Chapter 8

Foot and Ankle

Joseph S. Park, Venkat Perumal

Foot and Ankle

General Guidelines

Preoperative antibiotics are given half an hour before the incision is made

Placing a bump beneath the appropriate hip can facilitate access to the desired part of the foot/ankle, which is especially important when considering the sequence of multiple procedures: a bump beneath the ipsilateral hip allows access to the lateral calcaneus for medial displacement osteotomy and then is removed to allow external rotation and access to the posterior tibial tendon/medial ankle

A tourniquet is applied according to the surgeon’s preference

Careful dissection/cautery to maintain hemostasis may obviate the need for a tourniquet and prolonged ischemia; however, the need for clear visualization of neurovascular structures and during arthroscopy is critical, and a tourniquet should be used as necessary

An Esmarch bandage or pneumatic tourniquet may be used

All bony prominences should be adequately padded

Review the pertinent anatomy and mark the palpable landmarks

Regional Anatomy

Osteology

Arthrology

Ankle Joint (Figs. 8-5 to 8-7)

The ankle joint is a strong and stable joint

The ankle joint is a synovial hinge joint

A capsule encloses the joint and is attached to the bony articular margins

Ligaments

• Medial/deltoid ligament

• Lateral ligaments

• Anterior talofibular ligament

• Calcaneofibular ligament

• Posterior talofibular ligament

Nerve supply

• Deep peroneal and tibial nerve

Movements

• Dorsiflexion

• Plantar flexion

FIGURE 8-5 Ligaments of the hind foot—lateral view.

FIGURE 8-6 Ligaments of the hind foot—medial view.

FIGURE 8-7 A, Inferior view of the talus showing the interosseous ligament. B, Dorsal view of the hind foot (after removal of the talus) showing the calcaneal facets with the spring ligaments.

Subtalar Joint (see Figs. 8-5 to 8-7)

The subtalar joint is a plane synovial joint

A capsule attaches to articular margins of the talus and calcaneus

Ligaments

• Medial and lateral talocalcaneal ligaments

• Interosseous talocalcaneal ligament (the main support)

Movements

• Inversion

• Eversion

Talocalcaneonavicular Joint (see Figs. 8-5 to 8-7)

The talocalcaneonavicular joint is a synovial joint

A capsule incompletely encloses the joint

Ligaments

• Plantar calcaneonavicular ligament

Movements

• Gliding and rotatory movements

• Limited inversion and eversion

Calcaneocuboid (CC) Joint (Fig. 8-8)

The CC joint is a plane synovial joint

A capsule encloses the joint

Ligaments

• Bifurcated “Y” ligaments

• Long plantar ligament

• Short plantar ligament

Movements

• Limited inversion and eversion

FIGURE 8-8 Dorsal view of the ankle and foot.

Naviculocuneiform (see Fig. 8-8)

A synovial joint of gliding variety between the navicular and three cuneiforms

The capsule is reinforced by dorsal and plantar ligaments

The joint cavity is continuous with the intercuneiform, cuneocuboid, cuneometatarsal, and intermetatarsal joints

Naviculocuboid (see Fig. 8-8)

A fibrous joint

The dorsal, plantar, and interosseous ligaments reinforce joint stability

Intercuneiform and Cuneocuboid (see Fig. 8-8)

Plane synovial joints

Stabilized by the dorsal, plantar, and interosseous ligaments

The joint cavity communicates with the cavity of the cuneonavicular joint

The cuneocuboid joint is syndesmosis

Tarsometatarsal (Lisfranc Joint) and Intermetatarsal Joints (see Fig. 8-8)

Plane synovial joints

The tarsometatarsal joint of the great toe has a separate joint cavity

Stabilized by the dorsal, plantar, and interosseous ligaments

Movements

• Plantar flexion–dorsiflexion—first cuneometatarsal, fourth and fifth

• Rotation

Metatarsophalangeal (MTP) and Interphalangeal Joints (see Fig. 8-8)

MTP joints are condyloid joints

Stabilized by plantar plates and oblique collateral ligaments

Deep transverse ligaments connect all five MTP joints

The second toe is long axis, and adduction-abduction is performed by interossei

Interphalangeal joints are hinge joints

• Interphalangeal joints are stabilized by collateral ligaments and the capsular plantar ligament (fibrous plate)

• Interphalangeal joints only provide plantar flexion movement

Arches of the Foot

Maintained by the shape of bones, strong ligaments, tendons, and muscle tone

• Lateral longitudinal (Fig. 8-9)

• Lateral half of the calcaneus, cuboid, and fourth and fifth metatarsal bones

FIGURE 8-9 The lateral bony plantar arch.

• Medial longitudinal (Fig. 8-10)

• Medial half of the calcaneus, the talus, the navicular, the three cuneiforms, and the first three metatarsals

FIGURE 8-10 The medial bony plantar arch.

• Transverse arch (Fig. 8-11)

• Bases of the metatarsal bones, cuboid, and three cuneiforms

Muscles

Extrinsic Muscles

Muscles are in the leg, but their tendons function within the foot

• Anterior compartment (innervated by the deep peroneal/anterior tibial nerve; Fig. 8-12)

• From medial to lateral: tibialis anterior (TA), extensor hallucis longus (EHL), extensor digitorum longus (EDL), and peroneus tertius

FIGURE 8-12 Muscles of the anterior compartment of the leg and dorsum of the foot.

• Lateral compartment (innervated by the superficial peroneal nerve; Fig. 8-13)

• Peroneus longus and brevis muscle

• Tendons descend together in a common tendon sheath underneath the superior peroneal retinaculum

FIGURE 8-13 The lateral/peroneal compartment of the leg.

• Posterior compartment (innervated by the posterior tibial nerve; Figs. 8-14 to 8-16)

• Superficial layer

• Triceps surae

• Deep layer

• Flexor digitorum longus (FDL)

• Tibialis posterior

• Flexor hallucis longus ( FHL)

FIGURE 8-14 The posterior compartment of the leg (gastrocnemius).

FIGURE 8-15 The posterior compartment of the leg (soleus).

FIGURE 8-16 The posterior compartment of the leg (deep layers).

• Assisted by the peroneals, FHL, and FDL

• Dorsiflexors

• TA

• Assisted by the EHL, EDL, and peroneus tertius

• Eversion

• Peroneus longus, brevis, and tertius

• Inversion

• TA and tibialis posterior

Intrinsic Muscles

Muscles that originate, insert, and function in the foot

• EDB

• Originates from the lateral aspect of the os calcis and the floor of the tarsal sinus and inserts into the lateral aspect of the extensor hood of the medial four toes; innervated by the deep peroneal nerve

Plantar intrinsic muscles lie in four layers

• First layer (Fig. 8-17)

• Abductor hallucis

• Flexor digitorum brevis

• Abductor digiti minimi

FIGURE 8-17 Muscles of the sole of the foot—first layer.

• Second layer (Fig. 8-18)

• Third layer (Fig. 8-19)

• Short intrinsic to great and small toes

• Flexor hallucis brevis

• Adductor hallucis

• Flexor digiti minimi brevis

FIGURE 8-19 Muscles of the sole of the foot—third layer.

• Fourth layer (Fig. 8-20)

• Interossei

• Insertion of the peroneus longus, tibialis anterior, and tibialis posterior

FIGURE 8-20 Muscles of the sole of the foot—fourth layer.

Nerves (Figs. 8-21 and 8-22)

Most innervations are of sciatic origin (except for the saphenous nerve)

The sciatic nerve separates near the apex of the popliteal fossa to the medial popliteal (tibial nerve) and the lateral popliteal (common peroneal nerve)

FIGURE 8-21 Cutaneous innervation of the leg and foot.

FIGURE 8-22 Deep innervation of the leg and sole.

Tibial Nerve

Medial sural cutaneous nerve

Medial plantar nerve

Lateral plantar nerve

Common Peroneal Nerve

Lateral sural cutaneous nerve

Superficial peroneal nerve

Medial branch of dorsal cutaneous nerve

Intermediate branch of dorsal cutaneous nerve

Deep peroneal (anterior tibial) nerve

• Dorsal digital nerves—adjacent sides of the first and second toes

Saphenous Nerve

The largest cutaneous branch of the femoral nerve

Follows the saphenous vein, supplying the medial side of the leg, the skin of the ankle, and further down along the medial side of the foot up to the base of the great toe

Sural Nerve

Formed by the union of the medial sural cutaneous nerve to the peroneal communicating branch of the lateral sural cutaneous nerve

Supplies the lower lateral side of the leg and the calcaneal branches to the heel; continues as the lateral dorsal cutaneous nerve, supplying the lateral side of the foot and little toe

Vascularity (Figs. 8-23 and 8-24)

The popliteal artery divides at the lower border of the popliteus muscle into the anterior and posterior tibial artery

FIGURE 8-23 The arterial system of the anterior leg and dorsum of the foot.

FIGURE 8-24 The arterial system of the posterior leg and sole of the foot.

Anterior Tibial Artery

Medial and lateral malleolar arteries

Dorsalis pedis artery

• Lateral tarsal artery

• Medial tarsal artery

• Arcuate artery—forms an arch at the base of the metatarsals

• First dorsal metatarsal artery

• Deep plantar artery

Posterior Tibial Artery

The peroneal artery arises 2 to 3 cm below the popliteus muscle

• Calcaneal

• Posterior lateral malleolar branches

• Perforating branch—to the artery of the tarsal sinus

Medial calcaneal branches

Medial plantar artery

The lateral plantar artery unites with the deep plantar branch of the dorsalis pedis to form the plantar arch

Blood Supply of the Talus (Figs. 8-25 and 8-26)

Neck of the talus

• Superior surface of the neck

• Medial talar arteries—medial recurrent tarsal artery (branch of the anterior tibial artery)

• Inferior surface of the neck

• Artery of the tarsal canal (branch of the posterior tibial artery)

• Medial surface of the body

• Deltoid branch (posterior tibial artery)

• Posterior tubercle

• Direct branch from the posterior tibial artery—infrequently from the peroneals

• Lateral surface

• Artery of the tarsal sinus

Head of the talus

• Superior neck vessels and branches of the tarsal sinus artery

Talar body

The tarsal canal artery supplies the middle half to two thirds of the body; internal anastomosis supplies the remainder

The deltoid branches combined with the branches of the sinus tarsi artery provide a significant source of vascularity

FIGURE 8-25 The arterial supply of the talus (distribution of blood supply).

FIGURE 8-26 The arterial supply of the talus (main source of blood supply).

Cross-Sectional Anatomy

Foot and Ankle

Lower tibia (Fig. 8-27)

FIGURE 8-27 Cross-sectional anatomy—lower third of the leg.

Ankle (Fig. 8-28)

FIGURE 8-28 Cross-sectional anatomy—ankle joint.

Foot (hind and mid parts; see Figs. 8-29 and 8-30)

FIGURE 8-29 Cross-sectional anatomy—hind foot.

FIGURE 8-30 Cross-sectional anatomy—mid foot.

Common Hazards (Figs. 8-31 to 8-33)

Medial neurovascular bundle

Anterior neurovascular bundle

Sural nerve

Dorsalis pedis artery

Surface Landmarks

Superficial bony landmarks (Figs. 8-34 and 8-35)

FIGURE 8-34 Superficial bony landmarks—dorsal view.

FIGURE 8-35 Superficial bony landmarks—posterior view.

Surgical Approaches to the Ankle

Anterior Approach to the Ankle (Video 8-1)

Indications

Ankle arthrotomy, fracture fixation, total ankle arthroplasty, and open treatment of osteochondral defects

Position (Fig. 8-36)

Supine

Place a bump under the ipsilateral hip to maintain neutral rotation of the leg

Use a calf or thigh tourniquet (depending on the procedure)

Partial exsanguination can allow better visualization of the neurovascular bundle

FIGURE 8-36 Positioning of the patient for surgery on dorsum of the foot.

Incision

Make a 15-cm incision over the anterior ankle

• Begin 10 cm proximal to the joint, lateral to the palpable TA tendon (Fig. 8-37)

FIGURE 8-37 Skin marking. A 10- to 15-cm longitudinal incision crossing the joint midway between the medial and lateral malleoli, ending on the dorsum of the foot.

• Cross the joint midway between the malleoli

• Dissect carefully in the distal aspect of the incision to avoid injury to the superficial peroneal nerve branches

• For total ankle arthroplasty, the interval between the TA and EHL is typically used; the interval between the EHL and EDL allows for direct visualization of the bundle and medial retraction of the neurovascular structures

Superficial Dissection (TA/EHL Interval)

Incise the deep fascia of the leg in line with the skin incision (Fig. 8-38)

• Incise the extensor retinaculum over the EHL, maintaining the sheath for the TA

• Retract the EHL laterally and incise the posterior aspect of the EHL sheath to visualize the ankle capsule (Fig. 8-39)

• The anterior tibial artery and deep peroneal nerve should be identified and protected lateral to this interval

FIGURE 8-38 Identify and protect the superficial peroneal nerve.

FIGURE 8-39 Cut the extensor retinaculum medial to the tibialis anterior tendon (desirable for exposure of the proximal tibia) or identify the plane between the extensor hallucis longus (EHL) tendon (medial) and the extensor digitorum longus tendon (lateral), the neurovascular bundle (deep peroneal nerve and anterior tibial artery) between them. Start a few centimeters above the ankle and dissect the bundle carefully distally as the EHL tendon crosses medially (this approach is desirable for distal extension to the dorsum of the foot).

Superficial Dissection (Alternative—EHL/EDL Interval)

Incise the deep fascia of the leg in line with the skin incision

Incise the extensor retinaculum

Find the plane between the EHL and EDL a few centimeters above the joint (Fig. 8-40)

FIGURE 8-40 The intramuscular plane between the tibialis anterior and extensor hallucis longus. n., Nerve.

Identify and mobilize the anterior tibial artery and deep peroneal nerve

Retract the EHL and neurovascular bundle medially and the EDL laterally

This approach allows for distal extension to approach the dorsal mid foot (Fig. 8-41)

FIGURE 8-41 Retract the extensor hallucis longus tendon.

Deep Dissection

Incise the capsule of the ankle joint in line with the incision (Fig. 8-42)

FIGURE 8-42 Incise the capsule of the ankle joint in line with the incision.

Expose the full width of the ankle joint by subperiosteal and subcapsular dissection of the tibia and talus (Fig. 8-43)

FIGURE 8-43 Retraction of the tendons exposes the overlying fat above the ankle joint capsule. Incise the capsule longitudinally to expose the width of the ankle joint.

Retractors should be placed on the periosteal layer to avoid excessive pressure on the skin or neurovascular bundle

Closure

Attempt to close the ankle capsule prior to layered closure; the extensor retinaculum should also be reapproximated to prevent bow-stringing of tendons

Anteromedial Approach to the Ankle (Video 8-2)

Indications

Ankle Arthrodesis

Pilon fractures fixation

Position

Supine

Incision

The incision should be centered over the anterior ankle just medial to the TA tendon

• Skin and subcutaneous tissue are incised

Hazards

Branches of the saphenous nerve and great saphenous vein

Superficial Dissection

The deep fascia medial to the tibialis anterior is incised and the retinaculum is exposed (Fig. 8-44)

• The retinaculum is incised medial to the TA

FIGURE 8-44 The deep fascia medial to the tibialis anterior is incised and the retinaculum is exposed.

The TA tendon is retracted laterally along with the EHL and the deep peroneal nerve/anterior tibial artery

Deep Dissection

The anteromedial ankle joint capsule is exposed along with the distal aspect of the tibia

• Ankle arthrotomy is performed to visualize the articular surfaces of the tibial plafond and talar dome

Anterolateral Approach to the Ankle

Indications

Ankle arthrodesis, open reduction and internal fixation (ORIF) of a pilon fracture, and debridement of syndesmosis

Position

Supine with a sandbag underneath the ipsilateral bump

Incision

A 12- to 15-cm incision is made along the anterolateral aspect of the ankle, slightly anterior to the anterior border of the fibula; curve the incision inferiorly, crossing the ankle joint 2 cm medial to the tip of the lateral malleolus (Fig. 8-45)

Superficial Dissection

Incise the fascia in line with the skin incision (Fig. 8-46)

Hazard

Carefully dissect and protect the medial branch of dorsal cutaneous nerve (superficial peroneal nerve) as it crosses the field

Deep Dissection (Figs. 8-47 and 8-48)

Divide the superior and inferior extensor retinaculum (Fig. 8-49)

• Identify the peroneus tertius and EDL and approach the tibia just lateral to these tendons

• Medial retraction of the extensor muscle group exposes the anterior aspect of the distal tibia and the anterior ankle joint capsule

Proximal extension

• Proximal extension can be performed to explore the anterior compartment

Distal extension

• Distal extension can be used to expose the sinus tarsi, CC joint, and tarsometatarsal (TMT) joint on the lateral half of the foot

FIGURE 8-47 Deep dissection to expose the ankle joint and dome of the talus.

FIGURE 8-48 Deep dissection to expose the ankle joint and dome of the talus.

FIGURE 8-49 Divide the extensor retinaculum and identify the plane lateral to the extensor digitorum longus and the peroneus tertius.

Hazard

The medial branch of dorsal cutaneous nerve (superficial peroneal nerve)

Closure

Extensor muscles fall back into place

• Reapproximate the extensor retinaculum to prevent bow-stringing

Standard two-layer closure of skin

Direct Posterior Approach to the Achilles Tendon

Indications

Achilles tendon rupture

Chronic Achilles tendinopathy and FHL transfer

Haglund resection

Position (Fig. 8-50)

Prone position

Surgical Exposure (Figs. 8-51 and 8-52)

For acute Achilles tendon ruptures

• A longitudinal incision is made 1 cm medial to the Achilles tendon to improve soft tissue coverage over the tendon after repair (Fig. 8-51); the deep fascia over the Achilles tendon is incised medial to the tendon
In an alternative approach an incision is made just lateral to the Achilles tendon (Fig. 8-52)

In patients with chronic tendinopathy, a midline posterior incision over the tendon is typically used to allow access to the calcaneus (Fig. 8-53)

• The paratenon is incised in the midline so that the paratenon can be closed after the reconstruction

FIGURE 8-51 A and B, Surgical approach for acute Achilles tendon ruptures.

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Jun 7, 2016 | Posted by admin in ORTHOPEDIC | Comments Off

Fastest Musculoskeletal Insight Engine

Foot and Ankle

General Guidelines

Regional Anatomy

Talus (Fig. 8-1)

Calcaneus (Fig. 8-2)

Cuboid (Fig. 8-3)

Navicular (see Fig. 8-3)

Cuneiforms (see Fig. 8-3)

Metatarsals (Fig. 8-4)

Phalanges (see Fig. 8-4)

Sesamoids

Arthrology

Ankle Joint (Figs. 8-5 to 8-7)

Subtalar Joint (see Figs. 8-5 to 8-7)

Talocalcaneonavicular Joint (see Figs. 8-5 to 8-7)

Calcaneocuboid (CC) Joint (Fig. 8-8)

Naviculocuneiform (see Fig. 8-8)

Naviculocuboid (see Fig. 8-8)

Intercuneiform and Cuneocuboid (see Fig. 8-8)

Tarsometatarsal (Lisfranc Joint) and Intermetatarsal Joints (see Fig. 8-8)

Metatarsophalangeal (MTP) and Interphalangeal Joints (see Fig. 8-8)

Arches of the Foot

Muscles

Intrinsic Muscles

Nerves (Figs. 8-21 and 8-22)

Tibial Nerve

Common Peroneal Nerve

Saphenous Nerve

Sural Nerve

Vascularity (Figs. 8-23 and 8-24)

Anterior Tibial Artery

Posterior Tibial Artery

Blood Supply of the Talus (Figs. 8-25 and 8-26)

Cross-Sectional Anatomy

Common Hazards (Figs. 8-31 to 8-33)

Surface Landmarks

Anterior Approach to the Ankle (Video 8-1)

Position (Fig. 8-36)

Incision

Superficial Dissection (TA/EHL Interval)

Superficial Dissection (Alternative—EHL/EDL Interval)

Deep Dissection

Closure

Anteromedial Approach to the Ankle (Video 8-2)

Position

Incision

Hazards

Superficial Dissection

Deep Dissection

Anterolateral Approach to the Ankle

Position

Incision

Superficial Dissection

Hazard

Deep Dissection (Figs. 8-47 and 8-48)

Hazard

Closure

Direct Posterior Approach to the Achilles Tendon

Position (Fig. 8-50)

Surgical Exposure (Figs. 8-51 and 8-52)

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