Common Foot and Ankle Tendon Transfers

Tendon transfers in the foot and ankle is complicated. The joints must be flexible and the muscle strength should be Grade IV or more for a tendon transfer to achieve its effect. Here is the mnemonic to remember the structures at the medial side of the ankle (Tom, Dick, and Harry): This mnemonic (Tom, Dick, and Harry) contains the muscles that are the horsepower for the tendon transfer in the foot and the ankle. The T, D, a, n, and H of Tom, Dick and Harry correspond to Tibialis posterior, flexor Digitorum longus, posterior tibial artery, tibial nerve and flexor Hallucis longus. These three muscles, the flexor Hallucis longus, the flexor Digitorum longus, and the tibialis posterior are very important tendons that can be used for tendon transfers. The flexor halluces longus transfer can be used if there is a large chronic defect that results from Achilles tendon tear, and if the gap of the tear is 5 cm or more, then you transfer the flexor halluces longus tendon. The flexor hallucis longus is next to the Achilles tendon, you can transfer this tendon. The same concept may be done with the tibialis posterior tendon tear (stage II), which means that is flexible and it may be treated with a tendon transfer by the tendon that is next to the tibialis posterior, the flexor digitorum longus tendon. You must add a bony realignment procedure such as medial calcaneal displacement osteotomy. Lateral column lengthening is also done if there is excessive forefoot abduction (too many toes), more than 40% talonavicular uncoverage. When there is chronic tear of both peroneal tendons, you will transfer the flexor hallucis longus when both tendons are involved and this can be treated by tenodesis to the healthy tendon if only on tendon is involved. You will use the girdle stone procedure, which is flexor to extensor of the lesser toes for flexible hammer toe and claw toes. In Charcot-Marie-Tooth disease, the patient will have varus of the hindfoot, cavus, and plantar flexion of the first metatarsal. When the deformity of the foot is flexible, you will do a soft tissue procedure. You will transfer the peroneus longus tendon to the peroneus brevis tendon and this will eliminate the strong plantar flexion of the first ray and this improves the eversion power of the peroneus brevis muscle.  Transfer of the tibialis posterior to the dorsum of the foot through the interosseous membrane will decrease the varus movement and it will assist in ankle dorsiflexion.  Equinovaurs foot is the most common deficit following a stroke or traumatic brain injury, this occurs due to over activity of the tibialis anterior muscle. This condition can be treated with split tibialis anterior tendon transfer (SPLATT) combined with Achilles tendon lengthening or gastrocnemius recession. The deformity has to be flexible.  Peroneal nerve palsy or foot drop: posterior tibial tendon transfer through the interosseous membrane to the dorsum of the foot. The chopart amputation is a partial foot amputation through the calcaneal cuboid and talonavicular joints, transferring the tibialis and lengthening of the Achilles tendon to avoid equinus deformity of the hindfoot. Dynamic supination deformity in the swing phase can occur following Ponseti casting for a club foot. This occurs due to the overpull of the tibialis anterior. This is treated with a tibialis anterior tendon transfer to the lateral cuneiform.

Opioid Epidemic

Physicians face increased pressure to decrease the patient’s pain. Patients may have pain due to injury, from surgery, or from other conditions that cause pain. Pain is a common thing for most individuals.  One of the medications that doctors use to decrease the pain, especially if the pain is severe, is opioids. The use of opioids has increased significantly die to multiple factors. Opioid is a general term that represents opiates, for example morphine, which is derived directly from opium. The opioid can be semi-synthetic opiates such as oxycodone, which is derived from the extract of the opium poppy, and ti can be synthetic opiates such as Fentanyl.  Many people die or get hurt annually from the abuse of prescription opioids. The most powerful types of opiates include codeine, morphine, heroin, and fentanyl. Thousands of people visit the ER due to misuse of prescription pain medication. 75% of these people are using prescription drugs that were prescribed to somebody else. Opiate abuse is an epidemic in the United States. Prescription opiate misuse may lead to abuse and addiction to heroin and Fentanyl. There are some studies about pain and the effect of opioids. Some of these studies are sponsored by the pharmaceutical manufacturers, but most of these studies are short term studies that did not have a long term follow up. As a result, a 1% risk of opioid addiction is often cited. Studies have demonstrated that the risk of addiction to prescription opioids is 3% to 45% when used on a long term basis. In fact, when opioid use occurs beyond 12 weeks, 50% of the patients will still be taking the opiated beyond 5 years. The new laws limit the amount of opiate pills that can be dispensed from a single provider. In fact, it limits the time of dispensing and the number of pills to a single patient. Some studies showed that patient that are taking preoperative opioids are associated with increased length of hospital stay, increased morbidity, and a worse outcome. When you give opioids to the patient for a longer time post-operatively, this will impact the surgeon and the hospital when it comes to the patient reported outcomes, and it can also affect patient satisfaction. Pain it’s the cognitive, emotional, and behavioral response. Pain intensity varies from person to person which is related to stress, distress, coping abilities, and psychological factors. In general, the physician should work with the patient for better pain relief and for safer prescribing of medications. The best pain relief is self-efficacy and resilience.  Encourage the patient to recover and adapt during stressful situations. Depression and catastrophic thinking increases pain intensity. Encourage the patient to get back to a normal routine as quickly as possible. People who have resilience have a lower level of pain and set goals for recovery which enhances their functional ability. Opiate sparing strategies may prevent long term use of prescription opioids. Three categories of types of strategies are Physical, mental/cognitive and, medication.  Physical strategies include massage, TENS unit, acupuncture, ice, and heat. Mental/cognitive coping strategies include teddy bear therapy, meditation, yoga, biofeedback, cognitive-behavioral therapy, and music therapy. Medication strategies do not have to include opiate. This strategy can include a field or nerve block, NSAIDS, or gabapentin. We can utilize a combination of all of these three strategies. A combination of these strategies will definitely help to relieve the patient’s pain and anxiety, giving the patient confidence in the system.  A study on opioids following outpatient upper extremity surgery found that 77% of patients took 15 or fewer pills. Almost half of patients took 5 or fewer pills and the majority of patients used opiates for less than 2 days. A patient in the Netherlands leaves the hospital after an operation to fix the ankle with Tylenol, and these patients are satisfied with their pain medication. With the laws regulating pain medications, the doctor should have empathetic communication with the patient and explain why they cannot give more pain medications. Discuss with the patient about opiates and promote alternative pain management strategies. Get help from other people such as the nurses, physiotherapists, and occupational therapists. Discuss post-surgical pain management with the patient, and when the patient has a history of substance abuse, try to help them.Guide your patient to the best team that can help the patient. Send them to pain management. Get some help for your patient. Excessive post-surgical prescription of opiates is commonly reported as a contributing facture to diversion and abuse. It is better to use immediate-release opioids, instead of extended-release opioids. Pain blocks are effective and can reduce the need for opiates. Minimally invasive procedures can reduce the pain of the patient. It is better for the patient to have multimodal therapy. It is more effective and safer than narcotics alone. 

Stress Fractures of the Metatarsal Bones

Bone is a living tissue, and it responds to stress by making new bone. When the bone fails to respond adequately to stress, a fatigue fracture may occur. The stress fracture occurs when the bone fails due to repetitive small stresses (microtrauma). The fracture can present itself early on as a minor injury with minor symptoms. If the fracture is not treated adequately it can become very disabling. A high index of suspicion is necessary for the diagnosis of stress fractures of the metatarsal bones. In athletes, there may be localized pain that worsens with progressive activity such as increased training, increased running mileage, a change in running surface, or changing shoes. Early on, x-ray may be negative in the majority of patients. Bone scan or MRI can be used to detect early activity in the bone. Usually the patient will have vague symptoms. The patient may see different doctors in order to obtain different opinions. A lot of tests may be done, and a neuroma or metatarsalgia may be given as a diagnosis. Female athletes who have decreased bone density and possible eating disorders will have an increased incidence of stress fracture of the metatarsal bones. Female athletes with stress fractures should have a complete dietary and menstrual history. There is a correlation between eating disorders, amenorrhoea, and osteoporosis in female athletes. This is the common areas for stress fractures of the metatarsal bones. In runners, the fracture usually occurs in the metatarsal neck. In dancers, the fracture occurs at the base of the 2^nd metatarsal. Fracture may result in delayed union. Restrict weight bearing for 6 weeks. Look for anatomic causes of fracture in the 2^nd and 3^rd metatarsal neck such as heel cord tenderness, a short 1^st metatarsal, or a long 2^nd metatarsal. Check for metabolic bone disease, osteoporosis, or osteomalacia. Upon physical examination, the patient will have tenderness, induration, and maybe a mass. They will also have a cavus foot, and the MRI and bone scan can be helpful. Metatarsal shaft stress fractures can occur due to the stress of weight bearing or prolonged walking. The fracture is sometimes called a “march” fracture that occurs in military recruits and in runners who increase activity levels. It usually occurs in the 2^nd metatarsal followed by the 3^rd metatarsal in frequency. The fracture is diaphyseal in location, and there will be localized tenderness at the fracture site. The 2^nd metatarsal is the longest and most rigid of the metatarsal bones, and it is usually exposed to greater repetitive stresses. X-rays are usually normal. A bone scan or MRI may be needed. Fracture of the proximal 5^th metatarsal occurs in a watershed area of the blood supply that is susceptible to stress fracture nonunion. The blood supply in this area is tenuous. Healing is difficult with a high incidence of delayed and nonunion. The stress fracture occurs distal to the 4^th and 5^th intermetatarsal joint.  The Jones fracture is an acute fracture, and a stress fracture is a chronic condition that will require surgery. There are three types of fractures at the proximal fifth metatarsal: zone I, zone II, and zone III. Zone I is a tuberosity avulsion fracture. Zone II is a Jones fracture. Zone III is a stress fracture. The stress fracture occurs distal to the ligament that connects the 4^th and 5^th metatarsal together. The stress fracture can occur in cavus foot due to increased ground reaction force over the 5^th metatarsal. It will be overloaded on the lateral border of the foot. There will be dull pain activity related symptoms before the stress fracture shows up on x-ray. X-rays will show the fracture and its location. The x-ray will show varying degrees of sclerosis and widening of the fracture line. Treatment is a lag screw fixation with or without bone graft.

Intertrochanteric Hip Fractures

Intertrochanteric hip fractures with a regular fracture pattern can be either stable or unstable. The obliquity of the intertrochanteric fracture is different than in the reverse oblique fracture pattern. Stable intertrochanteric fracture is stable and most studies show that there is equal outcome between the sliding hip screw and the intramedullary nail for a stable fracture pattern (the sliding hip screw is cheaper). A construct with two screws is as good as a construct with three of four screws. A displaced fracture is probably a high energy fracture, but it is not comminuted. If this fracture does not align with traction on the fracture table, then you need to do open reduction, and if the fracture appears stable after open reduction, it is easier when you are there to do compression hip screw. The best treatment for a reverse oblique fracture is cephalomedullary nail. A sliding hip screw may fail if used for reverse oblique hip fractures. Unstable fractures are best treated with a cephalomedullary nail. A fracture of the hip above a retrograde nail will require reduction and internal fixation with a compression hip screw. An antegrade nail for this hip fracture will not work unless you remove the retrograde nail which can be a much bigger operation than using a compression hip screw. A thin or incompetent lateral wall increases the chances of intraoperative lateral wall blow out. This intraoperative complication increases the chances of postoperative failure of the hardware and the need for reoperation. If the lateral wall thickness is less than 20 mm, then the hip fracture should not be treated with a compression hip screw. The integrity of the lateral wall is a predictor for fracture pattern stability, and it is an x-ray sign that guides the implant choice.

L5 Nerve Root

The L5 nerve root arises from the spinal canal, it is part of the lumbosacral plexus. It is also part of the sciatic nerve. The L5 nerve root supplies the muscle that allows extension of the toes and dorsiflexion of the ankle. It is also responsible for supplying sensation to the dorsum of the foot and leg. When the L5 nerve root gets involved, you will have sciatica with a positive straight leg raising. Straight leg raising (tension sign) occurs from L5-S1 involvement.  The tension sign produces pain and paresthesia in the leg at 30-70 degrees of hip flexion.  Injuries to the L5 nerve root include intervertebral disc herniation, spondylolisthesis, sacral fractures and sacroiliac joint injury.  In intervertebral disc herniation the L5 nerve root involvement can cause Trendelenburg gait due to posterolateral disc herniation. This is because it affects the gluteus medius and minimus. Trendelenburg gait can also occur with L5-S1 foraminal disc herniation. Posterolateral disc herniation affects the transversing or the descending nerve root at the level of L4-L5 (affects the L5 nerve root). Foraminal disc herniation, which is far lateral or the extra foraminal, affects the exiting nerve root or upper nerve root (L5-S1 will affect L5 nerve root). The lumbar disc herniation affects L 4-L5, and L5- S1 level in about 95% of the time and it will involve the L5-S1 nerve roots. In general, the L5 nerve root involvement will cause weakness with hip abduction, big toe extension, and ankle dorsiflexion.  If there is a sacroiliac joint injury, the lumbosacral plexus can be injured. That will predominately affect the L5 nerve root causing the patient to have foot drop. When doing surgery on the sacroiliac joint, and the surgeon goes anteriorly to fix the injury and places a retractor in the anterior aspect of the sacrum, the L4-L5 nerve roots can be injured. These nerves are about 1 cm medial to the sacroiliac joint at it inferior part. In displaced sacral fracture, the L5 nerve root can be injured especially if it is a fracture of the ala of the sacrum which occurs about 5% of the time. With degenerative spondylolisthesis, the vertebra do not slip a lot. Degenerative spondylolisthesis occurs at L4-L5, occurs more often in females and involves the L5 nerve root.  In isthmic spondylolisthesis, if it occurs at L5-S1, it may involve the L5 nerve root and cause hamstring tightness.  Spondylolysis is a fracture of the Pars interarticularis. With isthmic spondylolisthesis the vertebra is slipped and it may slip a lot.

Pediatric Femoral Shaft Fractures

Treatment for pediatric femoral shaft fracture varies. Treatment can include casting or surgery, depending on the age of the patient and the pattern of the fracture. A fracture of the femur that occurs in a child before the walking age, there should be concern for non-accidental trauma, suspect abuse.  Pediatric patients 0-6 months of age should be treated with a Pavlik harness, 6months to 5 years of age should be treated with an immediate spica cast. Moderate evidence supports treatment with an early spica cast or traction with delayed spica cast for children aged 6 mo. - 5 years with a diaphyseal femur fracture with less than 2 cm of shortening.  A spica cast is not used for a patient that has shortening of 2-3 cm. If there is excessive shortening or potential shortening, there will be loss of reduction in the spica cast and the child can be treated by traction and delayed spica cast or by a different alternative. In very unstable fractures, you are going to use traction with a delayed spica cast or external fixator.  Children 5 years of age to 11 years, consider using flexible rods, plate, or external fixator. To use flexible IM nails, the fracture must be axially stable and it can be used in children between the ages of 5-11 years, and should not be used in children weighing more than 100 pounds or in children older than 11 years. An alternative technique, different than the flexible IM nail should be used in older children that weigh more than 100 pounds or if the child is more than 11 years old. For the flexible nails to work, the fracture must be short, oblique, or transverse.  It is probably better if the fracture is in the mid-diaphysis area. In comminuted fractures, or very distal or proximal fractures, it may be hard to control the fracture with a flexible IM rod. Approximately 50% of fractures treated with flexible nails have about 15 degrees of malalignment.  The nail size of the IM flexible nail is determined by multiplying the width of the isthmus of the femoral canal by 0.4 and the goal is to have 80% fill.  Sub muscular plate fixation can be used in children more than 5 years old and in the patient that weigh more than 100 pounds. It can also be used in very proximal or very distal fractures where the flexible rod will not work, especially if the fracture is unstable. It can be used in cases of severe comminution when you will use the plate as a bridge plate. It can be used for open fractures, if there is associated vascular injury, if the fract5uer is significantly comminuted, or it can be used in polytrauma patient. With external fixation there is increased risk of re-fracture after removal of the fixator. The main blood supply to the femoral head is the deep branch of the medial femoral circumflex artery and these branches are near the piriformis fossa and are vulnerable to be injured with a piriformis entry nailing. Osteonecrosis of the femoral head can occur with an open proximal physis. Piriformis or near piriformis entry rigid nailing is not usually recommended for the young child. If the IM rod needs to be done, it is better to go through a greater trochanteric entry which can also have its own complication such as coxa valgus or premature fusion of the greater trochanter apophysis.   Rigid trochanteric entry nailing may be an option for children at or near skeletal maturity.  The most common complication in younger patients is leg length discrepancy with over growth of up to 2 cm in patients younger than 10 years of age. It typically occurs within 2 years of the injury. Leg length discrepancy can occur from excessive shortening following a cast treatment. Do not accept more than 2 cm of shortening.  Monitor the child for development of compartment syndrome following spica cast. When you do traction and you delay the spica cast, a proximal tibial traction pin can cause recurvatum due to damage of the anterior part of the tibial tubercle apophysis. 

Low Back Pain

What are the important facts about low back pain? No definitive etiology is found in about 85% of the patients. 90% of patients with a single episode of low back pain return to work within 6 weeks, and most patients get better with time. The history of low back pain is the single most important factor predicting future occupational low back pain. Low back pain is the second most common cause of work absenteeism. Persistent back pain more than 6 months constitutes more than 4% of the cases. Disability is closely linked to compensation and litigation. The least amount of pressure on the disc is measured with the person lying supine. The highest disc pressure is measured while sitting and 20 degree forward leaning with 20 kg load in the arm. By keeping the weight of the load close to the body, this reduces the compressive forces being placed on the lumbar spine. Yoga activities and exercises performed during sitting probably have less pressure being placed on the discs. What are the physical factors that lead to low back pain? Lifting heavy objects. Holding the load close to the body is important to reduce the compressive forces being placed on the lumbar spine.  Cigarette smoking is another factor. Nicotine causes disc degeneration, it interferes with the vascularity of the spine and the nutrition of the discs. Operating motor vehicles, prolonged sitting, lack of fitness, operating vibrating tools also contribute to low back pain. Sports related activities can lead to low back pain. One example includes golf.  Pain results from twisting and excessive forward bending and overarching of the spine during the swing.  At the age of 40, the average person loses 50% of their rotational movement of the spine. It is important to perform stretching and warmups before starting the game. Another example of a sport related activity leading to low back pain is horseback riding. Vibration caused by horseback riding increases the load on the discs. The back muscles work constantly to keep you posture straight. Caring for horses could be bad for the back due to the bending and the lifting associated with their care. The etiology of low back pain. Virtually any structure in the spine and close to the spine can hurt, causing what seems to be low back pain. These structures include facet joints, intervertebral discs, spinal canal/nerve roots, sacroiliac joints, muscles, ligaments, nerves, hip joint/piriformis syndrome, and trochanteric bursitis. Red flags for cancer include patients over the age of 50, pain at rest and at night, unexplained weight loss, history of cancer, bone destruction involving the pedicle in pathognomonic. Look for the winking owl sign of the vertebrae. The red flags for infection include diabetes mellitus, intravenous drug abuse, fever, urinary tract infection, and previous surgery on the spine. The physical examination includes the initial assessment, focus on the red flags such as fractures, tumor, infection, or cauda equina syndrome. Symptoms and signs of cauda equina syndrome are back pain more than leg pain, bladder or bowel disturbances, bilateral leg pain and weakness, saddle anesthesia (rectal and genital area sensory changes). In the absence of red flags, imaging studies are usually not helpful in the first 4-6 weeks. It is hard to explain to the patient why you did not get an x-ray, although not getting and early x-ray is a good patient care, but it may lead to suboptimal patient satisfaction. Intensive work-up may not be necessary in the early stages of routine low back pain. Conservative treatment of low back pain include anti-inflammatory medication and muscle relaxants which are usually helpful, and a soft brace or corset. Physical therapy is an important aspect of the treatment and should be done as soon as pain control is achieved. The combination of physical therapy and return to work is important. If a patient sustained chronic, disabling occupational low back pain without any intensive rehab, there is a 50% chance of going back to work if the person is out of work for 6 months. The chance of returning to work drops to 20% if the person is out of work for 1 year. The chance of returning to work is almost none if the person is out of work for 2 years. It is important to do therapy and encourage the patient to go back to work. The best treatment for acute low back pain is to continue with the ordinary daily activities within the limits permitted by the pain.  The best treatment for low back pain is for the patient to go back to work.