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An Introductory Surgical Anatomy Case Series: Ankle Surgery Clare Gabrielle and Amir Salehi-Sedah University of Edinburgh SSC5 Orthopaedics ProjectLearning Outcomes • Enhance Understanding of Ankle Anatomy • Identify Important Surgical Landmarks of the Ankle • Discuss Ankle Fracture and Injuries • Revision of important UKMLA Orthopaedic Presentations • Provide an Introduction to real surgical procedures through images • Inspire Future Orthopaedic Surgeons!Anatomy RecapAnatomy RecapCase #1 Presenting at A and E A 39-year-old man has presented after twisting his right ankle playing football. He reported immediately following the injury: pain, swelling, and not being able to bear weight with his right leg.Patient Background • HxPC – Twisting injury during football match (external rotation of foot), indicates severe pain and swelling of the right ankle, unable to weight bear • PMHx – No significant history, no previous orthopaedic or rheumatology history • DHx – Occasional paracetamol • SHx – Occasional EtOH, plays football regularly, partner at home, stairs in home • FHx – No history of orthopaedic or rheumatology disorders, no familial conditionsOn Ankle Examination • Lateral Aspect of Right Ankle – Swelling, Bruising and Deformity • Skin is Intact but taunt • Normal Neurovascular Examination • No abnormalities on knee examinationInvestigations • Bloods oFBC, Group and Save, Coag Screen, (U&Es sometimes indicated if imaging with contrasts are used) oNo Abnormalities • Imaging o Radiographs - AP , Lateral, mortise (10 degrees internal rotation for malleoli to be in the same plane) o(CT if indicated to assess syndesmotic involvement)Xray What finding can be seen on the AP Lateral radiographs? Medial Malleolar Fracture Posterior Malleolar Fracture Calcaneal Fracture Lateral Malleolar Fracture What classification of lateral malleolar Xray fracture can be seen on the AP Lateral radiographs? Weber A Weber B Weber C Weber DManagement • Conservative oUsually in the elderly or a more frail patient if reduction can be achieved oWill be reduced in A/E oCast and frequent x-rays oVery uncommon due to likelihood of deltoid ligament ruptures (medial malleolus) oTypes ▪Moonboot + Elevation – Removable ▪Plaster Backslab – Non RemovableManagement • Surgical oLateral Malleolar ORIF ▪Lateral plate • Easiest Access • Risk of wound discomfort from superficial plate position ▪Posterior plate • Done if patient has risk of skin breakdown at lateral malleolus from lateral plate • Useful in poor quality bone • Risk of peroneal tendon irritation oFibular Nail ▪Done in patients with more osteoporotic bone with risk of diabetes, neuropathy or skin contusion ▪Requires fluoroscopy – more expensive/less accessibleSurgical Overview Lateral Plate ORIF (Open Reduction Internal Fixation) oIncision oExposure oReduction oLag Screw oPlating oClosing Warning! The Following Slides will Contain Pictures of Real Anatomy Specimens If you feel uncomfortable or distressed at any time, feel free to take time for as long you need then return to the teaching or contact support if you need it. Some Resources Available: • University of Edinburgh Advice Place - https://www.eusa.ed.ac.uk/adviceplace/wellbeing/mentalhealth • Samaritans – 116 123 • Nightline – 0131 557 444 When landmarking for this procedure, what structure(s) is the surgeon aiming to avoid Landmarking on the anterior aspect of the fibula? Superficial Peroneal Nerve Peroneus Longus Superficial Branches of Sural Nerve Peroneus Brevis Retraction of Skin and Incision of Incision of the Skin Subcutaneous Tissue down to the Fibula What structure is the being Removing Subcutaneous tissue and Periosteum from the Fracture Site shown in the picture? Superficial Peroneal Nerve Peroneus Longus Superficial Branches of Sural Nerve Peroneus BrevisReduction of fibula (and retraction Lag Screw and Neutralization of the superficial peroneal nerve beforehand to protect it) Plate Placed on Lateral Fibula Each hole will be drilled, measured, tapped and have a screw inserted. This will be done in the order of: Proximal screw nearest lag screw, distal screw nearest lag screw, all remaining proximal screws, all remaining distal screwsLag Screw and Plating Principles • Lag Screw oScrew is inserted perpendicularly to fracture site oThreads only engage the far cortex to pull both cortexes together • Neutralization Plate oScrew cannot bear weight alone oPlate will provide the stability to allow for mobilization Irrigation with Saline and Finished Plate Checking Skin Closes over plateClosing of Subcutaenous Closing of Skin TissueXray AP Lateral **Fluoroscopy would have been done throughout the procedure to check the lag screw and plate position before closing**Case #2 Presenting at A and E: A 35-year-old recreational athlete reports sudden pain in the back of his left ankle after feeling a "pop" during a tennis match. He is unable to bear weight on the affected leg.Case #2 History and Physical Exam: • HxPC – 'pop' during push off in tennis, unable to weight bear • PMHx – No significant history, no previous orthopaedic or rheumatology history • DHx – Occasional corticosteroid use for shoulder pain • SHx – occasional EtOH, plays tennis regularly, partner at home, bungalow • FHx – No history of orthopaedic or rheumatology disorders, no familial conditionsAchilles T endon • Largest and strongest tendon in the human body, formed by the confluence of the gastrocnemius and soleus muscles • Inserts on the posterior calcaneus, enabling plantar flexion essential for walking, running, and jumping. • Posterior tibial artery • Peroneal artery • Sural nerve (sensory contribution), with minor contributions from tibial nerve.Achilles T endon Rupture • Sudden forced plantar flexion • Rapid dorsiflexion of a plantar flexed foot --> weakness to ankle plantar flexion and increased passive dorsiflexion • Rupture typically occurs 4–6 cm proximal to the calcaneal insertion in a region with poor vascular supply • Pain and difficulty walking Achilles Tendon Rupture VideoThe Patient's Ankle on Clinicalhat clinical test would you Examination perform to help with diagnosis Eversion Stress Test Talar Tiltest Thompson's T est Silfverskiöld estClinical Examinations Thompson’s T est • Clinical examination procedure for discovering the signs of an Achilles tendon rupture. • Looking for three diagnostic markers → Simmonds Triad 1. Angle of declination 2. Palpation for a gap 3. Calf squeezeThompson’ s est & Simmonds T riad Rajat Mitta,AcuteAchilles tendon rupture: diagnosis and management. MedicineToday 2024; 25(9): 41-44 Palpable GapOn Ankle Examination • Positive Thompson test: No plantar flexion upon calf squeeze. • Palpable gap in the Achilles tendon 4 cm proximal to the calcaneal insertion. • Swelling and bruising over the posterior ankle. • Normal Neurovascular Examination • No abnormalities on knee examinationInvestigations • Bloods oFBC, Group and Save, Coag Screen, oNo Abnormalities • Imaging oUltrasound oMRIMRI RadiopaediaManagement • Depends on severity • Type I is treated conservatively with immobilisation and non-weight- bearing activities for at least four weeks after the injury; • Types II-IV require surgical treatment, such as open repair, percutaneous repair , and augmentative repair . • After surgery, the patient is prescribed with conservative treatment described above.Surgical Approach – Overview Incision and Exposure Preparation of theendon • Debridement • Mobilisation Tendon Repair • Suturingechnique – Krackow suturingSurgical Approach – Overview Course of nerve and vein Incision made appropriately identified Which nerve and vein are to be Approach avoided on the approach? Deep Peroneal Nerve and Great Saphenous Vein Sural Nerve and Great Saphernous Vein Sural Nerve and Lesser Saphenous Vein Deep Peroneal Nerve and Lesser Saphenous Vein Which landmark of the tendon Landmarking is used to avoid nerve damage Medial Border of Achilles Midline of Achilles Lateral Border of Achilles Posterior MalleolusSurgical Approach – Overview Blunt spreading of the superficial layer Deep fascia exposedSurgical Approach – Overview Paratenon Sponge used to gently separate Haematoma of the paratenon the surface of the deep fascia Surgical Approach – Overview Paratenous sleeve cut to expose the injured Achilles Proximal Achilles tendon ruptureSurgical Approach – Overview PAchilles Distal AchillesSurgical Approach Krackow suture techniqueSurgical Approach The Krackow suture technique Kang et al., 2014Surgical Approach Achilles Tendon Reconstruction Paratenon and deep fascia stitched to maintain the integrity of the tendon and start recoveryReferences • Radiopaedia.org. (n.d.). Achilles tendon tear. Retrieved January 7, 2025, from https://radiopaedia.org/articles/achilles-tendon-tear • Rajat Mitta, Acute Achilles tendon rupture: diagnosis and management. Medicine Today 2024; 25(9): 41-44 • Orthobullets. (n.d.). Achilles tendon rupture. Retrieved January 7, 2025, from https://www.orthobullets.com/foot-and-ankle/7021/achilles-tendon- rupture#popup/image/7762 • Podiatry Institute. (n.d.). Achilles tendon repair video. Retrieved January 7, 2025, from https://podiatryinstitute.com/PI_videos/achilles.html • tendon-rupture-surgery/t & Ankle Specialists. (n.d.). Achilles tendon rupture surgery. Retrieved January 7, 2025, from https://socalfootandankle.com/achilles- • VuMedi. (n.d.). ORIF of ankle fracture [Video]. Retrieved January 2, 2025, from https://www.vumedi.com/video/orif-of-ankle-fracture/ • TeachMeAnatomy. (n.d.). Posterior compartment of the leg [Illustration]. Retrieved January 2, 2025, from https://teachmeanatomy.info/lower- limb/muscles/leg/posterior-compartment/ • Health Jade. (n.d.). Foot drop [Illustration]. Retrieved January 2, 2025, from https://healthjade.net/foot-drop/ • 3D4Medical. (n.d.). Muscle compartments of the leg [Image]. Retrieved January 2, 2025, from https://3d4medical.com/blog/muscle-compartments-of-the-leg • White, T. O., & Mackenzie, S. P. (2023). McRae’s orthopaedic trauma and emergency fracture management (4th ed.). Elsevier. • AO Surgery Reference. (n.d.). Fibula oblique (C1) fracture: Lag screw and neutralization plate [Image & Information]. Retrieved January 2, 2025, from https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/basic-technique/fibula-oblique-c1-fracture-lag-screw-and- neutralization-plate • Radiopaedia. (n.d.). Weber classification of ankle fractures [Image]. Retrieved January 2, 2025, from https://radiopaedia.org/articles/weber-classification-of- ankle-fractures?lang=us • The Skeletal System. (n.d.). Ankle bones [Image]. Retrieved January 2, 2025, from https://www.theskeletalsystem.net/ankle-bones • https://www.manchestereveningnews.co.uk/sport/football/football-news/gallery/1310304ted [Image gallery]. Retrieved January 2, 2025, from • GiveMeSport. (n.d.). Wimbledon: Andy Murray news – Beat Djokovic and Federer on grass. Retrieved January 2, 2025, from https://www.givemesport.com/wimbledon-andy-murray-news-beat-djokovic-federer-grass/ • Kang, C., Hwang, D. S., Hwang, J. M., Song, J. H., Shin, B. K., & Park, J. H. (2014). Treatment of Achilles tendon rupture with absorbable suture. Journal of Korean Foot and Ankle Society, 18(3), 115–118. https://doi.org/10.14193/jkfas.2014.18.3.115 • Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. JBone Joint Surg Am. 2012 Dec 5;94(23):2136-43. doi: 10.2106/JBJS.K.00917. PMID: 23224384; PMCID: PMC3509775. • Orthobullets. (n.d.). Achilles tendon rupture. Retrieved January 5, 2025, from https://www.orthobullets.com/foot-and-ankle/7021/achilles-tendon-rupture