Penn Presby Forefoot Surgery

-arises from lateral tibia condyle and the anterior fibula
-splits into 4 tendons after passing under the extensor retinaculum
-EDB joins on the lateral side to 1,2,3
-divides into 3 slips at the proximal phalanx
-middle slip inserts base of middle phalanx
-medial and lateral insert base of distal phalanx

-the most proximal portion of the apparatus
-wraps around the capsule of the MPJ
-inserts at the jxn of the plantar plate, DTIL and flexor tendon sheath
-**so the EDL is held to the plantar aspect of prox phalanx

-provides insertion for the lumbricals
-lumbrical muscle passes plantar to the DTIL to insert into the extensor hood

-originates in the Deep posterior
-divides into 4 slips in the 2nd layer of foot
-inserts into distal phalanx
-4 lumbricals originate from 4 tendons medially
-the QP inserts into its lateral portion

-originates from the plantar calcaneus in 1st layer
-splits at the level of the proximal phalanx to let FDL pass through
-inserts into base of proximal phalanx
-fxns to PF the IPJ, this causes retrograde DF at the MPJ

-bipennate muscles
-1st DI originates from adjacent 1st and 2nd met shafts an inserts medially into base of 2nd proximal phalanx
-the remaining DI orginate from adjacent sides of corresponding lesser mets and insert laterally into the bases of proximal phalnx 2,3,4

-unipennate muscles
-originate from medial aspect of met shafts
-inserts medially into 3,4,5 base of proximal phalanx

-originates from the lateral aspect of the 5th met
-inserts laterally into the base of the proximal phalanx of 5th digit

-originates from inferior surface of calcaneus
-inserts into the lateral aspect of the FDL tendon
-provides stability to lumbricals and FDL
-straightens out the medial proximal pull of the FDL

-the QP looses it mechanical advantage
-QP straightens out the medial proximal pull of the FDL

-four in number originate from medial aspect of FDL tendon
-travel plantar to transverve met ligament
-insert medially into extensor hood (wing)

-Sodium hydroxide
-phenol

-winograd
-frost

-whitney
-terminal syme
-zadik

-only a portion of the nail root is removed (nail matrix)
-so only part of the eponychium is usually incised

-biomechanical malfunction
-long 2nd toe
-shoes may play a role

-gun barrel sign of the middle phalanx on AP radiograph
-looks like a hollowed circle

-flexor stabilzation

-flexors overpower the interossei

-pronated foot (this causes hypermobility of the forefoot, so the flexors fire early to stabilize the hypermobile forefoot and this causes overpowering of the interosseus muscles)
-can also occur in weak interosei secondary to neuropathy

-supinated foot
-usually the triceps are weak, so the deep muscles of the legs try to substitute (TA,FDL,FHL) fire earlier and longer causing contracture of lesser digits

-flexor substitution (TA, FHL, FDL substitute for a weak triceps)

flexor substitution HT

-EDL overpowers the lumbricals
-seen in ankle equinus
-also seen in peripheral neuropathy and NM dz that weaken the lumbricals

-EDL overpowers the lumbricals
-in anterior pes cavus, the passive pull on the EDL causes DF at MPJ and passive contracture at DIPJ by flexor

-HEECAT
-head resection of prox phalanx
-extensor hood resection
-extensor tendon lengthening
-dorsal capsulotomy
-plantar capsule release
-arthrodesis of PIPJ
-flexor tendon

-flexor tendon release
-dipj fusion

-non reducible contracture of IPJ

-end to end fusion with K wire
-peg in hole fusion w/ K wire
-spike in hole

-0.045 if not crossing the MPJ
-0.062 if crossing the MPJ
-leave in for 4-6 wks

-skin plasty to lengthen dorsal medial skin
-tendon transfer or lengthening
-capsulotomy
-syndactyly of 4th to 5th
-amputation
-combo of procedures

-acute pain plantarly MPJ (2nd is MC)
-grape size lump beneath the MPJ (bursal sac)
-sharp pain, bruise, throbbing
-hx of inc activity, trauma, steroid injecton

-long 2nd met
-hypertrophic cortex of involved met
-altered MPJ congruity
-positive drawer sign

-hallux valgus
-elongated 2nd met
-hypermobility of 1st ray
-basically anything that can cause plantar plate attentuation(plantar plate is the most stabilizing structure of the MPJ)

-stabilize the met and move the prox phalanx in the sagital plane
-greater then 50% of dorsal dislocation in the vertical height of the met head is positive for plantar plate attenuation or rupture

-met stress fx
-freibergs infraction
-DJD
-synovial cyst
-neuroma

-metatarsal splint pad (holds 2nd digit down)
-cross over tape method (piece of tape horshoed over the base of the digit and criss crossed plantarly)
-NSAIDS

-FDL tendon is split and brought up dorsally to the proximal phalanx
-often combined with plantar plate repair
-EDL tendon can also be lengthened
-Weil osteotomy can be used if the met is long (long horizontal cut that displaces the head proximally w/o head lowering)

-premature closure of the epiphyseal plate
-can be congenital, iatrogenic or traumatic

-more common in the 4th met
-more common in females

1. osteotomy; through and through cut
2. corticotomy; cut cortex only

-latency between placement and distraction is from 5days to 2 weeks

-1 mm/day (according to Ilizarov)
-can use it for brachymetatarsia

-when radiographic evidence of osseous union is present

-no need for bone graft
-no NV compromise bc all structures are gradually lengthened
-gain more length
-can gradually lengthen soft tissue structures

-address 1st met deformity(HAV, hypermobility, sagittal plane position)
-or arthrodesis or plasty of 2nd digit to remove retrograde force

-address 5th met deformity (tailors bunion, adducted 5th)
-or arthrodesis or plasty of 4th digit t remove retrograde force

-usually due to long third met or iatrogenic transfer lesion

-abnormal STJ pronation
-uncompensated FF or RF varus with a pronating foot
-congential PF or DF 5th ray
-lack of transverse head od adductor hallucis into 5th MPJ

-prominent 5th met head

-increased IM angle between 4th and 5th (>8)
-lateral bowing of 5th met

-reverse Hohman(head displacced)
-reverse Wilson(head displaced)
-reverse austin (head displaced)
-reverse offset V
5th met head resection
joint arthroplasty
-NOTE: use base procedure it IM angle is increased

-resect the lateral surface of the 5th met head

-removal of the mets

-saves the talus and calcaneus

-ankle disarticulation, but retains part of the calcaneus
-removal of the malleoli and anterior calcaneus, then fuse the end of the tibia and fibular to the posterior portion of the calcaneus

-ankle dislocation and removal of malleoli

-through a portion of the mets

-removal of all or part of a toe with a flap used for closure

-3rd interspace

Joplins neuroma (medial dorsal cutaneous)

1.Heuter
2. Hauser
3. Mortons
4. Islins

-Sullivans sign (splaying of digits)
-Mulders click

1. 3cm incision between met heads
2. transect the DTIL
3. excise the webspace
-you can also enter plantarly

-medial sagittal hood
-lateral sagittal hood
-medial sesamoid
-lateral sesamoid
-medial collateral
-lateral collateral
-plantar fascia (slips insert into lateral sesamoid)
-transverse intermetatarsal ligament (superior and inferior slips)