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1. Diabetic Infection 6/30/2014 5:14:00 PM
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Infection- minimal number of viral particles necessary to establish disease
states:
 106  Bone infection
 105
 Soft tissue infection
 102
 Infection of soft tissue or bone + foreign body
 Allows differentiation b/w colonization & infection
-Subjective
 CC: foul smelling ulcer for 3 days etc…
 NLDOCAT
 “Systemic” signs of infection N/C/V/D/F/SOB
 “Local” signs of infection calor, dolar, rubor, tumor, pain
 5 Questions to ask:
1) Trauma?

2. 2) Previous amputations of infections?
3) Recent glucose/HgA1C?
4) NPO status- looking ahead for surgical debridement?
5) Tetanus status?
-PMH co-morbidities associated with disease
-FH parents alive/cause of death
-PSH foot & ankle, CABG, Vascular surg
-Meds dosage & frequency
 Add up all insulin types and divide by 4
-Allergies type of rxn (true rxn or not)
-Social working? how long & how much of drug? Housing?
-ROS
 General, Eyes, Lungs, Pv, Neuro, Musc
 Now the whole thing:
o HEENT, Resp, Cardio, GI/GU, Musc, Skin, Neuro, Lymph
-Objective
 Vitals Temp/HR/RR/BP & Height/weight
o SIRS (need at least 2 of below criteria)
 Temp (96.8 or 100.4)
 HR (>90) & RR (>20)
 WBC (<4k or >12K or 10% bands)
o Septicemia bacteremia + fever, chills, nausea etc…
 Lower Extremity focused
o Vasc: doppler, CFT, edema
 ABI: >1.2= calcification (monkebergs sclerosis)
< 0.45= inadequate for healing in diabetics
 TcPo2: need to be > 30mmHg for adequate healing
o Neuro: protective & vibratory sensation
 Prop & Vib posterior column
 Light touch & pain/temp anterior lateral
o Derm: Depth, Diameter, Drainage, Odor, Base, Border
 PROBE TO BONE??

3.  Grayson- 89% PPI for OM
 Lavery- 98% NPI for OM
 *Wagner: 0= pre-ulcer, 1= superficial, 2= deep to
bone, 3= deep to bone + abscess/infection
 UT: 0= normal, 1= superficial, 2= tendon, 3= bone
 A= Normal , B= Infected, B= Ischemic, D= both
 PEDIS: (Perfusion Extent Depth Infection Sensation)
 1= uninfected
 2= (Mild) > 2 manifestations of inflam
 Erythema/cellulitis < 2 cm around ulcer
 3= (Mod) Erythema/cellulitis > 2 cm around
ulcer, streaking lymp, abscess, gangrene
 4= (Severe) + N/C/V/D/F/SOB/Confusion
o Musc: boney prominences ?
 Foot type, Previous amputations, Strength
-What to order
1) Imaging:
 X-rays
o Gas= emergency
 Get more PROXIMAL films
 BECKS+ (Bacteroides, E. coli, clostridium, klebsiella,
stap/strep, peptococcus, peptostrepto c
o OM (may take 10-14 days/ need 30-50% resorption)
 Acute= soft tissue swelling, periosteal rxn, lytic
changes, cortical destruction
 Chronic= sequestrum, involucrum, cloca, brodie’s
 MRI
o No contrast if Poor renal function
o T1= low signal
o T2/Stir= high signal in cortex/medullary bone
 Bone Scan
o Increased uptake in all 4 phases
o Charcot vs. “Acute” OM
 Charcot has more diffuse “periarticular” uptake on
phase 3

4.  Ceretec (Tech-HMPAO) sensitive & specific “safer”
 Only shows ACUTE infections
 Determines if hotspot is in or out of bone
 Indium-111 Oxime done in 24hrs
 Better for CHRONIC infections
2) CBC w/ diff:
 Hemoglobin (12-18) **Transfuse if < 8
 Hematocrit (35-55%) **Transfuse if < 24
o 1 unit PRBC= increase Hg by 1 & Hct by 2
o 1 unit Whole blood= increase Hg 2 & Hct 4
 Platelets (100-450) ** No surgery if < 100
 WBC (<4,000 or >12,000)
 **Absolute Neutrophil Count shift to left with bands & segments
o Left shift= neutrophils + bands > 80
3) BMP
 Sodium (hypernaturemia- dehydration, Na overload, vol overload)
 Glucose- healing potential haulted if >150-175 mg/dL
 Creatinine- kidney function measuring GFR
4) Hba1C (add 30 mg/dl each increase inn HbA1c)
 HbA1c of 5%= 100 mg/dL
 HbA1c of 6%= 130 mg/dL
5) Coag’s
 PT (10-16)
 PTT (25-35)
 INR (1) **Need < 1.6 for surgery
o 1 unit FFP decreases INR by 0.2
6) Inflammatory markers
 ESR (0-20 mm/hr) NOT SPECFIC
o Kaleta- if > 70 suspect OM
 CRP (0-0.8 mg/L) more closely follows the severity of ds
7) Albumin (3.5-5 g/L)
 Pre-albumin (19-36 mg/dL) **shorter half life
8) EKG/CXR/HCG
 EKG Males > 40 & Females >50 going to surgery
 CXR smoking history
 HCG women < 50 yrs

5. 9) Culture (always get AFTER debridement)
 Gram stains
o G(+): stains purple (Teichoic acids, lacks outer-membrane)
 Cocci: Staph (cat + “cluster”) & Strep (cat – “chains”)
 S. aureus (coagulase +)
 Rods: clostridrum, bacillus, etc..
o G(-): stains pink (Endotoxin in outer-membrane)
 Cocci: Neisseria (oxidase + diplococci)
 Rods: Pseudomonas (oxidase + lactose non-ferm)
 Aerobic, Anaerobic, Fungal, Acid-fast
 Culture & Sensitivity
 Blood culture (3 diff locations 10 min apart)
10) Non-invasive studies
 Doppler: want biphasic
 Segmental pressures: > 10 mmHg drop indicates occlusion
 ABI: need > 0.45 (Wagner)
 TcPo2: need > 30 mmhg (Wyss, Harrington & Burgess, JBJS)
o Will be decreased from edematous states
-Decision making
 Admit or home
o Make “Outpatient” if:
 Local infection that can be controlled w/ PO Abx
 Benign medical conditions
o Make “Inpatient” if:
 Systemic infection requiring IV Abx
 Needed surgical intervention
 Immunocompromised (Dm, PVD, HIV, RA, Elderly,
Steriod)
 Admit (ADCVANDLIMAX)
 Antibiotics/Meds
o Creatinine clearance (140-age) x weight (kg) (x 0.85 in women) / 72 x serum Cr
o Vanc (1g q12 IV) & Zoysn (4.5 g q6 IV)
 Adjust vanc according to trough levels
o PCN Allergy (Clinda 600 mg q6 IV) & (Cipro 400 mg q12 IV)
o PCN & Quin allergy Clinda & Aztreonam (1 g q8 IV)

6. o Sliding scale of insulin
 Once glucose is 200mg/dL then give 2 units, and 2
more units each 50 increase of glucose
 Surgery (make NPO)
o Beside I&D (localized, neuropathic, etc..)
 Irrigation w/ local debridement
 Wet to dry dressing (dakins, betadine, saline)
 Cultures & tissue biopsy
o OR I&D (tracks or probes, abscess, gas in tissue)
 Debridement, Drainage, Decompression
 Remove all tendons in the way
 Pulse lavage at least 3 liters (DAB vs. TAB)
 Deep cultures & Tissue biopsy
 Clean margins with bone resection procedure
 Antibiotic beads (PMMA)
 Commonly used antibiotics include: gentamycin,
tobramycin, and vancomycin
 Packed open and eventual DPC
 Chronic OM
 Sequesterum is non-viable and a nidus for
infections so it must be removed
o TMA
 Incisions:
 Fishmouth w/ adequate plantar flap
 Tennis racquet for lesser met amp
 Preserve only P. brevis & PT
 Adjunct TAL

7. DVT 6/30/2014 5:14:00 PM
-Introduction
DVT clot formed in deep venous system of LE
 PE “detached” thrombus from LE that travels to arteries of lung
 Risk Factors (I AM CLOTTED)
o Inactivity, A fib/Age, MI, Coag state, Longevity of surgery,
Obesity, Tobacco use, Trauma, Estrogen, DVT history
 Common locations
o 20% of calf emboli will become thigh emboli
o 1/5th of PE come from calf
-Clinical Diagnosing:
 Clinically: red, hot, swollen, painful calf - edema is the most reliable
sign of DVT (compare suspected calf to the contralateral side)
 Homan’s test DF foot elicits pain in calf
 Pratt’s sign calf compression elicits pain
-Diagnostic Tests:
 Non-invasive
o Duplex Doppler: lack of venous compression indicates DVT
 Can have color flow imaging to enhance sensitivity
 Allows to determine direction of blood flow and the
amount of reduction in lumen diameter
 Grady-Bensmetal JBJS, 1994: duplex ultrasound has
the PPV of 7/9
o Impedence plethysmography
 measures small changes in electrical resistance of the
chest, calf or other regions of the body.
 These measurements reflect blood volume changes, and
can indirectly indicate the presence or absence of
venous thrombosis
o MRI provide visual images of your veins and may show if
you have a clot

8. o D-dimer detect fragments produced by clot lysis
 high sensitivity may be useful for excluding the
diagnosis of acute DVT, particularly when the pre-test
probability for the disease is low
 Invasive
o Contrast venography
 Gold standard for detecting DVT
 Disadvantages contrast agent can cause reactions
such as urticaria, angioedema, bronchospasm, cv
collapse or injury to kidney
 Creatinine > 2.0 mg/d is relative contraindication
-Diagnosing PE
 PE COD: Right-sided heart failure
o Increased right ventricular wall causes underfilling of left
ventricle provoking myocardial ischemia compromising
coronary artery perfusion leading to circulatory collapse.
 Clinically: sudden onset of chest pain, dyspnea, hemoptysis,
tachycardia Pt may be febrile, hypotensive and cyantic
o Triad CP, Dyspnea, Hemoptysis
 Diagnosis:
o 1) Blood gasses: PaO2 < 80 mmHg
o 2) Chest x-ray: 50% are normal; a normal or near normal
chest x-ray in a dyspenic patient suggests PTE.
 Abnormalities include: focal oligemia (Westermark’s
sign), a peripheral wedge shaped density above
diaphragm (Hamptom’s hump) or enlarged right
descending pulm artery
o 3) Ventilation- Perfusion Scan (V/Q Scan)
 **A mismatch demonstrating an area of ventilation but
NO perfusion suggests PE
 Ventilation: inhalation of xenon 133
 Perfusion: T99 labeled albumin
 V/Q mismatch: acute PE, previous PE, centrally located
cancer, radiation

9. o 4) Pulmonary angiography
 Definitive test, indicated if V/Q scan is inconclusive
 Diagnostic signs: intraluminal filling defect, abrupt
vessel cutoff, loss of side branches
-Prophylactic Measures:
 Non-pharmacologic
o Compression stockings
o SCDs prevents stasis due to increased venous return
 Pharmacologic
o Heparin
 Pre-op 5,000 units SQ q2h
 Post-op 5,000 units SQ q8-qh
-Treatment
 Heparin IV
o MOA Binds & accelerates Anti-thrombin 3 which potentiates
the inhibition of coag factors 10a and 2a““works in blood”
o Loading dose: 10,000 -15,000u or 80u/kg
o Maintenance dose: start with 1,000 u/hr (18u/kg/hr)
o MONITOR PTT DAILY (goal 60-90 seconds)
 Titrate to 1.5-2 x normal (30ish x 2= 60)
o Reversal Protamine sulfate
 1 mg protamine pre 100 u heparin
o LMWH (Lovenox)
 More predictable efficacy and lower incidence of adverse
effects such as HIT, patients can inject LMWH
themselves at home
 Therapeutic 30 mg SQ BID (for 7-10 days)
 Prophylactic 1 mg/kg SQ (for 7-10 days)
 Coumadin
o MOA interfere with the synthesis of Vit. K clotting factors
2, 7, 9, 10, and Protein S & C “works in the liver”
o Start after heparin is therapeutic
o Commonly 2.5 mg qd
o MONITOR PT DAILY (1-1.15 x normal/INR 2 -3)

10.  Titrate to 1-1.15 x normal (1.2 ish x 2= 17)
o Reversal Vit. K or FFP
 Thrombolytic (Urokinase, Streptokinase, tPA)
o MOA aid in conversion of plasminogen to “Plasmin” which
cleaves thrombin & fibrin clots (+) PT & PTT
o Must be initiated w/in 24-48 hrs
o Loading dose 250,000 Units infused over 30 min
o Dosage/Duration 100,000 Units/hr for 72 hr
 Surgical
o Greenfield filter placed in IVC below renal veins
o Embolectomy

11. Hallux Limitus & Rigidus 6/30/2014 5:14:00 PM
-Introduction
 Normal 70 DF & 30 PF
 Limitus decrease in ROM “limited dorsiflexion” < 20 degrees
 Rigidus Absent ROM due to “ankylosis” <10 degrees
o Presence of bony ankylosis & sesamoid immobilization
 Classification
o Functional Dorsi decreased ONLY when loaded (Stage 1)
o Structural Dorsi decreased BOTH loaded & unloaded
o Primary long 1st metatarsal
o Secondary DJD, trauma, arthritis
 Etiology
o Long/short 1st, MPE, Trauma, Hypermobility, Arthritis
 Clinical findings:
o Dorsal bunion w/ tenderness on dorsiflexion
o Apropulsive gait w/ early off & abductory twist
 Radio findings:
o Joint space narrow w/ loose bodies
o Squared/flattened met head
o Subchondral scerlosis
o Met primus elevatus
-Classification Systems (Drago, Oloff, Regnauld)
 Regnauld
o Stage 1
 Joint enlargement w/ mild spurring
 Functional Hallux Limit
o Stage 2
 Narrowing of joint space
 Flattening met head with dorsal exostosis
o Stage 3
 Severe loss of joint space w/ crepitus on ROM
 Joint mice w/ extensive spurring & DJD
o Stage 4
 Complete bony ankylosis “obliteration of joint”

12. -Conservative treatment (Stages 1 & 2)
 Activity modification & PT
 Orthotics (rocker bottom, morton’s extension, 1st ray cut out)
 NSAIDs (PO) or Corticosteriod (injection
-Surgical treatment (Stages 3 & 4)
 Joint Preservation (> 50% of cartilage) “CCBWY”
1) Cheilectomy resection of dorsal exostosis
2) Cotton opening wedge osteotomy
3) Bonney & Kessel dorsal wedge of phalanx base
4) Waterman dorsal wedge of met base
5) Youngswick plantarflexory osteotomy
 Joint Destruction (< 50& of cartilage) “K FILM”
1) Keller resection 1/3 proximal phalanx base
2) Implant (total vs. hemi) function as spacer
3) Fusion “Mckeever” 15 dorsiflexed & 10 abducted
4) Mayo/Stone Mayo (artic surface) & Stone (1/4th met head)
5) Lapidus TMT joint fusion
-Post-Op Management
 Orthotic + padding
 PT with passive ROM exercises
 Serial radiographs

13. Bunion case 6/30/2014 5:14:00 PM
-Introduction:
 Goals (RED CAR):
o Reduction of abnormal osseous angles
o Establish congruous 1st MPJ
o Decrease medial eminence
o Control correction of factors that lead to deformity
o Align sesamoids back to proper position
o Restoration of 1st MPJ weight bearing function
 Etiology
o Primary hypermobile/long 1st or pronation
o Secondary trauma, RA, pes planus, gout
 Pathology
o Progressive disorder with these factors affecting:
 Hyperpronation unlock MTJ loss P. longus 1st ray
instable retrograde buckle adductor advantage
ligament instability arthritic changes
o Stages:
 1- lateral displacement of prox phalanx
 2- HAV where 1st abuts 2nd digit
 3- increase IM angle
 4- subluxed hallux w/ overriding digits
 Anatomy
o 4 articular surfaces
o 9 ligaments (2 collateral, 4 sesamoidal, Intersesamoidal,
DTIML, Capsule)
o FHL only tendon that DOESN’T attach to MPJ capsule
o Square met head is most stable
-Radiography
 In the area of patient’s presenting complaint I see:
o AP view
1) (Mild or Severe) soft tissue swelling
2) (Mild or Severe) HAV deformity at level of MPJ defined by
(mild or mod) increases in:

14.  IM angle (8-12°)
 HAI angle (< 10°)
 HA angle (15°)
3) PASA & DASA (normal, deviated, subluxed)
 Positional (P +D < HA) “subluxed/deviated joint”
 Structural (P + D = HA) “congruous joint”
4) Tibial sesamoid position (1-7)
5) Length of 1st met (normal, long, short) using:
 Met parabola- (142°)
 Met protrusion index (0-2 mm)
6) Metatarsus adductus/Engel (< 15°)
 Abnormal MA may mask IM deformity
o Lateral View
1) 1st met is (elevated, normal, short) compared to 2nd met
using Seiberg’s index
 distal distance – proximal distance (+ = Elevatus)
o 2) Foot type (pes planus, cavus, normal)
-Capsule Tendon Balancing Procedures
 Silver (1923) resection of DM eminence w/ lateral capsulotomy
and medial capsulorraphy
 Mcbride “True” (1928) silver + fibular sesamoid removal and
transfer of adductor tendon
 Hiss (1931) transfer adductor from plantar to medial
 Joplin’s sling (1950) transfer adductor thru met
 Component procedures:
o Adductor transfer
o EHL lengthening
o EHB tenotomy
o Capsulorraphy (Washington, H, T, Inverted L, Linear)
-Osetotomies
 Hallux interphalangeus “Distal” Akin
 Abnormal DASA “Proximal” Akin (5-10 mm from MPJ)
 Abnormal PASA Reverdin 

15. o 1st cut: = to articular surface
o 2nd cut:  to long axis
o Green plantar cut to protect sesamoids w/ hinge intact
o Laird lateral cortical hinge not maintained (IM correction)
 True IM < 16° Distal osteotomy
o Austin/Kalish/Youngswick stable sag & frontal planes
o Mitchell shortens “lateral hinge intact”
o Hoffman shortens “trapezoid osteotomy”
o Wilson shortens “oblique osteotomy”
o Scarf Central cut DD PP w/ 70° angles
o Keller resection of prox phalanx base “elderly”
o Mckeever fusion “for arthritic joint”
 True IM > 16° Proximal osteotomy “hinge axis concept”
o Ludloff cut PD DP
o Mau cut PP DD “better stability”
o Juvara oblique CBW 40° cut “avoid growth plate”
 A) wedge B) wedge + hinge cut C) no wedge
o CBW/OBW shortens or lengthens 1st met
o Cresecentic bad stability
o Lapidus hypermobile first or large met/IM
o Logroscino Reverdin + CBW
-Surgical technique
 Single screw halfway b/w line  to long axis & line  to
osteotomy
 K-wire dorsal distal medial to plantar proximal lateral
-Post-op
 NWB 4-6 weeks
 Serial radiographs
-Complications
 Hallux varus (staking, aggressive bandage, fibular sesamoid
removed, overcorrection on IM)
o Systemic Repair of Hallux Varus (McGlamry)

16.  Complete ST release, Correction of structural deformity
(IM angle), Tendon transfers, Tibial sesamoidectomy,
Joint arthroplasty
 Capital fragment on floor (Christenson; 1992)
o Mix 1 L NS (+) 1 mL Neosporin irrigant (+) 1:100K Bacitracin
o Transfer to 3 different basins w/ solution x5
o Document and tell patient
 Others: infection, avn, non-union, fixation failure, shortening,
reoccurrence, sesamoiditis

17. Haglunds & Retrocal Exostosis 6/30/2014 5:14:00 PM
-Introduction
 Haglunds posterior-superior painful bursal projection of
calcaneus due to enlargement of this cal region
o Involves retrocalc & achilles bursa
o Caused by: shoe gear irritation or cavus foot
 Retrocal Exostosis ensethopathy at achilles tendon
o Intratendinous calcification of soft tissues
o Traverses “Entire” posterior aspect of heel
o Caused by: trauma or overuse causing thickening
 DDX:
o Calc bursisitis, Achilles tendonitis, Achilles rupture, Tumor
-Radiology
 Fowler & Phillip (normal 45-70)
o Line posterior calc w/ line tangent to PS prominence
o Pathologic > 75
 Total angle (normal < 90)
o Calcaneal inclination (+) Fowler & Phillip
o Pathologic > 90
 Parallel pitch lines
o Line 1 tangent to ant. tuber & medial plantar tuber
 Then draw line  to this
o Line 2 parallel to “Line 1” and  to perpendicular line
o Pathologic bursal projection above “Line 2”
-Conservative treatment
 Shoe (heel lift, padding, orthotic)
 NSAIDS
-Surgical treatment (avoid chasing the “bump”)
 Keck & Kelly remove wedge from posterior-superior calc

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

19. Pes Planus (Flexible vs. Rigid) 6/30/2014 5:14:00 PM
-Etiology
 Flexible
o Equinus
o Congenital (talipes calcaneovalgus)
o Structural (compensated FF varus or valgus)
o Ligamentous (PTTD or ligamentous laxity)
 Rigid
o Tarsal coalition (Syn-desmosis, chondrosis, ostosis)
 *TC (12-16), CN (12-8), TN (3-5)
 True collation= intra-articular fusion of 2 bones
o Congenital (Apert’s or Nievergelt-pearlman)
 Both seen with cuneiform coalitions
o Trauma (fractures)
o Peroneal spasm
-Planes of dominance:
 STJ axis 42 transverse & 16 sagittal
 MTJ “oblique” 52 transverse & 57 sagittal
o DF, PF, abduction, adduction
 MTJ “longitudinal” 15 transverse & 9 sagittal
o Inversion & eversion
-Clinical exam
 Hubscher maneuver dorsiflex hallux creates windlass mech.
o Arch elevation, PF 1st ray, RF supination, Ext leg rotation
 ROM (Ankle, STJ, MTJ)
o Ankle 10 dorsiflexion & 20 plantarflexion
o STJ 10 eversion & 20 inversion
o MTJ “longitundal” 4-6
 Have patient stand in angle & base
o Too many toes sign
o RSCP in > 4 valgus

20. o Single heel rise test
 Coalition findings
o Progressive valgus w/ bow strung peroneal tendons “SPASM”
-Classifications
 Johnson & Strom
o 1) tenosynovitis + mild tendon degeneration “flexible”
 Tendon debridement + orthotics
o 2) elongated & degenerated + TTS “flexible”
 Tendon transfer & RF procedure
o 3) elongated & ruptured + inability in SHR test “rigid
 Triple or Double arthrodesis
o 4) rigid ankle valgus
 Triple or TCC arthrodesis
 Deland 2A) <30% TN uncover 2B) >30% TN uncover
 Funk 1) avulsion 2) ms rupture 3) in-continuity tear 4) tenosyno
 Conti (MRI)
o 1A) couple long splits 1B) multiple long splits & fibrosis
o 2) narrowing of tendon w/ DEGENERATION
o 3A) disuse swelling & degen 3B) complete rupture
-Radiology
 AP view (transverse plane)
o TN articulation (75%) DECREASED
o TC “Kites” (20) INCREASED
o Cuboid Abduction (0-5) INCREASED
 Lateral view (sagittal plane)
o CI (20) DECREASED
o TD (20) INCREASED
o LTC (40) INCREASED
o Navic-Cub superimposed INCREASED
o Cyma line ANTERIOR BREAK
o Meary’s (0-15) NEGATIVE “decreased”
 Calc axial (frontal plane)
o RF eversion “rule out ankle valgus”

21. o Decreased height of sustentaculum
 Harris-Beath evaluates middle & posterior facets
o Views= 35, 40, 45 axial views
 Medial Oblique
o Anteater sign “CN coalition”
 Lateral Oblique
o Anterior facet coalition
 CT Scan
o Modality of choice for coalition
o Asses subtle cortical changes in surrounding
-Flexible Procedures:
 Goals:
o Primary joint stability
o Secondary recreate arch height
o Most procedures will include TAL procedure
 Soft tissue
1) PT repair remove degenerated section
2) FDL TT suture w/in PT sheath to help reestablish arch
3) PB-PL anastomsis removes deforming force
 Transverse correction
1) Evans opening wedge 1.5 cm proximal to CC joint
2) CCJ distract arthrodesis lengthens lateral column
3) Kidner advancement & reattachment of PT
 Sagittal correction
1) Cotton plantarflexes 1st ray (bone graft)
2) Arthrodesis:
o Lowman TN fusion (+) TAL
o Hoke NC fusion
o Miller NC fusion (+) 1st Met-Cuneiform
o Lapidus 1st Met-Cuneifrom fusion
3) Young TS reroute TA thru navicular

22.  Frontal correction
1) Calc Osteotomies:
o Dwyer closing wedge osteotomy
o Kouts slide fragment medial (increases supination)
2) Arthroeresis (MTJ must have locking ability on RF)
o MBA “self-locking” blocks anterior migration of talus
 RF valgus or FF varus must be reducible in order to do
 Leading edge should approach but NOT cross bisection
of talus on AP view
 Should allow 2-4 of STJ eversion
o STA-Peg (non-ang) “axis-altering” elevates STJ
o Sgarlato “direct-impact” impingement force laterally
3) Historical
o Chambers- bone graft in “sinus tarsi”
o Selakovic- bone graft under “sustentaculum”
o Baker & Hill- bone graft under “posterior STJ facet”

23. Pes Cavus 6/30/2014 5:14:00 PM
-Etiology
 Stable “Static” vs. Progressive
o Stable conditions treatable w/ ST procedure
 Rigid vs. Flexible
o Rigid conditions requires osteotomies & arthrodesis
 Bilateral:
o *CMT, CP, SC tumor, Spina bifida, Polio, infection
o Charcot Marie Tooth (autosomal dominant)
 Bilateral slowing of sensory & motor nerve conduction
 HSMN I classic CMT usually in 2nd decade
(hypertrophic)
 HSMN II manifests later in life (axonal)
 Unilateral:
o Crush syndrome, SC injury, Deep post compart syndrome
-Clinical exam
 Charcot Marie Tooth
o Claw toes- over recruitment of long extensors
o Cavus- PL overpowers TA causing PF 1st ray
o Foot drop- “stork legs” due to muscle wasting
 Coleman Block Test (sagittal plane deformity evaluation)
o Forefoot (1st ray) is suspended off a block
o FF driven calcaneus returns from varus back to normal
o RF driven calcaneus stays in varus after removing forefoot
elements
o Anterior cavus (apex found at intersection of Meary’s angle)
 Caused by: forefoot “PLANTARFLEXED” On rearfoot
 Local (1st ray) vs. Global (entire FF)
 Flexible (DF at Midfoot) vs. Rigid (pseudoequinus)
 Metatarsus apex at lisfranc
 Forefoot apex at choparts
o Posterior cavus (increased CI angle > 30 & varus position)
 Caused by: rearfoot “DORSIFLEXED” on forefoot

24.  Flexible (no change in CI on WB) vs. Rigid (Decreased
CI on WB)
 Secondary to anterior cavus
 Neurological evaluation
o Asses motor, sensory systems, reflexes and coordination
tests.
 Biomechanical evaluation
o ROM (AJ, STJ, MTJ)
o Wide based gait = neurologic
o Extensor substitution HT (exentsors > lumbricales)
o Pseduoequinus- ankle must dorsiflex cuz forefoot cant
 EMG & Nerve conduction testing
-Classifications
 Ruch/Surgical
-Stage 1 (flexible may appear normal on WB)
o Deformity restricted to Metatarsal, MPJ or Digits
o Tx: digital fusion, extensor tenotomy, flexor transfers
-Stage 2 (more rigid deformity)
o Deformity consists of rigid PF 1st ray & RF varus
o Tx: DFWO, Dwyer, STATT, Peroneal stop
-Stage 3 (marked rigid deformity)
o Severe global RF & FF deformity on neuromuscular cause
o Tx: MTJ osteotomies, Triple arthrodesis, tendon transfer
 Japas
o Anterior cavus (apex found at intersection of Meary’s angle)
 Caused by: forefoot PLANTARFLEXED On rearfoot
 Local (1st ray) vs. Global (entire FF)
 Flexible (DF at Midfoot) vs. Rigid (pseudoequinus)
1) Metatarsus apex at lisfranc
2) Lesser tarsus entire lesser tarsal region
3) Forefoot apex at choparts
4) Combined 2 or more of the above
o Posterior cavus (increased CI angle > 30 & varus position)
 Caused by: rearfoot DORSIFLEXED on forefoot

25.  Flexible (no change in CI on WB) vs. Rigid (Decreased
CI on WB)
 Secondary to anterior cavus
-Radiology
 AP view (transverse plane)
o TN articulation (75%) INCREASED
o TC “Kites” (20) DECREASED
o Cuboid Abduction (0-5) DECREASED
 Lateral view (sagittal plane)
o CI (20) INCREASED
o TD (20) DECREASED
o LTC (40) DECREASED
o Cyma line POSTERIOR BREAK
o Meary’s (0-15) POSITIVE “increase”
-Operative treatment
 Goals must identify apex of deformity/rigid vs. flexible
 Soft Tissue Release
o Steindler stripping removes all plantar fascia at insertion
 PF, Abd hallucis, Abd dmq, FDB, Quad plantae
o Plantar medial release release all muscle/ligaments medial
o Historical
 Borst & Larsen- release mc joints & plantar intrinsics
 Garceau & Brahms- resect motor branches
 Tendon Transfers (flexible deformities)
o Jones EHL thru 1st met head “dorsiflexes hallux”
o Heyman EHL & EDL thru each respected met head
o Hibbs EDL transferred to 3rd cuneiform
o Girdlestone FDL transferred to dorsal prox phalanx
o STATT lateral half transferred to p. tertius insertion
o TPTT difficult out of phase transfer
o Peroneal anastomosis transfer PL to PB “Stop procedure”
 Osseous procedures (rigid & neuromuscular)

26. o Cole dfwo at NC “coparts joint”
o Japas displacement V osteotomy thru all midfoot joints
o Jahss Cole at lisfranc joint
o DFMO dorsiflexes forefoot
o Dwyer lateral closing wedge “take out of varus”
 Arthrodesis
o Triple (Ryerson- 1920)
 Resect (TN CC TC) ** fix in opposite order
 Position:
 Dorsiflexion- 0
 RF valgus- 5
 Abduction- 5
 Ext rotation- 15
 Incisions
 Lateral (fib malleolous to 4th met base)
 Exposes TC & CC
 Reflect EDB, protect peroneal, incise plug
 Inverted L capsular incision
 Dissect until visualization of STJ facets
 Dorso-Medial (distal med malleolus to NCJ)
 Exposes TN
 Incision carried longitundal to PT & TA
 Fixation
 TC aimed posterior-lateral from talar neck (6.5
partial cancellous)
 TN screw < 40mm (4.5 cortical) or staple
 CC screw < 40mm (4.5 cortical) or staple
 Post-op
 Admit for pain control
 NWB 8 weeks
 Progressive PT after 10-12 weeks