Good morning. I'm trying to make this a little bit interesting, best I can. I know it's foot stuff that most of you probably just ignore or send it to somebody else, but for the test you're going to be responsible for some of this stuff. And so I'll try to make it as interesting as I can, even though I know it's boring. So the gait cycle, I don't even like the gait cycle, but I'll explain to you why this is somewhat relevant. As we look at the stance phase, stance phase is when your foot is on the ground. You have heel strike, foot flat and toe off. And the reason why it's important is the symptomatic problem that you get from pathology, whether it be Achilles or the anterior tib will come into play. Swing phase is when your foot's off the ground will come into here. So at heel strike, the anterior compartment, the anterior tibialis primarily is eccentrically contracting, slowing the foot down from hitting the ground. The hind foot's actually in varus and inversion to give you something stable when you hit the ground. And this will come into play even though biomechanics I know is really boring for all of your athletes that you see with stress fractures, navicular stress fractures, fifth metatarsal, posterior tib. The position of the foot at heel strike and toe off, suddenly it all will make sense. So at heel strike, they're in varus and inversion. So if you have a cavus foot that's really rigid, that's why these patients get a lot of fifth metatarsal stress fractures, navicular stress fractures, et cetera, because they're very rigid and they strike the side of the foot very hard. At foot flat, ideally the hind foot should go into valgus and eversion to unlock and ground accommodate. But again, if you're a cavus foot, that doesn't happen. And so they constantly put stress on the lateral border of the foot and through the navicular. And that's the problem that these patients face. As you go to toe off, the gastroxylasis is contracting concentrically. Your hind foot goes into varus and inversion, secondary to the posterior tib tendon. And that's why patients who have early posterior tib tendon dysfunction, your athletes will have that pain along the posterior medial border. And they may be fine with non-impact, walking and biking. But when they start doing their aggressive activity, they start getting pain. Because when that foot is massively everted at the end of foot flat and the posterior tib is firing hard against the resistance, they start generating the pain. And that's where the pathology and the biomechanics come into play. Walking is straightforward, double limb support. Running is when both feet are off the ground. There's a classic, I think it was 1984 Olympics, where there was a speed walking and she got excited when she entered the arena at the end of the entire thing. She got so excited she had both feet off the ground. The judge called it and she lost. So that's how important it is. It affects your athletes. So if anybody treats a speed walker, this is probably really important. The tib-fib joint, the syndesmosis, is a real joint. It does come into play when you talk about how we fix it. Traditionally, a lot of people have used screws. Look at the last five years, seven years of data out there, flexible fixation. As long as it's reduced is the key. It's likely superior than rigid fixation because it is a real joint. You don't want a constrictor joint that needs an articulation. The subtalar joint is a confusing joint. The best way to think about it is that it's inclined about 40 degrees in the coronal plane. And so as the joint goes side to side, your foot goes side to side. It's not a ankle joint that's parallel to the floor that allows the up and down. And it's not a tilt. I used to think when I was a resident the joint tilted, which is clearly nonsensical. It slides. If you just take a model and watch the joint move, or if you do what I do and do it in the operating room, you kind of understand what it does. The most important thing to understand for biomechanics is that you have less eversion than inversion. Why is that relevant? We look at the cavus foot again. If you have a rigid cavus foot, you can't ever as much relative to someone who has a flat foot. So flat foot patients typically can accommodate for a longer period of time with orthotics and braces compared to a cavus foot. If you have a mild cavus, you can do an orthotic. Once these patients have a slightly more rigid or deformed cavus, you can't spin their foot back around. And that's why they have a lot more problems with athletics. The transverse torso joints are your talon and vicular CC joint. They work in conjunction with the subtalar joint. And basically when the foot is everted, they're parallel to each other so the foot is unlocked and more sloppy, allowing for ground accommodation. When they're inverted during toe off, the whole hind foot is locked and rigid. The reason why that's important biomechanically is your gastroc soleus is firing as hard as it can to propel you forward. So you want a rigid construct. The benefit of that is that it allows you to have a nice rigid construct for push off. The problem is if you're a cavus foot, again, you get more overload. And if you're a flat foot and you have posterior tip tendon dysfunction, that never occurs and these patients have pain and discomfort. So a flexible flat foot that's non-painful, they can still generate a single limb rise and force their foot into inversion. That's very different than a patient that has posterior tip tendon dysfunction where the tendon and the muscle unit are unable to pull that foot into inversion. So muscle function during gait at foot flat, the gastroc soleus is eccentrically contracting, slowing the body down. Why is that important? Well, you know that if somebody has a chronic Achilles tendon rupture, they may be able to walk fine, but they have a hard time running. They have a hard time going downstairs because their body's going forward and their gastroc's not slowing them down. At toe off, it's concentrically contracting, acceleration, so your Achilles tendonitis, tendinosis, they'll have pain during their push off because that's when it's causing them pain. At heel strike, the tibant is slowing the aspect of the foot down so you don't get that foot slap. Now that's not uncommon in your athletes unless they have an anterior tip tendon traumatic rupture, but in your elderly athletes, they can get a non-traumatic anterior tip tendon rupture and also their foot slap in the ground. During swing phase, it concentrically contracts, clearing the ground, that's why you get the steppage gait when you have an anterior tip tendon rupture or a foot drop. So if your gastroc is weak, patients may present you with actual heel pain, they may not present you with saying I had a chronic Achilles rupture, so always keep that in mind. Any patient that comes to you with heel pain, if you see that stuff, it's not always plantar fasciitis, just make sure their Achilles is intact. I missed this as a fellow and one of my attendings missed it at the same time when he went to my mentor, Dr. Myerson, who called us both morons for not examining the patient and he was right because we missed an obvious problem just by not laying our hands on the patient. At toe off, you get weak push off and then for the weak anterior tip, you get that steppage gait and that foot slap as you all know. This can be from a perineal nerve palsy or from rupture of the anterior tip, it's non-function of that tendon obviously. So 65-year-old male presents with a painless mass on the anterior aspect of the ankle. He knows difficulty navigating stairs, exam is relevant for a steppage gait. These patients typically do not note any history of trauma. This answer is not a nerve palsy or EHL rupture or radiculopathy because there's no reason for that. Atraumatic loss of function of only the anterior aspect of the ankle is the anterior tip tendon and this is how they present and this is how the question is always written and it may be that mass that gets misdiagnosed as possible tumor, they get ultrasounds, MRIs, which is fine but if you already know the diagnosis, that's just to confirm and the answer for any person with an anterior tip tendon rupture, age is no longer relevant, is to reconstruct it with an allograft or repair it primarily to get to early. There's actually a nice article by Bob Anderson that shows it doesn't matter how old you are, you actually do better with this surgically corrected. But if you don't, you can give them an AFO. Plantar fasciitis you all know of and you all hate. The only thing I will tell you for the test is that you want to think about the tight heel cord. That's one of the more popular things now. Treatment that's non-operative, the two things that have been proven the most is heel cord stretching and plantar fascia specific stretching. So you can give them a handout, send them to physical therapy but that plantar fascia specific stretch was published by a guy named Kyoto which shows us much better than just heel cord stretching alone. If you look at injections, whether it be PRP, steroid, whatever you want to throw in there, amnion, there's really no long-term benefit proven to that relative to stretching. So for the test, they're not going to answer that. In reality, a lot of us will do a lot of those things. Surgical treatment, the historical one is partial plantar fascia release. The downside of that is if you excessively release the plantar fascia, you lose that secondary stability to the arch, the primaries, the ligaments of the midfoot but secondary is the plantar fascia. So if you over-release that, the foot will collapse and they get a painful flat foot that's really unfixable. They get this weird lateral column foot pain on the side of the foot, not posterior tib and there's really no solution for these people except to consider a hindfoot fusion which is not ideal. Orthotripsy you may have heard of is not for the test. It's questionable efficacy so don't put that down either. Gastroc recessions, the one thing they may ask you, they'll give you the scenario of a tight heel cord, failed non-operative intervention and then the surgical treatment is to release the gastroc, not to touch the plantar fascia. So example, 32-year-old male, pain along the plantar heel that's worse than the AM, classic for plantar fasciitis. Improves after walking, again classic. It gets worse with walking. It is not plantar fasciitis, at least for the test. They're getting to something else, whether that be a stress fracture of the calcaneus, whether it be back stress neuritis with running, but plantar fascia gets better after 10-15 minutes of walking. It's a classic test question. What they're going to give you is this, exam that shows zero degrees of motion with the knee and extension, dorsiflexion of the knee and extension. When you flex the knee, you eliminate the gastroc contracture so the soleus is still flexible. You get more motion and what they're trying to tell you is the patient's failed non-op, what are you going to do? Release the gastroc has been proven to help these patients. It is not anything else. So see gastroc recession. The superficial perineal nerve is along the anterior border of the ankle and then cuts into two branches, the medial and intermediate. The motor proximally, now distally there is no motor as you all know, but proximally it's the perineals, the perineus longus and the brevis. Sensory as you know is the dorsum of the foot, but not the first web space and it's at risk primarily when you do ankle arthroscopy and that lateral portal. If you make your incisions with the foot under distraction, you're going to tension the superficial perineal nerve and have a higher risk of injuring the SPN. That's why you should make your portals without distraction and then put distraction on. Anytime you do an ankle fracture, it's obviously at risk. There's a couple articles, I've written one about the anatomy. The only thing you really have to know is it can be anywhere. We found it from two centimeters up to 12, 15 centimeters. It doesn't matter where you are, always keep an eye on it for it. If you do cut it, it's going to be a painful neuroma type symptom, no motor pathology down distally, but still not ideal. When we do anterior approaches, if you do ankle fractures or pylons, you have to go from the front for whatever weird reason, then you may injure it with that approach as well along the lateral border of your incision. The DPN is really not that relevant for most things in the foot. It's the anterior compartment of the leg as you know proximally. The one thing that you should know is the first web space and it has a motor function of the EHB and EDB in the foot. It's at risk primarily when you're doing your Lisfranc approaches. It's between the first and second metatarsal. If you make that approach standardly for your Lisfrancs, your midfoot fusions, et cetera, you will injure that nerve if you're not paying attention. My advice is just go lateral to the second, medial to the third. You never have to worry about this nerve again, but that's just a personal preference. If somebody has dorsal osteophytes, they may have pain, especially for your athletes with runners when they lace their shoes and they say, I get numbness down my big toe or between my big toe and second toe. They may have subtle osteophyte formation and they may have impingement of the DPN or anterior tussle tunnels, the other term that's used for that. So for an athlete, tight shoes, radiating pain down in the first web space, it's compression of the deep perineal nerve. The sore nerve is not that relevant in non-surgical aspects of the foot, but when you do surgery, whether it's an Achilles rupture, whether it's a post lateral approach, calc fracture, anything you're going to do on the posture or lateral board of the foot, this nerve will basically quit on you. It's a very high risk of getting a neuroma. It's really annoying. And you should at least know the location. It's the lateral dorsum of the foot. It's a lateral foot. So the dorsum of the foot is the SPN. Lateral board of the foot is a sore nerve. Inferior board of the foot is the tibial nerve, lateral plantar, medial plantar. And they will like, sometimes they do like asking you diagrammatically what part of the foot is a problem, but if it's lateral dorsal, it's not superficial perineal. It's actually the sore nerve is that lateral side of the foot for you. Twenty-five year old female underwent an open Achilles repair, has a neuropraxia to the sore nerve. The location of the numbness is, so you have dorsal medial, no. That's SPN. Medial ankle is saphenous. Dorsal lateral, that is sore. And then plantar lateral is lateral plantar nerve. And these are easy questions for them to ask and very straightforward. Cava varus I talked about a little bit is already the plantar flexed first metatarsal hindfoot varus. That's where you have that tripod effect where it overly makes the hindfoot rigid. Mechanically you cannot invert and the foot is basically a rigid block. And the best way to think about that, because you have a million things to think about, is that cava's foot is rigid, cannot accommodate. You slam the outside of the foot every time you take a step and it cannot be fixed with orthotics very easily. This is a treatment we always try. It's called a lateral post. So when you look at orthotics, the first word is where you put in the material. So lateral post, you're going to put it on the outside. You're going to decrease the arch and put a well up for the first metatarsal because the first metatarsal is relatively plantar flexed. So if you take the foot and you evert it, the first metatarsal needs a space to go into, otherwise it doesn't work. You can't just move the hindfoot without correcting for the forefoot. And that's how the orthotic has to be written. If you just do the hindfoot, these patients come back usually pretty mad because their forefoot starts to hurt a lot. The Coleman block is asked a lot. To simplify it for you, you're trying to test for supple motion of the hindfoot and whether it is the hindfoot that's varus or whether it's just the plantar flexed first ray that's causing the hindfoot to spin into varus. So if you put a block underneath the heel, the first metatarsal will drop into the floor if the hindfoot is supple. What that means is the hindfoot has mobility. The problem is coming from a plantar flexed first ray, so all you technically have to do is break the first metatarsal, pull it up, and the hindfoot will correct in a clinical fashion. If there's no correction, so you take the forefoot out of the equation, you have the hindfoot now off on the block and the forefoot is off the ground but the hindfoot doesn't correct, that means the hindfoot is intrinsically in varus. You need to do a calcaneolostomy and a first metatarsal osteotomy as well. In reality, none of this is relevant. You always do both most of the time anyways. This is all nonsensical test question stuff. I don't even do the Coleman block because it's pointless, but this is what we test on. So testing versus reality, as you all know, is very different. Pest plantus is not exactly the opposite of cavovirus. I used to think it was, but it's actually a completely different pathology. These people are loosey-goosey feet. They have all this valgus, abduction, everything. You know what a flatfoot looks like, but mechanically this is the important part. The foot is loose, so you end up putting strain on the ligaments of the hindfoot, the spring ligament, the midfoot ligaments, the posterior tip, and you end up getting a gastric contracture. So if you have a flatfoot, it doesn't mean you can't do athletics. Some of our greatest athletes have flat feet. There's nothing wrong with that. However, over time, they might get strained to the posterior tip tendon or the spring ligament may start to strain, and that's when they get problems. It's not the flatfoot itself. It's the long-term consequence of banging on that foot all day. So orthotics and braces help a lot with these patients. The orthotic, if you see a flatfoot athlete, it is not unreasonable, even if they're painless, to let them have an orthotic, though that's not a necessity, but it's more of a long-term prevention idea. You want to do the opposite of a cavus in some ways. You're going to put a medial post, more mature on the inside. You want to support the arch and support the first metatarsal, called medial forefoot posting, so that when their foot hits the ground, the foot doesn't spin out and valgus as much as it usually would, taking the strain off the posterior tip tendon. This is the most common orthotic that you'll see and prescribe. So 29-year-old male presents with hindfoot varus, that is, corrects with the Coleman block. So corrects with the Coleman block means they put a piece of wood underneath the heel, taking the first metatarsal off the floor, and the foot spun back down, which means the hindfoot is supple. So the most appropriate orthotic is A, hindfoot eversion, lowered arch, and voila for the first metatarsal. If the hindfoot doesn't correct, the orthotic's not going to help you, and that's what they're getting at. So rigid deformities cannot be corrected with an orthotic. So if somebody has a rigid flatfoot deformity, you can't put material in there to twist the foot around to help them. You can accommodate the deformity, but you can't correct it, and that's what this question is getting at. The patient has a correctable cavus deformity, therefore an orthotic will help to correct their deformity, but if it's said their foot is rigid and doesn't correct at all, there's no way to put an orthotic in to move their foot around because their hindfoot is rigid. Does that make sense to everybody? And it's important to know this stuff because I'll ask you. Heel-to-toe contracture is very quote-unquote cool in foot and ankle now because I think because it makes a lot of money per case, that's my primary opinion. But if you have an Achilles contracture versus a gastroc contracture, it's very important to know the silver skull test, knee extended, the ankle should have an equine contracture for both of these. With the knee flexed, if the ankle moves up more, more dorsal flexion, that's an isolated gastroc versus an isolated Achilles. An isolated gastroc contracture is associated with a lot of pathology. Achilles, people think it's actually, there's an article that came out of Grand Rapids that says for foot pain, so that's how simple foot and ankle people are. If you have a tight calf, it really does solve all your foot problems. You just blast a gastroc and move on in life. And that's an exaggeration, but not really. You can actually look it up as a Foot and Ankle International. But you should think about this every time an athlete comes to you with foot pain because stretching for this, a heel lift and sometimes surgical intervention is necessary and they're going to ask you this for Achilles and plantar fascia problems all the time. Think about this when you're looking at a flat foot. If you ever see a neuropathic and then plantar fasciitis, Achilles tendonitis, this is a hot answer is the gastroc contracture and the surgical treatment is a gastroc recession versus working on the Achilles tendon or the plantar fascia itself. And this is a change over the last seven, eight years. What's most commonly injured structure during the creation of the anterolateral portal for ankle arthroscopy, the DPN is dead center. We do not make a central anterior portal for that reason and the artery is there. The superficial perineal nerve we talked about obviously is at risk. The posterior tendon is too far away and the anterior tip tendon can be injured on the medial portal. So laterally it has to be the superficial perineal nerve. 45-year-old woman developed pain along the plantar aspect of the heel for the past month. Pain with the first few steps in the morning, but it improves until the end of the day. The next treatment option is, it's not surgery, daily stretching and a cushioned heel insert. This is always the non-operative management. So for the hallux and lesser toes, which I know you really don't want to pay attention to, I'm sure you don't treat bunions, but these are just some numbers. You can look at it in your handout. The normal hallux valgus angle is less than 15 degrees. The normal IM angle, which is the space between the first and second, is less than 9 degrees. The surgical considerations are listed here. If it's a small bunion, so less than 13 degrees of IM angle, you want to do what you remember from residency. It's a distal metatarsal osteotomy. You basically break it distally. The reason to simplify this, the smaller the bunion, you don't need as much of a lever arm, so you can go distal and just shove it over, move the medial eminence, and you're good to go. If it's a bigger bunion, you need more mechanical leverage. The 13 is a very good number to memorize if you have to pick a number. If the intermetatarsal angle is more than 13, you need to go proximal. It doesn't matter what you do. It could be a proximal chevron, an opening wedge, a crescentic, it can be a lapidus type operation, but you just need to go proximal to get mechanical advantage to correct this deformity. If there's instability, if they give you this, the patient has instability of the first TMT or arthritis of the first TMT, the answer is a lapidus, which is a first TMT arthrodesis where you can rotate and put the foot back where it belongs. And this operation is very popular among your foot and ankle colleagues because it works really well. It's stable. It's not going to recur, but it has its own downsides. But I do, a lot of us will do 80% of our bunions with the lapidus nowadays. And it's just surgeon preference. Arthritis, rigid deformity, spasticity. If they give you a patient that has a stiff toe, even if the x-rays look normal, you need to fuse that toe because no soft tissue correction is going to fix that. It's rare, but if you have a patient with CP or something like that, or they're older and it's rigid, do a fusion. If they have pain in the joint, they get a fusion regardless of what the x-rays look like. So soft tissue procedures alone are always wrong, at least for the test. Never do that. If it says osteotomy alone without any soft tissue operation, that's always wrong unless every answer has no soft tissue. Sometimes they just assume that's part of the operation. If you have five answers, none of them have a soft tissue thrown in there. They're just assuming you're going to do the soft tissue as well. But if you see an answer with like a chevron with soft tissue release, then an opening wedge osteotomy, no soft tissue release. I pick the one that has no soft tissue release. It's part of the operation. And then high recurrence rate, you probably all still remember this from boards, is juvenile hallux valgus. If you don't do a good job, you undercorrect the IMA or you don't do a bony correction. You just whack off a piece of bone. It doesn't work. Hallux varus, this is a surgical problem. We create this. So patients will come in after this is my patient. I went nuts after her recurrent bunion, and I corrected her IM angle to negative one. That's a surgical mistake. They will traditionally get hallux varus, and that's what happens. So you want to look for pain. If they have pain in the MTP joints, you've got to fuse it. If they're not flexible or they're rigid despite having no arthritis, you have to fuse it because no soft tissue procedure is going to work. Then you're looking for arthritis in the alignment. I'm really going to ask you to correct this with an osteotomy. I think for a sports test, what you have to know is you have varus. If it's rigid, you fuse it. If it's flexible, you can do a soft tissue procedure, release, do a tendon transfer EHL or a split EHB. You can augment with a suture button if you want. And if the IM angle is overcorrected, technically you have to do an osteotomy to uncorrect that or put it back where it was. But just remember if it's rigid or arthritic, you have to fuse it. Surgical treatment for a flexible is some sort of tendon transfer, the EHL or EHB, and a soft tissue release. Hallux rigidus is more common in athletics, a more common question you'll be asked. They have stiffness, pain with motion, swelling and redness over the big toe, mostly dorsal pain versus medial pain. Medial pain with shoe wear is a bunion. Dorsal pain with or without shoes is hallux rigidus. What you're looking for on an x-ray or as a lateral, you're going to look for the lateral dorsal osteophytes. You're looking for the amount of joint space that is lost. This is kind of this grade 3 versus grade 2. If you have more than 50 percent of your joint space still intact, then it's a grade 2. It's not that bad, quote unquote. If it's more than 50 percent joint space that is lost, it's a grade 3. And what you really want to check for on those patients is called a grind test, where you take the big toe and you actually grind it into the metatarsal head. If they don't have pain, then you can get away with a chylectomy. If you see these other erosive changes and psoriatic stuff, just have to keep that in mind. The non-operative treatment is the standard stuff. It's a carbon fiber plate to minimize that dorsal angulation of the big toe, high box shoes, or steel shank or stiff shoes. So chylectomy and debridement, that is only for pain at extreme only. No pain with the grind test, so that grade 3, no grind. X-rays look bad, but they don't have any pain at the central grind. You're allowed to do or quote unquote can do a chylectomy because they likely would do okay. Pain only secondary to shoe wear. Those patients do really well with the chylectomy. When you look at all the data for chylectomy, the only thing that's reproducible is relief of pain from shoe wear. Everything else isn't really changed, and that's most people's experience. So if somebody says, I want to wear high heels, I want to run 10 miles, and I can only run 2 now, it's because my toe hurts after 2 miles. There's no change in their function really after a chylectomy. It just makes what they can do less painful. So that's where all this other stuff comes into play. Oops, let me get that. Well, I broke it, so I'll go off my memory here. So CARTIVA and all these interposition orthoplasties you may have heard of is because chylectomy is not that effective in operation, but those are not an answer for your test questions at all. So never pick a joint replacement for hallux rigidus. It's either chylectomy or it's a fusion. Turf toe. Turf toe is a very common complication for athletes, and it's hyperdorsiflexion with tearing of the plantar plate. You always want to get bilateral x-rays to exclude this as just a simple bipartite sesamoid, and you want to see the position of the sesamoids relative to the metatarsal head. Treatment, swelling reduction, boot, graphite plates for grade 1, which I'll get into. Return to play. This is very important for you. Return to play. 60 degrees painless dorsiflexion. That's a criteria that's, there's not a lot of literature on this, but that is a criteria that's out there. That's a number you can hang your hat on. 60 degrees painless range of motion, return to play, typically for your grade 1, grade 2s. Surgery for the unstable joint, grade 3. So classically, maybe 10, 15 years ago, grade 3 turf toe was not treated surgically. There's really only one great article, or not even great, good article by Bob Anderson that shows that grade 3 probably does better with surgery. So grade 3 means the entire plantar plate is ruptured, you have proximal migration of the sesamoids, or you have a sesamoid fracture. Those patients do better with surgical stabilization versus letting them ride it out. So the treatment, if you're going to do surgery, sesamoidectomy, you want to repair the FHB. If you do a tibial sesamoidectomy in isolation, as you would imagine, you get hallux valgus. If you get a fibular sesamoidectomy in isolation, you're going to get hallux varus. And if you do sesamoidectomy of both, you're going to get a cock up toe. So grade 1 plantar plate is symptomatic treatment. Strap them. They can go back to play. Grade 2 is easy to remember. Two weeks and 60 degrees range of motion. And grade 3 is surgical intervention. You see the sesamoids are abnormal. They're completely retracted or a sesamoid fracture. Or they show you an MRI with a complete tear of the plantar plate. That's a surgical problem. So a 52-year-old male presents with increasing pain, deformity, and limitation in great toe motion. His examination demonstrates pain through the mid-range of motion of the joint. So this is arthritis. Pain through the mid-range of joint is a positive grind test. He has arthritis. Treatments may include all the following except you can do a carbon fiber insert. You can definitely do a fusion. Obviously, anti-inflammatory is okay. But you never do a sesamoidectomy for this problem because it doesn't make any sense. You would never take out both sesamoids. So the lesser toes. There's not much here of much interest to many of you. But just for the test, we look at this as a hammer toe for this flexible or rigid. If it's a flexible hammer toe, you can do a flexor tenotomy where you cut the small flexor of the toe and rock and roll. Historically, it used to say flexor to extensor tendent trans, which I don't know anybody that even does that operation anymore, so be shocked if they ask you that. If it's rigid, you do a PAP orthoplasty or a fusion. You just take out the knuckle and fire in a screw or wire and just get that toe rigidly straight. It is very effective. And anytime something's recurrent or spastic in the foot and ankle, we end up fusing it typically. Claw toe, you'll see this. The only reason I think about a claw toe is that if they give you a patient with claw toes, one through five or two through four or two through five in a younger patient, you want to think about some neurologic problem, whether it be CMT, whether it be diabetes or some sort of unknown neuropathy. You will rarely ever get one through five claw toes in a normal human being. You get the second or the third, but when multiple toes are involved, always think about a neurologic problem. I know that's not my job for the exam, but from the foot, but think about that because it's important. It's by definition contracture of the extensors and the flexors and that's what it is. It's multiple toes typically, but usually one or two, not all five. That's an imbalance between the extrinsics and the EDL and FDL. And the extrinsics are stronger than the intrinsics, which is why you have to think about a neuropathic condition or some neurologic cause in these patients. The surgical treatment is very straightforward. You want to remove the extensor deformities. You lengthen the extensors, release the capsule, pop the toe down. If the toe is not reducible, this is what they like to ask, do you have a claw toe? You've released the soft tissue dorsally, yet the toe is not reducible. What's the next appropriate step? The answer is to do an osteotomy of the metatarsal to shorten it so you effectively lengthen everything and the toe can drop down. That's what they may ask you. The complication of this particular osteotomy is called a floating toe. It's where the, because you have the intrinsics now relatively dorsal to the center of rotation, the toe cocks up a little bit. It's a cosmetic problem, not a functional problem. And they may ask you that, though I'd be shocked because I know you don't care as much. This is a sportsy type problem for your athletes. So anyone, men or women, high level athletes, a lot of lunging or impact type activity, you can injure the plantar plate of the second toe, not the big toe, the second toe. They get pain and swelling in the second MTP joint. What they're going to ask you is what is the primary pathology? And that is a plantar plate rupture. And you get this crossover toe where the toe deviates slightly medial and slightly dorsal. And that's a crossover toe. Multiple reasons for this. Impact, short first ray, long second ray, bad surgery if you've had an elevated first metatarsal. And never inject the lesser toe joints. That's a mistake. It's done all the time because patients feel really good. But never do that. I will tell you there's litigation when people do that. So just don't put steroid in the second toe or third toe joint. Because what happens is you make them feel good. You end up weakening the plantar plate. And they promise you they'll come back in six weeks with the toe popped up and over. And they say, why did that occur? And usually blame somebody else for bad luck. But somebody else will blame you. So just that's the number one atrogenic cause of this problem. We do like to be sporty in foot and ankle. So we made this the vertical toe lockman. You've got your knee lockman. And we do the same exam with as much force on the toe. It's a stupid test. But it actually is a real thing. It's been proven to be associated with by MRI a plantar plate tear. It's as simple as you think it is. You take the second toe and you shuck it up and down. If it hurts, it's a plantar plate tear. If it doesn't hurt, it's not. And you compare it to the third toe. It has been proven by Coughlin that it is 100% associated with a plantar plate tear by MRI. So if you have that exam finding where the toe shucks and hurts, you know this is the problem. The answer is not an injection. It's strap the toe down, make it more rigid. And then surgical treatment I'll get into in a second. So if it's dislocated, you do a while, as I said. But the most appropriate answer for a crossover toe nowadays is a plantar plate repair. You repair the pathology that's there. You make an incision from the dorsal aspect or the plantar aspect, depending on your preference. You actually repair that tissue. It's not the most powerful operation in the world, but it is effective in many patients. So that's the best answer for the test. Fibroids infection. You'll see this as a sports physician once in a while. They'll have pain, discomfort in the second toe. A couple clinical findings. They have pain and swelling, but they also have a very thick second MTP. It looks like a tumor initially. The first time I had this when I was a practicing physician in Michigan, I swear to God I thought it was a tumor. Very thick second metatarsal x-rays looked weird. It wasn't that standard flattening. Got an MRI, which is periosteal thickening from fibroids. And you'll have that fat second MTP. It's usually in younger patients, and they don't get arthritis at 20 and 30. That just doesn't occur in the second toe. So you're going to look for this classic x-ray on the oblique where you have flattening of the second metatarsal head. That is fibroids infraction. It can happen in the third and the fourth. It doesn't mean it has to be the second, but second is most common. One of the factors is elevated first ray, secondary to bad surgery or a short first ray from what God gave you, just like you see in this patient here. And that's associated with this particular problem. The treatment, early is just a synevectomy, but the one answer that really is most important is a rotational osteotomy. So they give you the x-ray of a patient with this problem. What surgical treatment can you do besides rigid shoes? And everything you do, the same thing you do for hallux rigid is carbon fiber plates, steel shank, is you do a derotational osteotomy. You actually make a wedge resection of the met head, and you rotate the viable plantar cartilage up dorsally to shorten and give that now good plantar cartilage now as their normal articular cartilage for the phalanx. It's actually a relatively effective operation. If they have bad arthritis, they have to do an arthroplasty, but when we say arthroplasty for an ankle, it means some sort of interposition, but they're not going to ask you that. I'd be shocked. The nerve disorders across the tunnel, you have to be responsible for this, unfortunately. Simple things are if they have a bad valgus, you put orthotics in to take tension off the tibial nerve. If they have a lot of edema, stockings can help to take pressure off the nerve, and cortisone injections actually are reasonable to do, but they're all temporizing. The surgical treatment, if they ask you this, they failed these non-operative intervention, you have positive findings by EMG, is you release the tarsal tunnel, but the most important part is to release the deep and superficial abductor hallucinous fascia. So it's not a short incision, it's a long incision from the tibial nerve all the way down to the bottom of the foot. If you don't do that, you're going to have a higher risk for occurrence, and that's what they want you to know. So that part in red is what's most commonly asked to have an effective outcome. And if you're going to treat tarsal tunnel, don't leave them alone for a year or two years. If you're going to operate, their best outcomes are within a year. As you can imagine, chronic compression of the nerve does lead to chronic changes, so you're trying to avoid that. So if you're going to do surgery, do it within a year. Not that you can't do it after a year, but don't make them wait, because it's just not going to get better if you failed on non-operative management. Entrapment neuropathy is what a Morton's neuroma is. This is not a compression or inflammation of the nerve, this is actually a pathology that has shown the nerve itself is pathologic, and that's why we excise it. That's the term, perineal fibrosis, is what you see in pathology. That's why a ligament release doesn't work. That's why injections typically don't help long-term, but we can try them. And that's why excision is the right answer if they fail non-operative management. The key exam is everyone has pain in the front of their foot. That gives you a lot of different pathology. The most important is radiating into the toes. If they say it shoots into my second and third toes or my third and fourth toes, that is a Morton's neuroma versus I have pain on the bottom of my foot. Pain on the bottom of your foot can be lots of things, metatarsalgia, fat patatrophy, arthritis, can be a neuroma, but for the exam, pain shooting into the toes is key and that's what you want to have. Worse with shoes, neuroma is always worse with shoes, they feel better barefoot, so these are the signs they'll give you on the test. Mulder's sign is where you put upward pressure from the plantar aspect of the foot. You're taking the neuroma and sticking it in between the metatarsal heads, whichever one you're second or third, or third and fourth, and then you compress the foot. You get a click with pain, that's a positive Mulder's sign. Diagnostic test, you always get an x-ray and no other test is necessary for a testing purpose. So for your exam, if they ask you, patient has a positive Mulder's click, pain radiating into the toes, failed non-op management, what's the next most appropriate step, it is not an ultrasound or MRI or anything like that, it's excision. However, in reality, nobody does that anymore because patients are loony and so we always get a test to prove to them that there's something wrong, because you can't convince anybody that as a physician you know anything anymore, and that's just reality. I'm sure nobody here operates on the knee or the shoulder without an MRI, even though you know what the problem is, it's just a reality situation. Morton's neuroma, non-operative against steroids, you can do once, twice, but you should not do really more than three. If you do seven, eight, ten of these, it causes long-term damage to the nerve, it causes damage to the soft tissue, so it's one or two. About 20-30% will get long-term relief, and actually there's a nice study that came out last year that showed if you just shoot lidocaine in, it's as effective as cortisone. So I'm not sure what the heck we're doing with these things, but it's something you can do. The one thing you should know for the test, because this is what they're going to ask you, alcohol sclerosing is not an answer. Don't do that, there's plenty of data that suggests that it's not helpful, and our society, the OFAS has a position statement that says this is not appropriate. There's new stuff like cold ablation and things like that, that don't answer that right now, there's no data on that to tell you yes or no. So it's an injection, non-operative management with metatarsal pads, wider shoes, etc. If it's surgical, it's excision, 80-95% satisfaction with what the literature says, I'll tell you it's probably more in the 70-80% range. You just do not do a ligament release, you've got to excise the nerve, you can go from plantar or dorsal, it doesn't really matter, because 5% of the time when you go dorsal, people have proven that you take out the artery by accident, not the nerve, always a fun conversation to have. If you go plantar, 5% of the time you get a painful scar. So that's the data that's out there. So the rate of complications of continued pain is about the same. For revision, it's always go plantar. Bacterial neuritis, this is a sports thing for sure, it's called your jogger's foot or your marathoner's foot, it's commonly confused with plantar fasciitis, and I'll try to differentiate the two for you. It's compression of the first branch of the lateral plantar nerve off the tibial nerve. The key innervation is the abductor digiti minimi, and that's why an EMG, nerve conduction velocity, actually can help, because you can actually test for the abductor and see if it's pathologic. The key physical exam findings are inferior medial heel pain, not just plantar heel pain, and pain with compression of the abductor. Surgical treatment is release of both the superficial and deep fascia of the abductor hallucis, so it's that inferior aspect of the tarsal tunnel that you want to release, and this actually is an effective operation. This original article showed an 85% success rate, and I'll tell you if this is a real diagnosis, they actually do well. So when they ask you the question on the test, they're going to specify whether it's pain on the bottom of the foot, then it gets better with walking, that's plantar fasciitis. If it's pain with activity more on the bottom and inside of the foot, they'll show you the spot, they'll usually put an X over the abductor, that's Bacterial neuritis, that's not going to get better with your stretching or any of that stuff, that is a surgical problem in general for these patients. You can do orthotics and all that jazz, but typically it's surgery. So differentiate the two, plantar fasciitis is pain over the plantar fascia, not medial. First branch is medial heel pain, pain with compression of the abductor hallucis, or if you've ever had surgery to the foot, so somebody like me gets to the foot and we do a bad job, the one nerve that you're going to hit is the first branch of the lateral plantar nerve because it crosses obliquely, so TTC fusions, plantar fascia releases, you get glass stuck in your foot by accident, that's the nerve that's going to get hit because it's going transversely where the medial branch is going straight across and typically is never really injured. Diabetic feet, which I'm sure you don't want to hear about, but I'll give you the few things they might ask you about because I'm sure if they walk in your office, just give them a card that says go left. So neuropathic, not ischemic, is the ulceration. This is kind of the biggest way to differentiate vascular versus diabetic. So diabetics typically do not present with an ischemic ulceration. Horrific diabetics will, but in general, this is a neuropathic problem. They have loss of protective sensation, which is what that 5.07 filament is. The relevance of this is that if you cannot feel this filament, most patients will have, if you cannot feel the filament, you are at high risk for ulceration. If you can feel the filament, it means only 10% of those patients will have a high risk for ulceration. So it doesn't mean that if you can feel the filament that you're guaranteed not to get a neuropathic ulcer. So I don't even do this test. I treat everybody as if they're going to get an ulcer because the test isn't that relevant if 10% of patients will still get an ulcer, but for your test, that's what you're checking. If they cannot feel that filament, by definition, they're neuropathic and you have to treat them as such, which means diabetic orthotics, diabetic shoes, can't walk barefoot, all the torture that comes with it. If they ask you what the predictive sign for developing a foot complication, what that means is an amputation. That's what they're getting at from this question. It's a history of a foot ulcer, not lacking sensation to the filament. So lacking sensation to the filament increases your risk for ulceration, getting a risk for a complication, which is an amputation. If you had a prior foot ulcer, that's a much higher risk of getting a complication. The treatment for ulcerations in a diabetic is to breathe the callus and dead tissue, and then you put them in what we call a total contact cast. It's a very weird cast. You pad the bony extremities, the anterior tip, the medial male, lateral male, fifth and first metatarsal head. One wrap of web roll, and then plaster, and then fiberglass. If you put this cast on yourself, there's actually a higher risk if you're not good at it of cutting off the toes or getting a complication. Again, when I was at Michigan, which Bruce is probably never going to invite me again, but my first year or two, I did that. I did not know what I was doing because I didn't practice enough. I put a total contact cast on a guy, came back, three weeks later I cut his toe off for him because we end up crushing into the fifth metatarsal head. So you have to be careful. It's a very dangerous cast to put on per se, so if you're not good at it, don't do it. And they may ask you that as a complication. It's ulcerations and iatrogenic. And usually you change them every week because they get so loose from the edema. If done well, it's very effective for non-infected ulcerations. Ninety percent effective for your Wagner grade one, grade two, so that's not your deep infections. Surgical treatment, if you've done the total contact casting and they got better, but then they got the ulcer again, the answer is not to repeat the same thing again. Then you need some sort of surgical intervention based on the x-rays. If they have a stable deformity, which means the foot's not slopping around, but they got a prominence, you can open up the side of the foot and take off the prominence to level it off so no longer having that pressure. If it's unstable, the foot's slopping around and that's why they have a prominence, you cannot just cut off bone, you have to do an osteotomy and fusion. We never do ORFs on these people. They always get a large arthrodesis with a lot of metal. Ankle or hind foot involvement almost universally means that you have to do a fusion because they're too unstable in that part of the body. If they have a forefoot ulcer, going back to that Achilles contraction in the beginning, so recurrent forefoot ulceration, despite appropriate treatment, it's from an Aquinas contraction and they'll give that to you, that information, do an Achilles lengthening or a gastroc recession based on their exam. It is not cut off the front of the foot. If it's in the forefoot and you got them to heal once and it came back, it's because they have a mechanical reason to overload the front of the foot and you do a lengthening, that actually can solve the problem a lot. If it's osteo, gangrene, it's obvious, amputation, I don't know if that's a sports question but if that comes up, just cut it off. The one thing you do for diabetics, I mean, these guys are laughing but that's what we do. They want you to be, I know you just had this horrible dermatologic infectious disease lecture which verified my decision to orthopedics because I can't stand any of that stuff. They still want us to be doctors, not surgeons. This is how the tests go. You have to look at the biological level, so your albumin, you have to look at the vascular level before you jump to the operating room. So, these patients come with ulcerations. It's not just go to the operating room, it's take a step back, look at the patient and then do the surgery and they like to ask this question. Your ABI should be better than 0.45, your toe pressure should be better than 45 and your transgenic oxygen should be greater than 30. Not as much important for you to remember but this is the most important thing. Your lymphocyte count has to be better than 1500 and your albumin has to be greater than 3.5. This is the kind of question I like to ask. Patients in intensive care unit or patient presents with this ulceration, infected, whatever, the next and most appropriate step is to evaluate their nutritional status. If they give you these lab values, albumin is 2.4 and lymphocyte count is 500, what's the next most appropriate step? It's nutritional optimization followed by surgical intervention. It is not I'm going to go to the operating room and do my thing because they don't want us to do surgery that's going to fail. And they do like this nutrition question. I've seen it a lot in the OITE. My residents tell me this comes back on the boards and it's something that they're going to ask you about if it comes up. So, it's not operate first, it's get them healthy and then operate as best, as healthy as you can make them. For Charcot neuroarthropathy, which is these weird deformities that we see in diabetics most commonly in America, basically they'll come with some sort of weird swelling of the ankle or the foot without an ulceration. This is the biggest thing that they may ask you. Patient comes in with a swollen foot, you get consulted, is it osteomyelitis or is it Charcot? If there's no ulceration anywhere in that foot, it's Charcot, not osteo. And if it, you can elevate overnight or even after a few hours, the swelling goes down, it's Charcot, not osteo. Osteo swelling never goes away, Charcot goes away with elevation. So, swelling, deformity in a foot or ankle without an ulceration is taught commonly Charcot. If there's an ulceration directly probing to bone, then it's osteo versus Charcot. The treatment for Charcot is not surgery initially, it's edema control and mobilization with a total contact cast that I told you, you change it every week. Weight bearing restriction, usually we'll try to keep them off of it. Dysphosphonates, they may throw that at you. I would not answer that yet because there's no proven benefit. You want to get to what we call the subacute chronic stage where the bone's not getting eaten away and it's more stable and then you can do surgery for it. Ankle arthritis, this you'll see as well. You always want to put a brace on non-surgically. Arizona brace is that big leather gauntlet you're probably all familiar with that no patient ever uses or a rigid AFO. We prescribe it, it's a waste of money I think, but we do anyways. And if they ask you for a shoe, it's a single hind foot rocker shoe. It's a rocker is where the convex part is. So, if it's an ankle arthritis, you want it more posterior. So, hind foot rocker. If it's midfoot arthritis, you want it in the midfoot. If they have forefoot arthritis, theoretically you can make a forefoot rocker and put the convexity more anterior or more distal. The surgical treatment, terbium and encolectomy for the ankle is not a thing. That's for your ankle impingement. I know you had an ankle lecture already. So, if somebody has ankle instability, they have ankle impingement, then you can go ahead and do an ankle arthroscopy and clean out the front of the ankle. But that is not for arthritis. That is only for impingement. If you do this for arthritis, and I'll tell you from experience because I didn't believe my elders, they do terribly. Because they're arthritic, you eliminate that anterior bony block. The talus shoots out the front. Three months later, they're really livid. And typically it's you because you did the surgery. And now you've made them from bad to worse and you're obligated to do a fusion replacement now. So, never do that. Arthritis is a great answer and replacement is a great answer as well. Either one works. When you look at ankle fusion, they have functional impact, difficulty on even ground, stairs, and aching with prolonged activity. So, for your athletic population, they probably will not like a fusion. They don't do so well. Now, athletic for these people does not mean that they're running, but it's more of your tennis, light tennis, hiking, things like that. That's when ankle replacement is probably a better answer. For ankle arthritis, the most common adjacent problem is subtalar arthritis. After 22 years, this is an Iowa study where they can keep their patients in the same state. And guaranteed after 22 years, you're going to get subtalar arthritis. That's the common question. If you have subtalar fusion, it's ankle arthritis. It's the same thing. There's no proven risk in knee arthritis based on most of the literature that I've read. But if they ever ask you that, it's ipsilateral knee because there's some controversy on that question. But Saltzman is who I believe the most and he showed no increase in knee arthritis, as long as it's done correctly. Modern ankle replacements, probably when a lot of you train, this was not an ideal thing to do. What was done 10 years ago or 15 years ago when I was a resident and a fellow, we don't even put that implant in because that was a terrible idea, but we keep trying. Modern ankle replacements, whatever that may mean, do okay. Eighty-nine percent survivorship at 10 years, you're looking at 7,500 ankles. There are problems with them, but this is a valid answer for your patients. What you should know if this comes up, what you should do is if there's no motion before, there's no motion afterwards, just like a hip or a knee, they don't get much. It's not as good as a hip or a knee, as you all know, and revisions are very difficult and they're not the same outcome as a primary ankle fusion. If it's infected, you have to do an orthodontics with an allograft. If for revision, if it's infected, you have to take it out, cement spacer, and then go ahead and do a TTC bone block fusion, and that doesn't always work so well. So what are you going to choose? Well, for a sports type review board course test, if there's deformity or if there's no motion, you want to fuse them. We do not do, ideally, replacements with deformity. That's not reality. They're diabetic, overweight, laborer, does not get an ankle replacement, infection, bone loss, and bad skin, ideally get a fusion. But if you have a thin patient, leg looks straight, good motion, bless you, older than 50, and no deformity, they want to do hiking, outdoor activity, or if they have ipsilateral hindfoot arthritis, so if they have subtalar arthritis or navicular arthritis, that is a better candidate for an ankle replacement and that's maybe what they're going to ask you. If they want to do running, jumping, cutting sports, they should not get any of these operations because they're not going to do well. So if you have no idea what to answer and they're asking you on the test, just put fusion and go home because that's a safe answer. But think about this 60-year-old, 50-year-old, active, thin patient, wants to hike, that is a good, they're leading you down the golden road of that ankle replacement. Hindfoot arthritis, this is primarily your subtalar, TNCC arthritis. The one thing they may ask you, if somebody had a calcaneus fracture and now they have subtalar arthritis, if they have anterior ankle pain because the calcaneus is so short, then you have to do a bone block subtalar fusion, which is commonly asked and rarely done because it's quite difficult to do. But if you see that x-ray, the history is calcaneus fracture, the only time we put bone block fusion is if they tell you the patient has ankle pain. I don't care how ugly the x-ray looks, if they don't tell you they have anterior ankle pain, it's an in situ subtalar fusion. And they will specifically tell you that. If they have posterior tendons function that's rigid or rheumatoid, you want to do a triple where you're going to fuse the back of the foot because that's the best way to realign the deformity. Hard to get deformity correction in a rigid hindfoot with just a subtalar joint. The TNCC and subtalar work as one, so you want to correct deformity, you have to go for all three. This is what a triple arthrodesis looks like, obviously. So if you don't know what to answer, if they have a patient with telenovicular arthritis, a deformity that's rigid in the hindfoot and it's not a calc fracture, just do triple arthrodesis, a very safe answer for you. If they had a calcaneus fracture, it's going to be an isolated subtalar fusion with or without a bone block if they have pain in the front of the ankle. And always look at the Achilles tendon. The union rate for subtalar fusions is okay, it's like 84%, 80% depending on what you read. The most important thing that they've asked is that you have a higher non-union rate if you have an adjacent joint fused. So if the ankle joint is fused, you actually have a harder time fusing the subtalar joint, which goes against common sense. But the reason is, as these patients are allowed to walk, because a lot of times we'll put them in a boot at two weeks, and the weight bear at six, is that there's a lot of strain at the subtalar fusion site because the ankle doesn't move. So in actuality, if you have a secondary fusion site above or below, we'll actually immobilize these patients longer because that strain is what causes these to fail. Smokers in a vascular bone is obviously part of it, but the number one reason was adjacent joint fusion. So if you have an ankle fusion, you try to do a subtalar fusion, it's actually a really high rate of non-union. Midfoot arthritis, you'll see this more common. That's associated with that, maybe that deep perineal nerve discussion I was talking about before. They have progressive flat foot in many cases and a heel contracture. What you'll see is, if they ask you about a flat foot, you always just want to take a quick look at the x-ray and look at the talonevicular joint. If the talonevicular joint looks congruent, then it's probably a midfoot-driven flat foot. If the talonevicular joint looks like it's, sorry, if it's off significantly, that's a hindfoot-driven flat foot, that's your posterior tip tendon dysfunction. So before you answer orthotics or a flat foot reconstruction as a calcaneal osteotomy, take a two-second look at the x-ray, and if it looks like this, where you see that the talonevicular joint doesn't look that bad, then you can take a quick look at the midfoot, see the midfoot looks all cattywampus. This person needs a midfoot realignment arthrodesis, not a calc osteotomy and tendon transfer, and that's why they try to trick you. The lateral is the best x-ray to look at. You'll see those osteophytes, and that's the easiest way to tell you it's the midfoot, not the hindfoot. The conservative treatment's the same, some sort of rigid insert, so carbon fiber full-length plate or rocker-bottom sole. It's a midfoot rocker sole because that's where the arthrodesis, and a cushioned heel. You can always put a steel shank in a shoe. Any one of these, conceptually, just to think about, you've got to make the shoe rigid in some way, shape, or form. The surgical treatment is very obvious. You just realign it and straighten it and fuse it. Shockingly, there was an article that showed you can't leave them deformed, which is how naïve our foot and ankle literature is, but you can't fuse people sideways, right? You would never fuse an elbow sideways, a shoulder in some bad position. You can't fuse the foot cocci. They do terribly. So the key is you want to realign the deformity and fuse them, remove all the osteophytes, and that should do okay. Helical contracture, every time you look at a fusion of the hindfoot or midfoot, you want to think about this. Subtalar dislocation, so I got this wrong when I took my board exams because I was not paying attention. It's always distal relative to proximal, which just seems pretty obvious, and I think everybody here is not a young resident anymore, so you know, but that's the discussion. So medial dislocation, subtalar, the calcaneus is medial relative to the tibia. It's the same thing with the lateral dislocation. It's lateral relative to the tibia. So if it's a medial subtalar dislocation, look at the x-rays very quickly and make sure you're not looking at a talar neck fracture. That is a common way to trick you. They're going to look at a subtalar dislocation or a talar neck fracture dislocation. Obviously treated very differently. If you look at the lateral here, you can see the entire talar neck. If you look at the AP, you can see the talar neck and head. If you can't see the neck and head and you're just looking at the body and the lateral, it looks like the talus looks cattywampus, that's a fracture dislocation of the talus, talar neck, and that's treated with RIF versus this. This is treated with closed reduction and a CT scan to look for interventricular bodies, which I'll discuss in a second, but the block to reduction, if it's a medial dislocation, is the lateral structure. So the extension digitorum brevis and or the perineal tendons. For the test, they will never ask you both. I'd be floored if they ask you both because it can be either one. So if it's a medial dislocation, EDB or perineal tendons, it's a lateral dislocation, it's only the posterior tip tendon which seems to get lodged into place. And you can see here, the talus is easily seen in view on that canali type view. The treatment is a closed reduction and a non-wipering short-legged cast for two weeks and then you can actually put them in a boot. Open reduction, if closed reduction fails, to remove interposed tissue. So if it doesn't just pop in place with appropriate sedation, you have to open and then you're obviously going to open on the side where the dislocation was to remove, on the opposite side to remove the interposed tissue. There's no role for ligamentous repair, even though that makes sense. You should not try to repair these patients. They'll be stiff and they're fine anyways. Post-reduction, you always get a CT to see if there's loose bodies or fractures, primarily within the subtalar joint that need to be excised surgically, which is pretty rare. Calcaneus fractures, I don't know what you were trained on, but there's a couple new articles that show that open treatment is really not ideal and for the test they like to harp on this. So calcaneus fractures, the most common complication from surgery is a wound complication. About 25% will get a superficial wound complication. Diabetic smokers and open obviously do worse. The most recent data suggests non-operative management is as good as surgical management when comparing to the classic open incision to non-surgical management. It is not accounting for MIS, percutaneous, but that's not enough data to tell you what to answer. Now most of us would do MIS or PERC fixation calc fractures, but for the exams that's not even an answer. So it's comparing open to closed and there's a nice article out of the British Medical Journal in 2011 that basically proved that we don't really help these patients at all. So if they ask this question in a patient with a closed calc fracture and it's not grossly deformed, there's no subtalar dislocation, they're not walking on the fibula, the answer is non-surgical management, which is weird, but that's what it is. So who should get an operation? Severe deformity, walking on the fibula, dislocation. You always get a CT and check. Tongue type fractures are very different. This is when they like to trick you. So tongue type is the only one where you have to have surgery. It's a simple, isolated tongue type. Nothing else. It's not a joint depression. That's urgent percutaneous fixation. And that fracture, we can see it's not a joint depression. You don't see a crush of the calcaneus. You can have a tongue type fragment in a joint depression. Don't confuse yourself with this fracture. This looks like the Achilles ripped the calcaneus up. I'm not sure what the mechanism is. I know that's part of it. This is urgent. Same day, close reduction. Don't open the wound. Don't wait 24 hours, 48 hours. If you don't want to do it, call someone who can and it's really easy to do. A couple hours in, plantar flex, pop it and fire some screws. And if you don't, that wound will pop open. I saw a lady like five years ago that was treated with delayed treatment and they opened it and you were staring at her calcaneus with the screws and the Achilles was in Valhalla somewhere. And we had to do a big reconstruction where this is a 20, 30 minute operation and it's a done deal. Even if they get arthritis, who cares? The most important thing is that you do not end up with an open wound in the back. So this is urgent percutaneous versus a joint depression which is non-operative versus operative. Is that relatively clear to everybody for the test? It's not reality but that's how you have to answer the test questions. Forty-year-old male, female fell during a hike and sustained a lateral subtalar dislocation. So the calcaneus is lateral to the talus. And the EW, the emergency waiting area, the doctor's having trouble reducing the joint. The most common obstacle reduction is, well, if the calcaneus is lateral, you pull the medial structure in there and so it's going to be the posterior tip tendon. The answer is not that the emergency room doctor is not as good as you, which is probably what you're all thinking. But the answer is they can't do it either probably and take it to the operating room. The Lisfrank joints, this is getting to the end now. We all know what this is. It's between the Lisfrank ligament between the medial cuneiform and the second metatarsal. There's nothing between the first and second metatarsal to hold it together. The interosseous ligament is the Lisfrank ligament and there's plantar ligaments as well. It's a constellation of things that hold this together. Most importantly, plantar is stronger than dorsal. The diagnosis is indirect mechanism injury, most common in sports, which is if somebody gets loaded from a plantar-reflex foot. So your football, soccer injuries, et cetera, somebody came from you from behind, tackled you, you get this pain discomfort in your foot. The radiographs are key. The first thing I'm going to ask you is they may show you non-weight-bearing x-rays. What's the next most appropriate step? Obviously, you all know it's a weight-bearing x-ray. That's the first thing before you do anything else. They have to be weight-bearing. If you don't have a weight-bearing x-ray, you don't move to the next step. That means no CT, no MRI, no surgery, no treatment without a weight-bearing x-ray. That's in, by definition, has to be done. Everything lines up in the foot. So all these things that you read about, medial border, this, that, everything just lines up. It's very basic. So the second and middle line up, the third and fourth line up on the oblique. Everybody should line up. Nobody's slightly off. There's no subtle anatomic variation where your second metatarsus is slightly lateral to the cuneiform. That's by definition a Lisfrank injury. These are all perfectly lined up. There's a fleck fracture. So you see this tiny little fleck. That's a version of the Lisfrank ligament. That's not okay. That's a surgical problem. Well, should you do an RIF or do you do a fusion? Well, there you can see here, the slight widening between the first and second. And you can see there's a polyendocuneiform variant as well. That is a Lisfrank injury. That underwent RIF. You could argue a fusion. I'll get into what to answer in a second. The other treatment options are non-operative treatment and a cast. This is wrong. There's no role for this for Lisfrank injuries. For a sprain, a strain of the Lisfrank ligament that has no widening on X-rays, but they have pain in the midfoot with the MRI confirmation of an intact Lisfrank ligament, that can be treated non-operatively. And only that. If you treat anything else, it'll all be due bad. Percutaneous fixation, even though some of us do this, I'm one of them, don't answer this for the test. It's wrong. You have to do an open approach, look at it, make it perfect, and then do your fixation. Fusion is actually not an unreasonable answer. There's a great article that came out looking at the military. The patients who had a midfoot fusion for a Lisfrank actually were three seconds or something like that faster than those at RIF. So there's some benefit to fusion. And I'll try to give you the best answer for this in a second. So purely ligamentous. If you see a ligamentous subluxation, dislocation on non-weight-bearing X-rays, like this is a bad injury, and the non-weight-bearing looks wide, weight-bearing looks worse, they're probably actually better getting a fusion. Hands down. If it's a subtle injury, non-weight-bearing is normal. But you get a stress X-ray and that pops open a little bit, that is still better with RIF because they still have some stability. When you talk to like Kotsia and these other guys that we talk to in our little society, those patients still probably do better with an RIF. So subtle instability only with weight-bearing X-rays, RIF is probably the better answer. Or if it's a bony injury. If you have bone breaks, RIF obviously is better. But if a ligamentous subluxation, dislocation, a fusion is actually your best answer. And that's really the best way to do it. Does that make sense to everyone? I don't know if they're going to ask you this type of a question because it's kind of subtle. There's less revision surgery with arthrodesis. And I'll tell you, if it was my Liz Frank, I got injured, I'd fuse it hands down and never get an RIF unless it was very subtle because they just get a lot of surgeries. Fifth metatarsal fractures, you all know about, zone 1, zone 2, zone 3. Zone 1, avulsion we don't operate on. It's almost very, very rare to operate once every 100 patients, 200 patients might need surgery for this. It's either a post-op shoe or I give everybody a boot because it's more comfortable. Surgery is very rarely indicated. Zone 2, your Jones fractures. These are the ones that you all know don't heal very well. But for the test, they may try to trick you. If they give you a 55-year-old sedentary patient that actually tripped and fell and broke their fifth metatarsal and it's a Jones fracture, which is 20 millimeters from the tip of the fifth metatarsal, you do not operate on that patient. It's a cast, technically still, non-weight bearing for six weeks. My partner published it. You can put them in a boot actually at two weeks. I don't suggest you do that for litigation reasons. But non-weight bearing cast, six weeks, then weight bearing in a boot. A normal human being, which is everyone in this room because none of you get paid professionally to do this stuff, does not get surgery for this. That's what they're going to ask you because even though we operate on almost everyone that walks in the door, it doesn't make it the right thing to do. If it's an athlete, your athletic patient, whether high school, collegiate, whatever it may be, military, they have to get back quickly. In America, it's RAF with a screw, intramedullary screw. There's no question about it. When you look at the type of screw, you want to put at least a five millimeter screw into the metatarsal. Non-unions and malunions are associated primarily with less than five millimeters. So 4.5 millimeter screws have a higher association of non-union. So you want to put five or larger depending on the size of the canal. Half of this comes from quill. George Quill is a Marsden Fellow many years ago, looked at athletes treated non-operatively. And half of them who had non-operative treatment would go back and refracture their foot. So that's what we advocate fixing these patients. Zone threes are different. These are stress fractures, prodromal pain. They're more in the mid-shaft area. You see this slightly distal to that fourth, fifth intermetatarsal junction. Those all have to get surgery because these are chronic stress. Non-operative management is not going to fix them. So you have to do intramedullary screw, usually biologic addition with bone grafting. Some would argue that you should plate these because you're plating on the tension side and it's more logical. And there's controversy to that where putting a screw is not as mechanically advantageous. And a lot of these will refracture. You have to be careful and always look at their biomechanics, cavus foot, adducted foot, et cetera. But for your purposes, if you have a zone three prodromal pain, the answer is not non-operative management. In any patient, it's ORF with a screw. Stress fractures are the same, insidious onset. The treatment is weight-bearing in a boot. Always look for metabolic bone disease, low vitamin D. The triad in female athletes, they're expecting to look for this, not just treat the stress fracture. Particular stress fractures historically used to be ORIF because we thought we were good surgeons. When you look at all the data now, it's non-operative management unless they fail that. So they have vague dorsal midfoot pain. If they show you an x-ray or clinical picture, the finger will be pointing down right at the level of the ankle joint. That's called the end spot, which is probably inappropriate, but I didn't make it up. But that's literally what people have termed this thing. If they point back, it's the ankle. But if they show the ankle joint itself and they're pointing down right here where this is, that's the end spot. That's an avicular stress fracture, not ankle pain. Runners, gymnastics get it all the time. The treatment is non-weight-bearing in a boot or a cast as long as you possibly can. Four months, people will actually say, if there's no improvement, then you can do surgery. But that's associated with worse outcomes. This is this article out of 2006. They showed it was similar. Four months to healing non-operatively. Patients that had surgery had a higher rate of osteonecrosis and failure to improve. And so it's a big deal to operate on these patients. Ideally, not up, not up, not up before you operate on them. Lateral stress process fracture of the talus, snowboarder, anybody with an athlete, ankle sprain that's not getting better. You get an x-ray. You're actually looking at the AP, not the mortis. Look for lateral process, persistent pain. Next up is a CT. If it's a big piece, you fix it. If it's a small piece, you leave it alone. I know I'm over time. These are the last questions. Atrial male has persistent lateral ankle pain after an injury while snowboarding, obvious giveaway. Initial x-rays were negative. The next step is you always want to get a CAT scan. You never just reassure a patient. Twenty-one-year-old athlete, pain along the lateral board of her foot, soreness in that same area for two weeks, so now they're getting to prodromal pain. Fifth metatarsal with sclerosis, the next step is repair with intramedial screw fixation. It's not non-operative because she had prodromal pain. Thank you very much. Thank you.

foot and ankle conditions

diagnosis

treatment options

weight-bearing x-rays

Morton's neuroma

surgical intervention

diabetic feet

ulcerations

ankle arthritis

fractures