Adult Elective Orthopaedics and Spine
Chapter 5 Foot and ankle
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source p. 270
Structured oral examination question 1#
source p. 271
Lateral ligament instability of the ankle
EXAMINER
Tell me what this diagram (Figure 5.1) represents and name the structures labelled 2, 3 and 5.
Tell me what this diagram (Figure 5.1) represents and name the structures labelled 2, 3 and 5.
CANDIDATE
structure 3 is the calcaneofibular ligament and structure 5 is the posterior distal tibiofibular ligament.
structure 3 is the calcaneofibular ligament and structure 5 is the posterior distal tibiofibular ligament.
EXAMINER
What structures are injured in a lateral ligament injury?
What structures are injured in a lateral ligament injury?
CANDIDATE
The mechanism is usually a rotational injury with sequential failure of the ligaments from front to back, hence the anterior talofibular ligament or ATFL is most commonly injured followed by the calcaneofibular ligament or CF Land the posterior talofibular ligament is the least frequently injured.
The mechanism is usually a rotational injury with sequential failure of the ligaments from front to back, hence the anterior talofibular ligament or ATFL is most commonly injured followed by the calcaneofibular ligament or CF Land the posterior talofibular ligament is the least frequently injured.
EXAMINER
How would you go about diagnosing a lateral ligament injury to the ankle?
How would you go about diagnosing a lateral ligament injury to the ankle?
CANDIDATE
There may be a history of recurrent sprains and instability. In apa tien t with a chronic history the clinical signs of instability would be a positive anterior drawer testor talar tilt t est.
There may be a history of recurrent sprains and instability. In apa tien t with a chronic history the clinical signs of instability would be a positive anterior drawer testor talar tilt t est.
EXAMINER
Tell me more about those two tests.
Tell me more about those two tests.
CANDIDATE
Pain or excess anterior translation or a sulcus sign developing at the anterolateral corner of the ankle are signs of an ATFL injury. The other ankle must be examined for comparison. The lack of a firm endpoint or tilt in excess of the normal side suggests instability and the CF Lis considered to be injured if this testis positive.
Pain or excess anterior translation or a sulcus sign developing at the anterolateral corner of the ankle are signs of an ATFL injury. The other ankle must be examined for comparison. The lack of a firm endpoint or tilt in excess of the normal side suggests instability and the CF Lis considered to be injured if this testis positive.
EXAMINER
What other clinical findings may be positive in apa tien t with recurrent ankle sprains?
What other clinical findings may be positive in apa tien t with recurrent ankle sprains?
CANDIDATE
Ankle sprains are more common inpatients with a cavus foot or hypermobility.
Ankle sprains are more common inpatients with a cavus foot or hypermobility.
EXAMINER
If you suspect a lateral ligament injury how will you proceed in managing this patient?
If you suspect a lateral ligament injury how will you proceed in managing this patient?
CANDIDATE
The first step in management would be rehabilitation with physiotherapy, concentrating on peroneal strengthening and proprioceptive training.
The first step in management would be rehabilitation with physiotherapy, concentrating on peroneal strengthening and proprioceptive training.
EXAMINER
What percentage of patients recover?
What percentage of patients recover?
source p. 272
CANDIDATE
The vast majority.
The vast majority.
EXAMINER
[That’s vague] Do a figure?
[That’s vague] Do a figure?
CANDIDATE
Sorry. Around 20% of patients develop symptoms of chronic ankle instability such as recurrent sprains, weakness and instability. Candidates should know this and may lose a mark.
Sorry. Around 20% of patients develop symptoms of chronic ankle instability such as recurrent sprains, weakness and instability. Candidates should know this and may lose a mark.
EXAMINER
How do you determine severe injuries?
How do you determine severe injuries?
CANDIDATE
The options for acute grade III injuries include cast immobilization or functional management. Cast immobilization involves 3 weeks in a below-knee walking cast followed by 12 weeks proprioceptive rehabilitation. Functional management involves early mobilization with external support and a protocol of rest, ice, compression and elevation.
The options for acute grade III injuries include cast immobilization or functional management. Cast immobilization involves 3 weeks in a below-knee walking cast followed by 12 weeks proprioceptive rehabilitation. Functional management involves early mobilization with external support and a protocol of rest, ice, compression and elevation.
EXAMINER
What if the patient continues to have significant symptoms despite adequate rehabilitation?
What if the patient continues to have significant symptoms despite adequate rehabilitation?
CANDIDATE
Other investigations includes tress X-rays of the ankle and/or ultrasonography to assess the degree of ligamentous injury and if the patient is still having significant pain and swelling an MRI scan to look for additional pathology.
Other investigations includes tress X-rays of the ankle and/or ultrasonography to assess the degree of ligamentous injury and if the patient is still having significant pain and swelling an MRI scan to look for additional pathology.
EXAMINER
What other conditions would you be looking for?
What other conditions would you be looking for?
CANDIDATE
My differential diagnosis for an ankle sprain that does not improve would be peroneal tendon pathology such as a split tear or subluxing tendons,
My differential diagnosis for an ankle sprain that does not improve would be peroneal tendon pathology such as a split tear or subluxing tendons,
EXAMINER
Do any scoring systems for chronic lateral instability?
Do any scoring systems for chronic lateral instability?
CANDIDATE
No, sorry. Karlsson score, American orthopaedic foot and ankle score (AOFAS) and the foot and ankle outcome score (FAOS).
No, sorry. Karlsson score, American orthopaedic foot and ankle score (AOFAS) and the foot and ankle outcome score (FAOS).
EXAMINER
What are the surgical options for management of an isolated lateral ankle ligament complex injury in a young patient who has failed to respond to non-operativ e treatments?
What are the surgical options for management of an isolated lateral ankle ligament complex injury in a young patient who has failed to respond to non-operativ e treatments?
CANDIDATE
The options f all into three broad categories. (1) Anatomic repair, (2) non-anatomic reconstruction, (3) anatomic tenodesis reconstruction.
The options f all into three broad categories. (1) Anatomic repair, (2) non-anatomic reconstruction, (3) anatomic tenodesis reconstruction.
EXAMINER
What is an anatomic repair?
What is an anatomic repair?
CANDIDATE
Anatomic repair involves the use of endogenous ligamentous tissue to restore the ligament. This is considered in cases when adequate tissue is present.
Anatomic repair involves the use of endogenous ligamentous tissue to restore the ligament. This is considered in cases when adequate tissue is present.
source p. 273
The Broström and the ‘modified Broström’ are the most widely used procedures for anatomic repair of the lateral ligament complex.
The complication rate is lower (fewer wounds, less risk of injury to the superficial peroneal nerve and decreased incidence of degenerative joint disease) compared to non-anatomical reconstructions with minimal effect on subtalar movement and a quicker rehab.
Failures have been atiribut ed to a variety of factors, including generalized ligamentous laxity, poor tissue quality , previous surgical repair, long-standing instability, and cavo-varus deformity.
EXAMINER
What do you mean by a non-anatomic reconstruction (checkrein procedure)?
What do you mean by a non-anatomic reconstruction (checkrein procedure)?
CANDIDATE
Non-anatomic reconstruction does not replicate the normal course and anatomy of the ATFL and CFL.
Non-anatomic reconstruction does not replicate the normal course and anatomy of the ATFL and CFL.
EXAMINER
What do we mean by anatomical reconstruction?
What do we mean by anatomical reconstruction?
CANDIDATE
These procedures utilize autogenous tendon gratis such as semitendinosus, gracilis or plantaris that are rerouted in such a way as to replicate the anatomic positions of the A TFL and CFL origin and insertion sites.
These procedures utilize autogenous tendon gratis such as semitendinosus, gracilis or plantaris that are rerouted in such a way as to replicate the anatomic positions of the A TFL and CFL origin and insertion sites.
EXAMINER
Are intra-articular lesions common in this group?
Are intra-articular lesions common in this group?
CANDIDATE
In one study associated intra-articular pathology amenable to arthroscopic treatment was identified in 83% of patients undergoing Brostrom repair [1].
In one study associated intra-articular pathology amenable to arthroscopic treatment was identified in 83% of patients undergoing Brostrom repair [1].
EXAMINER
Apa tien t asks how successful a ligament repair will be, what will you tell them?
Apa tien t asks how successful a ligament repair will be, what will you tell them?
CANDIDATE
I would expect a successful result in approximately 80% of patients.
I would expect a successful result in approximately 80% of patients.
EXAMINER
What are the reported results of using a free hamstring graft?
What are the reported results of using a free hamstring graft?
CANDIDATE
The reports are good but there are some reports of weakness of knee flexion beyond 70°, particularly when both gracilis and semitendinosus tendons are harvested. This leaves the stabilizing evertor muscles intact together while reconstructing the A TFL and CF Land so may also be considered to be an anatomic repair.
The reports are good but there are some reports of weakness of knee flexion beyond 70°, particularly when both gracilis and semitendinosus tendons are harvested. This leaves the stabilizing evertor muscles intact together while reconstructing the A TFL and CF Land so may also be considered to be an anatomic repair.
source p. 274
The selected fixation device should be secure enough to maintain appropriate graft tension intra operatively to support healing and potentially allow for early joint motion
EXAMINER
Thankyou.
Thankyou.
Figure 5.1 Diagram of the lateral ankle ligaments.
source p. 275
Structured oral examination question 2#
source p. 276
Ankle arthritis
EXAMINER
Describe the findings on this X-ray (Figure 5.2).
Describe the findings on this X-ray (Figure 5.2).
CANDIDATE
This is an AP weight-bearing radiograph of a left ankle showing narrowing of the joint space and some subchondral sclerosis.
This is an AP weight-bearing radiograph of a left ankle showing narrowing of the joint space and some subchondral sclerosis.
EXAMINER
What are the most common causes of arthritis of the ankle?
What are the most common causes of arthritis of the ankle?
CANDIDATE
In a recent epidemiological survey, the onset of ankle osteoarthritis was atiribut able to a previous rotational fracture (37.0% of cases), recurrent sprains (14.6%), a single sprain (13.7%), pilon fracture (9.0%), tibial shaft fracture (8.5%) and osteochondral lesion of the talus (OLT) (4.7%) [2].
In a recent epidemiological survey, the onset of ankle osteoarthritis was atiribut able to a previous rotational fracture (37.0% of cases), recurrent sprains (14.6%), a single sprain (13.7%), pilon fracture (9.0%), tibial shaft fracture (8.5%) and osteochondral lesion of the talus (OLT) (4.7%) [2].
EXAMINER
How is this patient likely to present?
How is this patient likely to present?
CANDIDATE
The patient is likely to complain of pain, restriction of movement, deformity and difficulty in undertaking activities of daily living (ADLs).
The patient is likely to complain of pain, restriction of movement, deformity and difficulty in undertaking activities of daily living (ADLs).
EXAMINER
Are you aware of any classification systems for arthritis of the ankle?
Are you aware of any classification systems for arthritis of the ankle?
CANDIDATE
No, I am not aware of any classification systems specific to the ankle. The Kellgren and Lawrence Radiographic Criteria can be used [3].
No, I am not aware of any classification systems specific to the ankle. The Kellgren and Lawrence Radiographic Criteria can be used [3].
EXAMINER
The X-ray you have been shown belongs to a 42-year-old manual worker who had an ankle fracture 7 years ago that was managed non-operativ ely. Describe your management strategy for this patient.
The X-ray you have been shown belongs to a 42-year-old manual worker who had an ankle fracture 7 years ago that was managed non-operativ ely. Describe your management strategy for this patient.
CANDIDATE
I would first want to take a full history and examine him, then obtain a lateral standing radiograph.
I would first want to take a full history and examine him, then obtain a lateral standing radiograph.
EXAMINER
Tell me about the management options a vailable for ankle arthritis.
Tell me about the management options a vailable for ankle arthritis.
CANDIDATE
intra-articular steroid injection or visc o-supplementation and physiotherapy. One study reported a strong positive effect on pain and function after four PRP injections a t weekly intervals [4].
intra-articular steroid injection or visc o-supplementation and physiotherapy. One study reported a strong positive effect on pain and function after four PRP injections a t weekly intervals [4].
EXAMINER
What surgical options are available?
What surgical options are available?
source p. 277
CANDIDATE
There are two types of surgical option a vailable, those aimed to ‘buy time ’ or provide temporary relief and definitive treatments. The other option is distraction arthroplasty [5]. The definitive surgical options are ankle fusion or ankle replacement.
There are two types of surgical option a vailable, those aimed to ‘buy time ’ or provide temporary relief and definitive treatments. The other option is distraction arthroplasty [5]. The definitive surgical options are ankle fusion or ankle replacement.
EXAMINER
What about arthroscopic debridement and osteophyte resection?
What about arthroscopic debridement and osteophyte resection?
CANDIDATE
This may be helpful inpatients with mild arthritis with a large osteophyte restricting motion or causing painful impingement at the extremes of motion.
This may be helpful inpatients with mild arthritis with a large osteophyte restricting motion or causing painful impingement at the extremes of motion.
EXAMINER
What about distraction arthroplasty?
What about distraction arthroplasty?
CANDIDATE
Distraction arthroplasty can be used on several joints including the hip, knee and ankle to preserve the joint space and decrease the weight-bearing load by using an external fixator to distract the respective joint. Distraction arthroplasty is best suited for post-traumatic ankle osteoarthritis.
Distraction arthroplasty can be used on several joints including the hip, knee and ankle to preserve the joint space and decrease the weight-bearing load by using an external fixator to distract the respective joint. Distraction arthroplasty is best suited for post-traumatic ankle osteoarthritis.
EXAMINER
Would you offer him distraction arthroplasty?
Would you offer him distraction arthroplasty?
CANDIDATE
Ankle function declines following joint distraction such that at 5 years around 50% of patients will either have gone on to ankle arthrodesis or replacement. Due to the relatively small number of studies with only level 4 evidence and no long-term follow-up I would rather offer him ankle arthrodesis [6].
Ankle function declines following joint distraction such that at 5 years around 50% of patients will either have gone on to ankle arthrodesis or replacement. Due to the relatively small number of studies with only level 4 evidence and no long-term follow-up I would rather offer him ankle arthrodesis [6].
EXAMINER
Isn’t fusion an outdated treatment now that ankle replacements are available?
Isn’t fusion an outdated treatment now that ankle replacements are available?
CANDIDATE
No, total ankle replacements are not suitable for every patient and ankle fusion is still considered the ‘gold standard’, especially so for younger patients with severe post-traumatic ankle arthritis.
No, total ankle replacements are not suitable for every patient and ankle fusion is still considered the ‘gold standard’, especially so for younger patients with severe post-traumatic ankle arthritis.
EXAMINER
which patients should be considered for ankle replacement surgery?
which patients should be considered for ankle replacement surgery?
CANDIDATE
Contraindications include younger, more-activ epa tien ts, significant ankle instability, particularly deltoid ligament insufficiency, significant deformity, especially varus or valgus of more than 10°, peripheral vascular disease, a poor soft -tissue envelope, marked osteoporosis or avascular necrosis of the tibial plafond or talar dome.
Contraindications include younger, more-activ epa tien ts, significant ankle instability, particularly deltoid ligament insufficiency, significant deformity, especially varus or valgus of more than 10°, peripheral vascular disease, a poor soft -tissue envelope, marked osteoporosis or avascular necrosis of the tibial plafond or talar dome.
EXAMINER
Do anything about the types of ankle replacement available?
Do anything about the types of ankle replacement available?
CANDIDATE
The earlier designs involved a two-component design such as the Agility total ankle replacement, which required fusion of the distal tibiofibular joint.
The earlier designs involved a two-component design such as the Agility total ankle replacement, which required fusion of the distal tibiofibular joint.
EXAMINER
Apa tien twants to know how longan ankle replacement will last. What will you tell them?
Apa tien twants to know how longan ankle replacement will last. What will you tell them?
CANDIDATE
The 10-year survival is about 85%, but there are fewer data available compared to knee and hip replacements [7–10].
The 10-year survival is about 85%, but there are fewer data available compared to knee and hip replacements [7–10].
EXAMINER
The 42-year-old patient we began by discussing wants an ankle replacement. What would you tell him?
The 42-year-old patient we began by discussing wants an ankle replacement. What would you tell him?
CANDIDATE
He is a young patient in a manual job. an ankle fusion would be a better option
He is a young patient in a manual job. an ankle fusion would be a better option
EXAMINER
He still w ants a replacement, as he is keen to get back to hill walking and sports and doesn’t want a stiff ankle. What will you tell him now?
He still w ants a replacement, as he is keen to get back to hill walking and sports and doesn’t want a stiff ankle. What will you tell him now?
CANDIDATE
He would be at risk of early failure with an ankle replacement due to his age and level of activity . Postoperative complications of total ankle replacement include infection, loosening , progressive intracomponent instability or deformity, subsidence and polyethylene failure.
He would be at risk of early failure with an ankle replacement due to his age and level of activity . Postoperative complications of total ankle replacement include infection, loosening , progressive intracomponent instability or deformity, subsidence and polyethylene failure.
EXAMINER
What position should his ankle be fused in?
What position should his ankle be fused in?
CANDIDATE
The ankle should be fused in 5° of hind-foot valgus, 10° of external rotation and the foot should be plantigrade.
The ankle should be fused in 5° of hind-foot valgus, 10° of external rotation and the foot should be plantigrade.
EXAMINER
What complications will you warn him about?
What complications will you warn him about?
CANDIDATE
Infection wound healing problems,
Infection wound healing problems,
EXAMINER
Anything new on the horizon?
Anything new on the horizon?
CANDIDATE
Ankle osteochondral allograft reconstruction involves replacing all or a large part of the arthritic ankle joint with a cadaveric bulk osteochondral allograft.
Ankle osteochondral allograft reconstruction involves replacing all or a large part of the arthritic ankle joint with a cadaveric bulk osteochondral allograft.
EXAMINER
Thankyou.
Thankyou.
Figure 5.2 X-ray showing ankle arthritis.
source p. 280
Structured oral examination question 3#
source p. 281
The rheumatoid foot
EXAMINER
Please have a look at this radiographic print and tell me what you see. (See Figure 5.3.)
Please have a look at this radiographic print and tell me what you see. (See Figure 5.3.)
CANDIDATE
This is an AP radiograph of a forefoot. There may be deformities of the lesser t oes and I would like to see a lateral view to clarify this.
This is an AP radiograph of a forefoot. There may be deformities of the lesser t oes and I would like to see a lateral view to clarify this.
EXAMINER
A lateral view would be very helpful. What do you think is the underlying diagnosis?
A lateral view would be very helpful. What do you think is the underlying diagnosis?
CANDIDATE
The changes suggest that this is an inflammatory polyarthropathy such as rheumatoid arthritis.
The changes suggest that this is an inflammatory polyarthropathy such as rheumatoid arthritis.
EXAMINER
Could it be anything else?
Could it be anything else?
CANDIDATE
The appearances could be secondary to a neuropathic process.
The appearances could be secondary to a neuropathic process.
EXAMINER
What might be the commonest neuropathic process that could cause these appearances?
What might be the commonest neuropathic process that could cause these appearances?
CANDIDATE
A peripheral neuropathy such as that associated with diabetes mellitus would be the commonest.
A peripheral neuropathy such as that associated with diabetes mellitus would be the commonest.
EXAMINER
How would you confirm your diagnosis?
How would you confirm your diagnosis?
CANDIDATE
A detailed history would be most informative Specifically, I would enquire about pain, swelling and sensory alteration.
A detailed history would be most informative Specifically, I would enquire about pain, swelling and sensory alteration.
EXAMINER
. This lady gives a clear history of progressive, painful, bilateral small joint swelling and post-immobility stiffness. She has gr eat difficulty finding comfortable shoes and describes the feeling of walking on pebbles. She is not aware of any diabetes or sensory loss. What are your thoughts at this stage?
. This lady gives a clear history of progressive, painful, bilateral small joint swelling and post-immobility stiffness. She has gr eat difficulty finding comfortable shoes and describes the feeling of walking on pebbles. She is not aware of any diabetes or sensory loss. What are your thoughts at this stage?
CANDIDATE
This appears to be an inflammatory arthropathy. This requires confirmed synovitis of one or more joints, with absence of alternative explanation for the synovitis, and achieving a score of 6 or greater out of 10 from domains including: Numbers and location of the involved joint(s). These criteria replaced the previous set from 1987, which were felt to lack sensitivity in early disease.
This appears to be an inflammatory arthropathy. This requires confirmed synovitis of one or more joints, with absence of alternative explanation for the synovitis, and achieving a score of 6 or greater out of 10 from domains including: Numbers and location of the involved joint(s). These criteria replaced the previous set from 1987, which were felt to lack sensitivity in early disease.
EXAMINER
Yes. Her feet are making her life pretiy miserable and she would like you, as an orthopaedic surgeon, to do something to make them better. Your examination finds marked active synovitis and plantar tenderness under the metatarsal heads as well as a minimally correctable hallux valgus. There is some hammering of the lesser toes with a cock-up deformity of the second toe. Sensation and perfusion appear good. What are you going to do?
Yes. Her feet are making her life pretiy miserable and she would like you, as an orthopaedic surgeon, to do something to make them better. Your examination finds marked active synovitis and plantar tenderness under the metatarsal heads as well as a minimally correctable hallux valgus. There is some hammering of the lesser toes with a cock-up deformity of the second toe. Sensation and perfusion appear good. What are you going to do?
CANDIDATE
First, I would want to know if she is known to a rheumatology service and has had any attempt at non-operativ e intervention.
First, I would want to know if she is known to a rheumatology service and has had any attempt at non-operativ e intervention.
EXAMINER
She has never seen a rheumatologist and has never sought help for her feet other than from you via her GP.
She has never seen a rheumatologist and has never sought help for her feet other than from you via her GP.
CANDIDATE
I would advise her that operations are helpful but that she should be formally assessed by a rheumatologist to confirm the diagnosis and achieve disease control using DMARDs. The key buzz phrase to mention (if appropriate) is that patients with rheumatoid arthritis require a (contemporary) multidisciplinary approach to their management.
I would advise her that operations are helpful but that she should be formally assessed by a rheumatologist to confirm the diagnosis and achieve disease control using DMARDs. The key buzz phrase to mention (if appropriate) is that patients with rheumatoid arthritis require a (contemporary) multidisciplinary approach to their management.
EXAMINER
I think that is appropriate advice at this stage. However, she returns to you a year later. Her synovitis is controlled by biological agents, but she has not found insoles and modified shoes helpful. How would you manage her at this point?
I think that is appropriate advice at this stage. However, she returns to you a year later. Her synovitis is controlled by biological agents, but she has not found insoles and modified shoes helpful. How would you manage her at this point?
CANDIDATE
I would suggest surgery in the form of forefoot reconstruction.
I would suggest surgery in the form of forefoot reconstruction.
EXAMINER
Why?
Why?
CANDIDATE
This is a proven intervention with good results.
This is a proven intervention with good results.
EXAMINER
How good?
How good?
CANDIDATE
More than 80% of patients report significant improvement.
More than 80% of patients report significant improvement.
EXAMINER
Would you fuse or excise the first metatarsophalangeal joint?
Would you fuse or excise the first metatarsophalangeal joint?
CANDIDATE
in a low-demand patient excision is associated with reduced complications and more rapid rehabilitation [ 11].
in a low-demand patient excision is associated with reduced complications and more rapid rehabilitation [ 11].
EXAMINER
How would you secure the arthrodesis?
How would you secure the arthrodesis?
source p. 283
CANDIDATE
I would use an oblique compression screw augmented by a dorsal locking plate as biomechanical and clinical studies have shown this to be the most reliable method.
I would use an oblique compression screw augmented by a dorsal locking plate as biomechanical and clinical studies have shown this to be the most reliable method.
EXAMINER
Would you always excise the lesser metatarsal heads in apa tien t of this age who now appears to have their disease under control?
Would you always excise the lesser metatarsal heads in apa tien t of this age who now appears to have their disease under control?
CANDIDATE
No. It would be appropriate to perform shortening osteotomies such as Weil osteotomies to preserve the metatarsal heads if they are not badly diseased.
No. It would be appropriate to perform shortening osteotomies such as Weil osteotomies to preserve the metatarsal heads if they are not badly diseased.
EXAMINER
Surely that just prolongs the procedure and increases the risk of complication?
Surely that just prolongs the procedure and increases the risk of complication?
CANDIDATE
Yes, but it is very difficult to salvage a rheumatoid foot without metatarsal heads if the disease progresses in subsequent years.
Yes, but it is very difficult to salvage a rheumatoid foot without metatarsal heads if the disease progresses in subsequent years.
EXAMINER
Tell me about the principles of surgery in rheumatoid arthritis.
Tell me about the principles of surgery in rheumatoid arthritis.
CANDIDATE
Surgery is indicated when symptoms and/or deformity are uncontrolled or geting worse.
Surgery is indicated when symptoms and/or deformity are uncontrolled or geting worse.
EXAMINER
What steps can a surgeon take to minimize the risk of complications?
What steps can a surgeon take to minimize the risk of complications?
CANDIDATE
A drug history is vital, Biological agents should be stopped in the run up to surgery and not resumed untilt here is good evidence of postoperative healing. Incisions must be planned with care, both to maintain adequate skin bridges and to ensure satisfactory wound closure if significant deformities are being corrected.
A drug history is vital, Biological agents should be stopped in the run up to surgery and not resumed untilt here is good evidence of postoperative healing. Incisions must be planned with care, both to maintain adequate skin bridges and to ensure satisfactory wound closure if significant deformities are being corrected.
EXAMINER
How long would you stop biological agents for?
How long would you stop biological agents for?
CANDIDATE
Two weeks pre- and postoperatively [12,13].
Two weeks pre- and postoperatively [12,13].
EXAMINER
What about other disease-modifying anft-rheuma tic drugs? Which other ones would you stop?
What about other disease-modifying anft-rheuma tic drugs? Which other ones would you stop?
CANDIDATE
Peri operative management of RA medications [ 14]: Steroids: low dose (≤ 7.5 mg/day) or any dose if for < 3 weeks should be given as usual daily dose. Methotrexate: continue, as does not impair wound healing or increase peri operative infection risk.
Peri operative management of RA medications [ 14]: Steroids: low dose (≤ 7.5 mg/day) or any dose if for < 3 weeks should be given as usual daily dose. Methotrexate: continue, as does not impair wound healing or increase peri operative infection risk.
source p. 284
EXAMINER
I would like to backtrack . Would you alter your management if she also had signs and symptoms of hindfoot arthritis?
I would like to backtrack . Would you alter your management if she also had signs and symptoms of hindfoot arthritis?
CANDIDATE
Flexible hindfoot deformity could be left un til more symptomatic.
Flexible hindfoot deformity could be left un til more symptomatic.
EXAMINER
Which hindfoot joints are most commonly affected in rheumatoid arthritis?
Which hindfoot joints are most commonly affected in rheumatoid arthritis?
CANDIDATE
The talo-navicular joint is most commonly affected, followed by the subtalar and calcaneocuboid joints.
The talo-navicular joint is most commonly affected, followed by the subtalar and calcaneocuboid joints.
EXAMINER
Can you outline the arguments for and against isolated talo-navicular fusion in RA?
Can you outline the arguments for and against isolated talo-navicular fusion in RA?
CANDIDATE
Isolated talo-navicular fusion is a lesser procedure than triple fusion for both patient and surgeon and effectively eliminates hindfoot motion Historically, a non-union rate of up to 37% has been reported,
Isolated talo-navicular fusion is a lesser procedure than triple fusion for both patient and surgeon and effectively eliminates hindfoot motion Historically, a non-union rate of up to 37% has been reported,
EXAMINER
Thankyou.
Thankyou.
source p. 285
Figure 5.3 AP radiograph of rheumatoid forefoot.
source p. 286
Structured oral examination question 4#
source p. 287
Cavus foot
EXAMINER
These are photographs of the left foot of a 20-year old man (Figure 5.4). Describe them.
These are photographs of the left foot of a 20-year old man (Figure 5.4). Describe them.
CANDIDATE
These clinical photographs show the anterior, medial and posterior views of a left foot with a cavus deformity.
These clinical photographs show the anterior, medial and posterior views of a left foot with a cavus deformity.
EXAMINER
What is the likely underlying cause?
What is the likely underlying cause?
CANDIDATE
The causes of a cavus foot may be broken down into congenital or acquired. The neuromuscular causes may be grouped into central nervous system disease such as cerebral palsy or Friedrich’s ataxia, spinal cord lesions such as spina bifid aor spinal dysraphism, peripheral nervous system lesions such as an HSMN or muscular causes such as muscular dystrophy. In the calcaneocavus foot the calf muscles are weak and the heel is in calcaneus and often valgus.
The causes of a cavus foot may be broken down into congenital or acquired. The neuromuscular causes may be grouped into central nervous system disease such as cerebral palsy or Friedrich’s ataxia, spinal cord lesions such as spina bifid aor spinal dysraphism, peripheral nervous system lesions such as an HSMN or muscular causes such as muscular dystrophy. In the calcaneocavus foot the calf muscles are weak and the heel is in calcaneus and often valgus.
EXAMINER
HSMN?
HSMN?
CANDIDATE
Hereditary sensorimotor neuropathies. These are a group of inherited neurological conditions. Char cot–Marie–Tooth is the most common of these conditions.
Hereditary sensorimotor neuropathies. These are a group of inherited neurological conditions. Char cot–Marie–Tooth is the most common of these conditions.
EXAMINER
Can you go into more detail? How do these conditions lead to a cavus foot deformity?
Can you go into more detail? How do these conditions lead to a cavus foot deformity?
CANDIDATE
The most commonly recognized is Charcot–Marie–Tooth (CMT) disease, which affects approximately 1 in 2500 people. Type I with an autosomal- dominant inheritance pattern tends to present in the second decade and patients have peroneal muscle weakness, abnormal (slow) nerve conduction studies, absent reflexes and hand involvement. Genetic analysi sis able to diagnose and group these conditions more accurately and at least 17 types of CM Thave been described.
The most commonly recognized is Charcot–Marie–Tooth (CMT) disease, which affects approximately 1 in 2500 people. Type I with an autosomal- dominant inheritance pattern tends to present in the second decade and patients have peroneal muscle weakness, abnormal (slow) nerve conduction studies, absent reflexes and hand involvement. Genetic analysi sis able to diagnose and group these conditions more accurately and at least 17 types of CM Thave been described.
EXAMINER
What causes the deformity in CMT?
What causes the deformity in CMT?
source p. 288
CANDIDATE
In CMT the tibialis anterior and peroneus brevis muscles are weak and the strength of the antagonistic muscles tibialis posterior and peroneus longus causes the deformity. In addition, the long extensors to the toes are recruited to assist ankle dorsiflexion, causing claw toe deformities.
In CMT the tibialis anterior and peroneus brevis muscles are weak and the strength of the antagonistic muscles tibialis posterior and peroneus longus causes the deformity. In addition, the long extensors to the toes are recruited to assist ankle dorsiflexion, causing claw toe deformities.
EXAMINER
What symptoms is this patient likely to complain about?
What symptoms is this patient likely to complain about?
CANDIDATE
instability of the ankle with a history of frequent ankle sprains and deformity of the foot with problems fiting footwear or alteration of g ait.
instability of the ankle with a history of frequent ankle sprains and deformity of the foot with problems fiting footwear or alteration of g ait.
EXAMINER
What are the main findings you would look for in the examination of a cavus foot?
What are the main findings you would look for in the examination of a cavus foot?
CANDIDATE
On general inspection I would be looking to see if the deformity was bilateral and whether there were stigmata of a generalized condition such as intrinsic muscle wasting involving the hands. I would undertake a neurological examination of the lo wer limbs to assess sensation, deep tendon reflexes and power of the major muscle groups, particularly the tibialis anterior (ankle dorsiflexion), tibialis posterior (inversion), peroneal longus (resisted plantar flexion) and peroneus brevis (eversion). I would also like to see the patient walk to see if they had a broad-based ataxic gait (Friedrich’s ataxia) or drop-foot gait.
On general inspection I would be looking to see if the deformity was bilateral and whether there were stigmata of a generalized condition such as intrinsic muscle wasting involving the hands. I would undertake a neurological examination of the lo wer limbs to assess sensation, deep tendon reflexes and power of the major muscle groups, particularly the tibialis anterior (ankle dorsiflexion), tibialis posterior (inversion), peroneal longus (resisted plantar flexion) and peroneus brevis (eversion). I would also like to see the patient walk to see if they had a broad-based ataxic gait (Friedrich’s ataxia) or drop-foot gait.
EXAMINER
What is shown in these diagrams (Figure 5.5)?
What is shown in these diagrams (Figure 5.5)?
CANDIDATE
These diagrams show the Coleman block test.
These diagrams show the Coleman block test.
EXAMINER
And what is that?
And what is that?
CANDIDATE
The Coleman block test assesses flexibility of the hindfoot deformity by eliminating the deforming drive of the forefoot. If the heel assumes neutral to 5° valgus alignment when viewed from behind the hindfoot deformity is considered flexible and driven by the forefoot [15].
The Coleman block test assesses flexibility of the hindfoot deformity by eliminating the deforming drive of the forefoot. If the heel assumes neutral to 5° valgus alignment when viewed from behind the hindfoot deformity is considered flexible and driven by the forefoot [15].
EXAMINER
What investigations would you use to evaluate this foot further?
What investigations would you use to evaluate this foot further?
source p. 289
CANDIDATE
An MRI scan of the spine is required if the patient has any signs or symptoms suggesting an underlying spinal cause.
An MRI scan of the spine is required if the patient has any signs or symptoms suggesting an underlying spinal cause.
EXAMINER
What information does the lateral X-ray provide?
What information does the lateral X-ray provide?
CANDIDATE
Normally this lies between ±5°. This angle is normally 150° but decreases as the cavus worsens. The calcaneal pitch angle, the angle between the floor and the undersurface of the calcaneum, should be less than 30° but may be elevated in a cavus foot.
Normally this lies between ±5°. This angle is normally 150° but decreases as the cavus worsens. The calcaneal pitch angle, the angle between the floor and the undersurface of the calcaneum, should be less than 30° but may be elevated in a cavus foot.
EXAMINER
What are the principles of managing this condition?
What are the principles of managing this condition?
CANDIDATE
Firstly, it is important to identify and if necessary address the underlying cause of the cavus. The patient should be assessed for neuromuscular causes and referred for a neurological opinion if appropriate. Management can be non-operativ e with the use of orthotics to try and offload pressure areas, prevent rubbing of the toes and improve stability. Surgical treatment needs to be tailored to the individual patient underlying pathology, risk of progression, level of deformity and muscular imbalance. No single surgical procedure is appropriate for all patients and frequently, multiple procedures are required.
Firstly, it is important to identify and if necessary address the underlying cause of the cavus. The patient should be assessed for neuromuscular causes and referred for a neurological opinion if appropriate. Management can be non-operativ e with the use of orthotics to try and offload pressure areas, prevent rubbing of the toes and improve stability. Surgical treatment needs to be tailored to the individual patient underlying pathology, risk of progression, level of deformity and muscular imbalance. No single surgical procedure is appropriate for all patients and frequently, multiple procedures are required.
EXAMINER
Thankyou.
Thankyou.
source p. 290
Figure 5.4 Cavus foot deformity.
Figure 5.5 Coleman block test.
Figure 5.6a,b AP and lateral radiographs of a cavus foot.
source p. 291
Surgery#
source p. 292
1. Soft -tissue releases
Plantar fascia release
In young children, surgical release of the plantar fascia and short toe flexors may be helpful.
Gastrocnemius/Achilles lengthening
Occasionally required for contracture, but it is important to make sure a true equinus is present onstanding lateral radiographs.
source p. 293
2. Tendon transfers
The most common tendon transfer incavo varus foot is peroneus longus to brevis transfer to improve power of eversion. It helps stabilize the ankle.
source p. 294
3. Osteotomies
The osteotomy can include a closing wedge, aver tical displacement, or a combination (triplanar osteotomy).
source p. 295
4. Fusion
For a rigid painful foot in a young adult a triple arthrodesis can be used as a salvage stabilizing procedure that relieves pain but sacrifices joint motion.
Complications include development of ankle arthritis, pseudo-arthrosis, residue deformity, midfoot arthritis overcorrection and AVN talus.
source p. 296
Structured oral examination question 5#
source p. 297
Acquired adult flafooot
EXAMINER
I would like you to look at this clinical photograph and tell me what you see (see Figure 5.7a).
I would like you to look at this clinical photograph and tell me what you see (see Figure 5.7a).
CANDIDATE
This shows the posterior view of feet in a weight-bearing stance. There is marked heel valgus, loss of the medial longitudinal arch and too many toes are visible [16].
This shows the posterior view of feet in a weight-bearing stance. There is marked heel valgus, loss of the medial longitudinal arch and too many toes are visible [16].
EXAMINER
What term is used to describe this situation?
What term is used to describe this situation?
CANDIDATE
Pes planus or flafooot.
Pes planus or flafooot.
EXAMINER
Yes. In adults, what are the causes of this condition?
Yes. In adults, what are the causes of this condition?
CANDIDATE
The commonest cause is tibialis posterior dysfunction. midfoot osteoarthritis and trauma (malunited calcaneum,
The commonest cause is tibialis posterior dysfunction. midfoot osteoarthritis and trauma (malunited calcaneum,
EXAMINER
. How common is adult flafooot?
. How common is adult flafooot?
CANDIDATE
It is commoner in females and the incidence increases with age.
It is commoner in females and the incidence increases with age.
EXAMINER
. Let’s stick with tibialis posterior dysfunction. Describe a typical patient.
. Let’s stick with tibialis posterior dysfunction. Describe a typical patient.
CANDIDATE
The classic patient would be a female aged between 45 and 65 years with pain along the course of the tibialis posterior tendon exacerbated by activity .
The classic patient would be a female aged between 45 and 65 years with pain along the course of the tibialis posterior tendon exacerbated by activity .
EXAMINER
What are the key examination points you would look for?
What are the key examination points you would look for?
CANDIDATE
The most useful testis the ability to perform a single heel raise. I would also assess for hindfoot flexibility. These would guide classification and treatment.
The most useful testis the ability to perform a single heel raise. I would also assess for hindfoot flexibility. These would guide classification and treatment.
EXAMINER
What are the origins and insertions of the tibialis posterior tendon?
What are the origins and insertions of the tibialis posterior tendon?
CANDIDATE
It arises from the posterior tibia interosseous membrane and the fibula in the proximal third of the leg and runs in the deep posterior compartment of the leg.
It arises from the posterior tibia interosseous membrane and the fibula in the proximal third of the leg and runs in the deep posterior compartment of the leg.
EXAMINER
How do you assess the strength of the tibialis posterior tendon?
How do you assess the strength of the tibialis posterior tendon?
CANDIDATE
The strength of the tendon is evaluated by asking the patient to attempt to invert the foot from a plantar flexed and everted position.
The strength of the tendon is evaluated by asking the patient to attempt to invert the foot from a plantar flexed and everted position.
source p. 298
EXAMINER
How does tibialis posterior dysfunction cause a flatfoot?
How does tibialis posterior dysfunction cause a flatfoot?
CANDIDATE
The function of the posterior tibial tendon is threefold: it acts as an invertor of the subtalar joint, plantar-flexor of the ankle and an adductor of the forefoot. The inversion pull of tibialis posterior on the subtalar joint locks the transverse tarsal joint, providing a rigid lever arm with which to push off following the heel-raise phase of gait. As the function of the tibialis posterior fails, the Achilles tendon remains close to the subtalar axis, thereby reducing its function as both an inverter and a stabilizer of the subtalar joint. The static stabilizers on the medial side, in particular the spring ligament and the deltoid ligament, attenuate further.
The function of the posterior tibial tendon is threefold: it acts as an invertor of the subtalar joint, plantar-flexor of the ankle and an adductor of the forefoot. The inversion pull of tibialis posterior on the subtalar joint locks the transverse tarsal joint, providing a rigid lever arm with which to push off following the heel-raise phase of gait. As the function of the tibialis posterior fails, the Achilles tendon remains close to the subtalar axis, thereby reducing its function as both an inverter and a stabilizer of the subtalar joint. The static stabilizers on the medial side, in particular the spring ligament and the deltoid ligament, attenuate further.
EXAMINER
As you have mentioned classification of tibialis posterior dysfunction could you tell me any more about this?
As you have mentioned classification of tibialis posterior dysfunction could you tell me any more about this?
CANDIDATE
Johnson and Strom proposed a three-stage classification in 1989. In stage 2 disease, there is a flexible planovalgus deformity and weakness of single heel raise. In stage 3 disease, the valgus hindfoot deformity has become fixed and reconstruction is not possible. With stage 4, there is additional tilting of the talus in the ankle mortise leading to significant ankle arthritis secondary to valgus strain.
Johnson and Strom proposed a three-stage classification in 1989. In stage 2 disease, there is a flexible planovalgus deformity and weakness of single heel raise. In stage 3 disease, the valgus hindfoot deformity has become fixed and reconstruction is not possible. With stage 4, there is additional tilting of the talus in the ankle mortise leading to significant ankle arthritis secondary to valgus strain.
EXAMINER
. How would you investigate this patient?
. How would you investigate this patient?
CANDIDATE
Weight-bearing AP and lateral radiographs of both the foot and ankle would help to assess structural change and exclude other causes of flafooot.
Weight-bearing AP and lateral radiographs of both the foot and ankle would help to assess structural change and exclude other causes of flafooot.
EXAMINER
Would the arch index influence your management?
Would the arch index influence your management?
source p. 299
CANDIDATE
No. It is mainly used as a research tool.
No. It is mainly used as a research tool.
EXAMINER
Is there a place for MRI?
Is there a place for MRI?
CANDIDATE
MRI is not routinely needed for the diagnosis of flatfeet. MRI is valuable if surgical management is being planned. It is also useful for assessing the medial structures such as the deltoid and spring ligaments and also the peroneal tendon [18].
MRI is not routinely needed for the diagnosis of flatfeet. MRI is valuable if surgical management is being planned. It is also useful for assessing the medial structures such as the deltoid and spring ligaments and also the peroneal tendon [18].
EXAMINER
Tell me what the treatment options are.
Tell me what the treatment options are.
CANDIDATE
For stage 1, I would offer debridement of the tendon followed by 6–8 weeks of casting or splintage, then provision of a definitive arch support orthosis [19]. For stage 2 disease I would offer either a lateral column lengthening or a medializing calcaneal osteotomy in conjunction with a FDL transfer to augmentor replace the tibialis posterior [20]. In stage 3 disease, triple arthrodesis is recommended [21].
For stage 1, I would offer debridement of the tendon followed by 6–8 weeks of casting or splintage, then provision of a definitive arch support orthosis [19]. For stage 2 disease I would offer either a lateral column lengthening or a medializing calcaneal osteotomy in conjunction with a FDL transfer to augmentor replace the tibialis posterior [20]. In stage 3 disease, triple arthrodesis is recommended [21].
EXAMINER
You seem very clear about surgical options Whatabout non-operativ e treatment?
You seem very clear about surgical options Whatabout non-operativ e treatment?
CANDIDATE
I should have mentioned that. Second, it may control progressive heel valgus and flattening of the medial archIt’s not great viva tactics to jump straight in to discussing surgical options for a condition unless it is very clear that’s what the examiners want to discuss.
I should have mentioned that. Second, it may control progressive heel valgus and flattening of the medial archIt’s not great viva tactics to jump straight in to discussing surgical options for a condition unless it is very clear that’s what the examiners want to discuss.
EXAMINER
You spoke about an FDL transfer. Tell me about this procedure.
You spoke about an FDL transfer. Tell me about this procedure.
CANDIDATE
After obtaining informed consent I would make an incision in the line of the posterior tibial tendon, starting posterior to the medial malleolus. The free FDL tendon is then passed through a tunnel drilled in the navicular and sutured back to itself under tension.
After obtaining informed consent I would make an incision in the line of the posterior tibial tendon, starting posterior to the medial malleolus. The free FDL tendon is then passed through a tunnel drilled in the navicular and sutured back to itself under tension.
EXAMINER
In what direction would you pass FDL through the navicular?
In what direction would you pass FDL through the navicular?
source p. 300
CANDIDATE
From plantar to dorsal.
From plantar to dorsal.
EXAMINER
What is the aim of a medializing calcaneal osteotomy?
What is the aim of a medializing calcaneal osteotomy?
CANDIDATE
The calcaneal osteotomy directly reduces the heel valgus and brings the weight-bearing axis closer to the long axis of the leg.
The calcaneal osteotomy directly reduces the heel valgus and brings the weight-bearing axis closer to the long axis of the leg.
EXAMINER
When obtaining consent, what would you advise about flexion of the toes after harvesting the flexor digitorum longus?
When obtaining consent, what would you advise about flexion of the toes after harvesting the flexor digitorum longus?
CANDIDATE
I would expect flexion of the lesser toes to be maintained by the flexor hallucis longus via the knot of Henry.
I would expect flexion of the lesser toes to be maintained by the flexor hallucis longus via the knot of Henry.
EXAMINER
Can you tell me alit ile more about the knot of Henry?
Can you tell me alit ile more about the knot of Henry?
CANDIDATE
There are a number of fibrous interconnections between the two tendons that afford a degree of cooperation in movement.
There are a number of fibrous interconnections between the two tendons that afford a degree of cooperation in movement.
EXAMINER
What would you tell the patient about the success rate of the operation?
What would you tell the patient about the success rate of the operation?
CANDIDATE
[22] reported that FDL transfer with medializing calcaneum osteotomy provided long-term pain relief and improved function in 85% of patients after a mean follow-up of 15.2 years.
[22] reported that FDL transfer with medializing calcaneum osteotomy provided long-term pain relief and improved function in 85% of patients after a mean follow-up of 15.2 years.
EXAMINER
Is there a place for any additional procedures such as first ray fusions or lateral column lengthening?
Is there a place for any additional procedures such as first ray fusions or lateral column lengthening?
CANDIDATE
One concern with stage 2 adult-acquired flafooot deformity is that there is a large variability in disease severity within the classification group including hindfoot valgus, medial column stability, forefoot abduction and supination.
One concern with stage 2 adult-acquired flafooot deformity is that there is a large variability in disease severity within the classification group including hindfoot valgus, medial column stability, forefoot abduction and supination.
EXAMINER
What approach would you use for a triple arthrodesis to correct significant, fixed valgus heel deformity?
What approach would you use for a triple arthrodesis to correct significant, fixed valgus heel deformity?
CANDIDATE
There are advocates of triple arthrodesis via a single medial approach, but this is difficult and not always possible.
There are advocates of triple arthrodesis via a single medial approach, but this is difficult and not always possible.
EXAMINER
One final question. An y new developments?
One final question. An y new developments?
source p. 301
CANDIDATE
PRP injections have recently been used in the early stages of posterior tendon dysfunction. We are awaiting randomized controlled data.
PRP injections have recently been used in the early stages of posterior tendon dysfunction. We are awaiting randomized controlled data.
EXAMINER
Thankyou.
Thankyou.
Figure 5.7a Acquired adult flafooot. Loss of medial arch. Valgus heel, ‘too many toes sign’.
Figure 5.7b Midfoot sagift al radiograph sMeary’s angle negative (> 10°). Reduced calcaneal pitch angle (10° approx., normal 20–30°).
source p. 302
Figure 5.7c Anteroposterior (AP) radiographs of midfoot abduction. T alo to first metatarsal an angle > 10°.
source p. 303
Figure 5.7d–f MRI tibialis posterior tendinopathy with fluid around tendon. Some increased signal within the tendon substance.
source p. 304
Structured oral examination question 6#
source p. 305
Hallux valgus
EXAMINER
Please have a look at these clinical photographs and tell me what you see (see Figures 5.8 and 5.9).
Please have a look at these clinical photographs and tell me what you see (see Figures 5.8 and 5.9).
CANDIDATE
These show a frontal view of a pair of feet and an oblique view of the left foot. The toenails appear friable and there is some excoriation around the lesser toes of the right foot.
These show a frontal view of a pair of feet and an oblique view of the left foot. The toenails appear friable and there is some excoriation around the lesser toes of the right foot.
EXAMINER
. This 65-year-old lady had her left second toe removed some years ago for a presentation similar to that which she now has on the right. Her left-sided symptoms have also recurred. How would you assess her further?
. This 65-year-old lady had her left second toe removed some years ago for a presentation similar to that which she now has on the right. Her left-sided symptoms have also recurred. How would you assess her further?
CANDIDATE
I would obtain a detailed history, looking to clarify the main source of her symptoms. Can I ask what symptoms she has?
I would obtain a detailed history, looking to clarify the main source of her symptoms. Can I ask what symptoms she has?
EXAMINER
What do you think they are likely to be?
What do you think they are likely to be?
CANDIDATE
I would expect she has pain from her bunions and toes caused by rubbing on footwear and each other.
I would expect she has pain from her bunions and toes caused by rubbing on footwear and each other.
EXAMINER
Let’s say she has all these symptoms to varying degrees. Tell me about your further assessment.
Let’s say she has all these symptoms to varying degrees. Tell me about your further assessment.
CANDIDATE
I would complete the history, including questioning about relevant conditions such as diabetes, inflammatory arthritis vascular disease and neuropathy, and proceed to examination. I would palpate for areas of tenderness, paying particular attention to the hallux MTP joint and lesser metatarsal heads. Neurovascular status will also be assessed.
I would complete the history, including questioning about relevant conditions such as diabetes, inflammatory arthritis vascular disease and neuropathy, and proceed to examination. I would palpate for areas of tenderness, paying particular attention to the hallux MTP joint and lesser metatarsal heads. Neurovascular status will also be assessed.
EXAMINER
You spoke about assessing the range of movement of the involved joints. Can you be more specific?
You spoke about assessing the range of movement of the involved joints. Can you be more specific?
CANDIDATE
I would want to assess the range of plantar and dorsiflexion of the hallux MTP joint.
I would want to assess the range of plantar and dorsiflexion of the hallux MTP joint.
EXAMINER
we might come back to that. Outline the value of plain radiographs in the management of hallux valgus.
we might come back to that. Outline the value of plain radiographs in the management of hallux valgus.
CANDIDATE
I would obtain weight-bearing AP and lateral radiographs of the foot.
I would obtain weight-bearing AP and lateral radiographs of the foot.
EXAMINER
Why weight-bearing?
Why weight-bearing?
CANDIDATE
Non-weight-bearing views tend to underestimate the severity of hallux valgus, and may give misleading information about alignment and relative metatarsal length.
Non-weight-bearing views tend to underestimate the severity of hallux valgus, and may give misleading information about alignment and relative metatarsal length.
EXAMINER
Keep going. What angles?
Keep going. What angles?
CANDIDATE
I would measure the intermetatarsal, hallux valgus and the distal metatarsal articular angles.
I would measure the intermetatarsal, hallux valgus and the distal metatarsal articular angles.
EXAMINER
What is the normal range of these angles and how would these influence your management? Can you demonstrate these angles on the radiographs (Figures 5.10–5.13)?
What is the normal range of these angles and how would these influence your management? Can you demonstrate these angles on the radiographs (Figures 5.10–5.13)?
CANDIDATE
the hallux valgus angle should be less than 15° and the distal metatarsal articular angle is normally a maximum of 15°.
the hallux valgus angle should be less than 15° and the distal metatarsal articular angle is normally a maximum of 15°.
EXAMINER
What about these radiographs?
What about these radiographs?
CANDIDATE
These demonstrate severe hallux valgus with an HVA 50°, IMA 22° and DMAA 8° (Figures 5.14–5.16).
These demonstrate severe hallux valgus with an HVA 50°, IMA 22° and DMAA 8° (Figures 5.14–5.16).
EXAMINER
If this lady had an intermetatarsal angle of 15° on the right with a hallux valgus angle of 35° and minimal passive correction of the hallux, what surgery would you plan?
If this lady had an intermetatarsal angle of 15° on the right with a hallux valgus angle of 35° and minimal passive correction of the hallux, what surgery would you plan?
CANDIDATE
If the first tarso-metatarsal joint is not lax, I would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary.
If the first tarso-metatarsal joint is not lax, I would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary.
EXAMINER
Why would you choose a scarf osteotomy?
Why would you choose a scarf osteotomy?
CANDIDATE
It is a very versatile procedure with stable fixation allowing early postoperative mobilization without a cast. It can also be used to shorten or lengthen the metatarsal [23].
It is a very versatile procedure with stable fixation allowing early postoperative mobilization without a cast. It can also be used to shorten or lengthen the metatarsal [23].
EXAMINER
How would you secure the osteotomy?
How would you secure the osteotomy?
CANDIDATE
With two headless compression screws.
With two headless compression screws.
EXAMINER
Why not use a simpler procedure such as a chevron or Mitchell osteotomy?
Why not use a simpler procedure such as a chevron or Mitchell osteotomy?
CANDIDATE
For the degree of deformity described, A further disadvantage of a Mitchell osteotomy is that it produces shortening of the first metatarsal, which could lead to transfer metatarsalgia.
For the degree of deformity described, A further disadvantage of a Mitchell osteotomy is that it produces shortening of the first metatarsal, which could lead to transfer metatarsalgia.
EXAMINER
Can you draw a scarf osteotomy?
Can you draw a scarf osteotomy?
CANDIDATE
No, sorry.
No, sorry.
source p. 307
EXAMINER
For your proposed management, what complications would you discuss when seeking consent?
For your proposed management, what complications would you discuss when seeking consent?
CANDIDATE
Firstly, I would advise that while early weight-bearing is possible with a scarf osteotomy, it takes up to a year for the foot to fully set ile after such surgery, but that typically 85% of patients are pleased with the outcome. I would advise a 1% risk of deep infection and as lightly higher risk of superficial infection Recurrence is possible with time, although the risk of this is greatest in adolescent cases.
Firstly, I would advise that while early weight-bearing is possible with a scarf osteotomy, it takes up to a year for the foot to fully set ile after such surgery, but that typically 85% of patients are pleased with the outcome. I would advise a 1% risk of deep infection and as lightly higher risk of superficial infection Recurrence is possible with time, although the risk of this is greatest in adolescent cases.
EXAMINER
How would you treat hallux varus?
How would you treat hallux varus?
CANDIDATE
A subtle varus may improve as the patient returns to normal footwear. arthrodesis of the first MTP joint arthrodesis is a reliable option in the presence of significant stiffness or arthrosis.
A subtle varus may improve as the patient returns to normal footwear. arthrodesis of the first MTP joint arthrodesis is a reliable option in the presence of significant stiffness or arthrosis.
EXAMINER
you have successfully treated this lady’s right foot and she is pleased with the result. Would you go ahead and do the same on the left?
you have successfully treated this lady’s right foot and she is pleased with the result. Would you go ahead and do the same on the left?
CANDIDATE
No. The absence of the second toe predisposes to recurrence and I would propose arthrodesis of the hallux MTP joint.
No. The absence of the second toe predisposes to recurrence and I would propose arthrodesis of the hallux MTP joint.
EXAMINER
One final question. What do we mean by a congruent versus incongruent hallux valgus (see Figures 5.17 and 5.18)?
One final question. What do we mean by a congruent versus incongruent hallux valgus (see Figures 5.17 and 5.18)?
CANDIDATE
If there is no lateral subluxation then the joint is congruent. An incongruent joint exists when the toe is in a valgus orientation and the articular surfaces do not align properly or concentrically.
If there is no lateral subluxation then the joint is congruent. An incongruent joint exists when the toe is in a valgus orientation and the articular surfaces do not align properly or concentrically.
EXAMINER
Thankyou.
Thankyou.
source p. 308
Figure 5.8 AP view of hallux valgus.
Figure 5.9 Oblique view of hallux valgus.
source p. 309
Figure 5.10 Hallux valgus angle (HVA). Angle between long axis of first metatarsal shaft and long a xis of first proximal phalanx. Normal < 15°. Mild 15–20°. Moderate 20–40°. Severe > 40°.
source p. 310
Figure 5.11 Hallux valgus interphalangeus angle (HVI). Angle between long axis of first distal phalanx and long axis of first proximal phalanx. Associated with congruent hallux valgus. Normal < 10°.
source p. 311
Figure 5.12 First to second intermetatarsal angle (IMA). Angle between long axis of first and second metatarsal shaft. Normal < 9°. Mild < 11°. Moderate 12–15°. Severe > 15°.
source p. 312
Figure 5.13 Distal metatarsal articular angle (DMAA). Angle between long axis of first metatarsal and perpendicular to a line along the articular surface. Increased angle associated with a congruent deformity. Normal < 10°.
source p. 313
Figure 5.14 Hallux valgus angle (HVA) (pronation oft oe). Normal < 15°.
source p. 314
Figure 5.15 Intermetatarsal angle (IMA) 22°. Normal < 9°.
source p. 315
Figure 5.16 Distal metatarsal articular angle (DMAA). Normal < 10°.
source p. 316
Figure 5.17 Congruent hallux valgus. Increased HVA, increased DMAA and congruent joint.
source p. 317
Figure 5.18 Incongruent hallux valgus. Increased HV Anormal DMAA and incongruent joint.
source p. 318
Structured oral examination question 7#
source p. 319
Hallux rigidus
EXAMINER
This 45-year-old male patient has presented with pain and stiffness of his right big toe. Describe the X-ray findings (see Figure 5.19).
This 45-year-old male patient has presented with pain and stiffness of his right big toe. Describe the X-ray findings (see Figure 5.19).
CANDIDATE
This is a radiograph of a right foot showing loss of joint space, The reis also a mild hallux valgus deformity.
This is a radiograph of a right foot showing loss of joint space, The reis also a mild hallux valgus deformity.
EXAMINER
what is this commonly called in orthopaedics?
what is this commonly called in orthopaedics?
CANDIDATE
Hallux rigidus.
Hallux rigidus.
EXAMINER
Tell me the range of movement of a healthy first MTP joint.
Tell me the range of movement of a healthy first MTP joint.
CANDIDATE
The joint should be able to dorsiflex between 70 and 90° and plantarflex between 24 and 40°.
The joint should be able to dorsiflex between 70 and 90° and plantarflex between 24 and 40°.
EXAMINER
How would you manage this patient?
How would you manage this patient?
CANDIDATE
I would also obtain a weight- bearing lateral and an oblique X-ray of the foot in addition to the AP view we have here.
I would also obtain a weight- bearing lateral and an oblique X-ray of the foot in addition to the AP view we have here.
EXAMINER
. If we concentrate on the clinical examination, what specific findings are you looking for to help with your management decision?
. If we concentrate on the clinical examination, what specific findings are you looking for to help with your management decision?
CANDIDATE
I would need to assess the integrity of the skin and the neurovascular status of the foot. There may be medial-sided numbness present if the medial dorsal cutaneous nerve is compressed by an osteophyte. A grind test of the joint would be informative [24]. This testis usually done with the MTPJ in relative neutral dorsiflexion and can be a pointer to articular cartilage involvement [25].
I would need to assess the integrity of the skin and the neurovascular status of the foot. There may be medial-sided numbness present if the medial dorsal cutaneous nerve is compressed by an osteophyte. A grind test of the joint would be informative [24]. This testis usually done with the MTPJ in relative neutral dorsiflexion and can be a pointer to articular cartilage involvement [25].
EXAMINER
What is the importance of the IPJ?
What is the importance of the IPJ?
CANDIDATE
Fusion of the first MTPJ may accelerate degeneration in the surrounding joints so if the IPJ is already symptomatic a motion-pr eserving procedure at the MTPJ may be more appropriate.
Fusion of the first MTPJ may accelerate degeneration in the surrounding joints so if the IPJ is already symptomatic a motion-pr eserving procedure at the MTPJ may be more appropriate.
EXAMINER
Are you aware of any grading systems for this condition?
Are you aware of any grading systems for this condition?
CANDIDATE
The most widely used is a radiographic grading by Hatirup and Johnson in which Grade 1 is a well-preserved joint space with mild to moderate osteophytes,
The most widely used is a radiographic grading by Hatirup and Johnson in which Grade 1 is a well-preserved joint space with mild to moderate osteophytes,
EXAMINER
Right, so talk me through the management options for apa tien t with hallux rigidus.
Right, so talk me through the management options for apa tien t with hallux rigidus.
source p. 320
CANDIDATE
In the first instance I would advise non-operativ e treatment. The options include activity modification, NS AIDS, footwear modification or an in tra-articular steroid injection.
In the first instance I would advise non-operativ e treatment. The options include activity modification, NS AIDS, footwear modification or an in tra-articular steroid injection.
EXAMINER
And the operative options?
And the operative options?
CANDIDATE
The choice depends on the grade of the arthritis, patient symptoms and expectations.
The choice depends on the grade of the arthritis, patient symptoms and expectations.
EXAMINER
then, back to the operative options for treatment.
then, back to the operative options for treatment.
CANDIDATE
In Grade 1 or 2 disease, a cheilectomy, in which the osteophytes and the dorsal 25–30% of the articular surface are resected. Satisfaction rates of 90% have been reported, with improvement in dorsiflexion from 20 to 40°. For Grade 2 or 3 disease inpatients who are young and still highly active I would combine a cheilectomy with a Moberg dorsal closing wedge osteotomy of the proximal phalanx. Arthrodesis of the first MTPJ is still the mainstay of treatment for severe disease and joint preparation with dome-shaped reamers and a lag screw and dorsal plate construct is the most biomechanically sound fixation [ 30].
In Grade 1 or 2 disease, a cheilectomy, in which the osteophytes and the dorsal 25–30% of the articular surface are resected. Satisfaction rates of 90% have been reported, with improvement in dorsiflexion from 20 to 40°. For Grade 2 or 3 disease inpatients who are young and still highly active I would combine a cheilectomy with a Moberg dorsal closing wedge osteotomy of the proximal phalanx. Arthrodesis of the first MTPJ is still the mainstay of treatment for severe disease and joint preparation with dome-shaped reamers and a lag screw and dorsal plate construct is the most biomechanically sound fixation [ 30].
EXAMINER
back to arthrodesis. What is the optimal position for fusion?
back to arthrodesis. What is the optimal position for fusion?
CANDIDATE
Dorsiflexion of 25° across the MTPJ, valgus of 10–15° and neutral rotation to ensure an effective plane of motion of the IP J.
Dorsiflexion of 25° across the MTPJ, valgus of 10–15° and neutral rotation to ensure an effective plane of motion of the IP J.
EXAMINER
How will you consent apa tien t for arthrodesis of the first MTPJ?
How will you consent apa tien t for arthrodesis of the first MTPJ?
CANDIDATE
I will explain that the aim of surgery is to relieve pain and optimize mobility. damage to the medial cutaneous nerve,
I will explain that the aim of surgery is to relieve pain and optimize mobility. damage to the medial cutaneous nerve,
EXAMINER
If we return to the patient we started discussing. He is a 45-year-old male who is a keen walker. He has significant stiffness and pain on mobilization and dorsiflexion, but a grind testis negative. He has exhausted non-operativ e measures. What treatment will you offer him?
If we return to the patient we started discussing. He is a 45-year-old male who is a keen walker. He has significant stiffness and pain on mobilization and dorsiflexion, but a grind testis negative. He has exhausted non-operativ e measures. What treatment will you offer him?
CANDIDATE
I would offer him a cheilectomy with a proximal phalanx osteotomy as this has the added benefit of improving range of movement over a cheilectomy on its own,
I would offer him a cheilectomy with a proximal phalanx osteotomy as this has the added benefit of improving range of movement over a cheilectomy on its own,
EXAMINER
He is not keen on the joint being stiffened up and has read on the internet about joint replacements and is keen for this.
He is not keen on the joint being stiffened up and has read on the internet about joint replacements and is keen for this.
CANDIDATE
I would inform him that for his age group there would be a significant risk of loosening of the prosthesis resulting in failure, thus the need for revision surgery. They reported a 20.9% rate of prosthesis loosening causing instability and pain during gait and an 11% chance of revision surgery being required.
I would inform him that for his age group there would be a significant risk of loosening of the prosthesis resulting in failure, thus the need for revision surgery. They reported a 20.9% rate of prosthesis loosening causing instability and pain during gait and an 11% chance of revision surgery being required.
EXAMINER
He is still not convinced.
He is still not convinced.
CANDIDATE
I would refer him to a colleague for a second opinion. [Bell] For the FRCS (Tr & Orth) exam joint replacement is very controversial.
I would refer him to a colleague for a second opinion. [Bell] For the FRCS (Tr & Orth) exam joint replacement is very controversial.
source p. 322
Figure 5.19 X-ray showing hallux rigidus.
source p. 323
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