Diabetic Infection 6/30/2014 10:14:00 AM

Infection- minimal number of viral particles necessary to establish disease

states:
10
6
Bone infection
10
5
Soft tissue infection
10
2
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) 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??
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, brodies
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
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) Coags
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
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)
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

DVT 6/30/2014 10:14:00 AM

-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 1/5
th
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)
Homans test DF foot elicits pain in calf
Pratts 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
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 (Westermarks
sign), a peripheral wedge shaped density above
diaphragm (Hamptoms 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
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 2aworks 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)
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

Hallux Limitus & Rigidus 6/30/2014 10:14:00 AM
-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 1
st
metatarsal
o Secondary DJD, trauma, arthritis
Etiology
o Long/short 1
st
, 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

-Conservative treatment (Stages 1 & 2)
Activity modification & PT
Orthotics (rocker bottom, mortons extension, 1
st
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 (1/4
th
met head)
5) Lapidus TMT joint fusion

-Post-Op Management
Orthotic + padding
PT with passive ROM exercises
Serial radiographs
Bunion case 6/30/2014 10:14:00 AM
-Introduction:
Goals (RED CAR):
o Reduction of abnormal osseous angles
o Establish congruous 1
st
MPJ
o Decrease medial eminence
o Control correction of factors that lead to deformity
o Align sesamoids back to proper position
o Restoration of 1
st
MPJ weight bearing function
Etiology
o Primary hypermobile/long 1
st
or pronation
o Secondary trauma, RA, pes planus, gout
Pathology
o Progressive disorder with these factors affecting:
Hyperpronation unlock MTJ loss P. longus 1
st
ray
instable retrograde buckle adductor advantage
ligament instability arthritic changes
o Stages:
1- lateral displacement of prox phalanx
2- HAV where 1
st
abuts 2
nd
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 DOESNT attach to MPJ capsule
o Square met head is most stable

-Radiography
In the area of patients 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:
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 1
st
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) 1
st
met is (elevated, normal, short) compared to 2
nd
met
using Seibergs 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
Joplins 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
o 1
st
cut: = to articular surface
o 2
nd
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 1
st
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)
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

Haglunds & Retrocal Exostosis 6/30/2014 10:14:00 AM

-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
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
Pes Planus (Flexible vs. Rigid) 6/30/2014 10:14:00 AM
-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 (Aperts 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 1
st
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
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 Mearys (0-15) NEGATIVE decreased
Calc axial (frontal plane)
o RF eversion rule out ankle valgus
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 1
st
ray (bone graft)
2) Arthrodesis:
o Lowman TN fusion (+) TAL
o Hoke NC fusion
o Miller NC fusion (+) 1
st
Met-Cuneiform
o Lapidus 1
st
Met-Cuneifrom fusion
3) Young TS reroute TA thru navicular

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



Pes Cavus 6/30/2014 10:14:00 AM
-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 2
nd
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 1
st
ray
o Foot drop- stork legs due to muscle wasting
Coleman Block Test (sagittal plane deformity evaluation)
o Forefoot (1
st
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 Mearys angle)
Caused by: forefoot PLANTARFLEXED On rearfoot
Local (1
st
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
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 1
st
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 Mearys angle)
Caused by: forefoot PLANTARFLEXED On rearfoot
Local (1
st
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
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 Mearys (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 1
st
met head dorsiflexes hallux
o Heyman EHL & EDL thru each respected met head
o Hibbs EDL transferred to 3
rd
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)
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 4
th
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