45 CHAPTER 5 ANKLE JOINT left FRONTAL VIEW TIBIA Interosseous Membrane Ant. inf. Tibio-fibular Lig. CUT 0 TIBIAL MALLEOLUS Deltoi Meial Ligament T.M. Tibialis posterior M. Flexor Halluis T.M. Flexor Halluis longus Posterior tibial Vein, Artery an Tibial Nerve FIBULAR MALLEOLUS TALUS Posterior Talofibular Ligament T.M. Peroneus Brevis T.M. Peroneus longus CALCANEUS Wire a: From lateral to meial, from istal to proximal: smooth wire for fixation of meial malleolar frature; some time olive wire, to ompress the fragment. It is not neessary to ross all the tibia; it is enough just to push on the wire. In this way there is not risk to amage the lateral soft tissues an the pressure to the bone is not so strong to allow the olive to penetrate into the soft bone as the malleolar ortex is very soft. Wire b: From postero lateral to antero meial from istal to proximal for fixation of the lateral melleolus to the tibia in frature or speial ase of lengthening: this wire is tensione with post at the same ring or in ifferent rings. a b Wire : This is half wire on half pin iameter 2 to 5 mm for fibular fixation in the nee to move own the fibula or for ifferential lengthening of the fibula; the AP wire into the fibula has to be avoie not to amage the soft tissues. Wires : For talus fixation in ase of ankle fusion on sub talar join fusion; the iretion is from postero lateral to antero meial an from postero meial to antero lateral, tangent to the meial malleolus to avoi the neuro vasular bunle.
APPENDIX 46 ANKLE JOINT left CUT 0 ANTERIOR T.M. Tibialis ant. T.M. Ext. Halluis T.M. Ext. Digitorum long. N. Peroneal prof. A.V. Tibial ant. TALUS T.M. Peroneal TIBIAL MALLEOLUS FIBULA T.M. Tibialis posterior T.M. Flexor alluis N. Tibialis A.V. Tibial posterior T.M. Peroneus brevis T.M. Peroneus longus T.M. Flexor Halluis longus T.M. Plantaris T.M. Triipitis (Tenon Calaneus) a b
47 CHAPTER 5 Os alaneum Meial Malleolus Lateral Malleolus setion large tarsal bones Talus CUT 0 Hea of Talus Tuberolum 5º metatarsal CUT 1 setion small tarsal bones Naviular bone Cuboi bone 1 st meial uneiform bone 2 n Mile uneiform bone 3 r lateral uneiform bone Iº Metatarsal post. tuberolus CUT 2 setion bones of anterior half of the foot 1 2 3 4 5 Metatarsal bones Proximal (1 st ) phalanges Mile (2 n ) phalanges Dorsum of the foot vessels, nerves an tenons Meial alaneal arteries The artery of the foot orsal Distal (3 r ) phalanges The bones are ivisible, at the transverse tarsal an tarso-metatarsal joints, into three setions: anterior, mile, an posterior Dorsal artery of the foot Aruate artery Lateral tarsal artery Common orsal igital arteries Common orsal igital arteries Proper orsal igital arteries
APPENDIX 48 DORSAL VIEW Hinfoot POSTERIOR VIEW TALUS N. Peroneal prof. A.V. Dorsalis Peis CUT 0 N. Tibial A.V. Tibial Posterior CALCANEUS CALCANEUS DORSAL VIEW The first setion is taken transversely at the level of the istal tibia. The view is from above looking own on the talus an alaneus. Here both malleoli are reaily palpable, as is the posterior tibial A. behin the meial malleolus. The alaneus is preominantly a anellous struture, with a thin ortial shell, partiularly in oler patients. The other bony lanmarks palpable at this level are the alaneal tuberosity for the insertion of the teno-ahilles, the meial an lateral alaneal proesses leaing to the alaneal boy on either sie, an on the lateral surfae the alaneouboi joint istally an anteriorly. On the meial aspet of the hinfoot the sustentaulum tali is palpable anteromeial to the istal tip of the meial malleolus. Here the meial subtalar faet is positione above, an the plantar vessels an N. pass inferiorly ajaent to the tenon of flexor halluis longus. Posterior to the meial malleolus runs the tibialis posterior tenon, whih is losest to bone. The tenon of the flexor igitorum longus is the next posterior struture, with the posterior tibial A, V, an the posterior tibial N. running between this an the flexor halluis longus tenon. POSTERIOR VIEW An oblique lateral to meial wire, positione at the height of the inferior aspet of the alaneal tuberosity, miway along the alaneal proess, provies the initial hinfoot fixation. This is plae onto a half ring, an two half pins are then inserte from the posterior aspet of the alaneus. They are plae posterior to anterior at about 60-90 to eah other, to about 5m from the anterior proess of the alaneus. This ombination ahieves optimal hinfoot stability. Alternatively rosse wires an be inserte, entre in the posterior aspet of the alaneus. However, beause of the bone struture these o not give fixation that is as goo as the wire an half pin ombination.
49 CHAPTER 5 CUT 1 Mifoot (Metatarsal Bases) Forefoot CUT 2 T. Extensor Digitorum Longus M. Extensor Digitorum Brevis METATARSAL SHAFT - II-V Styloi Proess (V) M. Peroneus Longus M. Flexor Halluis Brevis M. Abutor Halluis M. Flexor Digitorum Brevis A.V.N. Meial/Lateral Plantar M. Abutor Digiti Quinti M. Abutor Halluis M. Flexor Halluis Brevis M. Autor Halluis A.V.N. Meial/Lateral Plantar M. Abutor Digiti Quinti M. Extensor Halluis Longus/Brevis This setion is taken through the metatarsal bases, about 1m istal to the tarsometatarsal joints. At this level the metatarsals have reasonably thik orties with a meullary ore. The first metatarsal in partiular has a onsierable anellous entre with thik orties. The bases of the bones fit together in ross setion like keystones in an arhway, reating a stable bony arh with the highest point being aroun the thir metatarsal. The orsal surfae is quite superfiial, overe only by skin an fasia, extensor tenons an laterally by extensor igitorum brevis. The extensor retinaulum ens istally at the level of the tarso-metatarsal joints. The tenon of extensor halluis longus lies over the first metatarsal, the orsalis peis A. an eep peroneal N. over the seon, the extensor igitorum longus with the brevis tenons over the thir an fourth. The extensor igitorum tenon to the little toe, with that of abutor igiti minimi lies over the orsum, base an shaft of the fifth metatarsal. 3-5 mm 3-4 mm Fixation at this level is initially ahieve by rosse wires. The first from the meial sie, obliquely an orsally through the bases of first, seon an thir metatarsals. The seon wire enters from the lateral sie, again obliquely an orsally, but this one fixes the fifth, fourth an thir metatarsals as shown. This fixation an be supplemente for stability using 2-3mm Steinmann pins, or in the ase of the first metatarsal base using a threae half pin. These an be inserte into the entre of the metatarsal base from the orsal aspet of the foot. If a first metatarsal pin is use are must be taken to sprea the soft tissues with an artery to protet the orsal neurovasular strutures. Alternatively, espeially in the smaller foot, the naviular or uneiforms an be use as insertion points meially, an the uboi an be use laterally as insertion points. Note: it is possible to use 1 st to 5 th metatarsal wire.
APPENDIX 50 linial examples In the transosseous osteosynthesis the extene evie to foot is use to inrease the stability in the ankle or in the istal tibial epiphysis pathologies. The examples an be numerous aoring to the ifferent pathologies. The hybri system suggests the use of 1 or 2 half-pins in the alaneum aoring to the following metho: the foot onstrut onsists of a half ring posteriorly with threae plates extening anteriorly from eah en. Another half ring is use to onnet the threae plates anteriorly over the orsum of the foot. The frame is fixe posteriorly by a transverse wire an a 5 mm half pin. These wires/pins ross at an angle of 30-40 egrees. Two or three wires are use to fix the mifoot an forefoot. These wires pass transversely through the tarsal bones an the bases of the metatarsals; to improve the stability one half pin is inserte perpeniular to the first metatarsus.
51 CHAPTER 5 Fellowship opportunities Smith & Nephew, In. is prou to support global Ilizarov meial euation programs. Our traition of Ilizarov is rih in euation, an we ontinue that traition with our mini-fellowships by working with some of the worl s finest Ilizarov surgeons an euators. Loation: Leo, Italy Leo Milan Venie Host: Hospital: Prof. Maurizio Catagni Ospeale Alessanro Manzoni Florene Rome Duration: 8-week sessions: January February Marh April May June July August September Otober November Deember Fellows per session: 2 per session All loging an travel expenses pai. A moest stipen is also provie. Leo is loate in the seni lake ountry of northern Italy near Milan, an the Italian Alps. Loation: Kurgan, Russia Host: Hospital: Prof. Vlaimir Shevtsov Russian Ilizarov Sientifi Centre for Restorative Traumatology an Orthopaeis Duration: 6 week sessions April 1 May 14 May 15 June 30 July 1 August 15 August 16 September 30 Otober 1 November 15 Fellows per session: 4 per session. All loging an travel expenses pai. A moest stipen is also provie. This program allows a one-in-a-lifetime hane to explore the unique an wonerful Siberian ulture. To apply, please ontat Monia Dolbi at (901) 399-5625 or monia.olbi@smith-nephew.om Smith+Nephew Leaership in Worlwie Healthare The Ilizarov logo is a traemark of Meialplasti srl, Milan, Italy. 2003 Smith & Nephew, In.