Essentials of Foot and Ankle Surgery

Maneesh Bhatia, Maneesh Bhatia

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000369632
• Edition: 1
• Topic: Medicine
• Subtopic: Orthopedics

This book is a 'go-to' guide for postgraduate Orthopaedic examinations as well as for Orthopaedic surgeons for trauma and elective foot and ankle surgery.

A streamlined approach ensures that the 22 core topics are covered in a succinct and practical way. Foot and ankle surgery is a vast topic that can be daunting to revise due to the complex and diverse nature of associated pathologies. This highly illustrated succinct text, together with key learning points ensures a rapid understanding of all the essential elements of foot and ankle surgery.

* Provides 'need -to-know' information for Orthopaedic surgeons

* Assists with exam preparation for postgraduate exit exams such as the FRCS (Trauma & Orth)

* Simple, succinct and concise

* Over 500 illustrations to aid learning

* Accompanying website with MCQs and videos of clinical examination and surgical techniques

Orthopaedic surgeons, registrars and trainees, other specialty doctors, general practioners and physiotherapists with musculoskeletal interest and podiatrists will all find here 'gold standard' answers to foot and ankle conditions.

1 Foot and ankle examination

Nikhil Nanavati, Nicholas Eastley, and Maneesh Bhatia

Introduction

The foot and ankle are composed of multiple bones, joints, ligaments and tendons, each of which may be a source of a patient's pathology and symptoms. A general foot and ankle examination consists of seven components – inspection, gait analysis, palpation, joint range of movement, neurovascular (NV) status, key muscle strength and special tests.

History

A focussed, structured history can be a valuable tool to guide clinical examination. Begin by determining the patient's age and occupation. The most common presenting complaints in the foot and ankle are pain, stiffness, deformity, swelling, instability and difficulty with ambulation. The history should be used to characterise each of these symptoms, in particular their duration and impact on a patient's function. It is important to establish any history of trauma or any neurological changes. A significant past medical history, smoking and drinking in excess may have a major influence on a patient's fitness and outcome following surgery. It is important to determine any known history of diabetes, peripheral neuropathy, inflammatory arthropathy or peripheral vascular disease. Past or family history of deep vein thrombosis (DVT) or pulmonary embolism and other risk factors for thromboembolism are important if the patient needs plaster cast immobilisation or Achilles tendon surgery. A detailed history of current medications, especially warfarin or the newer direct oral anticoagulants (DOAC), is essential for perioperative planning. It is also key to get an idea of the expectations of every patient. Towards the end of the history taking session, the question “Is there anything I might have missed that you would like me to know?” can pay dividends.

General inspection

Inspection is a key component and will guide the remainder of the examination to provide a good idea of what clinical signs to expect moving forwards. Start by inspecting the patient's footwear, noting the distribution of any sole wear (remembering to ask when the shoes were bought) and any orthotic modifications or insoles. Take note of any walking aids nearby. Adequate exposure above the knees is required, and patients should be inspected from the front, side and back. Ask the patient to stand facing you and inspect their knees, noting any malalignment. Moving in a proximal to distal direction, note any scars (Figure 1.1), swellings (synovitis, osteoarthritis, ganglion) or skin abnormalities (colour changes, callosities, ulcer, nail changes). Also note any deformity involving the ankle, hindfoot, midfoot or toes. Ask the patient to turn 90° so that the medial border of the foot can be inspected. Look for swellings around the heel or Achilles tendon (Haglund's deformity or Achilles tendinopathy) or any flattening or accentuation of the medial longitudinal arch (pes planus or pes cavus, respectively). Next, ask the patient to turn a further 90° allowing you to inspect the back of the foot and ankle. Note any calf asymmetry (wasting or hypertrophy) or hindfoot valgus/varus which may be subtle (Figure 1.2). If deformity is identified in the coronal plane, the next step is to perform either the heel raise test (valgus deformity) or Coleman block test (varus deformity) (see in section “Special tests”). From behind the ankle, the little toe and half of the 4th toe should normally be visible. More toes will be visible in cases of severe planovalgus due to midfoot abduction (the ‘too many toes’ sign). Beware, however, that more toes will also become visible in any external rotational abnormality involving the leg or ankle. Finally, ask the patient to rotate another 90° to allow you to inspect the lateral border of the foot. A callosity at the base of 5th metatarsal is usually present when the patient walks on the lateral border of foot which can be seen in a cavovarus deformity.

Figure 1.1 The most common surgical scars seen in the foot and ankle. 1: Anterior approach to ankle; 2: Dorsal approach to 1st MTPJ; 3: Dorsal intermetatarsal longitudinal incision (Morton's neuroma excision from 3rd intermetatarsal space); 4: Approach for TMTJ fusion or ORIF for Lisfranc injury; 5: Posterior longitudinal approach Achilles tendon; 6: Posterolateral approach ankle; 7: Medial approach 1st MTPJ; 8: Posteromedial approach ankle/tibialis posterior reconstruction; 9: Lateral approach fibula; 10: Ollier's approach hindfoot/subtalar joint; 11: Lateral approach calcaneum.

Figure 1.2 A subtle pes planovalgus deformity of the left foot. Increased hindfoot valgus can be seen (red lines superimposed for comparison) with the ‘Too many toes’ sign (black arrow).

Inspection of the plantar aspect of the foot is important in order to check for callosities under the metatarsal heads (indicating overload) or infection between toes. This can be performed by asking the patient to sit (with feet over the edge) or lying on a couch.

Gait

Human gait is the cyclical forward progression of the body (Figure 1.3). A single gait cycle is defined as one heel strike to the next heel strike of the same leg. This cycle can be divided into the ‘stance’ and ‘swing’ phases. The swing phase comprises 35% of the gait cycle and occurs whilst the leg is progressing forwards in the air, i.e., between toe-off and heel strike of the same foot. During the swing phase, the ankle dorsiflexors bring the ankle to a neutral position to facilitate ground clearance. The stance phase comprises the remaining 65% of the gait cycle, and occurs whilst the foot is in contact with the ground, i.e., between heel strike and toe-off of the same foot. The stance phase is further subdivided into three ‘rockers’ (1):

• First Rocker: Period between heel strike and foot flat. Eccentric tibialis anterior contraction controls foot drop and the plantarflexion moment occurring about the ankle. The heel ground reaction force (GRF) occurs behind the ankle joint, resulting in ankle movement from neutral to 10° plantarflexion.
• Second Rocker: Period between foot-flat and heel-off. The ankle...