management

Surgical Algorithm

Stage 1 Tendonitis

Non-operative

Walking cast / NSAIDS

- 6/52

UCBL

- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch

Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)

Aim

Stable, shoe-able plantigrade foot

Multidisciplinary approach

Multidisciplinary foot clinics (MDFC) 1^st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:

Endocrinologist +/- diabetic nurse

- glycaemic control crucial

Podiatrist

- non-surgical debridement

- orthoses

Operative v Nonoperative Literature

1.  Buckley etal JBJS Am 2002

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

Improved Operative Outcome if

- not workers compensation

- women

- < 29

Definition

High ankle sprain

Epidemiology

Uncommon

- often unrecognised or misdiagnosed as lateral ligament injuries

- seen in ice hockey

1-15% of ankle sprains involve the syndesmosis

Mechanism Injury

Hyperdorsiflexion and forced external rotation

Anatomy

Structures

- anterior inferior tibiofibular ligament (AITFL)

Definition

Tibial facture with break in skin

- open wound communicating with fracture or haematoma

Patient is immediately at higher risk of deep infection

Diagnosis

Wound continuously oozes dark red fracture haematoma

Epidemiology

Up to 1/4 of tibia fractures open

Gustilo and Anderson Classification

Grade 1

- wound < 1cm

- usually inside out

AORI / Andersen Orthopedic Research Institute

T Tibial  F Femoral

1.  Contained Metaphyseal Defect

2.  Damaged Metaphyseal

A.  One Condyle

B.  Both Condyles

3.  Deficient Metaphysis +/- collaterals +/- extensor mechanism

1.  Contained Metaphyseal defect 

Incidence

10%

Requirements

70^o  swing phase

80^o climb up stairs

90^o climb down stairs + sit down in chair

100^o low chair

NHx

Stiffness usually subsides at 6-8/52

- generally improves out to 3/12

- slow improvement for up to next 9/12

Incidence

10 -15%

Include

- marginal necrosis

- wound slough

- sinus tract formation

- dehiscence

- haematoma

- oozing knee wound

Blood supply

Anterior knee has no muscles to supply vessels directly 

Incidence

Knee > Hip

- superficial position

- limited cover of well vascularised muscle 

- watershed area of skin blood supply anterior to the skin incision 

- much increased in fully constrained prosthesis 

Ideal < 1%

Risk Factors

Increased with

- revision

- prior infection

- RA / Psoriatic arthropathy

- DM

Types of Instability

1.  AP Instability

2.  Varus Valgus Instability

3.  Global Instability

4. Frank Dislocation