Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
.pdf
Gavin Heyes and Lyndon Mason
distal chevron osteotomy is the most appropriate
treatment.
20. Answer D. MTP joint synovitis
With the presence of a bunion deformity, the
metatarsal head is often elevated. This can frequently lead to transfer metatarsalgia to the lesser
metatarsals. Commo nly, this leads to synovitis
and pain of the 2nd and possibly 3rd MTP joint.
Certainly, this is far more common than other
causes of 2nd and 3rd MTP joint pain, Freiberg’s
disease, plantar plate rupture and Morton’s neuroma. Freiberg’s disease only usually affects one
metatarsal and occurs most commonly in adolescents. A mallet toe occurs at the distal interphalangeal joint and is unlikely to cause pain under
the metatarsal head.
Morton’s neuroma is common in middle-
aged (average 50 years old) women, and the
incidence is at least 4–15 times higher in females.
Clinically, there may be tenderness and a dorsal
bulging may be found. It may also be present as
an enlargement of the interdigital space. When
pressure is applied axially to the intermetatarsal
space, acute pain is induced. The pressure can be
exerted while tightening the metatarsals with the
other hand, and this may be associated with a
painful and palpable clicking sensation (Mulder’s
click). Mulder’s click demonstrates a 61% sensitivity and 62% accuracy. It most commonly
occurs in the third intermetatarsal space, which
it is theorised is due to the anastomosis of the
medial and lateral plantar nerves, making it
stiffer and more prone to injury.
21. Answer B. Internal fixation
Jones (1902) described a fracture in the proximal
three-quarter segment of the shaft distal to the
styloid. The Jones fracture was later defined by
Stewart (1960) as a transverse fracture at the
junction of the diaphysis and metaphysis without
extension into the 4th and 5th intermetatarsal
articulation. Dameron (1975) defined the proximal 5th metatarsal as having three zones: zone 1
– styloid process; zone 2 – meta-diaphyseal area;
zone 3 – proximal diaphysis.
Ekrol and Court-Brown (2004) further differentiated fractures of zone 1 and explained their
differences due to muscle insertion at the base of
the 5th metatarsal.
For treatment, zone 1 injuries have been
shown to be easily treated with symptomatic
measures, with this no different to cast immobilisation at 4 weeks and 3 months (Akimau et al.
2016). A boot, however, is preferred to a sandal, as
it results in significantly lower peak pressure at the
5th metatarsal during walking (Hunt et al. 2014).
In zone 2 and 3 injuries, biomechanical
testing has shown fracture gapping during
weight bearing (Morris et al. 2015). Zone 2 and
3 fractures are also at a watershed area, with the
retrograde nutrient artery being damaged during
fracture.
What is described in this clinical scenario is a
zone 3 fracture, probably secondary to a stress
fracture. It has been shown in an operative vs
non-operative study that the operative treatment
group demonstrated a reduced time to return to
sport and faster clinical union by almost 50%
compared with the non-operative group
(Mologne et al. 2005). In this patient, therefore,
surgery would be offered. In the non-athletic
group, conservative management is commonly
offered first (non-weight bearing cast); however,
there is still a 30% non-union risk and a 30%
refracture risk (Quill 1995).
Akimau PI et al. Symptomatic treatment or
cast immobilisation for avulsion fractures of the
base of the fifth metatarsal: a prospective, randomised, single- blinded non-inferiority controlled trial. J Bone Joint Surg Br.
2016;98:806–811.
Dameron JT. Fractures and anatomical variations of the proximal portion of the fifth metatarsal. J Bone Joint Surg Am. 1975;57:788–792.
Ekrol I, Court-Brown CM. Fractures of the
base of the 5th metatarsal. Foot 2004;14:96–98.
Hunt KJ et al. Site-specific loading at the
fifth metatarsal base in rehabilitative devices:
implications for Jones fracture treatment.
PM&R. 2014;6:1022–1029.
Jones RI. Fracture of the base of the fifth
metatarsal bone by indirect violence. Ann Surg.
1902;35:697.
Mologne TS, Lundeen JM, Clapper MF,
O’Brien TJ. Early screw fixation versus casting
in the treatment of acute Jones fractures. Am J
Sports Med. 2005;33:970–975.
Morris PM, Francois AG, Marcus RE,
Farrow LD. The effect of peroneus brevis tendon
194
Foot and Ankle I Structured SBA
anatomy on the stability of fractures at the fifth
metatarsal base. Foot Ankle Int. 2015;36:579–584.
Stewart IM. Jones’s fracture: fracture of base
of fifth metatarsal. Clin Orthop.1960;16:190–198.
Quill Jr GE. Fractures of the proximal fifth
metatarsal. Orthop Clin N Am. 1995;26:353–362.
22. Answer E. Weakness on tip toe stance
Excision of both sesamoids should be avoided if
at all possible. Excision of both sesamoids relatively lengthens the flexor hallucis brevis and
decreases its moment arm at the metatarsal phalangeal joint, essentially defunctio ning it. It has
been shown biomechanically that decreases in
the effective tendon moment arm of the flexor
hallucis longus tendon occurred with resection of
both the medial and lateral sesamoids. One of the
largest series of sesamoidectomy showed a 30%
extreme difficulty or an inabi lity to stand on tip
toe (Lee et al. 2005).
The most recent systematic review on sesa-
moidectomy showed that most did well, with
94.4% of patients returning to sports, with
90.0% returning to their previous level, at a mean
of 11.8±1.8 weeks. The overall complication rate,
however, was 22.5% and the revision rate was
3.0%. The complications varied but included
hallux valgus (medial sesamoidectomy), hallux
varus (lateral sesamoidectomy), loss of range of
motion of the 1st metatarsophalangeal joint,
weakness of plantar flexion strength and transfer
metatarsalgia. It was difficult to clearly divide the
complications; however, the alteration in mechanical loading after sesamoidectomy appears to
cause complications that include transfer metatarsalgia, neuroma, stress fracture of the metatarsals and lateral sesamoiditis (Shimozono et al.
2018).
Lee S, James WC, Cohen BE, Davis WH,
Anderson RB. Evaluation of hallux alignment
and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int. 2005;26:803–809.
Shimozono Y, Hurley ET, Brown AJ,
Kennedy JG. Sesamoidectomy for hallux sesamoid disorders: a systematic review. J Foot Ankle
Surg. 2018;57:1186–1190.
23. Answer E. Weil metatarsal osteotomy
Weil metatarsal osteotomy involves a nearhorizontal osteotomy at the metatarsal head and
neck. The most frequent complication reported
is a floating toe. Morton’s neuroma excision
complications do not typically include mechanical toe deformities. Complications may include
stump neuroma and painfu l or sensitive scar.
Stainsby procedure is used in toe clawing to
reduce the plantar plate to its correct position
under the metatarsal head. It is performed by
excising the proximal one-third to one-half of
the proximal phalanx and suturing the proximal
end of the extensors to the flexors. Loss of function of the toe is the most important problem.
Keller’s excision arthroplasty is performed on the
hallux with complications including weakness on
push off and cock-up deformity. Kidner’s procedure involves resection of a symptomatic
accessory navicular and reconstruction of the
tibialis posterior.
Trnka H, Schuh R. Strategies for managing
complications of osteotomies of the lesser metatarsals. In Advanced Reconstruction Foot and
Ankle 2, eds Alexander I, Blumen E, Greisberg
J. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2015.
Migues A, Slullitel G, Bilbao F, Carrasco M,
Solari G. Floating-toe deformity as a complica-
tion of the Weil osteotomy. Foot Ankle Int.
2004;25:609–613.
24. Answer E. Plantar flexion and pronation
Hallux valgus is a rotational and lateralising
deformity of the hallux. The phalanx deviates
into valgus and the metatarsal into varus. As
the metatarsal migrates medially, the flexor hallucis brevis (sesamoids contained within)
remains in place, becoming a valgus force to
the phalanx as well as a flexor. This initiates
rotation; the abductor hallucis becomes a plantar
flexor and pronator of the hallucis as it moves
plantarward and medially relative to its usual line
of pull.
25.
Answer B. Revision to 1st MTPJ fusion with
inlay bone graft
Improvements in AOFAS score to 74.9 can be
achieved with fusion, although one should be
aware that they unite slower, have a significantly
higher reoperation rate and have lower AOFAS
scores than primary fusions (Baumhauer and
Giovanni 2003; Gross et al. 2013). There is no
195
Gavin Heyes and Lyndon Mason
strong evidence for revision to a further silastic
implant. Given there is osteolysis around the
primary component, revision is likely to be technically challenging and will have a high probability of instability.
Baumhauer JF, DiGiovanni BF. Salvage of
first metatarsalphalangeal joint arthroplasty complications. Foot Ankle Clin N Am. 2003;8:37–48.
Gross CE, Hsu AR, Holmes GB, Lee S.
Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013;6:471–478.
26. Answer A. Freiberg’s disease
The history is typical for a presentation of
Freiberg’s disease. The radiograph description is
indicative of avascular necrosis of part of the
metatarsal head. The condition was first
described by Dr Alfred H. Freiberg in 1914. It
is an uncommon condition, occurring most
often in young women, athletes and those with
abnormally long metatarsals.
Kohler’s disease is osteochondritis of the
navicular, typically affecting children between 5
and 10 years and affects boys more often than
girls. Sever’s disease is calcaneal apophysitis.
Mueller–Weiss syndrome is adult-onset avascular necrosis of the navicular. Turf toe is a sprain
of varying grades affecting the big toe.
27. Answer E. Turner’s syndrome
Turner’s syndrome is characterised by brachyme-
tatarsia (described in the question), down-slanting
eyes, droopy eyelids, short, webbed neck, teeth
crowding, broad (Shield) chest, short carrying
angle and short fingers and occurs in females.
Klippel–Feil syndrome is a congenital condition
characterised by fusion of at least two cervical
vertebrae, a short neck, low hairline, scoliosis and
Sprengel deformity and may also have cardiac and
pulmonary abnormalities. Poland syndrome is a
congenital disorder characterised by underdeveloped chest muscle and short, webbed fingers on
one side. Trisomy 21 (Down’s syndrome) is a congenital disorder characterised by mild to moderate
developmental delay, poor immune function, heart
defects, epilepsy, thyroid disorder, micrognathia,
slanted eyes, macroglossia, short neck, large space
between 1st and 2nd toes and shortened metatarsals 3–5. Sprengel deformity is characterised by
malposition and hypoplasia of the scapula.
28. Answer A. Amputation through proximal one-
third of proximal phalanx
In a low-demand nursing home patient with
chronic infection and ulceration, an amputation
would have the least complications. In the
absence of infection and in a higher-demand
patient, option E would address all the involved
joints.
29. Answer A. Dorsal cheilectomy
This describes a grade 2 hallux rigidis (Coughlin
and Shurnas Classification, Table 9.5). A Dorsal
cheilectomy is the accepted procedure for a grade
2 as it will allow a greater range of motion.
Synovectomy alone would not provide sustainable pain relief or range of motion required for
this gentleman. Keller’s procedure would leave
him with functional loss, weakness and increased
complications. Arthrodesis would provide pain
relief but adversely affect function, it would also
not be necessary in a grade 2 hallux rigidus
although is often utilised if a cheilectomy were
to fail. There is no great evidence for arthroplasty
in active patients with grade 2 hallux rigidis and
should not be considered in the first instance.
Coughlin MJ, Shurnas PS. Hallux rigidus:
grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003;85-
A:2072–2088.
30. Answer D. Perpendicular to 2nd metatarsal
The goal in a conventionally shaped foot is to
maintain length in the 1st metatarsal.
Lengthening it could lead to significant 1st
MTP stiffness and pain. Shortening the 1st metatarsal risks transfer metatarsalgia. Option D
should not lengthen the metatarsal, as the 2nd
metatarsal normally is in parallel with the longitudinal axis of the foot. Option C would lengthen
the metatarsal, as the osteotomy would slide the
metatarsal head distally as it is reduced. Options
A and B would likely shorten and E may lengthen
the metatarsal through the same mechanisms as
previously discussed.
31. Answer D. Contracture of flexor digitorum
longus and/or brevis
What is described is ‘curly toes
genital abnormality usually caused by a contracture of one or both of the flexors. It is not
’. This is a con-
196
Foot and Ankle I Structured SBA
Table 9.5 Coughlin and Shurnas classification of hallux rigidus
Grade Dorsiflexion Radiographic findings Clinical findings
0 40°–60° +/– or 10–20% loss
compared to other side
1 30°–40° +/– or 20–50% loss
compared to other side
2 10°–30° +/– or 50–70% loss
compared with other side
3 <10° +/– or 75–100% loss
compared to other side.
<10° plantar flexion
4 Grade 3 Grade 3 Grade 3 BUT mid-range
Normal Stiffness
Dorsal osteophyte. Minimal joint space
narrowing, flattening of metatarsal head and
periarticular sclerosis
Dorsal, lateral +/– medial osteophyte.
Flattening metatarsal head with >1/4 dorsal
joint involvement. Mild to moderate joint
space narrowing
Grade 2 + substantial joint space narrowing
+/– periarticular cystic change. >1/4 dorsal
joint space involvement. Sesamoid
enlargement/ cystic change
Stiffness and mild pain on
end range of motion
Stiffness. Moderate to
severe pain, occurring just
before end range of motion
Stiffness and constant pain
except mid-range motion
pain on passive motion
associated with any bony abnormalities. It is
often bilateral and involves 1–3 of the lateral 3
digits. Treatment initially involves observation
and some passive stretching; in severe cases,
flexor tenotomy can be performed.
Ankle
32. Answer B. Anterolateral portal placement
Anterolateral portal placement is recommended
to be sited after anteromedial portal placement.
This is due to the risk of injury to the superficial
peroneal nerve during portal placement. The
portal is sited lateral to the peroneus tertius
tendon and medial to the lateral malleolus at
the level of the tibiotalar joint. The risk of injury
is reduced by illuminating the portal site from
internally, as the nerve can often be seen as a
shadow.
The anterocentral portal is not commonly
used due to risk of injury to the anterior tibial
artery and deep peroneal nerve, which, if injured,
would only give rise to numbness in the first
dorsal web space. The anteromedial portal is
sited medial to the tibialis anterior tendon and
anterior to the long saphenous vein. The saphenous nerve is at risk of injury, and injury will
lead to minor altered sensation on the medial
aspect of the foot. With the posterolateral portal,
the sural nerve, which provides sensation to the
lateral border of the foot, is at risk of injury.
With the posteromedial portal, the tibial nerve
is at risk of injury. This will cause sensation loss
to the plantar aspect of the foot.
Tonogai I, Hayashi F, Tsuruo Y, Sairyo K.
Anatomic study of anterior and posterior ankle
portal sites for ankle arthroscopy in plantarflexion and dorsiflexion: a cadaveric study in the
Japanese population. J Foot Ankle Surg.
2018;57:537–542.
Yammine K, Assi C. Neurovascular and
tendon injuries due to ankle arthroscopy portals:
a meta-analysis of interventional cadaveric studies. Surg Radiol Anat. 2018;40:489–497.
33. Answer B. Anterior talar fibular ligament
The anterior drawer test is carried out with the
foot in 20° of plantar flexion. It is considered to
be positive for injury to the anterior talar fibular
ligament (ATFL) if there is more than 8mm of
forward shift on lateral view. Injury to the ATFL
shown with a positive anterior drawer test and
symptomatic ankle instability in an otherwise
healthy adult suggests that the patient would
benefit from surgical management if physiotherapy had failed. Surgery for ankle instability can
be described as either anatomical or nonanatomical. A modified Brostrom–Gould is one
of the most common anatomical repairs carried
197
Gavin Heyes and Lyndon Mason
out. It is an operation which Brostrom originally
described as direct ligament repair to the ATFL
and which was later modified by Gould to
include detaching, shortening and reattaching
the ATFL and then including the inferior exten-
sor retinaculum into the repair to strengthen it.
This has been further modified by Molloy to
include bone anchors.
Croy T, Koppenhaver S, Saliba S, Hertel J.
Anterior talocrural joint laxity: diagnostic accur-
acy of the anterior drawer test of the ankle. J
Orthop Sports Phys Ther. 2013;43:911–919.
Karlsson J, Eriksson BI, Bergsten T,
Rudholm O, Sward L. Comparison of two ana-
tomic reconstructions for chronic lateral instabil-
ity of the ankle joint. Am J Sports Med.
1997;25:48–53.
Orr JD, Robbins J, Waterman BR.
Management of chronic lateral ankle instability
in military service members. Clin Sports Med.
2014;33:675–692.
34. Answer C. AITFL, IOL, PITFL
The tibial (or tibiofibular) clear space is defined
as the horizontal distance between the lateral
border of the posterior tibial malleolus (the inci-
sura fibularis) and the medial border of the fibula
at the point where the posterior malleolus is
widest on an AP radiograph. Tibiofibular dis-
tance should be 3.7mm ± 0.5mm, 1cm above
the joint. Ostrum et al. (1995) found gender
differences – normal tibial clear space should be
less than 5.2mm in women and less than 6.5mm
in men. Increased tibi ofibular clear space is a
radiographic finding that can be used to help
diagnose injuries to the distal tibiofibular syndes-
mosis. The syndesmosis has three main liga-
ments: the anterior-inferior tibiofibular
ligament (AITFL), the interosseous ligament
(IOL) and the posterior-inferior tibiofibular liga-
ment (PITFL). The presence of a fourth liga-
ment, the transverse ligament, is disputed in the
literature, with some authors detailing it as deep
fibres of the PITFL and others detailing it as a
separate ligament and thus this was not part of
the answers given. The intermalleolar ligament is
a secondary stabiliser.
The tibiofibular overlap is another measure
for syndesmosis injury. On an AP radiograph,
tibiofibular overlap should be measured from the
medial edge of the fibula to the lateral border of
the tibia, and it should exceed 6mm. The anterior
tubercle of tibia should overlap the fibula more
than 5.2mm in women and more than 6.5mm in
men (Ostrum et al. 1995). Some of the older
literature states this to be more than 1cm.
Ostrum RF, De Meo P, Subramanian R. A
critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot
Ankle Int. 1995;16:128–131.
35. Answer B. Medial malleolus transverse fracture
or deltoid disruption, ATFL disruption, lateral
short oblique fracture or spiral fracture of the
fibula above the syndesmosis, PITFL avulsion
or posterior malleolus fracture
The injury described was a pronation external
rotation injury (Lauge-Hansen 1950). Pronation
injuries start with medial-sided injuries first. As
the injury progresses, the external rotation
moment of the talus then leads to ATFL disruption or Wagstaff (avulsion of the AITFL from the
fibular) type fractures. The intraosseous part of
the syndesmosis is ruptured, and the injury progresses to a short oblique type of fracture of the
fibula above the syndesmosis. As the external
rotation moment continues, the PITFL is disrupted, either an avulsion or posterior malleolus
fracture. This renders the syndesmosis unstable
and can lead to ankle diastasis.
Supination injuries start on the anterolateral
aspect of the ankle.
Vertical medial malleolus fractures are seen
in supination adduction injury patterns and
occur after the lateral side has been injured.
Lauge-Hansen N. Fractures of the ankle. II.
Combined experimental-surgical and
experimental-roentgenologic investigations.
Arch Surg. 1950;60:957–985.
36. Answer D. Central medial talar dome
In an MRI-based study of 424 osteochondral
lesions, Elias et al. (2007) described a 9-zone grid
map of the talar dome, with zone 1 being anterior medial and zone 9 being posterior lateral.
Zone 4 is descr ibed as being central and medial
and was seen in 227 (53%) cases. Central lateral
was the second most frequent, with 110 (25.7%)
cases. Overall medial injuries were more
common (63%), with lateral injuries following
198
Foot and Ankle I Structured SBA
(33%) and the remaining (4%) in the midline.
Most medial injuries will describe a history of an
injury.
Elias I et al. Osteochondral lesions of the
talus: localization and morphologic data from
424 patients using a novel anatomical grid
scheme. Foot Ankle Int. 2007;28:154–161.
Looze CA et al. Evaluation and management
of osteochondral lesions of the talus. Cartilage
2017;8:19–30.
37. Answer C. Neutral dorsiflexion, 10° external
rotation, 5° hindfoot valgus
The optimal position for the ankle for ankle
arthrodesis is neutral dorsiflexion, 10° external
rotation and 5° hindfoot valgus. This was shown
in a biomechanical gait analysis by Buck et al.
(1987). They demonstrated that this positioning
of the ankle allows the greatest compensatory
motion at the foot and places the least strain on
the knee.
Buck P, Morrey BF, Chao EY. The optimum
position of arthrodesis of the ankle: a gait study
of the knee and ankle. J Bone Joint Surg Am.
1987;69:1052–1062.
38. Answer B. Neutral
Wei et al. (2014) undertook a study where patients
were categorised into groups based on ankle position at the time of the injury: Group I (varus),
Group II (valgus), Group III (dorsi-flexion),
Group IV (plantar flexion) and Group V (neutral). More than 90% of participants in Groups I–
IV as well as 57.2% of participants in Group V had
anatomical/good fracture reduction, respectively.
Fracture healing/union was significantly slower in
Group V vs Groups I, III and IV, and in Group II
vs Group IV. AOFAS scores were significantly
higher (P <0.005) in Groups III (96) and IV
(95.0, IQR: 90.0e100.0) vs Groups II (86.9, IQR:
75.0e90.0) and V (83.0, IQR: 73.0e86.0).
Wei SJ, Han F, Lan SH, Cai XH. Surgical
treatment of Pilon fracture based on ankle position at the time of injury/initial direction of
fracture displacement: a prospective cohort
study. Int J Surg. 2014;12:418–425.
This study equates to the fact that the neutral
position causes a full Pilon rather than the partial
articular fractures in other types. The eponymous Gosselin fracture is a neutral Pilon fracture
where a V-shaped fracture is formed from the
anterior and posterior fragments.
39. Answer E. Synovial sarcoma
Synovial sarcoma is the most common sarcoma of
the foot, it affects males more than females and it is
associated with metastasis in approximately onethird of patients. Sites of metastasis may also include
lymphatics, which is rare for soft tissue sarcoma.
The other answers are less common in the foot, with
metastasis the lowest at approximately 0.01%.
Herzog CE. Overview of sarcomas in the
adolescent and young adult population. J
Pediatr Hematol Oncol. 2005;27:215–218.
Maheshwari AV, Chiappetta G, Kugler CD,
Pitcher D, Temple HT. Metastatic skeletal dis-
ease of the foot: case reports and literature
review. Foot Ankle Int. 2008;29:699–710.
Diabetes
40. Answer E. Total contact casting
The history describes a grade 2 ulcer with active
Charcot, Eichenholtz Stage I. Although this
patient may at some point require an exostectomy, or midfoot reconstruction, in the presence
of an acute Charcot process and ulceration, an
attempt should be made to offload the ulcer and
contain the involved joints during the active
phase. The Eichenholtz stages are:
Stage I – Developmental (Acute)
Hyperaemia due to autonomic neuropathy
weakens bone and ligaments.
Diffuse swelling, joint laxity, subluxation,
frank dislocation, fine periarticular
fragmentation, debris formation.
Stage II – Coalescence (Quiescent)
Absorption of osseous debris, fusion of
larger fragments.
Dramatic sclerosis.
Joints become less mobile and more stable.
The ‘hypertrophic’ or ‘subacute’ phase of
Charcot.
Stage III – Consolidation (Resolution)
Osseous remodelling.
Eichenholtz SN. Charcot Joints. Springfield, IL:
Charles C. Thomas; 1966.
199
Gavin Heyes and Lyndon Mason
41. Answer C. Serum albumin 2.9g/dL
Ankle–brachial pressure index of <0.45 or trans-
cutaneous oxygen pressure <30mm Hg is a nega-
tive predictor of wound or ulcer healing.
Laboratory tests that assess nutrition and ability
to mount an immune response are also of value in
assessing ulcer healing potential. An albumin of
<3.0g/dL or a white cell count of <1.5 (10
are negative predictors of diabetic ulcer healing.
Transcutaneous oxygen pressures (TcPO2)
Considered gold standard to assess wound
healing potential.
Between 30 and 40mmHg is considered the
‘grey zone’ and concerning.
<20 has high rate of wound infections.
>40mmHg is a good sign of healing potential.
Ankle–brachial pressure and ischaemic index
Calcification in the arteries can result in
inaccurate Doppler flow readings
Calcifications falsely elevate the ABIs due to
decreased compliance of the calcified vessels.
Ratio of ankle to brachial pressures (<0.6 is
abnormal and concerning).
Index of 0.6, absolute ankle pressure of
>40mmHg and absolute toe pressure of
40mm Hg or more are good indicators that a
diabetic ulcer will heal.
Index of <0.45 is associated with poor wound
healing.
Serum albumin
<3.5 g/dL indicates malnourishment and is a
poor indicator of wound healing.
Total lymphocyte count
<1,500/mm
3
indicates immune deficiency
and is a poor indicator of wound healing.
A 5.07 Semmes–Weinstein monofilament at 10
sites (9 plantar and 1 dorsal) is the most repro-
ducible and valid test for checking protective foot
sensation.
General
42. Answer B. Distal short Chevron osteotomy
Specific components of the Chevron procedure
have been identified as being linked to the devel-
opment of post-operative AVN. Factors such as
9
positioning of the osteotomy cuts wholly within
the joint capsule; overzealous use of the saw in
the intermetatarsal space whilst performing the
transverse cuts and using a separate intermetatarsal incision for the release of the adductor
hallucis tendon, have all been cited as increasing
the risk of post-operative AVN.
/L)
M Rothwell, Pickard J. The chevron osteot-
omy and avasc ular necrosis. Foot (Edinburgh)
2013;23:34–38.
43. Answer B. Morphology of fracture determines
functional outcome in fixed posterior malleolar
fractures
There have been nine publications showing the estimation of posterior malleolar fracture size to be very
poor on plain radiographs. The position of the X-ray
source and its orientation to the sagittal fracture
line determines the fragment size you can see. Any
posteromedial involvement has a high chance of
not being seen as the fracture line is not orientated
correctly to be visible. Meijer et al. (2015) found that
the accuracy of measurement of posterior malleolar
fracture size on lateral radiograph was only 22%.
In 2016 and 2018, two systematic reviews
were undertaken looking at the outcomes of posterior malleolar fractures treated by traditional
means (fixation only occurred if greater than a
third of the art icular surface) (Odak et al. 2016;
Verhage et al. 2018). Both concluded that articular percentage involved had no relevance to outcome. More recently, a paper by Patel et al.
(2022) reviewed all posterior malleolar fracture
fixation literature, finding that morphology of
fracture dictated the functional outcome.
Although there are both clinical and anatomical studies showing that fixation of a posterior
malleolar fracture increases syndesmosis stability, not all posterior malleolar fractures have
syndesmosis instability and not all syndesmosis
injuries with posterior malleolar fractures have
just posterior injuries (Jayatilaka et al. 2019). In
high fibular fractures, inju ry to the AITFL means
that just posterior malleolar fracture fixation is
not enough to stabilise the syndesmosis.
Multiple studies have shown that posterolateral approach would not be recommended for
treatment of a posterior malleolar fracture in
cases of a high fibular fracture, comminuted
fibular fracture (where a direct lateral fibular
200
Foot and Ankle I Structured SBA
approach is recommended), Mason and Molloy
type 2B fracture (with medial fragment requiring
a medial posteromedial approach) or where
access to a die punch fragment is required
(Gandham et al. 2020).
Gandham S, Millward G, Molloy AP, Mason
LW. Posterior malleolar fractur es: a CT guided
incision analysis. Foot (Edinburgh)
2020;43:101662.
Jayatilaka MLT et al. Anatomy of the inser-
tion of the posterior inferior tibiofibular ligament and the posterior malleolar fracture. Foot
Ankle Int. 2019;40:1319–1324.
Kohler FC et al. The role of the posterior
malleolus in the treatment of unstable upper
ankle joint injuries: a biomechanical study. Foot
Ankle Surg. 2022;28:979–985.
Meijer DT et al. Guesstimation of posterior
malleolar fractures on lateral plain radiographs.
Injury 2015;46:2024–2029.
Odak S, Ahluwalia R, Unnikrishnan P,
Hennessy M, Platt S. Management of posterior
malleolar fractures: a systematic review. J Foot
Ankle Surg. 2016;55:140–145.
Patel S, Baburaj V, Sharma S, Mason LW,
Dhillon MS. Influence of posterior malleolar
fragment morphology on the outcomes of trimalleolar fractures: a systematic review and
meta-analysis. Foot Ankle Surg. 2022;
S1268–7731(22)00116-3.
Verhage SM, Hoogendoorn JM, Krijnen P,
Schipper IB. When and how to operate the pos-
terior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch
Orthopaed Trauma Surg. 2018;138:1213–1222.
44. Answer A. Intermetatarsal ligament
During a Morton’s neuroma excision through a
dorsal approach, the intermetatarsal tissues are
dissected and the deep transverse intermetatarsal
ligament is visualised and incised parallel to the
metatarsals. A laminar spreader can be inserted
between the metatarsal heads. The nerve is then
dissected first distally, until the bifurcation of the
two digital branches becomes apparent. The distal nerve branches are cut distally, and proximal
dissection on the plantar aspect of the nerve is
performed.
Adnan AF, Acuth H. The outcome after
using two different approaches for excision of
Morton’s neuroma. Chin Med J.
2010;123:2195–2198.
45. Answer E. Orthosis with a metatarsal bar
The age and the clinical presentation points
towards Freiberg’s disease. It is characterised by
infarction and fracture of the metatarsal head.
Diagnosis is made radiographically with plain
radiographs showing subchondral sclerosis, flattening of the involved MT head and eventual
joint destruction in advance disease . MRI studies
may be needed to detect early disease. Treatment
is activity modification and NSAIDs in early
disease. Surgical management is indicated for
progressive pain, joint destruction, and joint
deformity. First-li ne treatment in early stage of
the disease is by short leg walking cast or boot for
4-6 weeks or still-soled shoes with MT bars or
pads.
Carmont MR, Rees RJ, Blundell CM.
Current concepts review: Freiberg’s disease. Foot
Ankle Int. 2009;30:167–176.
46. Answer A. Accommodative orthotics
Tarsal coalition is a common congenital condition caused by failure of embryonic segmentation leading to abnormal coalition of two or
more of the tarsal bones. The condition is usually
asymptomatic but may present with a flatfoot
deformity or recurrent ankle sprains. Diagnosis
is made with plain radiographs of the foot and
ankle showing a coalition, most commonly a
calcaneonavicular or talocalcaneous coalition.
Treatment is initially accommodative orthotics
as this is a fixed case of pes planus and will not
correct passively. Surgical coalition resection or
joint arthrodesis is indicated for patients with
persistent symptoms who fail conservative management although studies are small. Fusion is
often preferred to excision in the adult
population.
47. Answer D. Total ankle fusion
The radiograph shows end stage arthritis to an
ankle with maintained subtalar joint. He is very
active and want to remain active. The option of
TTC fusion is not desirable as we would want to
maintain the subtalar motion. Distraction arthroesis and distal tibial osteotomy are options in
younger patients with moderate arthritis. There
2009.
201
Gavin Heyes and Lyndon Mason
is currently no difference in outcomes between
total ankle replacement and total ankle fusion in
the literature in ankles of minimal deformity.
Ankle replacements in deformities greater than
15° will require adjuncts such as calcaneal or tibial
osteotomies, which are not given as options.
48. Answer B. Hallux valgus
Sesamoid injuries of the hallux consist of a constellation of injuries to the sesamoid complex
consisting of fractures, tendonitis and ligamentous injuries. Diagnosis is suspected with hallux
pain that is worse with hyperextension and can
be confirmed with MRI studies. Treatment
depends on the specific injury to the sesamoid
complex, chronicity and patient activity
demands. Hallux valgus is a complication
because of tibial sesamoid excision.
Shimozono Y, Hurley ET, Brown AJ,
Kennedy JG. Sesamoidectomy for hallux sesam-
oid disorders: a systematic review. J Foot Ankle
Surg. 2018;57:1186–1190.
49. Answer B. C Sign
The abnormal Jack’s test indicates a fixed pes
planus deformity.
The C sign is seen on a lateral radiograph of
the ankle in those with the talocalcaneal subtype
of tarsal coalition. It can be seen in both osseous
and non-osseous coalition. A continuous Cshaped arc on a lateral ankle radiograph is
formed by the medial outline of the talar dome
and posteroinferior aspect of the sustentaculum
tali due to their bridging.
An anteater sign is formed from an elongated
anterior process of calcaneus in a calcaneonavicular coalition.
The fleck sign is a small bony fragment seen
in the space between the base of the 1st and 2nd
metatarsal associated with avulsion of the
Lisfranc ligament.
A rocker bottom foot (also known as a congenital vertical talus) is a congenital anomaly of
the foot characterised by a prominent calcaneus/
heel and a convexly rounded sole. A similar
appearance can also occur in a Charcot neuropathy patient with midfoot destruction and
tight triceps surae.
‘Too many toes’ signs is a clinical sign not
radiographic, where forefoot abduction reveals
more toes than would be expected, when the foot
is viewed from behind.
50. Answer A. Passive stretching
Metatarsus adductus is a common congenital condition in infants that is thought to be caused by intrauterine positioning that leads to abnormal adduction of the forefoot at the tarsometatarsal joint.
Diagnosis is made clinically with medial deviation of the forefoot with normal alignment of
the hindfoot. Treatment is generally nonoperative with stretching if the deformity can
be passively corrected, and with casting if the
deformity is rigid. Surgical management is indicated for patients with progressive deformities
who fail non-operative management.
Bleck EE. Metatarsus adductus: classification
and relationship to outcomes of treatment. J
Pediatr Orthop. 1983;3:149–159.
51. Answer C. Eliminating the effect of first ray
plantar flexion
Coleman block test evaluates hindfoot flexibility
and pronation of forefoot. The initial deformity
is in the forefoot followed by subsequent changes
in the hindfoot. The test is performed by placing
the patient’s foot on a wood block, 2–4 cm thick,
with the heel and lateral border of foot on the
block and bearing full weight while the 1st, 2nd
and 3rd metatarsals are allowed to hang freely
into plantar flexion and pronation.
Interpretation:
- test is based on premise that there is fixed
flexion of 1st metatarsal; this test negates
effect that forefoot (1st metatarsal in plantar
flexion) may have on the hindfoot in stance
- if heel varus corrects while the patient is
standing on the block, hindfoot is considered
flexible
- if subtalar joint is supple and corrects with
block test, then surgical procedures may be
directed to correcting forefoot pronation,
which is usu ally due to plantar flexion of 1st
metatarsal
- if hindfoot is rigid, then surgical correction of
both the forefoot and hindfoot are required.
Paulos L, Coleman SS, Samuelson KM. Pes
cavovarus: review of a surgical approach using
202
Foot and Ankle I Structured SBA
selective soft-tissue procedures. J Bone Joint Surg
Am. 1980;62:942–953.
52. Answer D. Tibia and fibula
The muscle in discussion is the tibialis posterior.
Adult acquired flatfoot deformity is generally
associated with a collapsing medial longitudinal
arch and a progressive loss of strength of the
posterior tibial tendon (PTT). This condition is
commonly associated with PTT dysfunction or
rupture, which can have an arthritic or a traumatic aetiology.
The tibialis posterior muscle is contained
within the deep posterior compa rtment of the
lower limb, arising from the adjacent posterior
surfaces of the tibia, fibula and interosseus membrane. The TP tendon has multiple insertions
within the foot, dividing into three main components: (i) anterior; (ii) middle; and (iii) posterior. The anterior component is the largest and
extends to the navicular tuberosity; it is reported
to contain a fibrocartilaginous or bony sesamoid
at this site. The sesamoid functions to provide a
pressure absorbing or gliding mechanism. The
middle and posterior components extend to the
remaining tarsal bones, the middle three metatarsals and the flexor hallucis brevis muscle.
Guelfi M et al. 2017. Anatomy, pathophysiology, and classification of posterior tibial tendon
dysfunction. Eur Rev Med Pharmacol Sci.
2017;21:13–19.
53. Answer E. Plantar plate rupture
The history of an acute event is much more likely
to represent a plantar plate rupture. The plantar
plate of the toe is a rectangular structure with a
stout distal insertion and relatively flimsy proximal origin. The anatomical relationships to
adjacent structures and composition are similar
between the volar plates of the fingers and plantar plates of the toes, however the weight bearing
nature of the foot and forces imposed by toe-off
may create chronic hyperextension of the metatarsophalangeal joint and predispose the plantar
plate to attenuation or rupture and can lead to
instability of the metatarsophalangeal joint. As
the toe has then clawed, the metatarsal head
moves plantarward, ultimately causing the callosity. The callosity represented is a mixture of a
second rocker and third rocker callosity, being
both prominent on stance phase and propulsive
phase of gait.
An intractable plantar keratosis is a focused,
painful lesion that commonly takes the form of a
discrete, focused callus, usually about 1cm, on
the plantar aspect of the forefoot. The other
options will not give rise to the callosity
presented.
Lucas DE, Philbin T, Hatic S 2nd. The plantar plate of the first metatarsophalangeal joint: an
anatomical study. Foot Ankle Spec.
2014;7:108–112.
54. Answer B. CT scan with metal reduction
artefact
The most common reported event was aseptic
loosening (19.3%) followed by infection (18.2%)
and alignment/mechanical issues (16.5%). The
above-described scenario brings the question of
ascertaining whether this is loosening or infection. The clinical and biochemical work-up
points in the direction that infection is unlikely
in this case and therefore it is safe to assume that
the most common cause here is aseptic
loosening. A CT is required to look at bone stock
prior to consideration of surgical management.
Glazebrook MA, Arsenault K, Dunbar M.
Evidence-based classification of complications in
total ankle arthroplasty. Foot Ankle Int.
2009;30:945–949.
55. Answer A. Dystonia
This clinical picture represents dystonia. The
foot corrects during muscle relaxant showing
that muscle activity is involved. Dystonia is a
movement disorder in which a person’s muscles
in the affected body part contract involuntarily,
resulting in abnormal postures, repetitive movements, or both. Many people with functional
dystonia report that the problem is triggered by
an event, often an injury, an operation, or a
physical illness, with a background of stress and
psychological difficulty.
Functional dystonia can be subdivided into
the two postural types: functional fixed dystonia
and functional paroxysmal dystonia. A coexisting diagnosis of chronic regional pain syndrome
(CRPS) is also common in patients with a fixed
functional dystonia, and severe pain frequently
accompanies the deformity.
203
Соседние файлы в папке Библиотека им академика М.И. Перельмана