AAOS Foot Ankle 2018ab

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)
AAOS Foot and Ankle 2018 - 100 MCQs
1. Figures 1 and 2 are the T2-weighted MR image and AP radiograph of a 55-year-old laborer who
sustains an ankle sprain after a fall from scaffolding. Initial films are read by radiology as normal.
Despite an exhaustive 6-month course of immobilization; shoe modifications; and therapy, the
patient continues to have activity-related lateral hindfoot pain, which has prevented him from
returning to work. On examination, the patient has full eversion strength that is painless. Ankle
range of motion is full and painless. No anterior drawer is observed. There is tenderness and mild
swelling distal to the sinus tarsi. Sensation and motor are intact and the skin is otherwise
unremarkable in appearance. An MRI is obtained. What is the next best step?
1. Referral for complex regional pain syndrome (CRPS) workup

2. Lace-up ankle brace
3. Excision of the superior anterior process of the calcaneus
4. Arthroscopic Brostrom
DISCUSSION
The patient has a nonunion of anterior process of the calcaneus. His symptoms are consistent with
the examination and imaging findings, and he has failed nonsurgical treatment. Therefore, surgical
excision of the nonunion fragment is indicated. No findings consistent with CRPS are seen in this
patient. He has activity-related pain at a focal area and is without skin changes. A lace-up ankle
brace is unlikely to provide substantial immobilization and pain control at the hindfoot. In addition,
the patient has tried nonsurgical therapies without lasting improvement. The patient has
complaints, examination, and imaging findings consistent with a single diagnosis. A lateral ankle
stabilization procedure such as a Brostrom is not indicated because the patient has no instability
on examination. ANSWER = 3.
2. Figure 1 is the T1-weighted lateral MR image and Figure 2 is the T2-weighted lateral MR image
of a 25-year-old woman with ankle pain for the last year that is associated with walking down
stairs and playing sports. No known injury has been identified. The ankle pain has been managed

with rest, therapy for range of motion, and a period of immobilization. Intra-articular steroid
injection provided limited relief of symptoms. What is the best next step?
1. Intra-articular platelet-rich plasma injection

2. Anterior ankle arthroscopy with marrow stimulation
3. Posterior ankle arthroscopy with debridement
4. Open peroneal tendon repair
DISCUSSION
The patient has ankle pain that is consistent with an os trigonum. The MR images show
inflammation about the posterior ankle and a bright line between the talus and the os trigonum.
Initial management typically is rest and therapy. Steroid injection under ultrasonography about the
os trigonum has been described. Surgical treatment can be either open or arthroscopic.
Arthroscopic treatment has shown earlier return to sport, but longer-term studies have not shown
a significant difference between the two techniques. ANSWER = 3.
(Case vignette No. 3 – 6)

Figures 1 through 3 are the AP and lateral radiographs of a 45-year-old laborer who fell from a
ladder 1 year ago. He injured the left lower extremity and was treated with non-weight bearing for
6 weeks, followed by progressive weight bearing in a CAM walking boot for a further 6 weeks.
Despite physical therapy, the patient has pain with uneven ground, prolonged standing, and gravel.
Shoe orthotics have failed to provide relief. The patient subjectively has no difficulty with
dorsiflexion.
3. What is the best next step?

1. University of California Biomechanics Lab orthotic
2. Gauntlet ankle brace
3. Corticosteroid injection in the ankle
4. The patient has failed further nonsurgical management and would like to proceed with definitive
surgical intervention. What is the most appropriate surgical intervention?
1. Subtalar arthrodesis
2. Triple arthrodesis
3. Calcaneal osteotomy
4. Ankle arthrodesis
5. After the procedure, the patient’s main complaint is limited ankle dorsiflexion. The patient reports
no tenderness to palpation along the anterior joint line. What is the most likely etiology to explain
the patient’s clinical complaints?
1. Loss of calcaneal height

2. Increased calcaneal width
3. Peroneal tendon dislocation
4. Hindfoot varus
6. Initial surgical treatment of this patient fracture compared with non surgical management is
associated with :
1. decreased rates of wound infection and increased rates of arthritis.

2. decreased rates of wound infection and decreased rates of arthritis.
3. increased rates of wound infection and increased rates of arthritis.
4. increased rates of wound infection and decreased rates of arthritis.
DISCUSSION
The clinical scenario depicts a patient with subtalar arthritis after nonsurgical management of a
calcaneus fracture. The most common sequelae following a calcaneus fracture, which is treated
nonsurgically, is subtalar arthritis. The common deformity is varus, loss of height, with increased
heel width. Chronic peroneal tendon dislocation can also occur secondary to the deformity.
Nonsurgical management consists of limiting the inversion and eversion movement of the
hindfoot, which is best accomplished with a gauntlet ankle brace, commercially known as an
Arizona brace, or a solid ankle-foot orthosis. In patients who have failed nonsurgical treatment of
bracing, surgical intervention consists of a subtalar arthrodesis in the setting of isolated subtalar
arthritis. Surgical decision making involves evaluating for anterior ankle impingement. For cases
in which the patient describes an inability to dorsiflex; limited ankle range of motion; or pain with
dorsiflexion, a significant loss of calcaneal height is seen that must be corrected. In addition to the
standard requirement of lateral wall exostectomy, a bone block is required to correct the loss of
height and restore the normal talar declination. This will eliminate the anterior ankle impingement.
Bone block fusions are less successful at correcting varus deformity secondary to the difficulty of
placing a bone block with a taller medial aspect from a lateral approach. Because of the difficulty
of achieving a successful bone block arthrodesis, this should only be done when the patient has
subjective complaints of impingement.
Primary surgical intervention with an extensile lateral approach has become controversial with
regards to the overall benefit when compared with nonsurgical intervention. For patients with
severe deformity (dislocation, weight bearing on the fibula), no question remains that surgery is
appropriate. However, in patients without significant deformity with primary articular collapse,
surgery has not demonstrated a significant benefit with regards to function compared with
nonsurgical intervention. The overall rates of arthritis are lower with surgery; however, the overall
rates of infection are substantially higher. ANSWER NO 3 = 2; ANSWER NO 4 = 1; ANSWER
NO 5 = 1; ANSWER NO 6 = 4.
7. A 40-year-old runner has a flexion deformity of the distal interphalangeal (DIP) joint of his second
toe. He has pain at the tip of the toe, particularly during longer runs. He has tried multiple pads
and shoes with a wider toe box without relief. On examination, the deformity is flexible and
passively correctible. The best surgical option is
1. DIP arthroplasty.
2. DIP fusion.
3. flexor digitorum longus (FDL) tenotomy.
4. FDL transfer to extensor hood.

DISCUSSION
A mallet toe is a flexion deformity at the level of the proximal interphalangeal joint of the second
toe. These can be flexible or rigid. Flexible deformities can be treated with flexor tenotomies.
Rigid deformities typically require a DIP joint fusion. The FDL transfer to the extensor hood is
typically done to correct a flexible proximal interphalangeal joint deformity (hammer toe).
ANSWER = 3.
(Case Vignette No. 8 – 11)

Figures 1 through 3 are the AP, oblique and lateral radiographs of a 56-year-old woman with a
history of Charcot-Marie-Tooth disease who has foot pain.
8. What muscle combination represents an agonist-antagonist combination that contributes to the

radiographic findings?
1. Posterior tibialis–peroneus brevis

2. Posterior tibialis–anterior tibialis
3. Anterior tibialis–gastrocnemius
4. Peroneus longus–peroneus tertius
9. The patient is predisposed to what problem because of her foot position?

1. Hallux valgus
2. Fifth metatarsal stress fracture

3. Osteochondral lesions of the talus
4. Morton’s neuroma
10. Patients with this deformity tend to complain of lateral foot pain resulting from what alteration
during the gait cycle?

1. Increased transverse tarsal joint mobility during stance phase
2. Increased transverse tarsal joint locking during stance phase
3. Increased plantarflexion during toe-off
4. Increased dorsiflexion during swing phase
11. Which pedorthic variation will provide the most relief?
1. Morton’s extension
2. Medial column post
3. First ray cut-out
4. Heel lift
DISCUSSION
Cavovarus foot can often be caused by neuromuscular disorders such as Charcot-Marie-Tooth. In
these disorders, weak anterior tibialis and peroneus brevis muscles are overpowered by the
stronger peroneus longus and posterior tibialis muscles, respectively, causing the cavovarus
deformity. Because of the hindfoot varus deformity, the transverse tarsal joints remain locked
during stance phase, causing increased pressure on the lateral border of the foot and putting these
patients at risk for fifth metatarsal stress fractures, peroneal tendon issues, and ankle instability.
Nonsurgical management for this deformity may include ankle bracing, ankle-foot-orthosis, or
pedorthic devices with a recession or cut-out for the first metatarsal head. ANSWER NO 8 = 1.
ANSWER NO 9 = 2; ANSWER NO 10 = 2; ANSWER NO 11 = 3.
12. A 19-year-old Division 1 basketball student athlete sustains a Jones fracture, zone II injury of the
proximal fifth metatarsal. No prior injury has occurred and he has no prodromal symptoms. The
patient stands at 6’4”, weighs 215 lb, and plays small forward. What is the best next step?
1. Non–weight-bearing cast for 6 weeks, then boot for 6 weeks, with rehabilitation and redshirt
season
2. Non–weight-bearing cast for 6 weeks, then boot, rehabilitation, with return to sports in 12
weeks if pain free
3. Percutaneous intramedullary screw fixation
4. Open reduction and internal fixation with plating with autologous bone grafting
DISCUSSION
Because of the potential for nonunion and delayed return to sports with nonsurgical care, surgical
treatment is accepted as standard for athletes to minimize potential time lost to slow or delayed
healing process. Intramedullary screw placement is associated with a predictable healing rate with
minimal soft-tissue complication and is advocated as the primary surgical intervention for this

fracture. Some advocate improving the biological environment and healing potential of the fracture
with bone marrow aspirate concentrate, which can be injected at the fracture site. No literature
supports autologous bone grafting with plating for the treatment of acute Jones fractures.
ANSWER = 3.
13. A 20-year old man sustains a twisting injury resulting in ankle pain and the inability to bear weight.
Radiographs reveal a posterior malleolus fracture, wide syndesmosis, and proximal fibula fracture.
To minimize the risk of malreducing the fibula in the incisura, the surgeon must
1. obtain a preoperative CT scan to identify bone interposition.
2. orient the reduction forceps in line with the anatomic axis of the ankle.
3. fix the syndesmosis before addressing the posterior malleolus.
4. use rigid fixation across the syndesmosis.
DISCUSSION
Studies show that a high percentage of syndesmosis injuries are fixed with the fibula poorly
reduced in the incisura. In cadaveric studies, orienting the clamps along the anatomic axis of the
ankle results in the best reduction. Recent studies have suggested that flexible fixation and later
removing the fixation results in improved position of the fibula in the incisura. Fixation of the
posterior malleolus can stabilize the syndesmosis without requiring syndesmotic fixation and the
potential for a malreduced joint. ANSWER = 2.

A 45-year-old woman is referred to you for evaluation of forefoot pain. She relays a history of
pain and numbness radiating into the third and fourth toes. Examination confirms the diagnosis
with a positive Mulder’s click.
14. What is the most likely pathologic finding in the resected specimen?
1. Endoneural fibrosis
2. Perineural hemorrhage
3. Rheumatoid nodules
4. Neural necrosis
15. After failure of appropriate non-operative management, you elect to proceed with surgical
intervention. Which approach will most likely result in an unsatisfactory outcome?
1. Neuroma resection through a dorsal approach
2. Neuroma resection through a plantar approach
3. Metatarsal shortening osteotomy with release of the intermetatarsal (IMT) ligament

4. Isolated IMT ligament release
DISCUSSION
Morton’s neuromas are a common cause of forefoot pain. They are caused by an entrapment
neuropathy of the digital nerve in the web space. Histologically, perineaural and endoneural
fibrosis are both present. Surgically, the IMT ligament is most commonly released and the
neuroma is resected. This can be done through a dorsal or plantar approach. The plantar approach
is typically reserved for revision cases but can be used in primary cases as well. Studies show that
isolated release of the IMT ligament is not appropriate because of the high rate of continued
postoperative pain, thought to be the result of irreversible changes that have already occurred in
the nerve. NO 14 ANSWER = 1; NO 15 ANSWER = 4.
16. A 25-year-old student has foot pain and swelling after being tackled while playing football. He
was unable to continue playing that day and non–weight-bearing radiographs were reported to be
normal. The examination shows moderate swelling and diffuse tenderness at the forefoot. Plantar
ecchymosis is noted in the midfoot. What is the best next step?
1. Six weeks of protected weight bearing in a boot
2. Weight-bearing radiographs of both feet
3. Referral to physical therapy
4. Continued crutches and repeat evaluation in 2 weeks
DISCUSSION
The patient has a history and examination concerning for an injury to the tarsometatarsal, or Lisfr
anc, joints, especially given the findingof plantar ecchymosis. Although the radiographs are unre
markabe, they are also nonweight bearing and may not show instability.Forthis reason, additional
imaging is indicated. Weightbearing radiograph can demonstrate instability of the Lisfranc joint.
MRI would bean appropriate test if weightbearing radiographs do not demonstrate instability.
Protected weight bearing or physical therapy is not
indicated because a midfoot injury has not been ruled out.
Repeating a clinical evaluation in 2 weeks may only delay diagnosis. ANSWER = 2.
17. Figure 1 is the AP radiograph of a 59-year-old woman with chronic plantar medial pain referable
to the first metatarso-sesamoidal joint of her right foot for which she subsequently underwent
corrective surgery. Figure 2 is the postoperative AP radiograph. What progressive forefoot
deformity may arise secondary to the selected surgical procedure?

1. Metatarsus primus elevatus
2. Metatarsus atavicus
3. Hallux varus
4. Hallux valgus
DISCUSSION
Surgical medial sesamoidectomy can lead to the development of hallux valgus deformity.
Metatarsus primus elevatus refers to fixed dorsal inclination of the first metatarsal in relation to
the lesser metatarsals, whereas metatarsus atavicus describes relative shortness of the first
metatarsal compared with the adjacent second metatarsal length. Excision of the lateral sesamoid
may predispose to hallux varus deformity. ANSWER = 4.

Figures 1 through 3 are the radiographs of a 45-year-old woman who had a misstep and noted
severe onset pain and deformity in the left lower extremity. The pain is isolated to the left ankle
without other limbs affected. A CT scan was performed before reduction and is shown in Figures
4 and 5. Examination demonstrates a closed injury with a clear deformity of the left ankle. The
patient is neurovascularly intact.
18. Reduction of the ankle was attempted with sedation in the emergency department without success.
What is the best next step to obtain a reduction?

1. Repeat closed reduction under general anesthesia
2. Closed reduction with placement of external fixator
3. Open reduction through a posterolateral approach
4. Open reduction through an anterolateral approach
19. Reduction and fixation of the posterolateral tibial fragment is associated with :
1. superior syndesmotic stability compared with syndesmotic screw fixation.

2. worse functional outcomes compared with no fixation.
3. malreduction of the distal tibio-fibular joint.
4. posteromedial talar subluxation
20. The most effective interval utilized to reduce and fixate the posterior malleolus is between the
1. posterior tibial tendon and flexor hallucis longus.

2. peroneal tendons and flexor hallucis longus.
3. peroneal tendons and posterior tibial tendon.
4. flexor digitorum longus and peroneal tendons.

21. Postoperative AP and lateral radiographs are shown in Figures 6 and 7. The patient is able to
ambulate without pain. However, she has limited range of motion compared with her contralateral
lower extremity. What is the most common arc of motion that is limited following this fracture
pattern with posterior fixation?
1. Inversion
2. Eversion
3. Dorsiflexion
4. Plantarflexion
DISCUSSION
The patient suffered a Bosworth fracture dislocation with fixed dislocation of the fibula on the
posterolateral tibial ridge. Additionally, the patient has both a posterolateral and a posteromedial
tibial fracture, which some have termed a “posterior pilon”. The initial radiographs reveal posterior
subluxation of the talus with associated posterior subluxation of the fibula without significant
coronal plane deformity. This deformity should raise the suspicion of a Bosworth fracture-
dislocation, especially if closed reduction is not successful. In this situation, the only effective
method to reduce the fracture is through an open posterolateral approach with the interval between
the flexor hallucis longus and the peroneal tendons. This is the same approach that is utilized for
fixation of the posterolateral fragment and fibula.
In cases of posterior malleolar involvement, fragment size >25% is associated with mechanical
instability of the joint and requires surgical reduction and fixation. However, studies have clearly
determined that syndesmotic reduction and stability is improved with direct reduction and fixation
of the posterior malleolus compared with syndesmotic fixation alone. A >2-mm stepoff or loss of
articular surface is associated with worse functional outcomes at 1 year compared with the
outcomes of patients who had anatomic reduction of the joint. This was independent of the size of
the posterior malleolar fragments. Postoperatively, despite anatomic reduction, loss of dorsiflexion
has been noted compared with the contralateral lower extremity. In rare cases, tethering of the
flexor hallucis longus can occur as well. In summary, posterior malleolar fracture fixation should
be based on whether an anatomic reduction of the fragments can be achieved, as opposed to making
the decision based solely on the size of the fragments. Fixation of the posteromedial fragment can

be done through the posterolateral approach (flexor hallucis longus and peroneals), thus avoiding
two posterior incisions. NO 18 ANSWER = 3; NO 19 ANSWER = 1; NO 20 ANSWER = 2;
NO 21 ANSWER = 3.
(No. 22 – 25) For the clinical scenarios described, please choose the appropriate surgical
procedure.
1. Uniplanar distal metatarsal osteotomy

2. Proximal metatarsal osteotomy
3. First metatarsal cuneiform arthrodesis
4. Arthrodesis first metatarsal phalangeal joint
5. Resection arthroplasty
6. Double metatarsal osteotomy
22. Figure 1 is the AP radiograph of an 18-year-old woman with a painful medial first metatarsal
phalangeal joint aggravated by activity. She has a strong family history of bunions. The medial
joint is tender to palpation, but there is little pain with range of motion.
23. Figure 2 is the AP radiograph of an 18-year-old man with a painful medial first metatarsal
phalangeal joint and deformity. He has a history of cerebral palsy that has been managed with
bracing and therapy. The medial joint is tender to palpation, but there is no pain with range of
motion.

24. Figure 3 is the AP radiograph of a 45-year-old woman with a painful medial first metatarsal
phalangeal joint and a progressively worsening deformity. The medial joint is tender to palpation
but there is little pain with range of motion. Piano key stress of the first metatarsal is painful.
25. Figure 4 is the AP radiograph of a 45-year-old woman with a painful medial first metatarsal
phalangeal joint and a progressively worsening deformity. The medial joint is tender to palpation,
but there is little pain with range of motion. Piano key stress of the first metatarsal is not painful
and the joint does not have excessive motion.
DISCUSSION
A broad array of surgical treatment options for hallux valgus are available, with multiple options
for almost any specific case. Even conventional wisdom on the limits of some procedures has been
challenged by more recent studies. The clinical scenarios presented are specific cases with

indications for the listed procedures. The first is a juvenile bunion with a congruent joint on
radiographs. A procedure that corrects both the intermetatarsal angle (IM) and distal metatarsal
articular angle is appropriate. Of the listed procedures, only the double metatarsal osteotomy
addresses both corrections. For the patient with cerebral palsy, fusion of the metatarsal phalangeal
joint is recommended because of the high rate of recurrence after hallux valgus procedures when
neuromuscular disease is present. For the patient with pain with stress of the first tarsometatarsal
joint (TMT) and subluxation of the first TMT on radiographs, a fusion of the first TMT is indicated.
The final patient for discussion has a severe bunion with an IM angle of >16°. Recent studies report
the inability of a distal metatarsal osteotomy to address a lesion of this magnitude, and the first
TMT fusion is frequently used to address severe bunions, but generally, with no pathology at the
TMT joint, a proximal joint-sparing osteotomy is recommended. ANSWER NO 22 = 6;

Figures 1 and 2 are the lateral and AP radiographs of a 34-year-old woman who has ankle pain
with a significant history of prior syndesmotic injury requiring syndesmotic fusion. Examination
is consistent with tenderness to palpation along the anterior aspect of the ankle without any pain
along the subtalar or talonavicular joints. Range of motion is noted as 0° of dorsiflexion and 9° of
plantarflexion with pain, 5° of inversion, and 10° of eversion. The patient has undergone a
lidocaine and corticosteroid injection with temporary relief of pain. No other intervention has taken
place.
1. Physical therapy
2. Platelet-rich plasma injection
3. Gauntlet ankle brace
4. Hinged ankle-foot orthosis (AFO)
27. Further nonsurgical treatment has failed to provide relief to the patient. What is the most
appropriate surgical intervention?
1. Anterior cheilectomy

2. Ankle arthrodesis
3. Total ankle arthroplasty (TAA)
4. Bipolar allograft ankle arthroplasty
28. After ankle arthrodesis, the most common long-term complication, despite successful arthrodesis
of the tibiotalar joint, is arthrosis of which joint?
1. Talonavicular
2. Knee
3. Calcaneocuboid
4. Subtalar
29. The patient would like to understand what function she would be able to achieve following a TAA.
Based on gait-analysis studies, compared with the contralateral normal lower extremity, the patient
should be counseled that following a successful TAA, she will be able to achieved
1. increased range of motion and increased power.

2. increased range of motion with decreased power.
3. decreased range of motion with increased power.
4. decreased range of motion and decreased power.
DISCUSSION
Ankle arthritis is most commonly secondary to trauma, which can complicate treatment in
younger, more active patients. This patient had a prior injury to the ankle that required a
syndesmotic fusion. The clinical symptoms, examination, and radiographs are consistent with
ankle arthritis. Regardless of patient age, the most appropriate nonsurgical intervention to
minimize the symptoms for the patient is a gauntlet ankle brace, also known commercially as an
Arizona brace, which immobilizes the ankle and hindfoot, minimizing the pain. Physical therapy
may worsen the pain and is not indicated. Platelet-rich plasma injections have not proven to be
effective. A hinged AFO would not immobilize the ankle joint.
At 34-years-old, the patient would be considered young to undergo a TAA. A definitive age cutoff
does not exist; each patient should be individually evaluated. However, the risk of multiple
revisions is high in this age group, and a replacement would be considered a higher risk option. In
this patient, with limited range of motion of the ankle (<10°), without preexisting adjacent joint
disease and without a contralateral ankle fusion, the most appropriate surgical option is an
arthrodesis. Allograft ankle replacement can be considered; however, the results have not been
consistent and at this time, it is not considered a first-line treatment. TAA is more ideal in an older
(age, >55 years) patient, with minimal coronal plane deformity (<10°), good preoperative range of
motion (>10°), preexisting subtalar or talonavicular degenerative joint disease, or with a
contralateral fusion. Anterior cheilectomy of the joint does not solve the existing arthritic condition

and can result in worsening pain with anterior translation of the talus. ANSWER NO 26 = 3;
30. Figures 1 and 2 are the T1- and T2-weighted MR images of a 38-year-old woman who twisted her
ankle playing volleyball. She was unable to bear weight for 3 days. Management by her primary
care physician for an ankle sprain included using an elastic ankle brace and undergoing physical
therapy for 12 weeks. She continues to have pain and instability with ambulation, aggravated by
uneven terrain and pivoting, and has a popping sensation with severe pain up to 3 times a day.
What is the best next step?
1. Surgical peroneal retinaculum repair

2. Surgical lateral ligament reconstruction
3. Arthroscopic treatment of osteochondral lesion
4. Cast immobilization for 6 weeks
DISCUSSION
Acute peroneal retinaculum rupture with subluxation of the peroneal tendons is an uncommon
injury commonly mistaken for an ankle sprain. The MR images show that the peroneus longus is
anterolateral to the fibula. The contour of the posterior fibula shows a shallow concave groove.
For low-demand patients with an acute dislocation, casting with the foot inverted is recommended.
In high-demand patients, or those with symptomatic chronic dislocations, surgical repair of the
retinaculum is recommended. Some authors have advocated a groove-deepening procedure to
enhance the stability of the tendons. The lateral ligament reconstruction uses either the allograft or
autograft tendon to stabilize the talus in the mortise. Surgical indications typically include
objective evidence of talar tilt or anterior subluxation on stress. The MR images do not demonstrate
an osteochondral lesion to address with an arthroscopy. The patient is neither low demand nor
acute, so cast immobilization is unlikely to be effective. ANSWER = 1.
31. Figures 1 through 3 are the AP and lateral radiographs of a 55-year-old man who has a painful first
metatarsophalangeal (MTP) joint. What is the best treatment?

1. Implant resurfacing arthroplasty
2. MTP arthrodesis
3. Cheilectomy
4. Interposition graft arthroplasty with platelet-rich plasma
DISCUSSION
Arthrodesis remains the benchmark standard surgical option for end-stage arthritis of the great toe
MTP joint, regardless of age or activity level. Cheilectomy for dorsal osteophyte resection can
improve shoe wear limitation but will not reliably improve pain or increase joint motion. Joint
arthroplasty retains some joint motion, but at the expense of metatarsal shortening, which may
cause transfer metatarsalgia and impose problematic salvage fusion because of bone loss, if
unsuccessful. Synthetic or any optional cartilage substitute appears to be favorable, with pain relief
and retained motion, but no long-term outcomes have been reported. Lastly joint arthroplasty with
interposition tendon graft yields pain relief with retention of some motion, but robust studies have
not been reported. ANSWER = 2.
32. Figures 1 and 2 are the clinical photographs of a 70-year-old diabetic patient with recurrent
callusing and activity-related pain over the tip of his third digit. In addition to pain, he had localized
cellulitis that was treated with a short course of oral antibiotics 4 months ago. He has partial
improvement with extra-depth shoes, padding, and recessed orthotics. He takes insulin (HbA1c
level, 7.2) and underwent a partial hallux amputation for infection 1 year ago. Radiographs are
unremarkable. Pulses are present. The skin is intact. His toe deformity is passively correctable.
Ankle range of motion shows 15° of dorsiflexion. What is the best next step?

1. Partial digital amputation through the middle phalanx
2. Achilles tendon lengthening
3. Percutaneous flexor tenotomy
4. Clawtoe correction with proximal interphalangeal joint fusion
DISCUSSION
This patient has a clawtoe deformity in the setting of diabetes and previous partial hallux
amputation. Despite appropriate shoe modifications, he has continued pain, and the toe is at risk
for ulceration and infection. Amputation would be an appropriate choice only in the setting of
active infection or ulceration. The patient does not have an Achilles contracture; therefore, a
lengthening procedure would also not be indicated. A clawtoe deformity correction is reserved for
rigid deformities. In addition, this option has more surgical risks in the setting relative to a flexor
tenotomy. The flexor tenotomy can be used to improve the deformity and subsequently decrease
the contact pressure in this area. ANSWER = 3.
(Case Vignette NO. 33 – 38)

Figures 1 and 2 are the weight-bearing AP and lateral radiographs of a 55-year-old woman who
has had progressive pain and deformity in her bilateral feet for several years. She had surgeries in
the remote past for the same problem.

33. What tendon may be contributing to the recurrence of deformity and may need to be released to
correct the deformity?
1. Abductor hallucis
2. Adductor hallucis
3. Flexor hallucis longus
4. Extensor hallucis longus
34. The patient has tried shoes with a wider toe box, pads and spacers, and NSAIDs without relief. In
planning for surgery, which is the best description of the deformity in her right foot?
1. Congruent metatarsophalangeal (MTP) joint, stable first tarsometatarsal (TMT) joint

2. Congruent MTP joint, unstable first TMT joint
3. Incongruent MTP joint, stable first TMT joint
4. Incongruent MTP joint, unstable first TMT joint
35. Assuming that the patient clinically does not have significant arthritic pain in the MTP joint, the
deformity would be best managed with which procedure?
1. Hallux MTP joint fusion

2. First TMT fusion (Lapidus)
3. Hallux proximal phalanx osteotomy
4. Distal chevron metatarsal osteotomy
36. The nerve most commonly injured during hallux valgus correction is a branch of which nerve?
1. Deep peroneal nerve

2. Superficial peroneal nerve
3. Saphenous nerve
4. Tibial nerve

37. What is the best early radiographic predictor of eventual recurrence of the hallux valgus deformity
after correction of hallux valgus?
1. Sesamoid position
2. Meary’s angle
3. First metatarsal declination
4. Distal metatarsal articular angle
38. The patient initially does well but is then lost to follow-up. Two years later, she has a varus
deformity of the great toe and difficulty with shoe wear. On examination, the joint is stiff and has
crepitus with motion. What is the best next step?
1. Revision hallux valgus correction

2. Hallux varus correction with extensor digitorum brevis (EDB) transfer
3. Proximal phalanx osteotomy
4. Hallux MTP joint fusion
DISCUSSION
Hallux valgus deformities are among the most common foot complaints that bring patients to a
surgeon’s office. The stability of the hallux depends on a host of static and dynamic stabilizers.
Although all of the muscles referenced in the first question play some role in the stability of the
hallux MTP joint, the adductor hallucis attaches to the base of the proximal phalanx and is often
part of the first web space release (along with the sesamoid suspensory ligament and the first MTP
capsule). The radiographs show a clearly incongruent MTP joint, and medial translation and
plantar gapping of the first tarsometatarsal joint is also seen, indicating instability.
In cases of severe hallux valgus deformities, a proximal procedure gives the best and most durable
correction. Particularly in the setting of first TMT instability, a Lapidus procedure (first TMT
fusion) is the best surgical option. Multiple studies show that maintenance of correction long term
requires being certain that the sesamoids are well-reduced at the time of the initial surgery. At the
time of bunion surgery, the medial eminence incision puts at risk the dorsomedial cutaneous nerve,
a branch of the superficial peroneal nerve. It is commonly injured and must always be protected
during this portion of the procedure.
Hallux varus is fortunately an uncommon complication of bunion surgery. Several tendon transfers
that can correct the deformity are available for cases that are recognized early and without arthritic
complications. After the joint becomes arthritic, a hallux MTP fusion is the best method of
correction. ANSWER NO 33 = 2; ANSWER NO 34 = 4; ANSWER NO 35 = 2; ANSWER NO
36 = 2; ANSWER NO 37 = 1; ANSWER NO 38 = 4.

39. Figures 1 and 2 are the sagittal and axial the axial T2-weighted MR images of a 59-year-old man
with 18-month history of chronic Achilles tendinosis that has been treated nonsurgically. He is
now requesting surgical intervention for his condition. What is the most appropriate treatment for
the Achilles tendon?
1. Percutaneous repair
2. Open debridement
3. Open debridement and tendon transfer
4. Open debridement and calcaneal ostectomy
DISCUSSION
Surgical treatment for severe chronic Achilles tendinopathy includes tendon debridement and
repair procedure, with reconstruction surgery (tendon transfer) used in the setting of large residual
Achilles defect. Local tendon transfers most commonly and effectively use the flexor hallucis
longus, although the flexor digitorum longus; peroneus brevis; and the plantaris are options if
necessary. Calcaneal ostectomy is done for insertional tendinopathy and Haglund’s deformity.
ANSWER = 3.
40. Figures 1 and 2 are the AP and lateral radiographs of a 45-year-old laborer who sustained a distal
tibia-fibula fracture and underwent open reduction and internal fixation 6 months ago. Medical
history shows hypertension and a history of low back pain. Incision healing was uneventful after
surgery. She began weight bearing 8 weeks after surgery. Since that time, she has persistent
activity-related pain and swelling at the fracture site. There is tenderness in these areas, but no
erythema or warmth. A laboratory workup is likely to show

1. elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
2. elevated thyroid-stimulating hormone (TSH).
3. low vitamin D (25(OH).
4. decreased parathyroid hormone.
DISCUSSION
The patient has a nonunion of a distal tibia fracture. Several studies have shown a relatively greater
percentage of low vitamin D in patients with nonunion, especially of lower extremity fractures.
CRP and ESR may be elevated with infection, but no indication is given that suggests infection in
this patient. In addition, the rate of infection is lower than the rate of low vitamin D. Parathyroid
hormone and TSH are also metabolic reasons for nonunion, but they have a much lower
incidence. ANSWER = 3.

Figures 1 and 2 are the AP and lateral radiographs of a 47-year-old diabetic man with a 1-month
history of wounds on the left foot, who is admitted for draining wounds. He is hemodynamically
stable, and his vitals are normal with a maximum temperature of 37.9°C. His pain is controlled
with intermittent morphine. Laboratory studies show a high white blood cell count of 16,000 /µL,
low hemoglobin level of 8.6 g/dL, high C-reactive protein level of 140 mg/L, low sodium 127
mmol/L, creatinine level of 50 µmol/L, and high serum glucose level of 8.3 mmol/l. On physical
examination, the patient’s leg is erythematous to the knee, he is tender to palpation from the knee
to the foot, there is purulent discharge from multiple wounds on the plantar foot, and ankle
plantarflexion strength is minimal.

41. The clinical findings are most consistent with what diagnosis?
1. Cellulitis
2. Abscess
3. Necrotizing fasciitis
4. Septic arthritis

1. MRI to evaluate for osteomyelitis
2. CT scan to evaluate for abscess

3. Observation for changes in clinical picture
4. Emergent surgical debridement
43. What is the most common result for the culture of the purulent material?
1. Staphylococcus aureus
2. Group A streptococcus
3. Streptococcus viridans
4. Polymicrobial
DISCUSSION
The initial stages of necrotizing fasciitis can resemble cellulitis. However, rapid deterioration of
the patient may occur and early aggressive surgical debridement decreases mortality. Group A
streptococcus is one of the most prevalent organisms, but infections are typically polymicrobial.
Diagnosis of necrotizing fasciitis is typically clinical. Imaging studies can assist with the

diagnosis, but advanced imaging takes valuable time and should not delay emergent surgical
debridement. The incidence of gas in the subcutaneous tissues is only 13%, but its presence should
trigger urgent debridement. ANSWER NO 41 = 3; ANSWER NO 42 = 4; ANSWER NO 43 =
4.
44. What joint-sparing procedure most effectively corrects midfoot abduction associated with flatfoot
deformity?
1. Medial cuneiform osteotomy
2. Lateral column lengthening
3. Flexor digitorum longus transfer
4. Medial displacement calcaneal osteotomy
DISCUSSION
Midfoot abduction in flatfoot deformity resulting from posterior tibialis tendon dysfunction is
primarily a transverse plane deformity; lateral column lengthening with either opening wedge
osteotomy of the anterior calcaneus or distraction arthrodesis of the calcaneocuboid joint will
provide the most correction. Medial cuneiform opening wedge osteotomy is done dorsally to
correct fixed forefoot supination in flatfoot deformity. Flexor digitorum longus tendon transfer is
necessary to maintain balance of the tendons around the midfoot but is not durable without
supplemental bony procedures. Medial displacement calcaneal osteotomy improves midfoot
abduction somewhat, but not as effectively as lateral column lengthening. ANSWER = 2.
45. Figures 1 and 2 are the lateral and AP radiographs of a 30-year-old heavy laborer who fell from a
ladder at 6 feet and has isolated foot and ankle pain. Past medical history includes smoking and
diabetes (HbA1c level, 6.8). Examination shows deformity with mild edema and ecchymosis.
Sensation and pulses are intact. Wrinkle sign is also present. What is the best next step?
1. Closed reduction and casting

2. Closed reduction and pinning

3. Open reduction and internal fixation (ORIF) through lateral incision
4. ORIF through medial and lateral incisions
DISCUSSION
The radiographs show a displaced talar neck fracture in a young patient. Even in light of the
patient’s risk factors (diabetes, smoking), ORIF should be considered. Nonsurgical management
would likely lead to malunion or nonunion. Surgical treatment typically consists of both medial
and laterally-based incisions to avoid varus malreduction that is often seen as a result of
comminution medially. The patient should be counseled on smoking cessation and diabetes
management, as well as the increased risks these factors present for management of this injury.
ANSWER = 4.
46. Figures 1 and 2 are the AP and lateral radiographs of a 6-year-old boy who has had 2 weeks of
intermittent right foot pain that does not interfere with most activities. On examination, the patient
has pain and tenderness to palpation over the dorsomedial aspect of the foot. No significant
deformities of the foot are noted. What is the best next step?
1. Vascularized bone grafting of navicular

2. Open reduction and internal fixation of the navicular
3. Non-weight-bearing cast for 6 weeks
4. Activity modification with soft arch supports
DISCUSSION
Kohler's disease is a rare, self-limiting, osteonecrosis of the navicular bone. It affects boys more
than girls and typical age of onset is between 4 and 5 years. The etiology is thought to be related
to the mechanical compression of the navicular from the ossified talus and cuneiforms because the
navicular is the last tarsal bone to ossify. This mechanical effect compresses the navicular bone's

perichondral ring of blood vessels, resulting in ischemia of the central spongy bone and
osteonecrosis. The prognosis remains excellent because of this radial arrangement of blood supply.
Radiologic findings show patchy areas of navicular with sclerosis, with loss of normal trabecular
pattern. Occasionally, the navicular may appear collapsed or may simply have increased density
with minimal fragmentation. Management includes pain control and use of soft arch supports or a
medial heel wedge. Patients with disabling symptoms may benefit from a short-leg walking cast
for 4 to 6 weeks. Symptoms in untreated patients persist longer than symptoms in treated patients.
Because this is a self-limited process, treatment does not affect the course of the disease. Patients
with persistent pain should be examined for other conditions such as talar coalition. ANSWER =
4.

A 50-year-old woman has insidious pain localized to her plantar forefoot that began 3 months ago.
She reports that the pain occasionally radiates into her second and third toe and is associated with
numbness of these digits. The pain worsens with walking and is relieved with rest.
47. What physical examination finding, if present, may help to confirm the correct diagnosis in this
patient?
1. Presence of a second hammertoe
2. Presence of gapping of the second and third toe
3. Second metatarsophalangeal tenderness
4. Pain with forefoot compression while palpating the second web space
48. Nonsurgical management of the patient’s problem should consist of

1. physical therapy.
2. use of wide toe box shoe and metatarsal pad.
3. serial alcohol injections.
4. serial corticosteroid injections.
49. Which intervention is most likely to result in long-term pain relief for the patient’s condition?
1. Intermetatarsal [IM] ligament release
2. Excision of the second IM nerve
3. Gastrocnemius recession
4. Second plantar plate repair
50. What is the most common complication of primary surgical treatment of this problem?
1. Persistence of pain as a result of inadequate resection

2. Instability of the metatarsophalangeal joint
3. Devascularization of the digit
4. Wound dehiscence
DISCUSSION
Morton’s neuroma is an entrapment neuropathy of the interdigital nerve in the forefoot. It is most
commonly seen in women in the 6th decade of life. Patients typically have pain in the plantar
forefoot that is exacerbated by walking. The most consistent examination finding is tenderness of
the involved web space, with an occasional palpable Mulder click. MRI, ultrasonography, and
diagnostic lidocaine injections are occasionally helpful in confirming the diagnosis. Nonsurgical
management should consist of using flat shoes with a wide toe box shoe and metatarsal pad.
Corticosteroid injections have not been shown to provide long-term relief of pain for this condition
but may provide short-term improvement. Serial corticosteroid injections cause local tissue
atrophy. Alcohol sclerosing injections of the web space have been advocated by some; however,
because of the lack of long-term clinical results and risk to surrounding tissues, they are not
recommended. Excision of the offending interdigital nerve, provides more reliable results than
release of the transverse metatarsal ligament. The most common complication of surgical excision
is persistence or recurrence of pain related to inadequate excision of nerve tissue and resultant
stump neuroma formation or pain resulting from inadvertent excision of the digital artery or
lumbrical tendon instead of the interdigital nerve. ANSWER NO 47 = 4; ANSWER NO 48 = 2;
ANSWER NO 49 = 2; ANSWER NO 50 = 1.
51. Figures 1 and 2 are the lateral and AP radiographs of a 50-year-old woman who has an insidious-
onset, 2-week history of progressive ankle pain and swelling that is worsened with ambulation and
which improves with rest. Examination shows mild swelling and warmth isolated to the distal leg
with diffuse tenderness. The calf is soft and nontender. Ankle range of motion appears symmetric
to the contralateral side. Sensation to light touch and motor are grossly intact, and the patient has
palpable pulses. The patient's medical history is remarkable for a 35-year history of type I diabetes,
hypertension, vision loss, renal insufficiency, and hypothyroidism. In addition to follow-up in 1
week, what is the best next step?
1. Walking boot and referral for physical therapy

2. Joint aspiration

3. Immobilization and non-weight bearing
4. 5-day course of oral methylprednisolone
DISCUSSION
The physician should be concerned about a stress fracture, as well as neuroarthropathy. Immediate
management of a known or suspected Charcot joint or stress fracture must include non-weight
bearing. The patient does not have a known history of neuropathy; however, she does have a long
history of diabetes with end-organ manifestations (renal disease and retinopathy). The use of light
touch on examination, particularly with the patient not blinded to testing, is not adequate to ensure
intact protective sensation. Because range of motion is not affected, it is unlikely a joint aspiration
will be of any utility. Oral steroids or nonsteroidal anti-inflammatory drugs would be
contraindicated for a number of reasons (kidney disease, diabetes) in this setting. ANSWER = 3.
52. Figure 1 is the lateral radiograph of a 60-year-old woman who was stepping off a step stool when
she felt a pop in the back of her foot. She was evaluated in the emergency department and was
noted to have pain in the left heel with minimal swelling; blanching of skin posteriorly; no
ecchymosis, and ankle motion was limited by pain with dorsiflexion. What is the best next step?
1. Immediate surgical reduction

2. Well-padded splint in neutral
3. CT scan to evaluate fracture
4. Serial neurovascular examination
DISCUSSION
Avulsion and tongue-type calcaneus fractures are uncommon and represent <15% of calcaneus
fractures. This type of fracture can lead to compromise of the posterior skin. Although no study
advocates a specific timing for surgery, recognizing the blanching skin as placing the soft-tissue
envelope at risk is an important step with fractures of this type. The fracture should be urgently
reduced if the bone prominence is impinging on the skin. In this patient, the blanching skin
indicates tension from the underlying displaced bone. The risk factors for skin compromise include
mechanism other than a fall, larger displacement, and smoking. Skin compromise is seen in 20%
of patients with tongue-type fractures. ANSWER = 1.

Figures 1 through 3 are the AP and lateral radiographs of a 56-year-old man with gradually
increasing pain, swelling, and stiffness of the left big toe for 2 years. There is no history of trauma,
systemic arthritis, or smoking. The first metatarsophalangeal joint dorsiflexion is limited to 15°
and plantarflexion to 10° with pain.
53. What is the most likely diagnosis?
1. Hallux valgus
2. Hallux rigidus
3. Psoriatic arthritis
4. Rheumatoid arthritis
54. What is the most effective nonsurgical treatment to relieve the patient’s symptoms?
1. Cortisone injection
2. Walking cast
3. Morton’s extension pedorthic
4. Rocker bottom shoes
55. Which surgical procedure will result in the highest percentage of successful outcomes?
1. Cheilectomy
2. Capsular interpositional arthroplasty

3. Total joint arthroplasty
4. Arthrodesis

DISCUSSION
A history of gradually increasing stiffness in the big toe without trauma combined with limited
painful dorsiflexion is the hallmark of hallux rigidus. In hallux valgus, deformity is more
conspicuous with relatively preserved motion, and radiographs typically show narrowing and
sclerosis of the joint with large osteophytes. Rheumatoid arthritis is typically indicated by
subchondral cyst formation with osteopenia. The most reliable nonoperative management is a
Morton’s extension pedorthosis. Although a rocker bottom shoe compensates for loss of
dorsiflexion; assists in toe off during gait; and provides considerable pain relief, it is not tolerated
well by patients. Cheilectomy provides excellent range of motion when <50% of the articular
cartilage is lost. Otherwise, arthrodesis provides excellent sustained pain relief. Capsular
interpositional arthroplasty has mixed results. Silastic and metal replacement arthroplasties have
high long-term failure rates. ANSWER NO 53 = 2; ANSWER NO 54 = 3; ANSWER NO 55 =
4.
56. Figure 1 is the clinical photograph of a 42-year-old woman with type 2 insulin-dependent diabetes
who has a 1-week history of redness and swelling along the forefoot. The patient has been admitted
to the hospital and is stable and afebrile on intravenous (IV) antibiotics. Her erythrocyte
sedimentation rate is 70 mm/h (reference range [RR], 0 to 20 mm/h), C-reactive protein level is
5.4 mg/L (RR, 0.08 to 3.1 mg/L), white blood cell count is 11.5 (RR, 4,500 to 11,000 /µL), and
her albumin level is 1.5. The examination demonstrates an inability to sense a 5.07 Semmes-
Weinstein monofilament and 1+ dorsalis pedis and posterior tibialis pulses. What is the best next
step?
1. Observation on continued IV antibiotic treatment

2. Emergent transmetatarsal amputation
3. Urgent surgical debridement
4. Noninvasive arterial flow studies
DISCUSSION
This is a neuropathic diabetic patient who presents with a clear infection and abscess of the great
toe and surrounding tissue. The neuropathy is the primary cause of why diabetic patients do not
complain of pain and present with infections at late stage, with significant swelling. The
significance of the infection and soft-tissue damage may be worse than the patient’s subjective
symptoms suggest. The patient is currently on IV antibiotics, which is a common scenario in the

inpatient hospital setting. Antibiotic suppression of the infection and diabetic immunocompromise
commonly result in lack of a febrile response. The laboratory values, specifically the albumin level
of 1.5, suggest the patient is nutritionally compromised and does not have the ability to heal the
wound. Hypoalbuminemia (albumin, <3.5 g/dL) is an independent risk factor for infectious and
wound healing complications. Continued IV antibiotics is not appropriate because this course will
not definitively treat the abscess. Obtaining arterial blood flow studies should not delay surgical
debridement. The patient has 1+ palpable pulses. Emergent amputation is not appropriate at this
time because of the stable clinical scenario. In the unstable patient, emergent guillotine amputation
would be appropriate to eliminate the infectious source. ANSWER = 3.
57. Orthosis management of flexible adult flatfoot deformity resulting from posterior tibialis tendon
insufficiency should comprise
1. modified University of California Biomechanics Laboratory orthosis.
2. supramalleolar orthosis.
3. lateral heel flare shoe modification.
4. off-the-shelf insoles.
DISCUSSION
A supramalleolar brace, either a hinged, rear-entry brace (Toledo Brace™) or a reinforced gauntlet
brace (Arizona brace™) most effectively controls deformity, pain, and instability. A lateral heel
flare shoe modification may be helpful in mild cases but is rarely as effective or as durable as
bracing. Off-the-shelf insoles do not provide mechanical correction, control of the hindfoot, or
support of the posterior tibialis tendon. A solid ankle-foot orthosis provides excellent control of
the deformity but is unnecessarily restrictive. ANSWER = 2.
(No. 58-62) For each of the following scenarios, choose the appropriate surgical treatment.
The responses can be used multiple times.
1. Arthroscopic marrow stimulation

2. Single osteochondral autograft
3. Particulated juvenile cartilage allograft
4. Bulk talar allograft
5. Supermalleolar tibial osteotomy
6. Ankle fusion
7. Total ankle arthroplasty
58. Figures 1 through 3 are the AP and lateral MR images of a 26-year-old man who continues to
report medial ankle pain 6 months after an inversion injury.

59. A 40-year old woman reports medial ankle pain for 2 years. She is an avid tennis player. MR
images show a medial full thickness 8-mm diameter cartilage lesion with underlying cystic lesion.
60. Figure 4 is a T2-weighted MR image that shows the osteochondral lesion of the medial shoulder
of the talar dome of a 40-year-old man who has had ankle pain for 5 years. He is an active
outdoorsman, and his recreational time is spent in the mountains.
61. Figures 5 and 6 are the AP and lateral radiographs of a 45-year-old man who has had ankle pain
for 5 years. He works as a roughneck in the oil field. The radiographs show extensive degenerative
changes of the ankle with significant loss of medial joint space on standing radiographs.

62. Figures 7 and 8 are the AP and lateral radiographs of a 55-year-old woman with long-standing
rheumatoid arthritis who has ankle pain.
DISCUSSION
The choice of treatment for damage to the ankle joint surface depends on both the character of the
lesion and the demands placed on the joint. Arthroscopic marrow stimulation is generally
considered first-line treatment for an ankle lesion. ANSWER NO 58 = 1; ANSWER NO 59 = 2;
63. What noninvasive arterial study parameter is most predictive of complete healing of a successfully
debrided diabetic foot ulcer in a patient with nonpalpable pulses?
1. Monophasic toe pressures of 30 mm Hg
2. Triphasic toe pressures of 30 mm Hg
3. Ankle-brachial index of 0.3
4. Transcutaneous oxygen tension of 40 mm Hg
DISCUSSION
As the incidence and prevalence of diabetes increases, so does the burden of care in treating
diabetic foot wounds. It is not only imperative to know how to treat these wounds but also to know
if they have the ability to heal. Vascular disease is 30 times more common in patients with diabetes
than in those without. Acceptable levels for healing include toe pressure >40 mm Hg, or an ankle-
brachial index >0.45. Of note, in patients with monophasic wave forms as a result of calcified
vessels, artificially elevated pressures can be seen, and therefore, transcutaneous oxygen levels are
a better indicator of healing capacity. A transcutaneous oxygen tension of >30 mm Hg indicates
the potential for healing. ANSWER = 4.

A 43-year-old woman sustains multiple fractures including a closed displaced talar neck fracture
in a motor vehicle collision.
64. What is the best definitive treatment?
1. Open reduction and internal fixation (ORIF) emergently

2. Percutaneous fixation emergently
3. ORIF semi-electively when soft tissue allows

4. Nonsurgical management because of polytrauma
65. 43-year-old woman sustains multiple fractures including a closed displaced talar neck fracture in
a motor vehicle collision.
What is the incidence of osteonecrosis after displaced talar neck fracture without associated
dislocation?
1. 0% to 15%
2. 20% to 50%
3. 60% to 80%
4. 100%
DISCUSSION
No correlation has been found between osteonecrosis or posttraumatic arthritis and open fractures,
comminuted fractures, or timing of fixation. Despite expert opinion and results showing no
correlation between timing of fixation and development of osteonecrosis, urgent reduction is still
recommended for displaced talus fractures to minimize soft-tissue compromise. A study of 25
patients found delayed fixation did not affect the prevalence of osteonecrosis, and posttraumatic
arthritis was actually a more common complication following surgical treatment. Vallier and
associates reported that mean time to fixation was less for patients who developed osteonecrosis
(3 to 4 days) than for those who did not (5 days).
A few authors have fixed fractures definitively within 8 and 12 hours, reporting
low osteonecrosis rates (16% and 16.6%, respectively), but rates increased (33% and 32%,
respectively) with displaced, subluxed, or dislocated fractures. ANSWER NO 64 = 3; ANSWER
NO 65 = 2.
66. Figures 1 and 2 are the lateral radiograph and clinical photograph of a 65-year-old woman with
diabetes who is seen for a second opinion. Two years before, she underwent a partial foot
amputation for foot infection. Her incision healed uneventfully. Since that time, the patient has
been ambulatory for only short periods. She is limited by pain and develops callusing and
ulceration over the anterior lateral aspect of the foot. What aspect of her initial care and surgical
considerations could have prevented this complication?

1. Vascular workup including CT angiography
2. Home exercise program
3. Anterior tibialis tendon transfer
4. Excision of the talar neck and head
DISCUSSION
The patient underwent a Chopart amputation through the hindfoot and developed an equinus
contracture. This led to ulceration in this area or anterior skin insufficiency, a frequent
complication of the Chopart amputation that results from the unopposed pull of the Achilles. This
complication can be prevented with successful transfer of the anterior tibialis into the talus. The
patient does not have an indication of poor blood supply. The patient’s symptoms and examination
are purely a mechanical phenomenon. In addition, the incision healed uneventfully after her first
surgery. Lengthening the Achilles may help prevent an equinus deformity; however, if done in
isolation, the patient will still have an unopposed muscle group, resulting in equinus. Without the
forefoot present as a lever arm, home exercise programs are unlikely to prevent contracture.
Excision of the talar head and neck would shorten the lever arm for the anterior tibialis transfer,
effectively weakening the effect of the transfer. ANSWER = 3.
67. A 45-year-old man has had 6 weeks of pain, worse with exercise, in the distal Achilles tendon
proximal to the insertion. What kind of physical therapy is most effective in treating this issue?
1. Concentric strengthening
2. Eccentric strengthening
3. Hydrotherapy
4. Electric stimulation
DISCUSSION
Eccentric strengthening has been shown in multiple studies to be more effective than other
nonsurgical management options for midsubstance Achilles tendinopathy. Eccentric therapy

involves loading the ankle into dorsiflexion, thought to stimulate increased type 1 collagen
synthesis, which helps repair the damaged tendon. ANSWER = 2.

Figures 1 through 3 are the standing AP and lateral non-weight-bearing oblique radiographs of a
53-year-old woman with a history of progressive left medial hindfoot pain and worsening
pronation of the foot. Physical examination reveals asymmetric hindfoot valgus, inability to
perform a single limb heel raise, full subtalar motion, passive dorsiflexion to -5° with the subtalar
joint reduced to neutral and flexible forefoot supination that corrects to neutral in plantar-flexion.
68. In addition to a deficient tibialis posterior tendon, what other structure is likely attenuated in this
patient?
1. Peroneus longus tendon

2. Spring ligament
3. Deltoid ligament
4. Flexor digitorum longus tendon
69. Reconstruction of the deformity would include transfer of the flexor digitorum longus tendon and
1. first tarsometatarsal arthrodesis.

2. medial displacement calcaneal osteotomy.
3. lateral column-lengthening calcaneal osteotomy.
4. naviculocuneiform arthrodesis.

70. After correction of the hindfoot alignment, the ankle cannot be passively dorsiflexed above neutral
with the knee extended but can be dorsiflexed past neutral with the knee flexed. What is the next
step in surgical management of this patient?
1. No further intervention needed

2. Perform a percutaneous tendoachilles-lengthening
3. Perform an open tendoachilles-lengthening
4. Perform a gastrocnemius recession
DISCUSSION
The history, examination, and imaging described for this patient is a stage IIA adult-acquired
flatfoot deformity. Weight-bearing radiographs reveal <30% talonavicular uncoverage and no
evidence of subtalar arthritis or medial column instability. The treatment of choice for a stage IIA
deformity that has failed nonsurgical management with orthotics, physical therapy, and bracing
involves a medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the
tarsal navicular. In addition to tibialis posterior tendon rupture, the plantar calcaneonavicular or
spring ligament is also frequently attenuated and contributes to peritalar subluxation. Handling of
the native posterior tibial tendon is controversial, with some authors advocating excision and
substitution with the flexor digitorum longus tendon and others recommending preserving the
tibial tendon and reinforcing it with the flexor digitorum longus tendon. If >50% talonavicular
uncoverage is present, manifested clinically by forefoot abduction and a positive “too many toes"
sign”, a lateral column-lengthening calcaneal osteotomy should be considered in addition to the
aforementioned procedures. Complete correction of an adult acquired flatfoot deformity should
also take into consideration forefoot supination and ankle equinus, which are often present. Given
that the patient’s forefoot supination was flexible and corrected with plantarflexion, no medial
column procedures should be required. If a fixed forefoot supination is present, a medial column
procedure such as naviculocuneiform arthrodesis, dorsal opening wedge medial cuneiform
osteotomy or first tarsometatarsal plantarflexion arthrodesis should be considered. Lastly, equinus
should always be assessed with a Silfverskiold test. A finding of equinus present with the knee
extended but not with the knee flexed indicates isolated gastrocnemius tightness, which can be
addressed with a gastrocnemius recession. ANSWER NO 68 = 2; ANSWER NO 69 = 3;
ANSWER NO 70 = 4.
71. A 55-year-old patient with a history of diabetic neuropathy and recently diagnosed Charcot
arthropathy has a painful red, swollen foot. Examination shows open ulceration over the medial
hindfoot with a small amount of serous drainage. The foot feels warm. Laboratory results show a
white blood cell (WBC) count of 12,000/µL (reference range [RR], 4,500 to 11000/µL) and a
glucose level of 230mg/dL (RR, 70 to 110 mg/dL). Which finding is most sensitive for the
diagnosis of osteomyelitis?
1. Serum WBC >15,000/µL
2. Low-signal intensity on the T1-weighted image and high-signal intensity on the T2-
weighted image seen on MRI

3. Positive probe-to-bone test
4. Positive bone scan
DISCUSSION
The diagnosis of infection in the diabetic foot with Charcot changes can be challenging. Ulceration
increases the risks of deep infection such as osteomyelitis. Exposed bone or a probe-to-bone test
are important physical examination findings that most strongly support existence of osteomyelitis.
MRI findings and radiographic findings can help establish a diagnosis, but their interpretation can
be difficult. Elevated WBC is a nonspecific marker for inflammation. A bone scan is expected to
be positive with any bony turnover and is nonspecific in isolation to diagnose osteomyelitis.
ANSWER = 3.
72. Figure 1 is the lateral radiograph of a 65-year-old man with a flatfoot deformity. He has failed to
improve with nonoperative care. Which procedure will correct the primary deformity?
1. Medial displacing calcaneal osteotomy and flexor digitorum longus tendon transfer
2. Gastrocnemius recession
3. Subtalar and talonavicular arthrodesis
4. First and second tarsometatarsal arthrodesis
DISCUSSION
This patient has a pes planus deformity, mainly resulting from instability of the tarsometatarsal
joints. Plantar gapping is seen on the lateral radiograph. Therefore, the only reliable way to correct
this deformity is with a midfoot arthrodesis. A medial displacing calcaneal osteotomy and flexor
digitorum longus tendon transfer is utilized for a flexible flatfoot deformity, whereas a hindfoot
arthrodesis is utilized for a fixed flatfoot deformity that occurs through the hindfoot. ANSWER =
4.

Figures 1 and 2 are the AP and lateral radiographs of a 65-year-old woman who is seen for
evaluation of bilateral foot pain. The pain is felt throughout the medial forefoot and is worsened
with walking and standing for prolonged periods. Pain occurs at night, and she also reports
occasional numbness and tingling. Examination identified tenderness at the first
metatarsophalangeal (MTP) joint and pain with any attempted range of motion. In addition,

flexible clawing of the second digit with mild callusing and tenderness at the tip of the toe and
beneath the second metatarsal head was seen. Sensation to light touch is intact. Pulses are palpable.
73. Which clinical test is most sensitive for the detection of neuropathy?
1. Deep tendon reflexes

2. Sensation to pinprick
3. Sensation to light touch
4. 5.07-gauge monofilament
74. What surgical procedure will most reliably treat the hallux pain and deformity?
1. Proximal metatarsal osteotomy

2. MTP arthrodesis
3. Cheilectomy
4. MTP hemiarthroplasty
DISCUSSION
The patient has a mixed picture of pain with both mechanical and neurogenic components.
Detection of neuropathy is important because these patients have longer healing times, increased
complications, and may not have protective sensation. Sensation to light touch is an inadequate
test to rule out neuropathy. The 10-gram monofilament test (5.07 Semmes-Weinstein) is favored
for detecting the presence of protective sensation. Vibratory testing is another test for detection of
neuropathy but has been found to have imperfect sensitivity. Combined results of these tests
improve sensitivity.
The patient has hallux valgus deformity with degenerative changes; therefore, arthrodesis is the
most appropriate procedure. Proximal metatarsal osteotomy or any other realignment procedure is
contraindicated for significant joint degeneration. Similarly, a cheilectomy is unlikely to provide
much benefit because the patient has pain with any motion at the hallux. Compared with fusion,

first MTP joint arthroplasty has been shown to be inferior in comparative studies. ANSWER NO
73 = 4, ANSWER NO 74 = 2.
75. A 30-year-old woman has a 2-year history of pain in her forefoot that is aggravated by activity and
often accompanied by swelling of the second metatarsal phalangeal joint. The patient has tried
metatarsal pad orthotics with limited benefit. The pain continues to limit her activity. The T1-
weighted lateral MR image of her lesion is shown by the arrow in Figure 1. What is the best next
step?
1. Oblique shortening osteotomy of second metatarsal

2. Partial plantar condylectomy of second metatarsal head
3. Plantar plate repair through a dorsal approach
4. Custom orthotic with Morton’s extension
DISCUSSION
Because of the recent development of repair techniques that utilize either a plantar or a dorsal
approach, increased attention has been paid to rupture of the plantar plate of the lesser metatarsal
phalangeal joint. The indication for surgical treatment is painful instability of the metatarsal
phalangeal joint not relieved by nonsurgical management, which mainly consists of metatarsal pad
and Achilles stretches. A Morton’s extension would be appropriate for first-ray pathology. The
oblique-shortening osteotomy is used for the symptomatic long lesser metatarsal and often is done
in conjunction with the plantar plate repair. The partial plantar condylectomy of the lesser
metatarsal head is utilized for intractable plantar keratosis. ANSWER = 3.

A 21-year-old female collegiate volleyball player is seen 2 days after sustaining an acute inversion
injury to her right ankle during a game. She has significant lateral ankle pain and swelling but can
bear partial weight with crutches. She reports a history of several previous sprains to her right
ankle. The examination demonstrates swelling and ecchymosis over the lateral ankle. Her standing
alignment demonstrates a varus hindfoot that does not correct with Coleman-Block testing. She
has tenderness to palpation over the anterior talofibular and calcaneofibular ligaments. No
tenderness to palpation is found over the malleoli. Mild deltoid tenderness is reported and no

syndesmosis tenderness. A stress examination demonstrates increased anterior drawer and talar tilt
compared with the contralateral side.
76. Based on the Ottawa ankle rules, what is the most appropriate initial imaging modality in the work-
up of this patient?
1. Weight-bearing ankle series
2. Weight-bearing ankle series including stress radiographs
3. MRI right ankle
4. No imaging is necessary
77. Most appropriate initial management of this patient?

1. Application of a below-knee walking cast
2. Acute repair of lateral ankle ligaments
3. Functional brace and early protected range of motion
4. Early aggressive range of motion, strengthening, and balance training
78. The patient returns for follow-up 6 weeks after injury, with persistent lateral ankle pain and
swelling and reports that her ankle gives way when she tries to move laterally. She has been unable
to resume volleyball activities, despite use of an ankle brace. The examination demonstrates
tenderness over the peroneal sheath and lateral ankle ligaments. She has pain with resisted ankle
eversion. Weight-bearing radiographs of the ankle are normal. What is the best next step?
1. Initiation of formal physical therapy
2. MRI of the right ankle
3. Placement of a below-knee cast
4. Corticosteroid injection to the ankle
79. After 3 months of nonsurgical management, the patient complains of several episodes of
instability. The anterior drawer test is positive. She demonstrates no other signs of global laxity.
What is the most appropriate procedure for treatment of the patient’s lateral ankle instability?
1. Chrismann-Snook lateral ligament reconstruction
2. Modified Brostrom lateral ligament reconstruction
3. Modified Brostrom lateral ligament reconstruction with calcaneal osteotomy
4. Anatomic allograft lateral ligament reconstruction with calcaneal osteotomy

80. At the time of surgery, a split-tear of the peroneus brevis immediately distal to the lateral malleolus
is noted, with normal appearance of the peroneus longus. The tear comprises 30% of the tendon.
What is best next step?
1. No further management of the tendon is necessary
2. Primary repair of the peroneus brevis split tear
3. Debridement of the torn portion with tubularization
4. Peroneus brevis to longus tenodesis
81. During postoperative rehabilitation, the patient notices a painful popping in the lateral ankle with
resisted eversion exercises. What characteristic contributes most to this issue?
1. Hindfoot varus
2. Female gender
3. Disruption of the superior peroneal retinaculum
4. Concave posterior fibular morphology
DISCUSSION
This scenario illustrates a classic case of development of chronic lateral ankle instability after an
acute inversion injury. Acute lateral ankle sprains typically present with pain, swelling, and
ecchymosis over the lateral ankle ligaments (anterior talofibular ligament/calcaneofibular
ligament). Typically no tenderness is found over the deltoid ligament or syndesmosis. Patients may
or may not demonstrate laxity on stress examination. The presence of an increased anterior drawer
or talar tilt typically indicates a high-grade sprain. In the absence of malleolar tenderness and if
the patient can bear weight, based on the Ottawa ankle rules, no imaging is necessary. Typical
initial management of an acute lateral ankle sprain should include protection in the form of a
functional brace, rest, ice, compression, and elevation. Early protected range of motion and weight
bearing, limiting ankle inversion, and plantarflexion has been shown to be superior to prolonged
immobilization for acute lateral ankle sprains. After initial swelling and pain subsides, ankle
strengthening and proprioception exercises should be initiated. Tenderness over the peroneal
tendons and pain with eversion after an acute inversion injury should raise concern for possible
associated peroneal tendon tear. MRI would be the imaging modality of choice in this scenario
because it will identify other intra-articular pathology in addition to a tear of the peroneal tendons.
If an athlete continues to demonstrate signs of instability, despite bracing and compliance with a
functional ankle rehabilitation program, surgical intervention should be considered. The
benchmark standard for primary management of chronic lateral ankle instability is a modified
Brostrom lateral ankle ligament reconstruction, which involves imbrication of the anterior
talofibular and calcaneofibular ligaments with advancement of the inferior extensor retinaculum.
If there is a concern for a peroneal tendon tear, this procedure should be done through an extensile
lateral approach, so peroneal pathology can be addressed as well. In the setting of a 30%
longitudinal split tear of peroneus brevis, debridement; repair; and tubularization is the treatment
of choice. Primary repair of these split tears is not usually successful because of poor tendon

vascularity. Tenodesis should be reserved for larger tears of >50% to 60%, irreparable tears, or
severe tendinopathy. Given that the patient has varus alignment of the hindfoot, strong
consideration should be made for doing a lateralizing calcaneal osteotomy. Failure to recognize
and address an underlying hindfoot varus is the most common cause of failure of lateral ligament
reconstructive procedures. If incision of the superior retinaculum is necessary because of peroneal
tendon pathology, resisted eversion should be avoided during early postoperative rehabilitation
because failure of the retinacular repair could result in subluxation of the peroneal tendons.
ANSWER NO 76 = 4; ANSWER NO 77 = 3, ANSWER NO 78 = 2; ANSWER NO 79 = 3;
ANSWER NO 80 = 3; ANSWER NO 81 =3.
82. Figures 1 and 2 are the AP and lateral radiographs of a 48-year-old woman who underwent a
revision Lapidus procedure for left hallux valgus and now has pain under the second metatarsal
head with callus that is refractory to nonsurgical treatment. What is the most appropriate surgical
treatment for this patient's symptoms?
1. Chevron osteotomy of the first metatarsal

2. Shortening osteotomy of the second metatarsal
3. Dorsiflexion osteotomy of the first proximal phalanx
4. Medial closing wedge osteotomy of the first proximal phalanx
DISCUSSION
Reduction in the first ray length after surgical correction of hallux valgus can lead to the
development of transfer lesions in the lesser metatarsal heads. The most appropriate surgical
treatment for transfer metatarsalgia with a relatively elongated second ray is shortening osteotomy
of the second metatarsal. Chevron osteotomy of the distal first metatarsal is used for correcting
hallux valgus, whereas osteotomies of the first proximal phalanx are used as adjunct procedures
for treating hallux valgus interphalangeus and hallux rigidus. ANSWER = 2.

A 14-year-old boy has had recurrent left ankle sprains. On examination, he is found to have a
significant restriction in hindfoot inversion and eversion compared with the contralateral side.
83. To confirm your diagnosis, you obtain a weight-bearing lateral radiograph of the foot (Figure 1).
On the lateral view, you see the “anteater” sign. This is indicative of what type of coalition?
1. Calcaneocuboid
2. Subtalar
3. Talonavicular
4. Calcaneonavicular
84. The most likely abnormality that would account for this clinical scenario in a 14-year-old is a result
of
1. failure of segmentation.
2. failure of formation.
3. atrophy of normal bone.
4. hypertrophy of normal bone.
85. Figures 2 and 3 are the patient’s T1- and T2-weighted MR images. What is the appropriate interval
for surgical resection?
1. Lateral through sinus tarsi

2. Posterior between the Achilles and peroneals

3. Medial between posterior tibial tendon and flexor digitorum longus (FDL)
4. Medial between flexor hallucis longus (FHL) and FDL
DISCUSSION
Tarsal coalition is an abnormal connection seen between two tarsal bones. These can be fibrous,
cartilaginous, or bony and are the result of failure of mesenchymal segmentation. These
connections are often discovered in patients aged 10 to 16 years, most commonly after sprains.
Examination will frequently demonstrate a significant restriction of hindfoot motion compared
with the contralateral side. On radiographs, a prominence of the anterior process of the calcaneus
toward the navicular is often seen, which is nicknamed the “anteater” sign. Of note, talocalcaneal
coalitions are often difficult to see on plain radiographic views and may require a CT or MRI to
confirm. When surgical resection is undertaken, calcaneonavicular coalitions are approached
through a longitudinal incision laterally over the sinus tarsi. During the resection, care should be
taken to avoid damage to the underlying talar head. Talocalcaneal coalitions are typically
approached medially, between the FDL and FHL (at the level of the sustentaculum tali).
86. Figures 1 and 2 are AP and oblique radiographs of a 44-year-old woman who has pain and
difficulty with shoe wear on both the medial and lateral aspects of the forefoot, both the hallux and
the fifth metatarsophalangeal (MTP) joint. Nonsurgical measures including use of wider toe box
shoes have failed to provide relief. The examination is consistent with bony prominences on both
the medial aspect of the hallux and lateral aspect of the fifth MTP joint. There is no pain with range
of motion of either joint. In addition to correction of the hallux valgus, the most appropriate
surgical correction to the fifth metatarsal to alleviate her complaints over the MTP would consist
of
1. metatarsal head resection.

2. partial lateral condylectomy.
3. distal chevron osteotomy.
4. midshaft diaphyseal osteotomy.

DISCUSSION
The patient’s complaints are consistent with both hallux valgus and a tailor’s bunion/bunionette
deformity. The pain over the fifth MTP joint is secondary to the relative prominence of the fifth
metatarsal head secondary to the deformity. The radiographs reveal a type 2 deformity with lateral
bowing in the distal aspect of the fifth metatarsal without any enlargement of the metatarsal head.
In discussing bunionettes, three types have been described: type I: enlargement of the first
metatarsal head; type II: lateral bowing in the distal half of the fifth metatarsal; type III: widened
fourth and fifth intermetatarsal angle. Surgical treatment is dictated by the bunionette type: type 1:
partial lateral condylectomy; type 2: distal chevron osteotomy; type 3: midshaft diaphyseal
osteotomy.
Metatarsal head resection has no role in the treatment of bunionette deformities and is more
commonly associated with treatment of patients with autoimmune disorders and treatment of
chronically dislocated toe. In cases of revision or salvage, metatarsal head resection can be
considered an option, but it is not appropriate as an initial treatment consideration. ANSWER =
3.

Figures 1 and 2 are the AP and lateral radiographs of a 68-year-old woman with poorly controlled
diabetes mellitus type II who turned in bed and felt a pop in her right ankle that was not particularly
painful. Severe edema is seen around the ankle.

2. Cam walker boot
3. Short-leg non–weight-bearing cast with follow-up in 4 weeks
4. Percutaneous screw fixation and non-weight bearing
88. The same patient returns 1 month later and has the AP and lateral radiographs in Figures 3 and 4.
She has blisters around the ankle with considerable swelling. Her diabetes is still not under control.
What is your treatment recommendation?

1. Closed reduction and total contact cast
2. External fixation
3. Fibular plating and medial malleolar screws fixation
4. Fibular and tibial platings
89. Two months after her injury, the edema is improved and the blisters have healed. However,
radiographs demonstrate worsening deformity. What is the best next step?
1. Fibular plating and medial malleolar screws fixation
2. Fibular and tibial platings

3. Tibiotalocalcaneal nailing with interlocking screws
4. Below-knee amputation
DISCUSSION
Patients with diabetes mellitus have higher complication rates in management of ankle fractures.
The history of relatively little pain in this patient suggests neuropathy. The arrow on Figure 1
indicates a nondisplaced fracture of the medial malleolus. Patients with neuropathy or

vasculopathy are at increased risk for delayed union and nonunion. Hence, the fracture should have
been treated with percutaneous screw fixation and non-weight bearing. One month after injury, the
blisters and severe swelling precluded surgery. Total contact casting is helpful in achieving healing
of soft tissues but often does not stabilize the fracture. Tibiotalocalcaneal arthrodesis and nailing
with locking screws has been shown to be an optimal salvage procedure Long nails should be used
to avoid stress fractures proximally. ANSWER NO 87 = 4; ANSWER NO 88 = 2; ANSWER
NO 89 = 3.
90. After surgical repair of an Achilles tendon rupture, a protocol that uses early motion has been
shown to decrease which postoperative complication?
1. Sural nerve injury
2. Rerupture
3. Loss of calf circumference
4. Loss of ankle range of motion
DISCUSSION
Achilles tendon ruptures are common athletic injuries that most frequently occur in men. Although
recent studies show acceptable results with surgical and nonsurgical management, early motion
has been shown to be clearly beneficial in both surgical and nonsurgical groups secondary to a
decreased rate of rerupture. The sural nerve runs along the Achilles tendon and must be protected
during surgical repair. The loss of calf circumference and loss of plantarflexion are both potential
complications of Achilles ruptures, but no direct correlation is found with early range of
motion. ANSWER = 2.
91. What imaging study is most sensitive and specific for a syndesmosis injury?
1. CT scan, with and without contrast
2. Plain radiograph of ankle, including knee
3. Gravity stress view of ankle
4. MRI
DISCUSSION
The lambda sign noted on the coronal MRI was both sensitive and specific for injuries involving
>2 mm of diastasis on arthroscopic stress examination of the syndesmosis. Although neither the
lambda sign nor any other finding on physical or radiographic examination represented an
independent predictor of syndesmotic instability, the presence of a lambda sign together with
positive physical examination findings might help healthcare providers determine which patients
might benefit from surgical intervention or referral. CT scan would be most helpful in assessing
postoperative fibular reduction in syndesmosis. Radiographs of the ankle including the knee are
most helpful for identifying Maisonneuve injury. Gravity stress is most helpful in identifying
deltoid injury in the setting of lateral malleolus fracture. ANSWER = 4.

92. Figures 1 and 2 are the AP and lateral radiographs of a 60-year-old woman with a long history of
foot deformity and pain along the midarch and lateral hindfoot. On examination, she has pes
planovalgus alignment with standing. She has tenderness in the sinus tarsi and subfibular region.
In the seated position, the deformity is unable to be fully corrected. What is the most appropriate
surgical approach?
1. Triple arthrodesis
2. Medial displacement calcaneal osteotomy and flexor digitorum longus (FDL)tendon
transfer
3. FDL transfer, lateral column lengthening, and Cotton osteotomy
4. Isolated subtalar joint arthrodesis
DISCUSSION
The patient has chronic, painful, severe flatfoot deformity that is not passively correctable. Joint-
preserving procedures and tendon transfers are generally indicated for patients without advanced
arthritis or stiffness. Subtalar joint fusion would be used for isolated subtalar joint arthritis but
would do little to correct the deformity and medial symptoms seen in this patient. Triple arthrodesis
will stabilize and improve the deformity and address the medial arthritic symptoms coming from
the talonavicular joint. ANSWER = 1.

A 46-year-old woman has had pain along the medial aspect of the foot and ankle over the last 3
months. She has noted swelling along the medial aspect of her ankle and has difficulty with impact
exercises, specifically running. The patient has a supple ankle and hindfoot with regards to range
of motion. Video 1 demonstrates the patient being asked to perform a single limb heel rise. Anti-
inflammatory drugs and activity modification have failed to provide relief.

93. What is the most effective nonsurgical management of the patient’s condition?
1. Short-leg walking cast in 20° of plantarflexion

2. Hinged ankle foot orthosis (AFO) with focused physical therapy
3. Custom-molded orthotic with a well for the first metatarsal head
4. Night splint and silicone heel lifts
94. The nonsurgical management has failed to provide sufficient relief, despite a trial of 6 months. The
patient would like to undergo surgical intervention. A clinical photograph of the patient’s forefoot
with passive correction of the hindfoot to neutral is shown in Figure 2. Weight- bearing AP and
lateral radiographs are shown in Figures 3 and 4. The most appropriate surgical treatment includes
tendon transfer and …
1. triple arthrodesis.
2. realignment midfoot arthrodesis.
3. first metatarsal dorsiflexion osteotomy and lateral slide calcaneal osteotomy.
4. plantarflexion osteotomy medial cuneiform and medial slide calcaneal osteotomy.
95. the most appropriate orthotic prescription to minimize the risk of recurrent, symptomatic deformity
would include
1. hindfoot eversion, decreased arch, and well for the first metatarsal head.

2. hindfoot inversion with arch support.
3. Morton’s extension carbon fiber plate.
4. closed cell cross-linked polyethylenefoam (Plastazote) orthotic with metatarsal pad.
96. The ligamentous complex that is incompetent in this patient’s condition (Figures 4 and 5) is the
1. spring.
2. deltoid.
3. Lisfranc.
4. syndesmotic.
97. Preoperatively, the patient is noted to have 5° of dorsiflexion with the knee in extension with 10°
of dorsiflexion with the knee in flexion. In addition to the surgical procedures previously listed,
this examination finding is indicative that an additional procedure should include
1. Achilles tendon lengthening.

2. peroneal brevis lengthening.
3. gastrocnemius recession.
4. hamstring lengthening.
DISCUSSION
The patient has posterior tibial tendon dysfunction (PTTD). This condition is most commonly
degenerative and results in swelling and pain along the course of the tendon. The tendon originates
in the posteromedial calf and inserts primarily at the medial pole of the navicular. Multiple further
attachments are noted along the plantar midfoot. Examination is consistent with pain along the
course of the posterior tibial tendon, most acutely inferior to the medial malleolus to the navicular.
A pes planovalgus deformity is noted. Difficulty or inability to perform a single limb heel rise is
secondary to the inability of the tendon to lock the hindfoot into varus. In more long-standing

deformity, with correction of the hindfoot to neutral, the forefoot remains supinated. Initial
nonsurgical management that has demonstrated the most success is the use of an AFO along with
focused physical therapy for the posterior tibial tendon. Orthotic management for patients who
have achieved pain resolution with the AFO or in very mild cases includes hindfoot inversion and
an arch support. In patients with persistent forefoot supination with correction of the hindfoot, a
medial forefoot support is also required. The spring ligament is attenuated and nonfunctional in
patients with PTTD.
Surgical management is dependent on the flexibility of the hindfoot in the presence of arthritis.
Extra-articular correction can be done in patients with no evidence of arthritis with a supple
hindfoot. Although no routine algorithm exists, a tendon transfer (flexor digitorum longus [FDL]
or flexor hallucis longus) is done to reconstruct the posterior tibial tendon. A medial slide calcaneal
osteotomy is done to translate the calcaneus medially. In cases of >50% uncoverage of the talus, a
lateral column lengthening is considered. In cases of a fixed forefoot supination, a Cotton
osteotomy/plantarflexion osteotomy of the medial cuneiform is done to restore the tripod of the
foot. In cases of documented instability of the first tarsometatarsal (TMT), a first TMT
plantarflexion arthrodesis is done. Many cases of PTTD have an associated equinus contracture.
The Silfverskiold test is done to determine if the contracture is isolated to the gastrocnemius
(improved ankle dorsiflexion with knee flexion), as opposed to an Achilles contracture (no change
with knee flexion). The contracture, if present, should be surgically corrected. Following surgical
correction, to minimize stress on the reconstruction, use of an orthotic with hindfoot inversion and
arch support may be prescribed. This will minimize stress on the FDL tendon transfer and the
remaining mobile midfoot joints. ANSWER NO 93 =2; ANSWER NO 94 = 4; ANSWER NO
95 = 2; ANSWER NO 96 = 1; ANSWER NO 97 = 3.

A 70-year-old man has foot and ankle pain resulting from pes planovalgus deformity and valgus
ankle deformity. The patient ultimately undergoes a tibiotalar calcaneal arthrodesis with a
retrograde hindfoot nail because of the deformity and the associated arthritis of the ankle and
subtalar joints.
98. Failure of which structure ultimately causes the deformity of the ankle?
1. Deltoid ligament
2. Posterior tibialis tendon
3. Spring ligament
4. Talocalcaneal interosseous ligament
99. Which nerve is most at risk with insertion of this implant?

1. Medial plantar nerve
2. Superficial peroneal nerve
3. Sural nerve

4. Lateral plantar nerve
100. Figure 1 is the postoperative tibiocalcaneal radiograph. Which complaint will the patient likely
report based on the screw lengths shown?
1. Pain and catching with active plantarflexion of hallux

2. Degenerative changes at the calcaneocuboid joint
3. Inability to perform a single heel rise
4. Numbness on the lateral border of the foot
DISCUSSION
The patient has a stage 4 flatfoot, meaning that a valgus deformity has developed at the tibiotalar
joint. This ankle deformity is the result of incompetence of the deltoid ligament. If a
tibiotalocalcaneal arthrodesis is to be done, a retrograde hindfoot nail is an option. The lateral
plantar nerve courses plantarly and crosses the midline at the location of the insertion of the nail.
Soft-tissue dissection to the calcaneus and careful retraction should be done to minimize the risk
of injury to this nerve. The radiographs reveal a long screw in the calcaneus, from lateral to medial,
just plantar to the sustentaculum. This location makes the flexor hallucis longus tendon at risk for
an injury or impingement. ANSWER NO 98 = 1; ANSWER NO 99 = 4; ANSWER NO 100 =
1.

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ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

AAOS Foot and Ankle 2018 - 100 MCQs

1. Referral for complex regional pain syndrome (CRPS) workup

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Intra-articular platelet-rich plasma injection

(Case vignette No. 3 – 6)

3. What is the best next step?

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Loss of calcaneal height

1. decreased rates of wound infection and increased rates of arthritis.

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 8 – 11)

8. What muscle combination represents an agonist-antagonist combination that contributes to the

1. Posterior tibialis–peroneus brevis

9. The patient is predisposed to what problem because of her foot position?

2. Fifth metatarsal stress fracture

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

11. Which pedorthic variation will provide the most relief?

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 14 – 15)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 18 – 21)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. superior syndesmotic stability compared with syndesmotic screw fixation.

1. posterior tibial tendon and flexor hallucis longus.

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Uniplanar distal metatarsal osteotomy

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 26 – 29)

26. What is the best next step?

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. increased range of motion and increased power.

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Surgical peroneal retinaculum repair

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette NO. 33 – 38)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Congruent metatarsophalangeal (MTP) joint, stable first tarsometatarsal (TMT) joint

1. Hallux MTP joint fusion

1. Deep peroneal nerve

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Revision hallux valgus correction

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 41 – 43)

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

42. What is the best next step?

2. CT scan to evaluate for abscess

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Closed reduction and casting

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Vascularized bone grafting of navicular

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

(Case Vignette No. 47 – 50)

48. Nonsurgical management of the patient’s problem should consist of

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Walking boot and referral for physical therapy

ORTHOPEDI UNHAS JUNE-AUG 2018 (ZT)

1. Immediate surgical reduction