The Foot & Ankle:

1. The Foot & Ankle: Dr. AamirShaikh. Clinical Lecturer of Orthopedics RCSI & UCD. 15th December 2010.

2. Anatomy of the Ankle Joint: Articulation between the lower end of the tibia, the two malleoli, and the body of the talus Synovial hinge joint Covered with a thin layer of hyaline cartilage

3. Anatomy of the Ankle Joint Anterior Malleoli Posterior Medial Tibial plafond Lateral

4. Movements of Ankle joint

5. Deltoid Ligament Supports the medial of the joint Strong ligament Originates from the medial malleolus and fans out to attach at four regions, including the navicular and talus A subluxed or dislocated ankle implies disruption of this ligament

6. Lateral Ligaments ATF Made up by the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament The anterior and posterior talofibular ligaments support the lateral side of the joint from the lateral malleolus of the fibula to the dorsal and ventral ends of the talus The joint is most stable in dorsiflexion and a sprained ankle is more likely to occur when the foot is plantar flexed. This type of injury more frequently occurs at the anterior talofibular ligament. CF PTF

7. Anatomy of the Subtalar Joint: Also known as talocalcaneal joint The joint allows inversion and eversion of the foot, but plays no role in dorsiflexion or plantarflexion of the foot It is considered a plane synovial joint, also commonly referred to as uni-axial hinge joint

8. Movements of Sub-talar joint:

9. Ligaments of Subtalar joint: The main ligament of the joint is the interosseoustalocalcaneal ligament, a thick, strong band of two partially joined fibres that bind the talus and calcaneus. It runs through the sinus tarsi, a canal between the articulations of the two bones.

10. Anatomy of Talocalcaneonavicular Joint The talocalcaneonavicular articulation is an arthrodial joint: the rounded head of the talus being received into the concavity formed by the posterior surface of the navicular, the anterior articular surface of the calcaneus, and the upper surface of the planter calcaneonavicular ligament The articulation is a synovial joint of the ball and socket type

11. Movements of Talocalcaneonavicular Joint The movement of the talo-calcaneo-navicular joint is more difficult to understand Whereas the axis of the ankle joint can easily be defined, the axis of the talocalcaneonavicular joint is drawn obliquely from lateral posterior to medial anterior Both articular surfaces of the talocalcaneonavicular joint are congruent only in the mid-position. An incongruence develops between the two articular surfaces by both eversion and inversion. This incongruence cannot be maintained for long periods when carrying weight The ankle joint and the talocalcaneonavicular joint must be regarded as a functional unit. The possible movements of these two joints can be compared to a spheroid joint which can be moved freely within its range of motion: flexion, supination, pronation, abduction and adduction which in some respects corresponds to a rotation

12. Ligaments of the TCN joint Plantarcalcaneonavicular ligament or spring ligament Attaches calceus ---navicular Supports head of talus Maintains medial longitudinal arch Bears major portion of body weight PCNL

13. Muscles and movements – Anterior compartment • Tibialis anterior • The tibialis anterior is a muscle that originates in the upper two-thirds of the lateral surface of the tibia and inserts into the medial cuneiform and first metatarsal bones of the foot. It acts to both dorsiflex and invert the foot • The tibialis anterior muscle is the most medial muscle of the anterior compartment of the leg. It functions to stabilize the ankle as the foot hits the ground during the contact phase of walking (eccentric contraction) and acts later to pull the foot clear of the ground during the swing phase (concentric contraction). It also functions to 'lock' the ankle, as in toe-kicking a ball, when held in an isometric contraction • Extensor hallucislongus • Arises from the anterior surface of the fibula for about the middle two-fourths of its extent, medial to the origin of the Extensor digitorumlongus; it also arises from the interosseous membrane to a similar extent and is inserted into the base of the distal phalanx of the great toe

14. Muscles and movements – Anterior compartment • Extensor digitorumlongus • Peroneusbrevis • Peroneuslongus

15. Dorsiflexion Occurs at ankle joint Range of Motion (ROM) 20⁰ Nerve supply L4/L5

16. Muscles and movements – Posterior compartment • Gastrocnemius • Very powerful superficial muscle • It runs from its two heads just above the knee (medial and lateral condyles) to the heel (Achilles tendon) • Most important role was plantar flexing in large contractions and in rapid development of tension • Soleus • It runs from just below the knee to the heel, and is involved in standing and walking. It is closely connected to the gastrocnemius muscle and some anatomists consider them to be a single muscle It originates from the posterior (back) surfaces of the head of the fibula and its upper quarter, as well as the middle third of the medial border of the tibia. Its other end forms the Achilles tendon with gastocnemius

17. Muscles and movements – Posterior compartment • Plantaris • Flexor digitorumlongus • Flexor hallucislongus

18. Plantarflexion is the main function of the calf muscle Occurs at ankle joint ROM 40⁰ Nerve supply L5/S1

19. Inversion Inversion is the movement of the sole towards the median plane Occurs at subtalar joint Muscles involved: Tibialis anterior Tibialis posterior Extensor hallucislongus

20. Eversion Eversion is the movement of the sole away from the median plane Muscles involved Peroneuslongus muscle Peroneusbrevis muscle

21. Bones of the foot

22. Osteoarthritis What is it? A degenerative joint disease that causes stiffness, pain, and reduction in movement Who are the two types? Primary OA: middle aged/ elderly, aetiology unknown Secondary OA: (common in ankle OA) predisposing factors include previous ankle fractures, being overweight and pesplanus

23. OA Pathogenesis Affects weight bearing jt Prevalence increases with age Disease accelerated by mechanical instability/ stress on jt/increased stress on jt surface initial changes in articular cartilage  fibrillation of cartilage vertical clefts  exposure of subchondral bone with continuous pressure this leads to sclerosis of subchondral bone (eburnation) bone degeneration under stress creates cysts At joint margins new bone forms resulting in spurs/osteophytes

24. Ankle arthritis on x-ray Narrowed joint space

25. Treatment: Conservative: • Weight loss • Modify daily activities, walking aids • Physiotherapy • Analgesia: aspirin, paracetamol, NSAIDS • Steroid injection into the joint • Orthotics • Dietary supplements (e.g. glucosamine)

26. How this affects patients • Joint stiffness • Joint swelling • Lost flexibility • Reduced range-of-motion • Difficulty walking • Difficulty with weight bearing, which may even cause slips and falls

27. Surgical: Arthroscopic debridement: Sometimes when OA of the ankle occurs, loose pieces of cartilage and bone float around inside the ankle joint These loose bodies can cause irritation in the joint, leading to inflammation. They can also get caught between the joint surfaces of the ankle. This can cause a sharp pain when it happens The cartilage surfaces of the joint can also become rough, with flaps of cartilage that peel off the surface. These can be shaved, making the surface smoother.

28. Ankle Replacement: Ankle Arthroplasty: Because no one wants to lose the ability to move the ankle, much research has been done trying to perfect an artificial ankle replacement Until now, the artificial ankle has not been nearly as successful as the artificial hip or knee. The ankle is a difficult joint to replace as the socket (usually called the mortise) is actually made up of two bones, the tibia and the fibula. These two bones move against one another slightly when we walk. This makes it difficult to get the artificial ankle socket to stay connected to the bone The biggest problem with the older artificial ankle designs is that they loosened after a relatively short time and began to cause pain When using the newer artificial ankle designs, surgeons have tried to solve this problem by actually fusing the tibia and fibula together during the operation and placing screws across the two bones. This has dramatically increased the success rate for the artificial ankle replacements done today

29. Ankle Arthrodesis: When the ankle joint becomes so painful that it is difficult to walk, surgery may be suggested to fuse the ankle joint In this operation, the three bones that make up the ankle joint (the talus, the tibia, and the fibula) are allowed to grow together, or fuse, into one bone. Once this is done the ankle no longer is able to move, but with a successful fusion the pain is gone. Most people with a successful fusion of the ankle are able to walk without much trouble, but it is very difficult to run because you lose the ability to push off with the toes Ankle fusion is a good operation, especially for a young, active person. It is usually the preferred option for post-traumatic arthritis of the ankle.

30. Ankle fracture: A painful can either be sprained(soft tissue damage) or fractured (broken bone) With a fractured ankle there is invariably soft tissue damage (i.e ligaments) Fractures of the ankle can be classified by the involvement of malleoli as uni, bi or tri-malleolar Uni Bi Tri

31. Ankle fracture: Mechanism of injury Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection.

32. Fixation of fractures: Open reduction and internal fixation (ORIF)

33. Ankle fracture: Syndesmosis The tibiofibularsyndesmosis is formed by the rough, convex surface of the medial side of the lower end of the fibula, and a rough concave surface on the lateral side of the tibia Below, to the extent of about 4 mm, these surfaces are smooth, and covered with cartilage, which is continuous with that of the ankle-joint

34. Ankle fracture Syndesmosis screw

35. Fractures of the distal fibula: Danis-Weber classification: • Type A fractures are horizontal avulsion fractures found below the mortise. They are stable and amenable to treatment with closed reduction and casting unless accompanied by a displaced medial malleolus fracture. • Type B fracture is a spiral fibular fracture that starts at the level of the mortise. This type of fracture occurs secondary to external rotational forces. These fractures may be stable or unstable depending on ligamentous injury or associated fractures on the medial side. • Type C fracture is above the level of the mortise and disrupts the ligamentous attachment between the fibula and the tibia distal to the fracture. These fractures are unstable and require open reduction and internal fixation.

36. Ankle fracture: Treatment Non-operative Weber A – 6 weeks Cast ( weight bearing ) Weber B – Undisplaced Cast ( non-weight bearing ) Ankle splints are commercially available or may be constructed by sandwiching 10-12 layers of plaster between 4 sheets of cotton padding

37. Ankle fracture: Treatment ORIF of Weber C fracture

38. Hallux Valgus: In the term "halluxvalgus“, the "hallux" refers to the great toe and the "valgus" refers to the deviation away from the midline, which the toe is undergoing The bump is the swollen bursal sac and/or an osseous (bony) deformity that has grown at the head of the first metatarsal Bunions are caused by a biomechanical abnormality, where certain tendons, ligaments, and supportive structures of the first metatarsal are no longer functioning correctly This biomechanical abnormality may be caused by a variety of conditions intrinsic to the structure of the foot--such as flat feet, excessive ligamentous flexibility, abnormal bone structure, and certain neurological conditions Although some experts are convinced that poor fitting footwear is the main cause of bunion formation, other sources concede only that footwear exacerbates the problem caused by the original deformity

39. Hallux Valgus: As the toe moves further and further into valgus: First metatarsal head becomes more prominent (first metatarsal exostosis) and a protective bursa may develop over it (bunion) Friction against the shoe may give rise to inflammatory changes within it (bursitis) 2° OA changes in first MP joint As the great toe moves laterally it crowds the other toes, and may come to lie above, or more commonly below the other toes

40. Hallux Valgus: • Mechanics of the forefoot are disturbed, leading to • Spreading of the forefoot • Callus formation under metatarsal heads • Anterior metatarsalgia (forefoot pain)

41. Hallux Valgus: Treatment: Conservative: 1. Follow the advice given by a Podiatrist 2. Use felt pads to help keep pressure off the painful area of the bunions. 3. Wear shoes that are wide and deep to accomadate the bunions. Fitting of footwear is very important. Avoid the use of high heel shoes. 4. Use exercises to keep the joint mobile 5. Night splints may help with the bunion symptoms. The aim of these are to hold the toe in a more correct position.

42. Hallux Valgus: Treatment: Surgical: Goals: Removing the abnormal bony enlargement of the first metatarsal Realigning the first metatarsal bone relative to the adjacent metatarsal bone Straightening the great toe relative to the first metatarsal and adjacent toes Realigning the cartilaginous surfaces of the great toe joint Addressing arthritic changes associated with the great toe joint Repositioning the sesamoid bones beneath the first metatarsal bone Shortening, lengthening, raising, or lowering the first metatarsal bone Correcting any abnormal bowing or misalignment within the great toe

43. Hallux Valgus: Treatment: Surgical: Chevron Osteotomy It is very rare that a bunion can be treated by simply shaving down the bump of the bone. Invariably, the deformity will recur and both the bunion and the halluxvalgus will return. Therefore, the shaving of the bunion, called an exostectomy, is performed in conjunction with a cut of the first metatarsal bone (which is called an osteotomy). Depending on the severity of the deformity, this osteotomy can be done either at the end of the metatarsal (a distal osteotomy) or if the deformity is more severe, the osteotomy is performed at the base of the first metatarsal (a proximal osteotomy). One of the more common distal metatarsal osteotomies that is performed is called the chevron osteotomy. Typically a small screw is inserted into the bone to hold the metatarsal head in place and speed up bone healing. Following a chevron osteotomy, walking is permitted in a surgical shoe the next day after surgery, and the shoe is worn for approximately three to four weeks before a more comfortable walking/running type shoe is worn. Before After Once the V-cut in the metatarsal is made, the bone is shifted over and the remaining edge of the bone is shaved down as shown here. An operation which is used frequently is called the chevron osteotomy. It is a V-shaped bone cut made in the metatarsal

44. HalluxValgus: Treatment Surgical: Myerson/Ludloff Osteotomy One of the more popular proximal metatarsal osteotomies that is performed is called the Myerson/Ludloff procedure This operation is performed for more advanced deformity Screws are inserted into the metatarsal to hold the bone cut secure and speed up bone healing Walking is permitted in a surgical shoe following surgery X-Rays of feet before and after the Myerson/Ludloff bunion operation. The metatarsal bone is held in place with screws which are buried in the bone The dotted red line shows the direction of the cut on the metatarsal bone when performing the Myerson/Ludloff bunion operation

45. Ruptured Achilles Tendon: • Males 30 – 50 yrs • “Weekend warriors” • Occurs approximately 2-6 cm – the "watershed zone" – above the calcaneal insertion of the tendon • That the left Achilles tendon is torn more frequently may be related to handedness; right-handed individuals "push off" more frequently with the left foot • The most common mechanisms of injury include sudden forced plantar flexion of the foot, unexpected dorsiflexion of the foot, and violent dorsiflexion of a plantar flexed foot. Other mechanisms include direct trauma • Will often complain of a “snap” or like “being kicked” • The peak Achilles tendon force (F) and the mechanical work (W) by the calf muscles are respectively approximately 2200N and 35J in the squat jump, 1900N and 30J in the countermove jump, and 3800N and 50J when hopping • The estimated peak load is 6-8 times the body weight during running with a tensile force of greater than 3000N

46. Ruptured Achilles Tendon: Examination Palpable gap 2-3cm above insertion Thompsons test

47. Ruptured Achilles Tendon: Treatment: Conservative Casting Placed in cast in equinis (plantar flexion) Some concerns about re-ruptrure (up to 20-40%) in some studies Recent trials have showed increased success with conservative mangaement

48. Ruptured Achilles Tendon: After application of the tourniquet and palpation of the rupture gap The incision is made through the skin and subcutaneous fat to the paratenon The paratenon is then divided longitudinally to expose the ruptured ends, which are irrigated and debrided The ends are then reapproximated and sutured with a heavy nonabsorbable suture using a modified Kessler, Krackow, or Bunnell technique, being careful not to overtighten

49. Thank you: