Tibial sesamoid position (1-7)5) Length of 1st met (normal, long, short) using:

Met parabola- (142°) Met protrusion index (0-2 mm)

6) Metatarsus adductus/Engel (< 15°) Abnormal MA may mask IM deformity

o Lateral View 1) 1st met is (elevated, normal, short) compared to 2nd met using Seiberg’s index

distal distance – proximal distance (+ = Elevatus)o 2) Foot type (pes planus, cavus, normal)

-Capsule Tendon Balancing Procedures Silver (1923) resection of DM eminence w/ lateral capsulotomy

and medial capsulorraphy Mcbride “True” (1928) silver + fibular sesamoid removal and

transfer of adductor tendon Hiss (1931) transfer adductor from plantar to medial Joplin’s sling (1950) transfer adductor thru met Component procedures :

o Adductor transfero EHL lengtheningo EHB tenotomyo Capsulorraphy (Washington, H, T, Inverted L, Linear)

-Osetotomies Hallux interphalangeus “Distal” Akin Abnormal DASA “Proximal” Akin (5-10 mm from MPJ) Abnormal PASA Reverdin

o 1 st cut : = to articular surfaceo 2 nd cut : to long axis

o Green plantar cut to protect sesamoids w/ hinge intacto Laird lateral cortical hinge not maintained (IM correction)

True IM < 16° Distal osteotomy o Austin/Kalish/Youngswick stable sag & frontal planeso Mitchell shortens “lateral hinge intact”o Hoffman shortens “trapezoid osteotomy”o Wilson shortens “oblique osteotomy”o Scarf Central cut DD PP w/ 70° angleso Keller resection of prox phalanx base “elderly”o Mckeever fusion “for arthritic joint”

True IM > 16° Proximal osteotomy “hinge axis concept”o Ludloff cut PD DPo Mau cut PP DD “better stability”o Juvara oblique CBW 40° cut “avoid growth plate”

A) wedge B) wedge + hinge cut C) no wedgeo CBW/OBW shortens or lengthens 1st meto Cresecentic bad stability o Lapidus hypermobile first or large met/IMo Logroscino Reverdin + CBW

-Surgical technique Single screw halfway b/w line to long axis & line to

osteotomy

K-wire dorsal distal medial to plantar proximal lateral-Post-op

NWB 4-6 weeks Serial radiographs

-Complications Hallux varus (staking, aggressive bandage, fibular sesamoid

removed, overcorrection on IM)o Systemic Repair of Hallux Varus (McGlamry)

Complete ST release, Correction of structural deformity (IM angle), Tendon transfers, Tibial sesamoidectomy, Joint arthroplasty

Capital fragment on floor (Christenson; 1992)o Mix 1 L NS (+) 1 mL Neosporin irrigant (+) 1:100K Bacitracino Transfer to 3 different basins w/ solution x5o Document and tell patient

Others: infection, avn, non-union, fixation failure, shortening, reoccurrence, sesamoiditis

Haglunds & Retrocal Exostosis 12/16/13 2:29 PM

-Introduction Haglunds posterior-superior painful bursal projection of

calcaneus due to enlargement of this cal regiono Involves retrocalc & achilles bursao Caused by : shoe gear irritation or cavus foot

Retrocal Exostosis ensethopathy at achilles tendono Intratendinous calcification of soft tissueso Traverses “Entire” posterior aspect of heelo Caused by : trauma or overuse causing thickening

DDX :o Calc bursisitis, Achilles tendonitis, Achilles rupture, Tumor

-Radiology Fowler & Phillip (normal 45-70)

o Line posterior calc w/ line tangent to PS prominence o Pathologic > 75

Total angle (normal < 90)o Calcaneal inclination (+) Fowler & Phillipo Pathologic > 90

Parallel pitch lines o Line 1 tangent to ant. tuber & medial plantar tuber

Then draw line to thiso Line 2 parallel to “Line 1” and to perpendicular lineo Pathologic bursal projection above “Line 2”

-Conservative treatment Shoe (heel lift, padding, orthotic) NSAIDS

-Surgical treatment (avoid chasing the “bump”) Keck & Kelly remove wedge from posterior-superior calc

o For structural cavus foot type Duvries lateral incision F & P Mercedes incision thru achilles, then resect bump Speed bridge resect bump then reapproximate w/ speed bridge

Pes Planus (Flexible vs. Rigid) 12/16/13 2:29 PM-Etiology

Flexible o Equinus o Congenital (talipes calcaneovalgus)o Structural (compensated FF varus or valgus)o Ligamentous (PTTD or ligamentous laxity)

Rigid o Tarsal coalition (Syn-desmosis, chondrosis, ostosis)

*TC (12-16), CN (12-8), TN (3-5) True collation= intra-articular fusion of 2 bones

o Congenital (Apert’s or Nievergelt-pearlman) Both seen with cuneiform coalitions

o Trauma (fractures)o Peroneal spasm

-Planes of dominance: STJ axis 42 transverse & 16 sagittal MTJ “oblique ” 52 transverse & 57 sagittal

o DF, PF, abduction, adduction MTJ “longitudinal” 15 transverse & 9 sagittal

o Inversion & eversion

-Clinical exam Hubscher maneuver dorsiflex hallux creates windlass mech.

o Arch elevation, PF 1st ray, RF supination, Ext leg rotation ROM (Ankle, STJ, MTJ)

o Ankle 10 dorsiflexion & 20 plantarflexion o STJ 10 eversion & 20 inversion o MTJ “longitundal” 4-6

Have patient stand in angle & base o Too many toes sign o RSCP in > 4 valguso Single heel rise test

Coalition findings o Progressive valgus w/ bow strung peroneal tendons “SPASM”

-Classifications Johnson & Strom

o 1) tenosynovitis + mild tendon degeneration “flexible” Tendon debridement + orthotics

o 2) elongated & degenerated + TTS “flexible” Tendon transfer & RF procedure

o 3) elongated & ruptured + inability in SHR test “rigid Triple or Double arthrodesis

o 4) rigid ankle valgus Triple or TCC arthrodesis

Deland 2A) <30% TN uncover 2B) >30% TN uncover Funk 1) avulsion 2) ms rupture 3) in-continuity tear 4) tenosyno Conti (MRI)

o 1A) couple long splits 1B) multiple long splits & fibrosiso 2) narrowing of tendon w/ DEGENERATIONo 3A) disuse swelling & degen 3B) complete rupture

-Radiology AP view (transverse plane)

o TN articulation (75%) DECREASEDo TC “Kites” (20) INCREASEDo Cuboid Abduction (0-5) INCREASED

Lateral view (sagittal plane)o CI (20) DECREASEDo TD (20) INCREASEDo LTC (40) INCREASEDo Navic-Cub superimposed INCREASEDo Cyma line ANTERIOR BREAK

o Meary’s (0-15) NEGATIVE “decreased” Calc axial (frontal plane)

o RF eversion “rule out ankle valgus”o Decreased height of sustentaculum

Harris-Beath evaluates middle & posterior facetso Views= 35, 40, 45 axial views

Medial Oblique o Anteater sign “CN coalition”

Lateral Oblique o Anterior facet coalition

CT Scan o Modality of choice for coalition o Asses subtle cortical changes in surrounding

-Flexible Procedures: Goals :

o Primary joint stability o Secondary recreate arch heighto Most procedures will include TAL procedure

Soft tissue 1) PT repair remove degenerated section

2) FDL TT suture w/in PT sheath to help reestablish arch 3) PB-PL anastomsis removes deforming force

Transverse correction 1) Evans opening wedge 1.5 cm proximal to CC joint2) CCJ distract arthrodesis lengthens lateral column3) Kidner advancement & reattachment of PT

Sagittal correction 1) Cotton plantarflexes 1st ray (bone graft)2) Arthrodesis:

o Lowman TN fusion (+) TALo Hoke NC fusion o Miller NC fusion (+) 1st Met-Cuneiform o Lapidus 1st Met-Cuneifrom fusion

3) Young TS reroute TA thru navicular

Frontal correction 1) Calc Osteotomies:

o Dwyer closing wedge osteotomyo Kouts slide fragment medial (increases supination)

2) Arthroeresis (MTJ must have locking ability on RF)o MBA “self-locking” blocks anterior migration of talus

RF valgus or FF varus must be reducible in order to do Leading edge should approach but NOT cross bisection

of talus on AP view Should allow 2-4 of STJ eversion

o STA-Peg (non-ang) “axis-altering” elevates STJ o Sgarlato “direct-impact” impingement force laterally

3) Historical o Chambers- bone graft in “sinus tarsi”o Selakovic- bone graft under “sustentaculum”o Baker & Hill- bone graft under “posterior STJ facet”

Pes Cavus 12/16/13 2:29 PM-Etiology

Stable “Static” vs. Progressive o Stable conditions treatable w/ ST procedure

Rigid vs. Flexible o Rigid conditions requires osteotomies & arthrodesis

Bilateral: o *CMT, CP, SC tumor, Spina bifida, Polio, infectiono Charcot Marie Tooth (autosomal dominant)

Bilateral slowing of sensory & motor nerve conduction HSMN I classic CMT usually in 2nd decade

(hypertrophic) HSMN II manifests later in life (axonal)

Unilateral: o Crush syndrome, SC injury, Deep post compart syndrome

-Clinical exam Charcot Marie Tooth

o Claw toes - over recruitment of long extensorso Cavus - PL overpowers TA causing PF 1st rayo Foot drop - “stork legs” due to muscle wasting

Coleman Block Test (sagittal plane deformity evaluation)o Forefoot (1st ray) is suspended off a block

o FF driven calcaneus returns from varus back to normal o RF driven calcaneus stays in varus after removing forefoot

elements o Anterior cavus (apex found at intersection of Meary’s angle)

Caused by : forefoot “PLANTARFLEXED” On rearfoot Local (1st ray) vs. Global (entire FF) Flexible (DF at Midfoot) vs. Rigid (pseudoequinus) Metatarsus apex at lisfranc Forefoot apex at choparts

o Posterior cavus (increased CI angle > 30 & varus position) Caused by : rearfoot “DORSIFLEXED” on forefoot Flexible (no change in CI on WB) vs. Rigid (Decreased CI

on WB) Secondary to anterior cavus

Neurological evaluation o Asses motor, sensory systems, reflexes and coordination

tests. Biomechanical evaluation

o ROM (AJ, STJ, MTJ)o Wide based gait = neurologico Extensor substitution HT (exentsors > lumbricales)o Pseduoequinus- ankle must dorsiflex cuz forefoot cant

EMG & Nerve conduction testing

-Classifications Ruch/Surgical

-Stage 1 (flexible may appear normal on WB)o Deformity restricted to Metatarsal, MPJ or Digitso Tx: digital fusion, extensor tenotomy, flexor transfers

-Stage 2 (more rigid deformity)o Deformity consists of rigid PF 1st ray & RF varuso Tx: DFWO, Dwyer, STATT, Peroneal stop

-Stage 3 (marked rigid deformity)o Severe global RF & FF deformity on neuromuscular causeo Tx: MTJ osteotomies, Triple arthrodesis, tendon transfer

Japas o Anterior cavus ( apex found at intersection of Meary’s angle)

Caused by: forefoot PLANTARFLEXED On rearfoot Local (1st ray) vs. Global (entire FF) Flexible (DF at Midfoot) vs. Rigid (pseudoequinus)

1) Metatarsus apex at lisfranc2) Lesser tarsus entire lesser tarsal region3) Forefoot apex at choparts4) Combined 2 or more of the above

o Posterior cavus (increased CI angle > 30 & varus position)

Caused by : rearfoot DORSIFLEXED on forefoot Flexible (no change in CI on WB) vs. Rigid (Decreased CI

on WB) Secondary to anterior cavus

-Radiology AP view (transverse plane)

o TN articulation (75%) INCREASEDo TC “Kites” (20) DECREASEDo Cuboid Abduction (0-5) DECREASED

Lateral view (sagittal plane)o CI (20) INCREASEDo TD (20) DECREASEDo LTC (40) DECREASEDo Cyma line POSTERIOR BREAKo Meary’s (0-15) POSITIVE “increase”

-Operative treatment Goals must identify apex of deformity/rigid vs. flexible Soft Tissue Release

o Steindler stripping removes all plantar fascia at insertion PF, Abd hallucis, Abd dmq, FDB, Quad plantae

o Plantar medial release release all muscle/ligaments medialo Historical

Borst & Larsen - release mc joints & plantar intrinsics Garceau & Brahms - resect motor branches

Tendon Transfers (flexible deformities)o Jones EHL thru 1st met head “dorsiflexes hallux”o Heyman EHL & EDL thru each respected met heado Hibbs EDL transferred to 3rd cuneiformo Girdlestone FDL transferred to dorsal prox phalanxo STATT lateral half transferred to p. tertius insertiono TPTT difficult out of phase transfero Peroneal anastomosis transfer PL to PB “Stop procedure”

Osseous procedures (rigid & neuromuscular)o Cole dfwo at NC “coparts joint”o Japas displacement V osteotomy thru all midfoot jointso Jahss Cole at lisfranc jointo DFMO dorsiflexes forefoot o Dwyer lateral closing wedge “take out of varus”

Arthrodesis o Triple (Ryerson- 1920)

Resect (TN CC TC) ** fix in opposite order

Position : Dorsiflexion- 0 RF valgus- 5 Abduction- 5 Ext rotation- 15

Incisions Lateral (fib malleolous to 4th met base)

Exposes TC & CC Reflect EDB, protect peroneal, incise plug Inverted L capsular incision Dissect until visualization of STJ facets

Dorso-Medial (distal med malleolus to NCJ) Exposes TN Incision carried longitundal to PT & TA

Fixation TC aimed posterior-lateral from talar neck (6.5

partial cancellous) TN screw < 40mm (4.5 cortical) or staple CC screw < 40mm (4.5 cortical) or staple

Post-op Admit for pain control NWB 8 weeks Progressive PT after 10-12 weeks