Pes Cavus12/16/13 2:29 PMInfection- minimal number of viral particles necessary to establish disease states:106 Bone infection105 Soft tissue infection102 Infection of soft tissue or bone + foreign bodyAllows differentiation b/w colonization & infection

-SubjectiveCC: foul smelling ulcer for 3 days etcNLDOCATSystemic signs of infection N/C/V/D/F/SOBLocal signs of infection calor, dolar, rubor, tumor, pain5 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?

-ROSGeneral, Eyes, Lungs, Pv, Neuro, MuscNow the whole thing:HEENT, Resp, Cardio, GI/GU, Musc, Skin, Neuro, Lymph

-Objective Vitals Temp/HR/RR/BP & Height/weightSIRS (need at least 2 of below criteria)Temp (96.8 or 100.4)HR (>90) & RR (>20)WBC (12K or 10% bands)Septicemia bacteremia + fever, chills, nausea etc

Lower Extremity focusedVasc: doppler, CFT, edemaABI: >1.2= calcification (monkebergs sclerosis) < 0.45= inadequate for healing in diabetics TcPo2: need to be > 30mmHg for adequate healingNeuro: protective & vibratory sensationProp & Vib posterior columnLight touch & pain/temp anterior lateral Derm: Depth, Diameter, Drainage, Odor, Base, BorderPROBE TO BONE??Grayson- 89% PPI for OMLavery- 98% NPI for OM*Wagner: 0= pre-ulcer, 1= superficial, 2= deep to bone, 3= deep to bone + abscess/infectionUT: 0= normal, 1= superficial, 2= tendon, 3= boneA= Normal , B= Infected, B= Ischemic, D= bothPEDIS: (Perfusion Extent Depth Infection Sensation)1= uninfected 2= (Mild) > 2 manifestations of inflamErythema/cellulitis < 2 cm around ulcer3= (Mod) Erythema/cellulitis > 2 cm around ulcer, streaking lymp, abscess, gangrene4= (Severe) + N/C/V/D/F/SOB/ConfusionMusc: boney prominences ?Foot type, Previous amputations, Strength

-What to order1) Imaging: X-rays Gas= emergency Get more PROXIMAL filmsBECKS+ (Bacteroides, E. coli, clostridium, klebsiella, stap/strep, peptococcus, peptostrepto cOM (may take 10-14 days/ need 30-50% resorption)Acute= soft tissue swelling, periosteal rxn, lytic changes, cortical destructionChronic= sequestrum, involucrum, cloca, brodiesMRI No contrast if Poor renal function T1= low signalT2/Stir= high signal in cortex/medullary bone Bone Scan Increased uptake in all 4 phases Charcot vs. Acute OMCharcot has more diffuse periarticular uptake on phase 3 Ceretec (Tech-HMPAO) sensitive & specific saferOnly shows ACUTE infectionsDetermines if hotspot is in or out of boneIndium-111 Oxime done in 24hrsBetter for CHRONIC infections2) CBC w/ diff:Hemoglobin (12-18) **Transfuse if < 8Hematocrit (35-55%) **Transfuse if < 241 unit PRBC= increase Hg by 1 & Hct by 21 unit Whole blood= increase Hg 2 & Hct 4Platelets (100-450) ** No surgery if < 100WBC (12,000) **Absolute Neutrophil Count shift to left with bands & segments Left shift= neutrophils + bands > 803) BMPSodium (hypernaturemia- dehydration, Na overload, vol overload)Glucose- healing potential haulted if >150-175 mg/dLCreatinine- kidney function measuring GFR4) Hba1C (add 30 mg/dl each increase inn HbA1c)HbA1c of 5%= 100 mg/dL HbA1c of 6%= 130 mg/dL5) CoagsPT (10-16)PTT (25-35)INR (1) **Need < 1.6 for surgery 1 unit FFP decreases INR by 0.26) Inflammatory markersESR (0-20 mm/hr) NOT SPECFIC Kaleta- if > 70 suspect OMCRP (0-0.8 mg/L) more closely follows the severity of ds7) Albumin (3.5-5 g/L) Pre-albumin (19-36 mg/dL) **shorter half life8) EKG/CXR/HCGEKG Males > 40 & Females >50 going to surgeryCXR smoking historyHCG women < 50 yrs9) Culture (always get AFTER debridement)Gram stainsG(+): stains purple (Teichoic acids, lacks outer-membrane)Cocci: Staph (cat + cluster) & Strep (cat chains)S. aureus (coagulase +)Rods: clostridrum, bacillus, etc..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)Will be decreased from edematous states

-Decision makingAdmit or homeMake Outpatient if:Local infection that can be controlled w/ PO AbxBenign medical conditionsMake Inpatient if:Systemic infection requiring IV AbxNeeded surgical interventionImmunocompromised (Dm, PVD, HIV, RA, Elderly, Steriod)Admit (ADCVANDLIMAX)Antibiotics/MedsCreatinine clearance (140-age) x weight (kg) (x 0.85 in women) / 72 x serum CrVanc (1g q12 IV) & Zoysn (4.5 g q6 IV)Adjust vanc according to trough levelsPCN Allergy (Clinda 600 mg q6 IV) & (Cipro 400 mg q12 IV)PCN & Quin allergy Clinda & Aztreonam (1 g q8 IV)Sliding scale of insulin Once glucose is 200mg/dL then give 2 units, and 2 more units each 50 increase of glucoseSurgery (make NPO)Beside I&D (localized, neuropathic, etc..)Irrigation w/ local debridementWet to dry dressing (dakins, betadine, saline)Cultures & tissue biopsyOR I&D (tracks or probes, abscess, gas in tissue)Debridement, Drainage, DecompressionRemove all tendons in the way Pulse lavage at least 3 liters (DAB vs. TAB)Deep cultures & Tissue biopsy Clean margins with bone resection procedureAntibiotic beads (PMMA)Commonly used antibiotics include: gentamycin, tobramycin, and vancomycinPacked open and eventual DPCChronic OMSequesterum is non-viable and a nidus for infections so it must be removedTMAIncisions: Fishmouth w/ adequate plantar flapTennis racquet for lesser met ampPreserve only P. brevis & PTAdjunct TAL

Diabetic Infection12/16/13 2:29 PM

-IntroductionDVT clot formed in deep venous system of LEPE detached thrombus from LE that travels to arteries of lungRisk Factors (I AM CLOTTED)Inactivity, A fib/Age, MI, Coag state, Longevity of surgery, Obesity, Tobacco use, Trauma, Estrogen, DVT history Common locations20% of calf emboli will become thigh emboli1/5th of PE come from calf

-Clinical Diagnosing: Clinically: red, hot, swollen, painful calf - edema is the most reliable sign of DVT (compare suspected calf to the contralateral side)Homans test DF foot elicits pain in calfPratts sign calf compression elicits pain

-Diagnostic Tests:Non-invasive Duplex Doppler: lack of venous compression indicates DVTCan 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 Impedence plethysmographymeasures 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 thrombosisMRI provide visual images of your veins and may show if you have a clotD-dimer detect fragments produced by clot lysishigh sensitivity may be useful for excluding the diagnosis of acute DVT, particularly when the pre-test probability for the disease is lowInvasive Contrast venographyGold 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 PEPE COD: Right-sided heart failureIncreased 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 cyanticTriad CP, Dyspnea, HemoptysisDiagnosis: 1) Blood gasses: PaO2 < 80 mmHg 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 artery3) Ventilation- Perfusion Scan (V/Q Scan) **A mismatch demonstrating an area of ventilation but NO perfusion suggests PEVentilation: inhalation of xenon 133 Perfusion: T99 labeled albumin V/Q mismatch: acute PE, previous PE, centrally located cancer, radiation4) Pulmonary angiographyDefinitive test, indicated if V/Q scan is inconclusive Diagnostic signs: intraluminal filling defect, abrupt vessel cutoff, loss of side branches-Prophylactic Measures:Non-pharmacologicCompression stockingsSCDs prevents stasis due to increased venous returnPharmacologicHeparinPre-op 5,000 units SQ q2hPost-op 5,000 units SQ q8-qh-TreatmentHeparin IV MOA Binds & accelerates Anti-thrombin 3 which potentiates the inhibition of coag factors 10a and 2aworks in bloodLoading dose: 10,000 -15,000u or 80u/kg Maintenance dose: start with 1,000 u/hr (18u/kg/hr) MONITOR PTT DAILY (goal 60-90 seconds) Titrate to 1.5-2 x normal (30ish x 2= 60)Reversal Protamine sulfate 1 mg protamine pre 100 u heparinLMWH (Lovenox)More predictable efficacy and lower incidence of adverse effects such as HIT, patients can inject LMWH themselves at homeTherapeutic 30 mg SQ BID (for 7-10 days)Prophylactic 1 mg/kg SQ (for 7-10 days)Coumadin MOA interfere with the synthesis of Vit. K clotting factors 2, 7, 9, 10, and Protein S & C works in the liverStart after heparin is therapeuticCommonly 2.5 mg qd MONITOR PT DAILY (1-1.15 x normal/INR 2 -3)Titrate to 1-1.15 x normal (1.2 ish x 2= 17)Reversal Vit. K or FFPThrombolytic (Urokinase, Streptokinase, tPA)MOA aid in conversion of plasminogen to Plasmin which cleaves thrombin & fibrin clots (+) PT & PTTMust be initiated w/in 24-48 hrsLoading dose 250,000 Units infused over 30 minDosage/Duration 100,000 Units/hr for 72 hrSurgical Greenfield filter placed in IVC below renal veinsEmbolectomy

DVT12/16/13 2:29 PM

-IntroductionNormal 70 DF & 30 PF Limitus decrease in ROM limited dorsiflexion < 20 degreesRigidus Absent ROM due to ankylosis 50% of cartilage) CCBWY1) Cheilectomy resection of dorsal exostosis2) Cotton opening wedge osteotomy 3) Bonney & Kessel dorsal wedge of phalanx base4) Waterman dorsal wedge of met base5) Youngswick plantarflexory osteotomy

Joint Destruction (< 50& of cartilage) K FILM1) Keller resection 1/3 proximal phalanx base2) Implant (total vs. hemi) function as spacer3) Fusion Mckeever 15 dorsiflexed & 10 abducted4) Mayo/Stone Mayo (artic surface) & Stone (1/4th met head)5) Lapidus TMT joint fusion

-Post-Op ManagementOrthotic + paddingPT with passive ROM exercisesSerial radiographsHallux Limitus & Rigidus12/16/13 2:29 PM

-Introduction: Goals (RED CAR):Reduction of abnormal osseous anglesEstablish congruous 1st MPJDecrease medial eminence Control correction of factors that lead to deformity Align sesamoids back to proper position Restoration of 1st MPJ weight bearing functionEtiologyPrimary hypermobile/long 1st or pronation Secondary trauma, RA, pes planus, goutPathologyProgressive disorder with these factors affecting:Hyperpronation unlock MTJ loss P. longus 1st ray instable retrograde buckle adductor advantage ligament instability arthritic changesStages: 1- lateral displacement of prox phalanx2- HAV where 1st abuts 2nd digit3- increase IM angle4- subluxed hallux w/ overriding digitsAnatomy4 articular surfaces 9 ligaments (2 collateral, 4 sesamoidal, Intersesamoidal, DTIML, Capsule)FHL only tendon that DOESNT attach to MPJ capsuleSquare met head is most stable

-Radiography In the area of patients presenting complaint I see: AP view1) (Mild or Severe) soft tissue swelling2) (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 jointStructural (P + D = HA) congruous joint4) Tibial sesamoid position (1-7)5) Length of 1st met (normal, long, short) using:Met parabola- (142) Met protrusion index (0-2 mm)6) Metatarsus adductus/Engel (< 15)Abnormal MA may mask IM deformityLateral View1) 1st met is (elevated, normal, short) compared to 2nd met using Seibergs indexdistal distance proximal distance (+ = Elevatus)2) Foot type (pes planus, cavus, normal)

-Capsule Tendon Balancing ProceduresSilver (1923) resection of DM eminence w/ lateral capsulotomy and medial capsulorraphy Mcbride True (1928) silver + fibular sesamoid removal and transfer of adductor tendonHiss (1931) transfer adductor from plantar to medial Joplins sling (1950) transfer adductor thru met Component procedures:Adductor transferEHL lengtheningEHB tenotomyCapsulorraphy (Washington, H, T, Inverted L, Linear)-Osetotomies Hallux interphalangeus Distal AkinAbnormal DASA Proximal Akin (5-10 mm from MPJ)Abnormal PASA Reverdin 1st cut: = to articular surface2nd cut: to long axisGreen plantar cut to protect sesamoids w/ hinge intactLaird lateral cortical hinge not maintained (IM correction)True IM < 16 Distal osteotomy Austin/Kalish/Youngswick stable sag & frontal planesMitchell shortens lateral hinge intactHoffman shortens trapezoid osteotomyWilson shortens oblique osteotomyScarf Central cut DD PP w/ 70 anglesKeller resection of prox phalanx base elderlyMckeever fusion for arthritic jointTrue IM > 16 Proximal osteotomy hinge axis conceptLudloff cut PD DPMau cut PP DD better stabilityJuvara oblique CBW 40 cut avoid growth plateA) wedge B) wedge + hinge cut C) no wedgeCBW/OBW shortens or lengthens 1st metCresecentic bad stability Lapidus hypermobile first or large met/IMLogroscino Reverdin + CBW-Surgical techniqueSingle screw halfway b/w line to long axis & line to osteotomyK-wire dorsal distal medial to plantar proximal lateral-Post-opNWB 4-6 weeks Serial radiographs -ComplicationsHallux varus (staking, aggressive bandage, fibular sesamoid removed, overcorrection on IM)Systemic Repair of Hallux Varus (McGlamry)Complete ST release, Correction of structural deformity (IM angle), Tendon transfers, Tibial sesamoidectomy, Joint arthroplastyCapital fragment on floor (Christenson; 1992)Mix 1 L NS (+) 1 mL Neosporin irrigant (+) 1:100K BacitracinTransfer to 3 different basins w/ solution x5Document and tell patientOthers: infection, avn, non-union, fixation failure, shortening, reoccurrence, sesamoiditis

Bunion case12/16/13 2:29 PM

-IntroductionHaglunds posterior-superior painful bursal projection of calcaneus due to enlargement of this cal regionInvolves retrocalc & achilles bursaCaused by: shoe gear irritation or cavus foot Retrocal Exostosis ensethopathy at achilles tendonIntratendinous calcification of soft tissuesTraverses Entire posterior aspect of heelCaused by: trauma or overuse causing thickening DDX:Calc bursisitis, Achilles tendonitis, Achilles rupture, Tumor

-RadiologyFowler & Phillip (normal 45-70)Line posterior calc w/ line tangent to PS prominence Pathologic > 75Total angle (normal < 90)Calcaneal inclination (+) Fowler & PhillipPathologic > 90Parallel pitch linesLine 1 tangent to ant. tuber & medial plantar tuberThen draw line to thisLine 2 parallel to Line 1 and to perpendicular linePathologic 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 calcFor structural cavus foot typeDuvries lateral incision F & P Mercedes incision thru achilles, then resect bumpHaglunds & Retrocal Exostosis12/16/13 2:29 PMSpeed bridge resect bump then reapproximate w/ speed bridge

-EtiologyFlexibleEquinusCongenital (talipes calcaneovalgus)Structural (compensated FF varus or valgus)Ligamentous (PTTD or ligamentous laxity)RigidTarsal coalition (Syn-desmosis, chondrosis, ostosis)*TC (12-16), CN (12-8), TN (3-5)True collation= intra-articular fusion of 2 bonesCongenital (Aperts or Nievergelt-pearlman)Both seen with cuneiform coalitionsTrauma (fractures)Peroneal spasm

-Planes of dominance: STJ axis 42 transverse & 16 sagittal MTJ oblique 52 transverse & 57 sagittalDF, PF, abduction, adductionMTJ longitudinal 15 transverse & 9 sagittal Inversion & eversion

-Clinical exam Hubscher maneuver dorsiflex hallux creates windlass mech.Arch elevation, PF 1st ray, RF supination, Ext leg rotationROM (Ankle, STJ, MTJ)Ankle 10 dorsiflexion & 20 plantarflexion STJ 10 eversion & 20 inversion MTJ longitundal 4-6Have patient stand in angle & base Too many toes sign RSCP in > 4 valgusSingle heel rise test Coalition findingsProgressive valgus w/ bow strung peroneal tendons SPASM

-Classifications Johnson & Strom1) tenosynovitis + mild tendon degeneration flexibleTendon debridement + orthotics2) elongated & degenerated + TTS flexibleTendon transfer & RF procedure3) elongated & ruptured + inability in SHR test rigidTriple or Double arthrodesis4) rigid ankle valgusTriple or TCC arthrodesisDeland 2A) 30% TN uncoverFunk 1) avulsion 2) ms rupture 3) in-continuity tear 4) tenosynoConti (MRI)1A) couple long splits 1B) multiple long splits & fibrosis2) narrowing of tendon w/ DEGENERATION3A) disuse swelling & degen 3B) complete rupture-Radiology AP view (transverse plane)TN articulation (75%) DECREASEDTC Kites (20) INCREASEDCuboid Abduction (0-5) INCREASEDLateral view (sagittal plane)CI (20) DECREASEDTD (20) INCREASEDLTC (40) INCREASEDNavic-Cub superimposed INCREASEDCyma line ANTERIOR BREAKMearys (0-15) NEGATIVE decreasedCalc axial (frontal plane)RF eversion rule out ankle valgusDecreased height of sustentaculumHarris-Beath evaluates middle & posterior facetsViews= 35, 40, 45 axial viewsMedial ObliqueAnteater sign CN coalitionLateral ObliqueAnterior facet coalition CT ScanModality of choice for coalition Asses subtle cortical changes in surrounding

-Flexible Procedures:Goals:Primary joint stability Secondary recreate arch heightMost 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 correction1) Evans opening wedge 1.5 cm proximal to CC joint2) CCJ distract arthrodesis lengthens lateral column3) Kidner advancement & reattachment of PT

Sagittal correction1) Cotton plantarflexes 1st ray (bone graft)2) Arthrodesis:Lowman TN fusion (+) TALHoke NC fusion Miller NC fusion (+) 1st Met-Cuneiform Lapidus 1st Met-Cuneifrom fusion 3) Young TS reroute TA thru navicular

Frontal correction1) Calc Osteotomies:Dwyer closing wedge osteotomyKouts slide fragment medial (increases supination)2) Arthroeresis (MTJ must have locking ability on RF)MBA self-locking blocks anterior migration of talusRF valgus or FF varus must be reducible in order to doLeading edge should approach but NOT cross bisection of talus on AP viewShould allow 2-4 of STJ eversionSTA-Peg (non-ang) axis-altering elevates STJ Sgarlato direct-impact impingement force laterally3) Historical Chambers- bone graft in sinus tarsiSelakovic- bone graft under sustentaculumBaker & Hill- bone graft under posterior STJ facet

Pes Planus (Flexible vs. Rigid)12/16/13 2:29 PM

-EtiologyStable Static vs. ProgressiveStable conditions treatable w/ ST procedureRigid vs. FlexibleRigid conditions requires osteotomies & arthrodesisBilateral:*CMT, CP, SC tumor, Spina bifida, Polio, infectionCharcot Marie Tooth (autosomal dominant) Bilateral slowing of sensory & motor nerve conductionHSMN I classic CMT usually in 2nd decade (hypertrophic)HSMN II manifests later in life (axonal)Unilateral:Crush syndrome, SC injury, Deep post compart syndrome

-Clinical exam Charcot Marie Tooth Claw toes- over recruitment of long extensorsCavus- PL overpowers TA causing PF 1st rayFoot drop- stork legs due to muscle wastingColeman Block Test (sagittal plane deformity evaluation)Forefoot (1st ray) is suspended off a blockFF driven calcaneus returns from varus back to normal RF driven calcaneus stays in varus after removing forefoot elements Anterior cavus (apex found at intersection of Mearys angle)Caused by: forefoot PLANTARFLEXED On rearfootLocal (1st ray) vs. Global (entire FF)Flexible (DF at Midfoot) vs. Rigid (pseudoequinus)Metatarsus apex at lisfrancForefoot apex at chopartsPosterior cavus (increased CI angle > 30 & varus position)Caused by: rearfoot DORSIFLEXED on forefootFlexible (no change in CI on WB) vs. Rigid (Decreased CI on WB)Secondary to anterior cavusNeurological evaluationAsses motor, sensory systems, reflexes and coordination tests.Biomechanical evaluation ROM (AJ, STJ, MTJ)Wide based gait = neurologicExtensor substitution HT (exentsors > lumbricales)Pseduoequinus- ankle must dorsiflex cuz forefoot cantEMG & Nerve conduction testing

-ClassificationsRuch/Surgical-Stage 1 (flexible may appear normal on WB)Deformity restricted to Metatarsal, MPJ or DigitsTx: digital fusion, extensor tenotomy, flexor transfers-Stage 2 (more rigid deformity)Deformity consists of rigid PF 1st ray & RF varusTx: DFWO, Dwyer, STATT, Peroneal stop-Stage 3 (marked rigid deformity)Severe global RF & FF deformity on neuromuscular causeTx: MTJ osteotomies, Triple arthrodesis, tendon transferJapasAnterior cavus (apex found at intersection of Mearys angle)Caused by: forefoot PLANTARFLEXED On rearfootLocal (1st ray) vs. Global (entire FF)Flexible (DF at Midfoot) vs. Rigid (pseudoequinus)1) Metatarsus apex at lisfranc2) Lesser tarsus entire lesser tarsal region3) Forefoot apex at choparts4) Combined 2 or more of the abovePosterior cavus (increased CI angle > 30 & varus position)Caused by: rearfoot DORSIFLEXED on forefootFlexible (no change in CI on WB) vs. Rigid (Decreased CI on WB)Secondary to anterior cavus

-Radiology AP view (transverse plane)TN articulation (75%) INCREASEDTC Kites (20) DECREASEDCuboid Abduction (0-5) DECREASEDLateral view (sagittal plane)CI (20) INCREASEDTD (20) DECREASEDLTC (40) DECREASEDCyma line POSTERIOR BREAKMearys (0-15) POSITIVE increase

-Operative treatmentGoals must identify apex of deformity/rigid vs. flexibleSoft Tissue ReleaseSteindler stripping removes all plantar fascia at insertionPF, Abd hallucis, Abd dmq, FDB, Quad plantaePlantar medial release release all muscle/ligaments medialHistorical Borst & Larsen- release mc joints & plantar intrinsicsGarceau & Brahms- resect motor branches Tendon Transfers (flexible deformities)Jones EHL thru 1st met head dorsiflexes halluxHeyman EHL & EDL thru each respected met headHibbs EDL transferred to 3rd cuneiformGirdlestone FDL transferred to dorsal prox phalanxSTATT lateral half transferred to p. tertius insertionTPTT difficult out of phase transferPeroneal anastomosis transfer PL to PB Stop procedureOsseous procedures (rigid & neuromuscular)Cole dfwo at NC coparts jointJapas displacement V osteotomy thru all midfoot jointsJahss Cole at lisfranc jointDFMO dorsiflexes forefoot Dwyer lateral closing wedge take out of varusArthrodesisTriple (Ryerson- 1920)Resect (TN CC TC) ** fix in opposite order Position:Dorsiflexion- 0RF valgus- 5Abduction- 5Ext rotation- 15IncisionsLateral (fib malleolous to 4th met base)Exposes TC & CCReflect EDB, protect peroneal, incise plugInverted L capsular incision Dissect until visualization of STJ facetsDorso-Medial (distal med malleolus to NCJ)Exposes TNIncision carried longitundal to PT & TAFixationTC aimed posterior-lateral from talar neck (6.5 partial cancellous)TN screw < 40mm (4.5 cortical) or stapleCC screw < 40mm (4.5 cortical) or staplePost-opAdmit for pain control NWB 8 weeksProgressive PT after 10-12 weeks