surgery review booklet
TRANSCRIPT
�1�
�
�����������
����� �������
�������������������������������������������������
�OCPM’s ACFAS ��������������!!"�
��
�#����$%�&$���$%�'�$���$�(������)*+�������!!,�
�2�
�
�
�������������������������
All pictures came from class notes / handouts.
Most of the pictures were referenced from Dr. Hetherington’s book.
�3�
�
-�(������.�������/� Topic Page # Charting Surgical Consult 6
Pre-Op Note 6 Post-Op Order 6 Admission Order & Note 6 Post-Op Note 7 Post-Op Visit 7
Layers of the Foot 8 Key Lab Values 8 Hospitalization Indications 9 Post-Op Fever Etiologies 9 Sutures Types 10 Selection 11 Technique 11 Classification Systems Stewart, Salter-Harris 12 Gustillo-Anderson, WatsonJones, Freiberg 13 Berndt-Hardy, Hawkin 14 Sneppen, Watson & Dobas, Kuwada 15 Rowe, Sander’s 16
Hardcastle, Dias, Danis-Weber 17 Lauge-Hansen 18
MRI 19 Anesthesia Anesthetics 20 Dosing 20
Onset/Duration 20 Increasing Comfort 21 Ankle Block 21 Hemostasis = Tourniquet Pressures 21
�4�
�
-�(������.���������.�������$�/�
Topic Page # Corticosteroid Injections Types 22 Side Effects 22 Cocktails 22 Radiographic Data 23 Joint Deformities 24 Osteotomies Proximal 25-27 Shaft 29-30 Distal 31-33 Internal Fixation Principles 34
Rule of 2’s 34 K-Wires 34 Steinmann Pins 34 Monofilament Wire 35 Tension Band Wiring 36 Staples 37 Screws Anatomy 38-39 Types 40-41
Fixation Technique 42-43 Selection 44
Soft Tissue Anchors 45 Plates 45-46 � �
�5�
�
-�(������.���������.�������$�/� Topic Page # External Fixation Principles 47 Complications 48
Types 48-49 Dynamics 50 Care & Management 50
Forefoot Pathologies / Surgical Procedures Hallux Limitus/Rigidus 51-52 Hammertoes 53-56 Etiologies for Contracted Digits
5th Digit Arthroplasty 57 Rearfoot Surgery Plantar Fasciotomy 58 Haglund’s Deformity 59 Keck & Kelly Osteotomies 59 Tendon Transfers & Indications Adductor Hallucis 60 Abductor Hallucis 60 Extensor Hallucis Longus 60 Jones Suspension 60 Hibbs 60 Tibialis Anterior 61 STATT 61 Cobb 61 Tibialis Posterior 62 Peroneus Longus 62 Bunions based on Angles 63 Other things to know… 67
�6�
�
CHARTING SURGICAL CONSULT
1. Chief Complaint 2. HPI (NLDOCAT) 3. Allergies 4. Medications 5. Social History 6. Medications 7. Family History
8. Primary Care Dr 9. Hospitalizations
10. RoS � Vitals / Vascular / Neuro / Derm /
Musculoskeletal 11. Ancillary (x-rays, labs, ect…)
PRE-OP NOTE Surgeon Pre-Op Dx Planned Procedure
Medications Allergies Diagnostic Data – Labs, x-rays, EKG, ect…
Consent Form: Describe Procedure & Care / Complications / Alleviations / Expected Outcomes / Arrange Pre-Op Testing
“Consent form was reviewed with patient, signed and placed in chart.” “All risks, possible complication and alternative treatments have been discussed with the patient in detail. All patients’ questions have been answered to satisfaction. No guarantees to the outcome have been made.” �
POST-OPERATIVE ORDERS: VANDIMAX Date/Time/Signature Vitals Activities Nursing Diet Ins/Outs Meds Ancillary X-ray
ADMISSION ORDERS & NOTE: ADC – VAANDILMAX Date/Time/Signature Admit to Dx Condition -
Vitals Activities Allergies Nursing Diet Ins/Outs Labs Meds Ancillary X-ray
�7�
�
POST-OP NOTE: SAPPA HEMI FC2P2 Surgeon Assistants Pre-Op Diagnosis Post-Op Diagnosis Procedure Anesthesia – type / how much
Hemostasis – type Estimated Blood Loss Materials – sutures/hardware Injectables – any post-incision
Findings Pathology Prophylaxis Complications Condition
“Patient tolerated procedure and anesthesia well. Patient transported to recovery by anesthesia with vitals stable and vascular status intact.” Also may include.. Pathology – bone, ST; Condition – stable, guarded, fair, poor; Prophylaxis POST-OP VISIT: SOAP Subjective 1. POV # ______, PVD #_______ 2. Procedure 3. N,V,C,F,SOB 4. Activity status 5. Pain / How controlled 6. Other Complaints
Objective 1. How patient presents – walking, wheelchair 2. Vascular, Neuro, Derm, Musculoskeletal
Assessment 1. Status Post-Op 2. Compliance
Plan 1. Treatment 2. Dr & Residents
�8�
�
LAYER OF THE FOOT 1st Layer
1. Abductor Hallucis M. 2. Abductor Digiti Minimi M. 3. Flexor Digitorum Brevis M.
2nd Layer 1. Quadratus Plantae M. 2. Lumbricales M.
3rd Layer 1. Flexor Hallucis Brevis M. 2. Flexor Digiti Minimi M. 3. Adductor Hallucis M.
4th Layer 1. Dorsal Interossei M. (4) 2. Plantar Interossei M. (3)
KEY LAB VALUES
Chem 7
Na Cl BUN
K CO Cr
CBC
HgB
HCT
Glucose�
Platelets�WBC�
(23-29mmol/L)�
(5-20mg/dL)�
(M: <1.2 W: <1.1mg/dL)�
(97-107mEq/L)�
(3.5-5mEq/L)�
(136-145mEq/L)�
(<110mh/dL)�
(4500 - 11,000/L)�
(M: 14.4-16.6g/dL) (W: 12.2-14.7g/dL)�
(M: 43-49%) (W: 37-43%)�
(150,000-450,000μL)
�9�
�
INDICATIONS FOR HOSPITALIZATION POST-OP
1. Fever >101.6o 2. Ascending Cellulitis / Suspect Osteomyelitis 3. Lymphangitis / Lymphademopathy 4. Immunosuppressed 5. Virulent / Resistant Organisms 6. Need for I&D Procedure 7. Need for IV Antibiotics 8. Failed response to outpatient therapy 9. Need a consult
POST-OP FEVER ETIOLOGY
1. Wind – Pulmonary
a. Aspiration / Pneumonia b. Occurs 24-48h c. Get chest x-ray
2. Water – UTI
a. Occurs in 2-6d
3. Wound a. Occurs in 3-5d
4. Walk – DVT / Pulmonary Embolism
a. Within 1st week b. Virchow’s Triad
i. Hypercoagulation ii. Venous Stasis
iii. Endothelial Damage
5. Wonder – drugs / fever / benign / medicines
�10�
�
SUTURES
Absorbable Sutures Filament Type Total Absorption Chromic Gut 70d Monocryl Monofilament 90d Maxon Monofilament 90-120d Vicryl Monofilament
or Braided 56-70d
Dexon
Mono- or Multifilament
90-120d
Dexon Plus Mono- or Multifilament
90-120d
Dexon S Multifilament 90-120d PDS Monofilament 180d Non – Absorbable Sutures Filament Type Advantages Stainless Steel Mono- or
Multifilament High strength, low tissue Rxn
Ethilon Nylon Monofilament Elasticity/Memory Prolene Monofilament Minimal Tissue Rxn Novafil Monofilament Elasticity/Tensile
strength Silk Multifilament Good Handling Nurolon Nylon Multifilament Mersilene Multifilament Consistent Tension Ticron Braided Minimal Tissue Rxn Ethibond Multifilament Good Handling
�11�
�
SUTURE SELECTION 1. Bone
a. Stainless Steel 2. Tendon
a. Prolene b. Ethibond c. Nylon d. Polyesters
3. Muscle a. PDS b. Vicryl c. Prolene
4. Fascia a. Prolene b. PDS
5. Subcutaneous Fat a. Vicryl
6. Subcuticular a. Monocryl b. Vicryl
7. Capsule a. Vicryl
8. Skin a. Nylon b. Silk
SUTURE TECHNIQUES 1. Simple Interrupted
Good for infected wounds Individual know for each throw
2. Horizontal Mattress Everts skin edges well
3. Vertical Mattress Everts tissue edges well
4. Continuous Running Good to save time Good for large wound areas
5. Subcuticular (Running Intradermal) Leaves the best scar
Deep Tissue � taper needle; 3-0 suture Subcutaneous Tissue � taper needle; 4-0 suture Dermal Layer � precision needle; 5-0 suture Capsule � 2-0 or 30 suture Subcutaneous � 4-0 suture Subcuticular � 5-0 clear suture Skin � 4-0 clear suture
�12�
�
STEWART CLASSIFICATION OF 5TH MET FRACTURES
Type I Supra-articular @ metaphyseal-diaphyseal junction True Jones! Type II Intra-articular avulsion, 1 or 2 fracture lines Type III Extra-articular avulsion, PB tears small fragment from the styloid process Type IV Intra-articular, comminuted fracture, assoc. with crush injury Type V Extra-articular avulsion @ of physis in children (SH Type I)
SALTER-HARRIS CLASSIFICATION OF EPIPHYSEAL INJURIES
Type I Epiphysis is completely separated from metaphysic Type II Epiphysis, and the growth plate, is partially separated from the metaphysis, which is cracked Type III Fracture runs through the epiphysis, across the growth plate from the metaphysic Type IV Fracture runs through the epiphysis, across the growth plate, and into the metaphysic Type V The end of the bone is crushed and the growth plate is compressed Type VI (Rang’s Addition) Avulsion of peri-chondral ring Type VII (Ogden’s Addition) Avulsion fracture of the epiphysis without involvement of the physis
�13�
�
GUSTILLO & ANDERSON OPEN FRACTURE CLASSIFICATION SYSTEM
Type I Fracture with open wound <1cm in length Clean, minimal soft tissue necrosis Usually traverse or short oblong Type II Fracture with open wound >1cm in length Clean, minimal soft tissue necrosis Usually traverse or short oblon Type III Fracture with open wound >5cm in length Contamination and/or necrosis of skin, muscle, NV, & ST Comminuted
� Type IIIa � Adequate bone coverage
� Type IIIb � Extensive soft tissue loss with periosteal stripping and bone
exposure � Type IIIc
� Arterial injury needing repair
NAVICULAR FRACTURE – WATSON JONES Type I Navicular tuberosity fracture Type II Avulsion fracture of dorsal lip Type III A: Transverse body fracture – Nondisplaced B: Transverse body fracture – Displaced Type IV Stress fracture
FREIBERG CLASSIFICATION – AVN OF 2ND MET Type I No DJD Articular cartilage intact Type II Peri-articular spurs Articular cartilage intact Type III Severe DJD Loss of Articular Cartilage Type IV Epiphyseal dysplasia; multiple head involvement
�14�
�
BERNDT-HARDY CLASSIFICATION OF TALAR DOME LESIONS Stage I Compression lesion or non-visible lesion Stage II Fragment attached Stage III Non-displaced fragment without attachment Stage IV Displaced fragment
TALAR NECK FRACTURE CLASSIFICATION – HAWKIN’S
Type I
Non-displaced talar neck Disrupts blood vessels entering dorsal talar neck and intra-osseous
vessels 20% chance AVN
Type II Displaced talar neck fracture with subluxed or dislocated STJ Disrupts dorsal neck arterial branches and branches entering from
inferiorly from sinus tarsi & tarsal canal 40% chance AVN
Type III Displaced talar neck fracture with dislocated STJ & ankle joint Disrupts all 3 major blood supplies 100% chance AVN
Type IV Displaced talar neck fracture with complete dislocation of STJ Ankle joint + subluxation or dislocation of the talonavicular joint Disrupts all 3 major blood supplies 100% chance AVN
�15�
�
SNEPPEN CLASSIFICATION OF TALAR BODY LESIONS Group I Transchondral / Compression fracture of the talar dome Group II Coronal/Sagital/Horizontal shearing fracture of the entire body Type I Coronal or Sagital A: Non-displaced B: Displacement of trochlear articular surface C: Displacement of trochlear articular surface with
associated STJ dislocation D: Total dislocation of the talar body Type II Horizontal A: Non-displaced B: Displacement Group III Fracture of posterior tubercle of talus Group IV Fracture of lateral process of talus Group V Crush fracture of the talar body
WATSON & DOBAS CLASSIFICATION – POSTERIOR LATERAL TUBERCLE OF TALUS (SHEPARD’S FRACTURE)
Stage I Normal Lateral talar process with no clinical significance Stage II Enlarged posterior lateral tubercle of the talus (Steida’s Process) Stage III Accessory bone / Os Trigonum that may be irritated by trauma Stage IV Os Trigonum + cartilaginous/synchrondrotic union with talus
KUWADA CLASSIFICATION OF ACHILLES RUPTURE Type I Partial rupture Type II Complete rupture <3cm gap Type III Complete rupture 3-6cm gap Type IV Complete rupture >6cm gap
�16�
�
ROWE CLASSIFICATION OF CALCANEAL FRACTURES Type I A Medial Tuberosity fracture
B Sustentaculum Tali fracture C Anterior Process fracture
Type II A Posterior break fracture without Achilles involved B Posterior break fracture with Achilles involvement Type III Extra-articular body fracture Type IV Intra-articular body fracture without depression Type V A Comminuted, Intra-articular fracture with depression B Comminuted fracture with severe joint depression
SANDER’S CT CLASSIFICATION OF CALCANEAL FRACTURES
* Fractures are classified according to the number of intra-articular fragments and location of fracture lines # of Fractures Type I Any non-displaced intra-articular fracture Type II 1 fracture through posterior facet creating 2 fragments Type III 2 fractures through the posterior facet creating 3 fragments Type IV 3+ intra-articular fracture lines Location of Fracture Lines:
�17�
�
LISFRANC’S FRACTURE CLASSIFICATION – HARDCASTLE Type A: Total or Homolateral – Disruption of the entire Lisfranc joint – Transverse or Sagital plane – Most common type
Type B: Partial B1 – Medial incongruity with the first met forced medially
– Involves 1st met OR mets 2,3,4 but NOT 5 B2 – Lateral incongruity with lesser mets forced laterally
Type C: Divergent C1 – Partial divergence with the 1st met medial and 2nd met laterally
displaced C2 – Total divergence with the 1st met displaced medially and lesser
mets displaced laterally
DIAS CLASSIFICATION OF LATERAL ANKLE LIGAMENT INJURY Grade I � Partial rupture of CFL Grade II � Complete rupture of ATFL Grade III � Complete rupture of ATFL, CFL, &/or PTFL Grade IV � Complete rupture of all 3: ATFL, CFL, & PTFL
+ Partial rupture of the Deltoid Lig
DANIS-WEBER CLASSIFICATION OF FIBULAR FRACTURES INVOLVED IN ANKLE FRACTURES
Type A Transverse avulsion fibular fracture BELOW… (SAD) Type B Spiral fracture AT… (SER or PAB) Type C Fibular Fracture ABOVE… (PER)
… the level of the syndesmosis�
�18�
�
LAUGE-HANSEN CLASSIFICATION OF ANKLE FRACTURES SUPINATION ADDUCTION (SAD) � Stage I Transverse avulsion of fibula @/below AJ level
Rupture of the Lateral Collateral Ligament � Stage II Oblique to Vertical fracture of the Medial Malleolus
PRONATION ABDUCTION (PAB) � Stage I Transverse avulsion fracture of Medial Malleolus
– or – Rupture of Deltoid Lig � Stage II Rupture of AITFL & PITFL
– or – Tillaux-Chaput / Wagstaffe fracture � Stage III Short oblique fracture of the fibula @ lvl of syndesmosis
SUPINATION EXTERNAL ROTATION (SER) *** Most Common! � Stage I Rupture of AITFL
– or – Tillaux-Chaput / Wagstaffe fracture � Stage II Spiral/Oblique fracture of fibula @ lvl of syndesmosis � Stage III Rupture of PITFL
– or – Avulsion fracture of Posterior Malleolus (Volkmann’s Fracture)
� Stage IV Transverse fracture of Medial Malleolus – or – Rupture of Deltoid Lig
PRONATION EXTERNAL ROTATION (PER) *** Longest healing time! � Stage I Transverse fracture of Medial Malleolus
– or – Rupture of Deltoid Lig � Stage II Rupture of AITFL & Interosseous membrane
– or – Tillaux-Chaput / Wagstaffe fracture � Stage III High Spiral Oblique fracture (Maisonneuve Fracture) � Stage IV Rupture of PITFL
– or – Avulsion fracture of Posterior Malleolus
�19�
�
MRI T1-Weighted � good for showing anatomical detail + Short TE + TR + Tissue with short T1 are brighter
+ Fat
T2-Weighted � good for highlighting areas of pathology + Long TE + TR + Tissue with long T2 are brighter
+ Water, Edema STIR � Short Tau Inversion Recovery + Fat suppression + Heavily water–weighted image + Very Sensitive for Bone Marrow abnormalities Gadolinium (best for infection) + Contrast–enhanced chemical agent + Shortens T1 relaxation times � Increases signal intensity on T1
weighted images + Usually used in conjunction with fat suppression + Good for identifying ST masses, inflammation processes, & for staging bone and ST infection
TE = Time to Echo dec TE + dec TR = T1-Weighted TR = Time of Repetition inc TE + inc TR = T2-Weighted �
�20�
�
ANESTHETICS Esters � Higher incidence of allergies � Metabolized in Blood (Cholinesterase in plasma) � Types ~ Cocaine ~ Procaine ~ Cholorprocaine ~ Tetracaine
Amides � Metabolized by CYP450 system in Liver � Types
~ Lidociane / Xylocaine (0.5, 1, 1.5, or 2% solutions) ~ Bupivicaine / Marcaine (0.25, 0.5, or 0.75% solutions) � C/I <12y/o ~ Mepivicaine / Carbocaine (1, 1.5, 2, or 3% solutions)
Dosing: 0.25% solution = 2.5 mg/cc drug 1cc = 1mL 0.5% solution = 5 mg/cc drug 1% solution = 10 mg/cc drug Ex: 5cc of 1% Xylocaine (lidocaine) = 50mg of Xylocaine given Ex: 3cc of 0.5% Marcaine (bupivicaine) = 15mg of Marcaine given Toxic Doses: Onset & Duration: Lidocaine Plain = 300mg Onset: 5min w/ Epi = 500mg Duration: 1-2h Marcaine Plain = 175mg Onset: 10-15min w/ Epi = 225mg Duration: 6-8h
�21�
�
6 Ways to Increase Comfort of the Injection: 1. Quick Stick 2. Slow Injection 3. Small Gauge Needle (large # = small gauge) 4. Small Syringe (less pressure) 5. Cold Spray 6. Warm the Solution (to body temp)
Ankle Ring Block: Superficial = Saphenous N., Sural N., Superficial Peroneal N. (IDCN, MDCN)
Deep = Posterior Tibial N., Deer Peroneal N. ** Fact: If you mix Lidocaine and Marcaine, you will only have partial anesthesia deep into surgery. Only mix to avoid toxic doses. ** Fact: If you need to inject more volume, use a small percent of drug solution. Ex: 30cc of 1% gives more anesthesia than 15cc of 2% Saphenous N .5-1cc Posterior Tibial N 1-3cc give the most here since this N is the largest Sural N .5-1cc Deep Peroneal N .5-1cc between 2 Long Extensor Tendons Superficial N .5-1cc plantarflex & invert Hemostasis = Tourniquet Pressures: Ankle: +100 over systolic ~250mmHg Thigh: +200 over systolic ~ 350mmHg
������������
�����������������
����� ���� �������
���������� � �
�����������
�����
��������������
Draw up with 18G Inject with 25 or 27G �
�22�
�
CORTICOSTEROID INJECTIONS Corticosteroid injections are used to control local inflammatory reactions Phosphates: short-acting (clear) Acetates: long-acting (cloudy) All corticosteroids are collagenilytic and therefore should not be injected into the same area of soft tissue more than 3-4 times per year. Side Effects: ~ Soft tissue atrophy ~ Tendon rupture ~ Skin discoloration (lightening) Cocktails Commonly used in Podiatry: 1. Plantar Fasciitis
a. 1cc Kenalog-10 (10mg/mL) b. 0.75cc 1% Lidocaine c. 0.75cc 0.5% Marcaine
2. Joint Injections
a. 0.2cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine
3. Intermetatarsal Neuromas
a. 0.3cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine
Always draw up the Lido/Marc 1st followed by Dex or Kenalog!�
�23�
�
RADIOGRAPHIC DATA Angle: Normal: Hallux Abductus Angle 0-15o Proximal Articular Set Angle (PASA) 0-8o Distal Articular Set Angle (DASA) 0-7o Intermetatarsal Angle 1-2 0-8o 2-5 16o + 4o 4-5 8o + 2o Hallux Interphalangeal Angle (HIA) 0-10o + 2o Metatarsal Length + 2mm Metatarsus Adductus 0-8o Tibial Sesamoid Position Positions 1-3 1 = Medial to midline of hallux 2 = Touching midline medially 3 = 2/3 medial + 1/3 lateral to midline 4 = 1/2 medial + 1/2 lateral to midline 5 = 1/3 medial + 2/3 lateral to midline 6 = touching midline laterally 7 = lateral to midline of hallux Calcaneal Inclination Angle 18-22o Talar Declination Angle 21o TaloCalcaneal Angle (Kite) 17-21o Böhler’s Angle 25-40o Angle of Gissane 125-140o Calcaneal Fracture resulting in
Joint Depression � Böhler’s Angle ↓ Angle of Gissane
�24�
�
CLASSIFICATION OF JOINT DEFORMITIES Positional Deformities:
PASA + DASA < HAA PASA and DASA within normal range (0-8o) Joint is Subluxed
Structural Deformities:
PASA + DASA = HAA PASA and DASA abnormal Joint is Congruous
Combined Deformities:
PASA + DASA < HAA PASA and DASA abnormal Joint is Dislocated
�25�
�
PROXIMAL OSTEOTOMIES IM between 15-22o, normal PASA NOT for a short metatarsal I. Closing Base Wedge
1-1.5cm from met-cuneiform joint 4-6weeks NWB
Indications: � Structural Lg IMA � Splayfoot � Juvenile/Recurrent HAV � Met Primus Elevatus � HAV + MetAdductus � C/I in Elderly
II. Juvara – Types A,B,C
A: Oblique, distal lateral to proximal medial with an intact medial cortical hinge B: same as A but the medial hinge is sectioned after wedge resection C: Oblique, without wedge resection
�26�
�
PROXIMAL OSTEOTOMIES CONTINUED… III. Opening Base Wedge
Good for a short metatarsal Use medial eminence for the graft
IV. Crescentic
1.5cm from met-cuneiform joint Easy traverse plane correction Good for short metatarsal
�27�
�
PROXIMAL OSTEOTOMIES CONTINUED… V. Double Osteotomy
IM and PASA correction VI. Proximal V
Good screw fixation Unlikely to get elevates
VII. Lapidus
IM > 18o Fusion of the base of 1st met to the medial
cuneiform Indications: � Pain with motion at met-cuneiform joint � Hypermobility of 1st met-cuneiform joint
�28�
�
�29�
�
MIDSHAFT OSTEOTOMIES ** Troughing is unique to midshaft osteotomies I. Ludloff Osteotomies
IM 1-2 angle: 13-20o Abnormal HAA Normal to short 1st metatarsal Elevatus is a risk
II. Mau
IM 1-2 angle: 13-20o Abnormal HAA Normal to short 1st metatarsal Due to cut, decreases elevates
potential
�30�
�
MIDSHAFT OSTEOTOMIES CONTINUED… III. Scarf – “Z”
Dorsal to Plantar – 50:50 or 66:33 cut Very Stable, technically difficult 2 screw fixation
IV. Off-Set “V”
Modification of the Austin Cut angled <55o
�31�
�
DISTAL OSTEOTOMIES HAV angle – 35o
IM angle -- 16 o Some PASA correction I. Reverdin
Some PF possible
II. Hohmann
Very unstable; Rigid Fixation necessary Shortening occurs with fragment removal
�32�
�
DISTAL OSTEOTOMIES CONTINUED… III. Mitchell – “Step-down Osteotomy”
Used for long 1st metatarsal Good visualization of possible change
IV. Wilson
Dramatic shortening possible
�33�
�
DISTAL OSTEOTOMIES CONTINUED… V. Austin / Chevron / Distal “V”
Transpositional – PASA, IM, DF/PF possible Joint preserving Possible of Juvenile HAV Displace capital fragment ¼ to ½ bone width
VI. Reverdin Green / Distal “L”
Cut 2/3 way through bone, then plantar cut
�34�
�
INTERNAL FIXATION
4 Main Principles of Internal Fixation:
1. Anatomical Reduction 2. Rigid Internal Fixation 3. Atraumatic Technique 4. Early active RoM
Rules of 2’s: Fracture / Osteotomy site should be 2x’s the diameter of the bone 2 points of fixation is better than 1 2 threads should purchase the distal cortex 2 finger tightness
Kirschner Wires (K-wires): Steel wires used as permanent or temporary fixation Dependent on diameter Available in both smooth and threaded Threaded wires provide more stable purchase BUT are weaker & harder to remove Both are measured by outer diameter ONLY maintain compression Sizes: 0.028, 0.035, 0.045, 0.062 inches
Steinmann Pins: Very similar to K-wires Larger diameter than K-wires Provide Inc Stability Measured in 64ths Sizes: 8/64 (1/8), 7/64, 6/64…
�35�
�
INTERNAL FIXATION CONTINUED… Monofilament Wire: Malleable Steel Provide interfragmentary compression Measured in Gauges (small gauge = large diameter) Techniques: � Cerclage fashion
� circling around a bone � Interfrag fashion
� placed in between 2 fragments � always pull on the proximal fragment � most stable
�36�
�
INTERNAL FIXATION CONTINUED… Monofilament Wire Continued… � Box Wire fashion
� 2 boxes at 90o to each other � One wire is placed medial to lateral � Other is placed dorsal to plantar
Tension Band Wiring: Combines K-wire with MF wire Requires that there is a soft tissue structural component Two K-wire’s placed the parallel fashion across fracture site with the
MF wire in a figure 8 pattern around the K-wire on the site opposite to the tendon’s anatomical pull.
Size of wire measured in gauges -- Lower gauge; thicker wire 26 & 28 are common in Podiatry
�37�
�
INTERNAL FIXATION CONTINUED… Staples:
Primarily used for fractures, osteotomies & fusions Inserted manually or with pneumatic gun Provide compression, distraction or maintain compression Be careful about thickness of bone – DO NOT use if cortical bone is
greater than 2-3mm, may cause cortical fractures or not seat in bone properly
Pre-Drills:
Neutralization� Compression � = Divergent Lines Distraction � = Convergent Lines Richards Staple: GOLD STANDARD for major fusion Os Staple: Heat activated Uniclip: Has an aperture Requires a tool to compress the legs after insertion
�38�
�
INTERNAL FIXATION CONTINUED… Screws: � These features can differ depending on the function of the screw. Head Has various configurations; hexagonal, cruciate, slotted… Land The curve-contoured underside of the screw head Increases the surface contact between the screw and the bone Reduces the chance from stress-risers Shaft/Shank Area of the screw that is void of the thread pattern Thread The means by which the screw purchases the bone Thread Diameter The diameter across the thread width
Measurement is the value used to describe the screw size Core Diameter Diameter between the thread patterns Pitch Distance between the adjacent threads Run-Out Junction where the shaft meets the thread Weakest point on the screw Avoid placing the run-out near the fracture / osteotomy site Lead Distance that the screw advances with each turn (360o) Rake Angle Thread to axis angle Tip Angle Tip to axis angle Tip Either rounded (needs pre-tapping) or fluted (self-tapping)
�39�
�
INTERNAL FIXATION CONTINUED… Screw Diagram:
�40�
�
INTERNAL FIXATION CONTINUED… Types of Screws: 1. Cortical Screws
Threaded the entire length of the screw Have smaller pitch for greater number of contacts between the
screw and the dense cortical bone 2. Cancellous Screws
Partially threaded Larger pitch to provide greater distance of contact between the
screw and the less dense, porous cancellous bone 3. Cannulated Screws
Hollow center down the length of the screw to be used over a guide wire
Offers easier placement and less complications May have decreased pullout strength
4. Herbert Screws
Ho head and two set of threads proximally not distally Proximal threads have greater pitch than the distal threads Indicated for intra-articular fractures Compressive strength of Herbert screw are less than conventional
screws 5. Interference Screws
Fully threaded, headless screw Does not provide interfragmentary compression but resists axial
displacement of one fragment on another Indicated for stabilization of tendon grafts to bone and tendon
reattachment
�41�
�
INTERNAL FIXATION CONTINUED… Types of Screws Continued: 6. Absorbable Screws
Available in natural / synthetic polymers Most common absorbable polymers used are based on alpha-
hydroxy acids such as L-lactic acid, glycolic acid, & para-dioxanone Need to be able to last 6-8 weeks
Basic Properties for the Ideal Absorbable Implant: ~ Posses and initial strength to meet biomechanical demands ~ Degrades in a predictable manner over time ~ Undergoes complete absorption without harm to surrounding tissues
�42�
�
INTERNAL FIXATION CONTINUED… General Screw Fixation Technique: ~ Place one screw perpendicular to the fracture / osteotomy line for maximal compression. Place the 2nd screw perpendicular to the longitudinal axis of the bone this provides greatest resistance to the axial loading forces on the bone. ~ If only a single screw placement is allowed – place the screw in an angle that is halfway between the angle that is perpendicular to the fracture line and perpendicular to the long axis of the bone
Diagram: A. 2 Screw Technique B. 1 Screw Technique
�43�
�
INTERNAL FIXATION CONTINUED… General Screw Fixation Technique Continued: Load Screw Technique This technique is commonly used in plate fixation. Involves placement of 2 screws in the plate that is closest to the
fracture line to be drilled offset away from the fracture line. As the screws are advanced the bone segments between the two screws
are further compressed. Lag Screw Technique Placement of the screw so that ONLY the thread engages the distal
cortex of the bone. Thus further advancement of the screw results in approximation and
subsequent interfragmentary compression. Most effective in fracture / osteotomy that is 2x’s the width of the
bone or has a fracture angle that is less than 40o. Partially Threaded Screw Insertion Technique
1. Thread / Pilot Hole 2. Countersink (increases surface contact between screw head and the bone) 3. Depth gauge (measures distance between the proximal and distal cortex) 4. Tap 5. Insert Screw
Fully Threaded Screw Insertion Technique
1. Thread / Pilot Hole 2. Countersink 3. Glide Hole 4. Depth gauge 5. Tap 6. Insert Screw
�44�
�
INTERNAL FIXATION CONTINUED… Screw Selection Chart:
Thread Diameter Thread Hole Gliding Hole Tap Diameter Mini-Fragment 1.5 1.1 1.5 1.5 2.0 1.5 2.0 2.0 2.7 2.0 2.7 2.7 Small-Fragment 3.5 2.5 3.5 3.5 4.0 (partial/cancel) 2.5 NA 3.5 4.0 (full/cancel) 2.5 NA 3.5 Large-Fragment 4.5 3.2 4.5 4.5 4.5 (mall) 3.2 NA 4.5 6.5 (partial/cancel) 3.2 NA 6.5 6.5 (full/cancel) 3.2 NA 6.5
�45�
�
INTERNAL FIXATION CONTINUED… Soft Tissue Anchors: � Used for reattachment of tendons or ligaments � 2 basic types: Expandable / Screw type � Complications: Improper Placement / Failure of Suture / Pullout Plates: � Various size and shape – allow alignment of the bones and stability
across the fracture / osteotomy site � Stability allows for early passive RoM � Adequate screw fixation is important for the plate to function properly � Plate designs include semitubular, 1/3 tubular, ¼ tubular, T – plate, L
– plate, calcaneal plate…
Types of Plates: 1. Neutralization Plate
a. Prevents torsional / bending forces from acting on the lag screws
b. The ridge extension of the plate on the bone proximal & distal to the fracture / osteotomy site helps neutralize any extra forces along the bone segment
2. Compression Plate a. Generate compressive forces along the fracture / osteotomy site
by either placing the plate on the tension side of the bone, off-set drilling (AKA load screw technique) or pre-bending the plate.
�46�
�
INTERNAL FIXATION CONTINUED… Plates Continued…
3. Dynamic Compression Plate (DCP) a. Employs the concepts of offset drilling with unique plate
designs to optimize the compressive forces of the plate b. Disadvantage is it increases periosteal damage and decrease
intramedullary blood supply to the area, decreasing the overall strength of the bone segment
4. Limited Contact Dynamic Compression Plate
a. Has a series of recessed undercuts on the undersurface of the plate which allows limited contact between the bone and the plate
b. Generates less disruption to the vascular supply
5. Buttress Plate a. Anchored to the main stable fragment b. Supports the load-bearing bone c. Indicated in impacted fracture that results in comminution (e.g.
tibial plateau and the tibial pilon fractures)
6. Bridge Plate a. Useful in unstable comminuted fractures by spanning the
length of the comminution b. Frequently used with bone grafts to fill the voids in the bone
�47�
�
EXTERNAL FIXATION External fixation implements the use of wires, pins, and rods to keep bone segments in alignment or compression. Furthermore they allow distraction of bone segments by the principle of tension-stress effect. Advantages: � Use in open fractures, acute, fractures, infected fractures and non-
unions � Requires minimal tissue dissection � Allows compression, neutralization, or fixed distraction of bone
segments � Length can be maintained in a comminuted fracture � Allows access to the wound site for care, monitoring and dressing
changes � Full weight bearing is allowed immediately post-operatively Disadvantages: � Requires skin and pin tract care � Difficult frame construction � Bulky frame � Fracture through the bone is possible � Refracture possible after frame removal � Expensive Basic Principles of External Fixation: 1. Frame should avoid and respect all vital structures in the area 2. Allow access to the wound site 3. Frame must meet the mechanical demand of the patient and injury
�48�
�
EXTERNAL FIXATION CONTINUED… Complications: � Pin irritation – avoid pin placement in muscle � Pin tract infection – most common complication (30%) � Neurovasculature Impalement – Anterior Tibial A. & Deep Fibular N.
and they are most commonly involved � Delayed Union / Non-Union – due to faulty frame construction � Compartment Syndrome – due to increase in the intracompartmental
pressures (mmHg) � Refracture – once the frame has been removed due to tension
shielding, a rare complication Types of External Fixators: 1. Unilateral Fixators � Produces compressive or distraction forces � Used to fixate fractures, fuse joints, and lengthen � Available in small or large, it is attached to the bone by multiple
half-pins screwed into the bone and attached to the fixator with the clamp
� Main disadvantage – not create any sagital plane stability & therefore should not weight bear immediately post-op
�49�
�
EXTERNAL FIXATION CONTINUED… Types of External Fixators Continued… 2. Circulator Fixators � Produces compressive and distraction forces � Used to fixate fractures, treat non-unions, limb-lengthening , soft
tissue lengthening, and correction of congenital deformities. � Utilizes trans-osseous wires with half-pins to position the wires in
different plane stability � Limited by the circular frame’s ability to fit the extremity and
patient’s comfort of wearing the apparatus 3. Hybrid Fixators � Combination of unilateral and the circular fixator � Used to treat tibial plafond fractures and pilon fractures � Utilizes trans-osseous wires and half-pins and footplate to allow
early weight bearing 4. Taylor Spatial Frame Fixators � Newest external fixation device � Allows for reduction and stabilization of fracture � Its unique feature allows for reduction of complex triplane
deformities
�50�
�
EXTERNAL FIXATION CONTINUED… Dynamization: After removal of the plate, the bone may be prone to re-fracture during weight-bearing because of weakening of the bone from disuse osteopenia. To prevent this complication it is important to gradually release tension in the trans-osseous wires and loosen the pins to allow the bone to gradually strengthen as it bears weight. Fixator Care & Management: Pin sites need to be kept clean with sterile solution and applied antibiotic cream in order to prevent infection and seal the opening around the pins. Avoid applying Betadine around the pins in order to avoid corrosion.
�51�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES Hallux Limitus / Rigidus Decreased or absent RoM at the 1st MPJ Normal RoM = 90o (20-25o PF + 60-65o DF) Radiographic Appearance AP � Focal joint space narrowing � Joint mice � Spurring � Asymmetry � Squaring of metatarsal head
Lateral � Dorsal Flag Sign � Spurring � Sclerosis � Metatarsus Primus Elevatus
Etiologies = TIN-MAC Trauma Infection Neoplasm of bone or soft tissue - Metabolic Anatomic Structural = short/long 1st ray, Met Primus Elevatus
1. Meary’s Angle deviation (b/s talus should b/s 1st met) 2. Parallelism between 1st & 2nd metatarsals 3. Metatarsal parabola / protrusion deviation Biomechanical = pronation, hypermobile 1st ray
Congenital
�52�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED… Hallux Limitus / Rigidus Continued… Joint Procedures: Joint Preserving
1. Cheilectomy = Valenti (V-cheliectomy) 2. Osteotomies � Proximal Phalanx = Bonny-Kessel (proximal DFWO) � 1st Metatarsal
Waterman = Distal DFWO Mitchell = step-down shortening procedure Youngswick = chevron double dorsal cut elevates Sagital Z = corrects for elevates Lambernudi = diaphyseal PFWO, for elevatus
Joint Destructive 1. Keller = Proximal Phalanx arthroplasty / for elderly / less
functional � Complications – transfer metatarsalgia, stress fracture of 2nd,
proximal migration of sesamoids 2. Implant = Hemi or Total – must cover cortical surfaces 3. McKeever = 1st MPJ arthrodesis – positioned dorsiflexed and
abducted with no rotation � DF = 10-15o off weight bearing – one finger under toe � 5-10o of abduction � Toe will no longer bend so patient cannot squat down
Joint Distraction with External Fixator:
1. Cheilectomy, mini rail 2. 7mm distraction intra-operatively, 2 weeks rest, then 1mm
distraction qd for 7d = Total 14mm Distraction
�53�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED… Hammertoes Function of Lesser Digits: � Decelerate the foot � Stabilize the forefoot � Aid in propulsion � Provide kinesthetic sensation Function of Musculature: � EDL / EDB = dorsiflex MPJ – passive flexion at PIPJ / DIPJ � FDL / FDB = actively plantarflex MPJ, PIPJ, DIPJ � Interossei = prevent buckling � Lumbricales = hold digits rectus (plantarflex MPJ, dorsiflex PIPJ /
DIPJ) Types of Deformities:
Etiologies for Contracted Digits:
1. Flexor Stabilization (Most Common) � Weakness of intrinsic Interossei Ms � Adv. of Quadratus Plantae � Pronated foot type – flexors fire longer and harder � Causes AdductoVarus deformity on 4th and 5th � Late stance phase biomechanical abnormality � Tx = Derotational Arthroplasty
MPJ PIPJ DIPJ Hammertoe Extension Flexion Extension Claw Toe Extension Flexion Flexion Mallet Toe Rectus Rectus Flexion
�54�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED… Hammertoes Etiologies Continued:
2. Flexor Substitution (Least Common) � Weakness of Triceps Surae – Flexors gain mechanical advantage
over extensors � Supinated foot type – late stance phase abnormality � Tx = suture FDL to Achilles tendon to strengthen muscles
� Must perform Arthrodesis
3. Extensor Substitution � Weak Tibialis Anterior – extensor gains mechanical advantage
over Lumbricales � Begins flexible and becomes rigid � reduce early w/ weight
bearing � Pes Cavus / Ankle Equinus / TA weakness / EDL spasticity and
pain are frequent symptoms � Swing phase biomechanical abnormality � Tx = Arthrodesis if Rigid
Hibb’s Tenosuspension if Flexible
�55�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED… Hammertoes Surgical Procedures: SOFT TISSUE 1. Tenotomy = stab incision medial or lateral to tendon deformities only � PF digit with blade in place – flexible deformities only � Older population only – lose strength & stability
2. Capsulotomy 3. Tendon Transfer 4. Girdlestone � Transfer FDL & FDB to dorsal head of proximal phalanx to restore
intrinsic function 5. Hibbs � Transfer EDL to base of proximal phalanx or met head
6. Kuwada & Dockery � Modification of Girdlestone – drill hole in base of proximal phalanx
and bring tendons up through it 7. Lengthening 8. Z-Plasty at level of MPJ 9. Percutaneous stab incision and splint **Complications: Muscle spasm caused by overcorrection, tenosynovitis, scarring, adhesion, weakness, bowstringing, and nerve entrapment OSSEOUS 1. Arthroplasty � Post – resection of base of proximal phalanx � Gotch & Kreuz – resect base of proximal phalanx and syndactylize
digits 2. Arthrodesis � Lambrinudi – fusion of PIPJs and DIPJs � Young-Thompson – Peg-in-Hole Fusion (Peg from Prox.Phalanx) � High amount of shortening
3. Taylor – PIPJ fusion using K-Wire
�56�
�
COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED… Hammertoes Sequential Reduction:
1. Z-Plasty 2. Arthroplasty 3. Extensor Hood Release 4. MPJ Capsulotomy 5. Volar Plate Release 6. Tendon Transfer (Girdlestone, Kuwanda & Dockery, Hibbs)
** Kelikian Push-Up Test: Performed between each step to determine if sufficient correction has been established. If you get dorsiflexion when placing GFR on the met head then do the next step. Hallux Hammertoe: Etiology: � Muscle imbalance � Iatrogenic after sesamoid removal or detachment of FHB � IPJ sesamoid binding FHL tendon Treatment: Flexible – IPJ fusion with EHL lengthening Rigid – IPJ fusion with Jones Tendon Transfer ~ Cut EHL distally from insertion ~ Drill hole transversely through 1st med head ~ Insert tendon through drill hole and suture back on itself
�57�
�
5TH DIGIT ARTHROPLASTY 1. Lazy “S” Incision � Lateral condylectomy of distal and middle phalanges with resection
of head of proximal phalanx
2. Derotational Arthroplasty � Distal Medial � Proximal Lateral Incision
3. Complications � Floppy Digit � Edema (sausage digit) � Floating Toe with Metatarsalgia � Regeneration of Proximal Phalanx � Infection � Decreased sensation � Blue toe
�58�
�
REARFOOT SURGERY Spurs are incidental findings only and are rarely the cause of pain.
1. May be painful if directed plantarly 2. Must be present to be approved for orthotics
Conservative therapies should be used for the first 3-9 months Plantar Fasciotomy:
1. Plantar L shaped incision at the medial midfoot 2. Release of the medial band of the plantar fascia 3. NWB for 3 weeks 4. Sutures out after 3 weeks
Endoscopic Plantar Fasciotomy:
1. Small incision in the medial rearfoot 3 fingers from the posterior heel and 2 fingers up from the plantar foot
2. Blunt dissection to the fascia 3. Insert spatula across plantar aspect of foot, dissecting fascia from
plantar fat pad – remove spatula 4. Insert trochar into slotted tube and insert through dissected incision
– remove trochar 5. Insert scope into tube laterally and blunt probe medially – separate
medial and central bands of plantar fascia 6. Insert cutting tool into medial tube and cut medial band of plantar
fascia while pulling instrument out of the tube 7. Visually observe abductor hallucis muscle belly before removing
tube and irrigating incision site
�59�
�
REARFOOT SURGERY CONTINUED… Haglund’s Deformity: Angles: Philip-Fowler Angle = normal 44-69o, >75o pathological Total angle of Ruck = Philip-Fowler + Calcaneal Inclination Angle –
Normal up to 90o, pathological if > 110o Parallel Pitch Lines – most objective method of determining a
Haglund’s deformity Procedures: Longitudinal incision lateral to TA Dissection down to posterosuperior Calcaneus Aggressive removal of pathologic bone, but don’t chase the bump If you need to reflect the TA, reattach with a soft tissue anchor and
remain NWB for 3 weeks Keck & Kelly Osteotomy: Indicated for increased CIA angle with no Haglund’s deformity Dorsal wedge osteotomy of the posterior Calcaneus Rotate posterior aspect of Calcaneus dorsally after wedge removal –
MAINTAIN PLANTAR HINGE Secure with cancellous screws NWB for 6 weeks
�60�
�
TENDON TRANSFERS Tendon Transfer – detachment of the tendon from insertion then relocate to new position Tendon Transplantation / Translocation – rerouting the tendon without detachment from its insertion Types: 1. Adductor Hallucis
� Resect at insertion, pass under the joint capsule and reattach at medial aspect of the capsule
� Indicated in HAV to realign the sesamoid apparatus 2. Abductor Hallucis
� Transected at insertion, rerouted inner 1st met head and fixated at lateral base of proximal hallux
� Indicated in Hallux Varus with an osteotomy 3. Extensor Hallux Longus
� Transected at origin, rerouted under DTIL, fixated to lateral base of proximal hallux
� IPJ needs fused � Indicated when have sagital component with Hallux Varus
4. Jones Suspension � EHL excised from insertion, drill a hole transversely through 1st
met head, rerouted through hole and sutured on itself � Indicated with cock-up deformity, flexible cavus, lesser
metatarsalgia, chronic ulcers, weak TA, flexible plantarflexion of 1st met
5. Hibb's Tenosuspension � EDL detached from insertion, bundled together and placed
through midfoot at the base of the 3rd met or lateral cuneiform � Indicated to release retrograde buckling at MPJs, met equines,
flexible cavus, claw toes
�61�
�
TENDON TRANSFERS CONTINUED… Types Continued... 6. Tibialis Anterior Transfer
� 3 incisions at (1) proximal dorsal leg, (2) TA insertion at medial plantar cuneiform / tubercle 1st met, and (3) the new area of insertion in the midfoot
� Release from insertion, reroute out the proximal incision, with tendon, with tendon passer brought to new insertion (usually 3rd cuneiform)
� Indicated for recurrent clubfoot, flexible forefoot equines, dropfoot, tarsometatarsal amputation, Charcot Marie Tooth deformity
7. Split Tibialis Anterior Tendon Transfer (STATT)
� 3 incisions at (1) base of 1st met, (2) anterior leg over TA just lateral to medial malleolus and (3) over peroneus tertius at base of 5th met
� Split tendon through proximal insertion, lateral slip passed through peroneus tertius sheath and sutured to tendon fixated to cuboid
� Indicated for spastic RF equines, spastic equinovarus, fixed equinovarus, FF equines, flexible cavovarus deformity, DF weakness, excessive supination in gait
8. Cobb Procedure
� STATT but reroute to TA to PA tendon � Indicated for PT dysfunction
�62�
�
TENDON TRANSFERS CONTINUED… Types Continued... 9. Tibialis Posterior Tendon Transfer
� 3 incision (1) insertion of the PT at navicular tuberosity, (2) anterior leg, middle 1/3 just lateral to tibial crest and (3) one at new insertion at dorsal midfoot
� Tendon released from navicular Tuberosity, dissected free at the medial leg insertion to expose the IM and the PT pulled through this opening then brought to new insertion level (usually 3rd cuneiform)
� Indicated for weak anterior muscles, equinovarus, spastic equinovarus, recurrent clubfoot, dropfoot, complications from Charcot Marie Tooth, peroneal nerve plaste, leprosy, Duchenne’s MS
� Muscle goes from a stance to a swing muscle during gait
10. Peroneus Longus Tendon Transfer � 3 incisions (1) lateral, lower leg, (2) lateral cuboid and (3) base of
3rd met/lateral cuneiform � Suture the Peroneus Longus to the Brevis , cut the longus at the
level of the cuboid and the tendon is brought through the proximal incision and back through the medical incision to the 3rd cuneiform
� Indicated for anterior muscle weakness, dropfoot
�63�
�
BUNION PROCEDURES TO KNOW BASED ON ANGLES IM Angle Normal: 0-8o
12-16o
Distal Osteotomy
Austin Hohman (Neck) -- Trapaziodal Mitchell (Neck) Wilson (Neck) Reverdin Laird (Distal L) Short Z Waterman Youngswick
>16o Proximal Osteotomy
Base Wedge Lapidus (Met-Cuneiform Fusion)Hypermobile Cresentic Juavara Proximal V of Kotzengerb
Comments: with a thin Met shaft � may need to use a proximal procedure Mitchell – shortens the length of met shaft � used in Long Met Length
( >2mm longer than 2nd met) Taylor’s Bunion = Symptomatic when IM4-5 >9o
Splayfoot = IM1-2 + IM4-5 >20o DASA Normal: 0-8o
>8o
Proximal Osteotomy
Proximal Akin -- cylindrical akin w/ long prox phalanx -- oblique -- transverse -- Bonnel-Kessel � DF wedge
Comments:
PASA Normal: 0-8o
>8o
Distal Osteotomy
Reverdin Reverdin Green� PASA
Comments:
�������
�64�
�
Abnormal PASA
+ IM Angle
IM:12-16o
+ Abn P
Distal Osteotomy
Biplane Austin Reverdin Laird (Distal L) � PASA + IM Reverdin Green Biplane Mitchell � Roux Hohmann
Shaft Osteotomy
Mau Ludloff Scarf / “Z” Klotzenberg Juvara
IM: >16o
+ Abn P Proximal Osteotomy
Lapidus w/ Reverdin V Osteotomy Logroscino (Base Wedge Reverdin) Cresentic Juavara Proximal V of Kotzengerb
Comments: HAA Normal: 0-16o
> 16o Silver McBride Adductor Hallucis Tenotomy Lateral Capulotomy
Comments: ST or Osseous Abnormality ↑ HAA + IM1-2 13-20o = Lodloff + Mau (+ ↑ PASA) = Scarf Z
HIA Normal: 0-10o
> 10o Distal Akin
Comments:
�65�
�
Tibial Sesamoid Position Normal: 0-3
4-7 Fibular Sesamoidectomy Fibular Sesamoid Release
Comments: �
Lateral Deviation
Angle Normal: 2.5o
+ IM4-5
Normal: 0-8o
IM: 8-12o Normal 2 Slight Increase LDA: Inc
Distal Osteotomy � exostectomy � dist. metaphyseal osteotomy
Reverse Austin Reverse Mitchell Reverse Hohmann Reverse Wilson Reverse Mercado
IM: > 15/16o Marked Inc LDA: ↑ Severe Lat Bowing
Proximal Osteotomy
Base Wedge
Comments:
�66�
�
� �
�67�
�
�
�
������0���������-���������1��������2�$�3����
�����������&�����������
Dr. Bodman’s Drugs p. 68
Dr. Caldwell’s Drugs p. 74
Dr. Caldwell’s Wound Care p. 84
Ankle Scopes p. 90
�68�
�
�69�
�
�70�
�
�71�
�
�72�
�
�73�
�
�74�
�
� �
�75�
�
β –���������’�������������������’��
� ��� � �� ���������
� ��� � �� ������������������
� ��� � �� ���������� ��������
� ��� � �� ��
� ���� � �� ���
�
����������������’���! "����� �������������������’s!��������#$�� �� �������
��������� �� ���%��#�� �������
������&� �� ���'� ���������
����" ������ �� �������
�(���"�"����� '���������’���)�*����� ��������
� ��+��,��� � �� ������ ��+�� � �� ���
� � � � � � � ��� � �� ��
� '�� -���� � �� ��� � ��.��� �� ��
� � ����. ������ � �� �� � ����� �� ��
�/0��#����
�–0�� 1������������-����*�����% #���
� � ���� ��2�����$�����"����# ��3� �#��
������+��0����#� - ������&� �2����44���0����#� - �����#�� � &��
����������������2 ��#����#��������� -��
��0��#�����$���#�5��# # ����- ��
�/0��#����
�–0�� 1������������-����
������� ���� ��2�����$���
� ��*���6�
������+��0��
44�'��-� ��1 -�� ��#��-��
����������&���2���# �7��
���� ������$ ����
8���� �
� �#�� ��
���#����� ��+������
�$ 2�����
�����������
44���0�������������� -����
������������������,�$ � ����
��#������ �� �#��#��#��$��������
�������������������
�&���� �#��#�#��#$ ��:�� ��7��
%���-�����#����Do NOT cover ��#������
�/0����-��<���2��
�–0�↑��<���2���
������+��0�↑��<���2��
�����������������������������
������������������ ����"���#$����%�#�����&���"�'��������
" '������ ������0�=��&�� ����������#�����# <�������+���� -���� ��2�,��� -���
>��? #$��#�������#$�#����#���������������������������"������������($)������������'������*+���&������������������"���,����"������������"�������
�������
�76�
�
β –���������’����%��������" '���
� � ����� �� ��>���.�+��#����@��,�������
� ���� � �� ��>���<���� ���� -����2���# �������
� � ���� �� ��>���<���� ���� -��� ���# �������
� ��� � �� ��>����+��#����'���,�������
�
�
�
�
�
�
�
�
�
�
� �
%���-�����#����
�/0��#������#��$��������
�–: Neisseria gonorrhea…�
������+��0���
-������.�����������/–���&���������
0��"�����������������"��.�������Augmentin ≤ 35% due to MRSA�
���������������������������6�������������.������ �����789��:;��&���"�����������
"������%�(0�
@��,��:�!8!BC2��E$�
��2���# ��:�FBC�2��G6$�
� ���# ��:�!8G2��E$�
'���,��:�!8H2��E$�
�77�
�
�����������’��G������� ������
� ��$���� ���I�&���������
� ��$�-��� ���"�� ��&������
� �&�.�� �������&�������#������
�
6�"����� ������
� �&���� �����&# �������
� � � ���������@ ����&�������#������
� �&�� # �����&�� ��������#�������
! "����� ������
� �& � ����������������
� �&��- �������# ��������
� �&#� ������� ����$ ��������#������
� �&#�. - ����J��#�.�������#������
� �&- � ������ ��&��
��
)�*����� ������
� �& � ������� � ����
�
�
�
�
�
�(���"�"����� ������
� �&#�+ �������
�
� �
�/0��������# <���2� ��#��#��$��������#$���!�-���
�–0����-��<���2��
� �/�����-��������
��0���
�/0����-� �#��$���������
�#��$��� -��� - ��
� � �#����
�–0������ ���I�
��0������ ����%8&��������<�=+>������"��.���������?���&�
�/0������#����2��-����G�#���
�–0���#��-�-�� *���–����I��
��0���
��–����� ������$ ���� �&����.��
�#���+��#�������2����
�� ���� ������ ���
���#����� ��+ � ��
8���� �
���+� ������������ ��
�����# ���
�/0�� 2� & ���#�,�↓↓↓�
�–0������ ����<���2��
� �J��#�.�������-��������
� � ����$ ������ ���� ���
��0���
4�<�����#��$�5��#����+�##���#$���G�#��8��������<������������� ���#����$���� ��
� 4x’s better for Staph // 7x’s better for Strep�
"������%�(0�
��� ��&�:�!HH�2��G6$�
��������&���0��"��
�/0���–���# <���2� ��#�� ���
�–0���
��0���
" '������ ������0���<� -���$������� ��� &��#������2 ��#����� � �� �7�
�&- � ��6�-���5��&���� ���!�-�����������?�-�&������ � �� �������2,7��� ��������&&���������������8�
�78�
�
���������’���
�� �����– ���# ����� ��� ���
�
�
�
�
�
�
�
�������������������
�
�
�
�
�
��#����������<��.����>����
�
�
�
�
�
"�� �������
�
�
�
�
�
�
�
�
�
�
�
� �
� �
%���-�����#����
�/0���–����#�
�–0���–����#��������-�������–���� �#��#��
� � ���������,���������–���� �#��#��
��0���–���������#�
4�"����� �� �#����P7�
�/0��#��$�5��#�������,����&�� ���#���� �������
�–0���������� ���#���� �������
��0����
4���#�,��"����� �� �#��
�
↓��� .���� �17�
�/0����
�–0� � #�-�
��0����
%���-�����#����
�/0����
�–0���������-��������
��0���
�
" '������ ������0���
>�� ���#��? #$���� � �� �������2,�
>�� ���#��? #$��� .����* �#��,�
��#������� �#����#��? #$����+�� � -8�
"������%�(0�
��<��.�:�G2��-�
� ���Q�!H��>� ��:�CHH�2�E$����R- ��,� ��
�79�
�
������������
�.#���������.��#������>����
�
�
�
��
����������������
���#��,� ��
��+���,� ��
�� 1�� ��
�
�
�
�
�
�
��
������������G������� ������
������,� �����>����
�
�
�
�
�
�
�
6�"����� ������
� "��+�<��� ����>����
�
�
! "����� ������
� ����<��� ��
�/0���RR�� ����� �����#�����8- && � ���
�–0�U� �
��0�U�
�/0���
�–0�����U����-�������
��0��� �@�&��������������?�����������B�������������������C�������������B����&�������������&&���������������������
�/0��� � ���
�–0��� ���#����� ��+ � ��
� � ����-�������
� � I��+� �����
� � �8���� �
� � �����������
�$ 2�����
��0���
�"�� ���" '�� �������0��
�#�#�� � #,�D)��� ����.��E�
���$��#�� � #,�D�� ����.��E�
*,��I/���–––����#��,� ��
*,���2/�––��� 1�� ���
�������������.�����������/�� �������'�DF+����"��������E�6��������DF+����.�&�������������E��� �������������������
�/0��� ���� ���
�–0��� ������#� - ���- && � ���
��0���
�"�� ���" '�� �������0��
�#�#�� � #,�D�� ����.��E�
���$��#�� � #,�D�� ����.��E�
�-������,�-�����
���# +�������+�������
�$���+��$��+ # ���
�/0����RR�� ����� �����#����
�–0�U� �
��0�U�
����G���������������"��������for pts allergic to β,��������,��@��"�&�������� ��������� "�������"3'�������%�(0�
CH120�� BCH�2�
CHRB)120���GHHH�2�
BCRVH120���G6CH�2�
WVH120�������GCHH�2�
�����������2$�:�CRGH�2>-�
�&�#���2$����2��WGC�2>-���
-��+���#$��-����# ��� �#��<���
"������%�(0�
������,� ��:�G2����?����$�����
D� ���;+���E�
�80�
�
����������’���
"��,�,�� ���
� ���,� ���
��#$��,�� ���
��#���,�� ���*�
�
�
�
�
�
�
�
�
��
�
��������’���
��,#$���,� ��
�
� �
�. #$���,� ��
�����@ #$�������
�
�
�
�0����?���,)�&�����������"��"����������������?���
�/0��� �#��$��������
� ���
�–0��� �8���� ��
I��+� �����
��#���+��#���
� � � +� ��<��� & ��������#�=�#���
� � �1�##� ��
� � $���,- ��
��0����
�"�� ���" '�� �������0��
������� & ������������~ Don’t give Doxycylcine before bed ������� �����"��������
�$�#����� # < #,�
�$�#�R��,�$��,� ���"��,�,�� �����
U���#���������# # ��
������"�������0�
������2���#�>�I -��J������������������������'����������=��
>��&����#�����" 2�� ��RR�↑���� � #,�
>��&����#���������#���������RR�↑���������-���#������+� � �1�
�+����# ��� ��� � #�-�+,0�
X��J��-������������X�� �1�
X���#�� -�������X������
�
�/0�����#��$�>��#����>���,��+��#�� ���� � #��� ���4�
�–0��� �
��0����
�/0�����#��$�>��#����
�–0��� �
��0����
�"�� ���" '�� �������0��
���'���#�
������2�-�*���#�"������ .�# ���X������-���-���� �#����
" '������ ������0���#��#���$ + #�����&�P��!�)�
,������ ���>�� ��� ����>������� ����
>��&����#�������+�.�� ���5��$���$,� ���
�����"����:���� �1��&���--���"��#$�
��+ ��-�? #$��6/�$�����%���1����
:���� �1��&���--���"��#$��
DK��"�����������L��E�
4���,#$������������� �-�=��-������
��������N� ���G�����������%����
"������%�(0�
@ #$������:�CHH�2�G�#�"�,�
�.R���1���������6CH�2��-����#�)�-�,��
�"�� ���" '�� �������0��
���'���#�
������2�-�*���#��
" '������ ������0��#��#���$ + #�����&�P��!�)�
↑" 2�� ��>>�↑����- ��
*������ �-��#����↑�
������������,,�"����0��"�����������
�81�
�
�������������
� �-��,� ������� ���
�
�
�
�
�
�
�
��
�
�
��������������
�
�
�
�
��
�
�
�������������
�� ��#$��� �–���&���#$���.�����%��#� ��>����#����
�
�
�
�
�
�
�
�
�/����%���������������� ������(0�������������
�/0��� J��� ��#�����������#���������# . �2�J��� # ��
������%��#����J��������#������������� ���J��������#������������
�#��$�������44�
�–0��� �
��0���� %8�&��2 � ��
�"�� ���" '�� �������0��
" ���$���
����-����+��������� # ���
" '�R" '������ �����0�
↑ ��� ��#��,������,� ��? #$��8��������#���%����&���>�" �.�������
4�#��$����������� �#��#�#��
��,#$���,� �����5������
-�<����� �-�� +������ �#�����#��
� �-��,� ��
45���&���2�� ��� ������ # <��
#��� �-��,� ��+�#���� �#��#�#��
��,#$���,� ����-������2 <��
� �-��,� ��+������� #�? ���
-�<�������� �#�����
"������%�(0�
���� ��:�EHH�2�G$�����R���
/� ������"��"��������&���.�������� ������������
�/0���
�–0��� �
��0�������� ������&��# �����
8����������������#������#�&���� �
�"�� ���" '�� �������0��
���,�%�+,��,�-�����
��<����%���������?���� � #,�
�����# ������ ���
�%�#�������"���� ���9+����������
�/0��� �#��$�5��#����
� � � ���
�–0��� �
��0��� �
�"�� ���" '�� �������0��
���#���������# # ���
" '�R" '������ �����0�T–S + Methotrexate = ↑ Bone Marrow Suppression T–S + Coumadin/Digoxin = ↑ Toxicity of C/D T–S + Oral Sulfonylureas = Hypoglycemia��
�82�
�
�����������������
��#��� -�.�����J��2,���
�
�
�
�
�
��
�
�
�
������������������������
���&����� ��� �����
�
�
�
�
�
�<�&����� ����<��� ����
�
�
�
�
��� &����� ����<������
�
�
�
�
�
�
�
�
�
�
�
�
�������������.�������(��������"�� ���" '�� �������0��
��� �$������������#$ ���
�>��? #$�����$���������# ���
"��1�%��?��'� ����
" '�R" '������ �����0�
↑ Anti-Coagulation effects of Warfarin�
�/0���
�–0��� �
��0�����%8�&��2 � �
"������%�(0�
J��2,��:�GC�2>12����- �2�-����
�����������������B8C�2>12��E$����R��R�CHH�2�# -�
�/0��� �
�–0�������#���# <���
�2� ��#��8�����2 ������� �&��# ����&�+�����5�Y� �#���
��0��� �
"������%�(0�
����:�BCH�2�+ -��
" '�R" '������ �����0�Not give within 2hr of: Multivitamins, Antacids, Sulcralfate MANY interactions! – Theophyline, Caffeine, Warfarin, NSAIDs, ddI (HIV) May see… Torsades de Pointes & Ventricular Fibrillation **May produce a false (+) on viral assay for opiates
"������%�(0�
�<��:�CHH�2��-�����>����
�/0�����#���� �
�–0�����8�2�����$����
��0��� �
�"�� ���" '�� �������0��
���>�*��-��$��>��$��+ # ����������������
����������.�������&&�����D/�E�
%���-�����#����
�/0�����#��$��������� �#�����
���#������$����-�
�–0�����
��0����%8�&��2 � ��
4����-� �����
4����-�&���- �+�# ��&��#�
�&��# ����? #$� ������+���
�#$���������� ��
4���,�?��1��2� ��#��%�
��� ���"�������0��
'�-����2��GF��
���2���#�>����� �2�� �?����'��B�������
(��������������������$���"�����
�83�
�
���������� &��� ��
�
�
�
�
�
�
��
�
�
��������������"��&��� �# �>Z� ���� �# ��� �����
�
�
�
�
��
�
�
�
�!������������ ��.�� -��@,<����
�
�
�
��
�
�
�
�
�
�������–������������"��#��,� ����+ � ���
�
�
�
��
�
�
��������������� 2��,�� �����,2�� ���
�
%���-�����#����
�/0�����#��$��������������
���#������ -��� - ��
��� ���
�–0�����8�2�����$����
��� ���,��+��#�� ���
��0�����
�������&������������� �(O��79+��������� ����N�"����� ����K�����������������0?��
"������%�(0�
��#�2 <������������ <��? #$� ����>�%��#� ��
�/0����� ��
� ��� ���
� ��� ���
�–0�����
��0��� �
�"�� ���" '�� �������0�
��#$���2 ��>��,��2 ��
�������
�$���+��$��+ # ��
↑�LFT’s�
��Y��# ���� #�� ���# ���
������ ���������������
�/0����� ��
� ��� ���
� ��� ���
�–0�����
��0��� �
�"�� ���" '�� �������0�
�,��������� ���
�>������# ���� -�� ��
��# ���������#$,�����WG���
�/����.����"�����������* Check weekly CBC’s�
�/0����� ���
� ��� ���
�–0�����
��0��� �
" '������ ������0�
��+���,� ��
�#�# ������,���#$,�
* Check weekly CPK’s��
"������%�(0�
)�2>12��-�
%���-�����#����
�/0����� ���
� ��� ���
�–0��������0��� �
�"�� ���" '�� �������0�
�>���
���#$�" �������# ���
* Check weekly CPK’s��
"������%�(0�
��0�GHH�2���- �2�"����
�������CH�2�+ -�
�84�
�
������������������#������.���������������
�
�
�
�
�
�
�
�
���+ ��& ������ � ���
�
�
�
�
�
�
�
�
J������.�����" &�������
�
�
�
�
�
�� ���&��< ����� �R�����
�
�
�
�
��
�
�
�
�
��������������������$ �+��-�.������ �#�.����
�
�<�����# ��
"����#��$,#���
��- -��
���-�� �
��������������
������"����D�&&���.��E� �
�"�� ���" '�� �������0�
�������#�>� ��$�>�*��-��$����
*���#�#�� � #,���LFT’s ���5������
�
" '������ ������0��
�#�# ��������������6/�$������%���1����
� 1��,������������,#$���,� ���
��� ���"�������0�
��# ��# ? #$ *J7
"����#��$,#�����������������
������"����D�&&���.��E� �
�"�� ���" '�� �������0� ����
*��-��$��>��+����������#��
������� � ���
�
" '������ ������0�P�)CH�6"E�
��# - ���������,������� ���
&��� ��������������#� �#,� ���
�&&� ����
"������%�(0��
������"�� �2�:�6CH�2��-�G�?��1>����<���6���
�������:�6CH�2��-�!���
"����#��$,#���
��- -��
���-�� �"������%�(0��
������:�!HH�2>?��1�
�"�� ���" '�� �������0��
��<�����1 �� ��$�
������ ���
"��2���#����# ���0�P�)CH�!�)�
(�������������"�����"����#��$,#��� �"�� ���" '�� �������0��
�����#$�� ��>� ��$�>�*��-��$��
�
" '������ ������0��
�������#�����# <���
=��&�� ��
%��+ #��#����
"������%�(0��
6CH�2�# -���)RF�?��1���
"������%�(0��
������"�� �2�:�6��GHH�2�#�+�� �����5����? #$�&��-�
�������������������������1��&���G�?��1��&�#$����8�&���]]]����#$��
�(���������N�� �����������
"������%�(0��
� �#�.���:�GH^�������������# ���� -�
Ivermectin = 200μg/kg po x1dose for 1R6-�,��
�85�
�
"���������#�����������
���������:�������,�#��� ���� �<������# � ���+ ����&&��#����#��B-�,���
�-��������-�#���?$ ����� �#� � �2����� �#�?���-���< ������#�
�� �#���? #$��#�� ���?�#�������������777�� �<�������#��? #$���� ����
�&&��# <���2� ��#�� ��5�� ���
�������������$�������!���������:��+���+��#���- ����-�������
���?�,���������������������#���&���H8V^�������#��� �- ���
����%���������
��-���#��#��* 2$����-�#���
��<�������#$���-$�� <��#,��7�
�
�����!� �-$�� <������R?�<���&�+� ��
*��-����#R���-���� �2��>���#$�#����>�-�� ��2��#�+��� ��������
�
�����������:�����#��������R������ 2 ��������� 2���
�?����-�#��
�R�� #$�� �� . �2�?���-��
����-$�� <��
����������+���
�/�����< -����� �#����
�-��$��2��&��� �&��#�-�?���-��
�/�����#���������������<���
�–����#��# ���#��������#���������- �2��1 ��
�
��������:�"��-�����������R����� ��#�����*,���2��� �?����-�#��
���# �����J����#$ �1�����?���-��
'��������2������# ���# ����� ��������#�
�/�����#���������������<���
�/�����< -����� �#����
�–����#��# ���#��������#���������- �2��1 ��
�
�������
�86�
�
�����������������:���� #�����2�-�����% ����� <����� <�?�
�-$�� <������,���#$����& ���
�?����-�#��
��,�+�����-��<����+����# <��?���-�& �#������$,-��2����
����&�����J�����7�
�����& � ���=���-���%� �#������
�/��'��#��B-�?����# ������� R������+����
�/������?��< ��������������#�
�/�����< -����� �#����
�–����#��# ���#��������#���������- �2��1 ��? #$������� <��-�� ��2��
�–�������+����# <���
�–���-$�� <����,�#����$���#$,��1 ��
�
�������������:�"��-�����"��-�����J��#��������J����������2����+�� ��#�����
�-$�� <��������� <��
�?����-�#��
�������# �2�5��� #$�� �� . �2����# ����$ �1�����=���-���
��,�+�����-��<����+����# <��?���-�& �#������$,-��2����
����&�����J�����7�
�<���w�����#�G ��$��&��������- �2��1 ��
�/��'��#��!-�?����# ����
�–����,�#����$���#$,��1 ��
�–����#��# ���#��������#���������- �2��1 ��? #$������� <��-�� ��2��
$��2��-���� �2�+�&���� #����1��
�-��>"�� ��2�������������
�
�����:���# ���#��� �#������#���������<,������,������� ����-$�� <��%��-����
���,���#$����
�-$�� <���������-$�� <��
��-���#��#��* 2$����-�#���
���, �2��$ �1�����
��&��#�-�?���-�� &��$��2�-�-� �,�
��������2�'������
�/��'��#��B-�?����# ����
�–����,�#����$���#$,��1 ��
�
�87�
�
��������:����+�����"����������2 ��#���I��#��#�#��������+�
���?��-����,����
����&����-�?$���& +���� �#����#�? #$�?���-�&�� -�
��-���� ����J����
���# ��>J�����$ �1������������# �2�=���-��
��-���#��#��* 2$����-�#���
�/��*�����#�# ���&&��#�
�/��'��#��B-�?����# ����
�–�� ��� ����6��-���� �2�
��&��#�-�?���-�� &��$��2�-�-� �,�
�������� -���������������������<���
��������=��*�������:�J +������
� VH^�����2����GH^���2 ��#��
����������� ������"�=��*����� ��
��������%�"������������ �$��#��� ��������#���������������?-�����-���&��#���$����,�����
"����=���-��
*��<,����-�#���
��������������������� ���- & �����# ����>��-�>�������1 ������,�������$��<����
'�������2��������&���"�,�=���-��� � � � � �����2������+�����
'����$��#��&����?�����-���#�����-�# <��=���-��
'�����?-��������# ��������-��&�����-���#����*��<,����-�# <��=���-��
��# ���0��+���+��#��*����#�� ���$���#�� ������< � �������#� �� ��?���-��
&����������# ���# �����&����# ���
�������������� .�-�������#�� ��#�-�?���-��
� CC^�����2����>>��))^�� ��� - .�-� �2�����#�-����������
� G^�� �<���
����������
� CC^�����2����>>��))^�� �
� ���,���#� �����<���#��+ �-�5���-�����������#� ����#������# �����
� � >����2������+��+ �-������������ ��#$��-���� �2�#$��� ����
����2���������
�������:�'� #��% ���#� ��
� ��.,������ �#��#������2������&&��-�RR�J����#��#�-�
�
�88�
�
������������������������� �����!�:�%�������� ��
� ����+ ���#��"�J����#���#R-�� <�-�2��?#$�&��#����
� �##���#�������,#���5�& +��+���#��RR� �&�����#��,��$�����
� �# ����#���2������# ���# �����
� �&� 2���#���
� �2����������H8HG^�
� GC2�#�+�������,��-�������-��<���,���-�#$ ���G>GE#$� ��$��
� �<��� ���� �#���� ���2��.��-���� �2�
���������:��$���+ �–��-���-����#���#� ������#��
� �J�&������# ��#���?��+���-�
� CHR6HH����&�+���-�-��?��&������# ��#��
� �� ��-�?���������#�����# <�#��#$��#$���+ ��
� G�+���-�-��?�:�!����&�-� �,����� ��# ���
�
������� ����������:�% ��,���-��1 ����� <����#�
� �� -��� ��5�"��� ��"��� ��� -��-�?��
� ��?+����&����1 ��
� J�-��� ��6)$�� ����#� �- �$�–����� ���- �#��,��
� ���������������� <��?�����<��� #�
����������:�*�����"������ ���������#�
� ��?+����&����1 ��
� �<���? #$�����<,��5�*,��& ��#����
� "����������? #$���,��#$���#�� �����2��#�
������� ��������#���# �����+�������� 2>���� ���
� �������&&��-��##���#����# ��#��������
� �#����w������#�������#��GF���
��������� ����2��–��,����� ����,����% �-�2��-�+�����#� ���?>%�< ���
� ���������#� ���&������R� �1�-�+�< ���#��-��������2��>�����
� ��� R������+������,� �������� � ��������,���
� �#�� ����������# ���
�
�
�89�
�
������&������ ��������-�*�����"���������+�����
� !R"�% ���# <��J�����–�������#��2������# ���# �����
� "����=���-��
������������ ����- �#�-�$������1 ������2��&#�
� �� -��� ��5�"��� ��
� �#����w������#����
� �&#���6)$�� ��������RR�����<�������-��,���<�� �2���-�����?������#��� �R
-�,�&���6R!$���������-� �-� ��������#$���� ��������-�#������<��� #�
� �/����# ��#������-��#$ ���#�$�����
������������� � �������:�����2������
� " 2��#�������2��� �������# ��# �����
� ����2��� ��$���#$,�# �������� ����?�,�&����-�2������# ���# ����� ����#�
�##��1�-�
� ��,�+�����-���������# + �# ����?-���
� �#�������?$���2������# ���# ����� ��?������#�+� �$�-�
����.,����/�������
� ���� ������#���,# ����.,���&��������,��
� '���������#� ��-���#�� �2��2��#�
� ��,�$�<����+��� �2������# ��� ����# ��#�� � ��
� �������? #$����������� ��������?�#���
����& ��
� ���� ��
� '�����
� $�����$,�� �����������������- �������$ + #��$���22��# ��# �2�5�
�&�����#��,�������# ����&����#� ��-�2��-�# ������-��#�� ��#$��?���-�
������:�J +� ���,� �"����,� +���������� � ��6�J �-���
���������������������������������"� !��������������
� %�������&����������������-�+���-�&��?�#��?���-�� #���
� ��#���� �������#������� �#���< ������#�
� ��,�� ������� �#� ����� �#�?���-�+�-�
� ���� ������2��� ���*,-��� -���#����#����J�� -� �������#�
�90�
�
�����������PORTALS: � Anterior � AnteroMedial
� Medial to Tibialis Anterior � Visualize: medial gutter & medial transchondral margins � Caution: TA, Saphenous V & N
� Accessory AnteroMedial � AnteroLateral
� Lateral to EDL or Peronial Tertius � Visualize: lateral gutter � Caution: EDL, Peronial Tertius, Superficial Peroneal N
� Accessory AnteroLateral � AnteroCentral
� Lateral to EHL � Caution: AntTibial A, Deep Peroneal N, EHL & EDL tendons
� Medial Midline Portal � Posterior � PosteroMedial
� Medial to the Achilles Tendon � Caution: Sural N, Lesser Saphenous V
� Accessory PosteroMedial � Modified PosteroMedial � PosteroLateral
� Lateral to the Achilles Tendon � Visualize: the posterior process of the talus & posterior media talar dome � Caution: T-D-A-N-H
� Accessory PosteroLateral � TransAchilles � Coaxial Portals
� 6 Central Points � Med / Central / Lat – TibioTalar Artic � Posterior Inferior TibioFibular Lig � Transverse TibioFibular Lig � Capsular Reflection of the FHL tend
� 7 Posterior Points � PostMed Gutter � Med / Central / Lat – Talar Dome � Post TibioFibular Artic � PostLat Gutter � Posterior Gutter
21 POINT EXAM: � 8 Anterior Points � Deltoid Lig � AntMed Gutter � Med / Central / Lat – Talar Dome � Ant TibioFibular Articulation � AntLat Gutter�� Anterior Gutter�