F&A - RC Qs

Question 1

<div>RC 2016 - When doing a subtalar arthrodesis from the lateral side, what is the structure you see once you have debrided the medial aspect of the joint? </div>

<ol> <li>FDL </li> <li>EDM </li> <li>FHL </li> <li>Tib post</li></ol>

Answer 1

C.<div><ul> <li>Discussed with LaMothe:</li> <ul> <li>If POSTERIOR to middle facet then FHL</li> <li>If ANTERIOR to middle facet the FDL as FHL under sustentaculum</li> </ul></ul></div>

Question 2

<div>RC 2015 - Contraction of the gastroc results in:</div>

<ul> <li>A. Plantarflexion</li> <li>B. Flexion of the knee and ankle</li> <li>C. Flexion of the knee and ankle and subtalar supination</li> <li>D. Flexion of the knee and ankle and subtalar pronation</li></ul>

Answer 2

C.<div><div>The Achilles tendon is part of a musculotendinous unit that spans three joints, producing knee flexion, tibiotalar flexion, and subtalar inversion</div></div>

Question 3

RC 2008 - A fisherman sustained an open medial malleolus fracture and sharp laceration to tib post tendon. How should you manage the Tib-post tendon injury? <ul> <li>A. Repair primarily</li> <li>B. UCBL orthosis</li> <li>C. Tenodesis the distal part to FHL</li> <li>D. Reconstruct the deficit with FDL to navicular</li></ul>

Answer 3

A.<div>Acute repair of a tibialis posterior tendon laceration can lead to a good result.</div><div>Small case series of these<br></br></div>

Question 4

<div>RC 2008 - Question on lesser toes, which is true</div>

<ol> <li>on ground 75% during stance phase</li> <li>max peak pressure of MT head is significantly larger</li> <li>equal distribution across lesser toes</li> <li>don’t provide stability in stance phase</li></ol>

Answer 4

<div>answer: b</div>

<ul> <li>They concluded that the toes are in contact for about 3/4 of the walking cycle and exert pressures similar to those from the metatarsal heads</li> <li>The great toe takes the highest pressures (30% of total toe pressure), with the second taking 25%, the third 20%, the fourth 15% and the fifth 10% = C is false</li> <li>While the extremes of the foot (heel and hallux) are in contact with the ground for only 54% to 64% of stance phase the forefoot, specifically the middle forefoot, contacts the ground for 86% of stance phase.</li></ul>

Question 5

RC 2014 - List 4 inverters of the subtalar joint

Answer 5

<ul> <li>Tib post</li> <li>Tib Ant</li> <li>FDL</li> <li>FHL</li> <li>Achilles</li></ul>

Question 6

<div>RC 2015 - In a Chopart amputation, what 2 things can you do to prevent equinus contracture?</div>

Answer 6

<div><div><ul> <li>Soft Tissue</li> <ul> <li>Transfer for MORE DF (to dorsum of talus)</li> <ul> <li>Tibialis anterior</li> <li>Peroneus longus</li> <li>Peroneus brevis</li> <li>EDL</li> </ul> <li>Less PF strength = Recession of gastrocs/Achilles</li> </ul> </ul> <ul> <li>Boney procedures:</li> <ul> <li>TTC fusion</li> </ul></ul></div></div>

Question 7

RC 2013 - Symes amputation due to diabetic toes. Which is an important part of the operation: <ol> <li>Attach fat pad to posterior tibia</li> <li>Attach fat pad to anterior tibia</li> <li>Resect fat pad</li> <li>Attach Tibialis Posterior to anterior tibia</li></ol>

Answer 7

“B.<ul> <li>"”Several techniques have been used to prevent migration of the heel pad on the end of the stump, such as taping the heel flap, skewering the heel flap to the bone with a kirchner wire, or leaving a small sliver of calcaneus attached the heel flap””</li> <li>Drill several holes through the anterior edge of the tibia and fibula, and suture the deep fascial lining the heel flap to the bones””</li></ul>”

Question 8

<div>RC 2018, 2014, 2012 - Patient has a Symes. All of the following except</div>

<ol> <li>Rigid socket not needed for success</li> <li>Lift often needed on contralateral side</li> <li>Heel pad migration may preclude weight bearing</li> <li>The long lever arm is an advantage</li></ol>

Answer 8

“B.<ul><li>A: SYMES amp has a bulbous end - so the prosthetics have cutouts that make them ‘nonrigid’</li><li>Carroll K - Prosthetics and Patient Management: A Comprehensive Clinical Approach</li><ul><li>Amputation limb is appreciably shorter than contralateral limb (so no contra-lateral lift needed)</li><li>Connection between socket and foot must be rigid</li></ul></ul><div><ul> <li>A: Rigid SOCKET is necessary to prevent fat pad migration; rigid prosthesis (aka. foot) is NOT necessary (can use carbon fiber energy storing foot)</li> <li>(rigid socket bears weight up the whole lower leg instead of being an end loading stump)</li> <li><br></br></li><ul> </ul></ul></div>”

Question 9

<div>RC 2018, 2016, 2014 - A 47yo male insulin-dependent diabetic presents with a callus on the plantar aspect of the 5th metatarsal head. This was managed with trimming of the callus and local skin care, but is worsening. On exam he has mild cavus alignment bilaterally. What is the best treatment?</div>

<ol> <li>Gastrocsoleus stretching exercises and referral for specialized diabetic footwear</li> <li>Medial calcaneal slide osteotomy</li> <li>Dorsiflexion osteotomy of the 5th metatarsal</li> <li>Percutaneous lengthening of the Achilles tendon</li></ol>

Answer 9

A.<div><ul> <li>Variations in 2016 question (poorly remembered) included improved glycemic control and ulcer debridement</li> </ul> <div>JAAOS 1995 The Diabetic Foot</div> <ul> <li>This patient is presenting with a Wagner Grade 0 ulcer ie. No open lesions</li> <li>Management should involve shoe modification and molded inserts</li> <li>For grade 1 or 2 (superficial & deep ulcers), total contact casting is the treatment modality of choice (90% healed at 5.5 weeks)</li><li>grade 3 = deep ulcer with exposed tendon + infection = debride, abx</li> <li>Nothing in this reference about perc TAL</li> </ul> <div></div> <div>JBJS 2003 Effect of Achilles lengthening on neuropathic plantar ulcers</div> <ul> <li>RCT of Achilles lengthening + total contact casting in patents w/ grade II ulcers and <5 degrees dorsiflexion (NOT THIS PATIENT)</li> <li>100% HEALING in the TAL group (vs 88% in the cast only)</li> <li>75% less recurrence at 7 months and 50% less recurrence at 2 years in TAL group</li></ul></div>

Question 10

<div>RC 2013, 2011 - Regarding diabetic healing, what is predictive of good healing?</div>

<ol> <li>Transcutaneous oxygen pressure > 30mmHg</li> <li>ABI of 1.5</li> <li>Toe pressure of 20 mmHg </li> <li>Your patient ate Lisa’s cooking</li></ol>

Answer 10

“A.<div><br></br></div><div><img></img></div><div><br></br></div><div>ie predictors of non healing</div><div><ul> <ul> <li>ABI < 0.45</li> <li>Transcutaneous pressure < 30mmHg</li> <li>Serum albumin < 2.5g/dl</li> <li>Absolute lymphocyte count < 1,500</li> </ul></ul><div><br></br></div></div>”

Question 11

<div>RC 2012 - What Transcutaneous O2 is needed for wound healing in diabetics?</div>

<ol> <li>15 mm</li> <li>30 mm</li> <li>50 mm</li> <li>70 mm</li></ol>

Answer 11

“2.<div><img></img><br></br></div>”

Question 12

RC 2015, 2012 - What is the most important predictor of healing in a diabetic ulcer? <ol> <li>severity of DM</li> <li>blood supply</li> <li>peripheral neuropathy</li> <li>chronicity of the ulcer</li></ol>

Answer 12

<div>ANSWER: B ***</div>

<ul> <li>Peripheral neuropathy is NUMBER 1 risk factor for development of ulceration but blood supply is predictive of healing potential</li> <li>Predictors of non-healing:</li> <ul> <li>ABI < 0.45</li> <li>Transcutaneous pressure < 30mmHg</li> <li>Serum albumin < 2.5g/dl</li> <li>Absolute lymphocyte count < 1,500</li> </ul></ul>

Question 13

<div>RC 2011 - DM is a common cause of Charcot arthropathy of the foot and ankle. List 3 other causes.</div>

Answer 13

<div><ul> <li>JAAOS 2009 Charcot Neuroarthropathy of the Foot and Ankle</li> <ul> <li>CNS: SCI, TBI, syphilis, myelo, syringomyelia, MS</li> <li>PNS: Alcoholism, Leprosy, CMT</li> <li>Congenital: insensitivity to pain</li> </ul></ul></div>

Question 14

<div>RC 2012 - Diabetic guy, with what sounds like a Charcot foot in the stem with medial arch collapse. What would you find on exam? </div>

<ol> <li>Pain doing a single heel rise</li> <li>Warm dry foot with prominence along medial talar head, increase callosities</li> <li>Decreased eversion and normal inversion</li></ol>

Answer 14

B.<div><br></br></div><div><div>Hard to rule out any option as could be painful for heel raise and could have change in ROM but I think best answer is B as it describes Charcot foot pathology</div></div>

Question 15

<div>RC 2014, 2009 - What is the cause of osteopenia in a neuropathic (Charcot) joint?</div>

<ol> <li>Increased blood flow</li> <li>Non-weight-bearing due to treatment</li> <li>Neuropathy</li> <li>Cannot remember the last option</li></ol>

Answer 15

A.<div><ul> <li>Autonomic Dysfunction:</li> <ul> <li><b><i><u>AV shunting / increased blood flow--> increased cytokines --> upregulation of osteoclasts --> bony resorption</u></i></b></li> </ul> <li>Neurotraumatic Destruction:</li> <ul> <li>Repetitive microtrauma –> sensory anomaly prevents recognition and activity modification</li> </ul> <li>Motor Neuropathy:</li> <ul> <li>Extrinsics > intrinsics –> equinus –> altered ground reaction forces –> fracture/deformity</li> </ul> <li>Inflammatory:</li> <ul> <li>TNFa, IL1 release –> NTKB –> osteoclast stimulation</li> </ul></ul></div>

Question 16

“<div>RC 2018, 2013 - Patient arrives in your clinic walking with a red and swollen foot. No fever. History of DM. XR looks like this (Dislocated midfoot). No skin breakdown. No pain. Treatment?</div> <div></div> <div><img></img></div> <ol> <li>Total contact cast</li> <li>ORIF</li> <li>Midfoot fusion</li> <li>Amputation</li> </ol> <div></div>”

Answer 16

<div>A.</div>

<div><br></br></div>

<div><ul> <li>Eichenholtz Classification:</li> <ul> <li>Inflammatory --> treatment total contact casting</li> <li>Fragmentation ---> total contact casting</li> <li>Coalescence --> total contact casting --> crow</li> <li>Reconstruction</li> <ul> <li>Indications for surgery:</li> <ul> <li>Ulceration from exostoses/dislocations</li> <li>Fusions in reconstructive phase</li> <li>Amputation for recurrent ulcerations/OM</li> </ul> </ul> </ul></ul></div>

Question 17

<div>RC 2018, 2016, 2013 - What is true regarding the sesamoid bones in the foot? </div>

<ol> <li>They are supplied by a single artery</li> <li>Together they receive 50% of weight during normal gait</li> <li>The fibular sesamoid is larger than the tibial</li> <li>Both sesamoids lie within the 2 muscle bellies of the flexor hallucis brevis</li></ol>

Answer 17

b.<div><ul> <li>Sesamoid complex transmits as much as 50% of body weight</li> <li>The larger tibial sesamoid lies within the medial head of the flexor halluces brevis, the smaller fibular sesamoid lies within the lateral head</li> <li>Usually a single artery per sesamoid, but up to 2-3 per sesamoid have been described</li></ul></div>

Question 18

RC 2017, 2014, 2012 - List 5 causes of adult cavovarus foot

Answer 18

<ul> <li>JAAOS - Adult Cavovarus Foot</li> <ul> <li>Congenital</li> <ul> <li>Myelomeningocele</li> <li>Syrinx</li> <li>Diastematomyelia </li> <li>SMA</li> <li>Hereditary motor and sensory neuropathy (CMT)</li> </ul> <li>Acquired/adult</li> <ul> <li>Neuro</li> <ul> <li>CNS: Stroke, SCI, TBI, tumour, MS</li> <li>PNS: tumor, polio</li> </ul> <li>Trauma</li> <ul> <li>Compartment syndrome</li> <li>Talus malunion</li> </ul> </ul> <ul> <li>Residual congenital cavovarus</li> </ul> </ul></ul>

Question 19

<div>RC 2016 - List 6 clinical / pathoanatomic findings in the flexible adult flatfoot</div>

Answer 19

“<ul> <li>Alignment</li> <ul> <li>Forefoot: ““too many toes”” sign</li> <li>Midfoot: pes planus, Loss of longitudinal arch</li> <li>Hindfoot: Excessive hindfoot valgus</li> </ul> </ul> <ul> <li>Equinus contracture</li> </ul> <ul> <li>Pain and tenderness along medial border of foot, posteromedial ankle</li> <li>Inability to perform single heel raise</li> <ul> <li>Weak Tib post</li> </ul></ul>”

Question 20

<div>RC 2013 - Flexible Pes Planovalgus with no abduction. She is unable to do a single stance heel raise. What operation</div>

<ol> <li>TN fusion</li> <li>Triple fusion</li> <li>FDL transfer with medializing calcaneal osteotomy</li> <li>TP advancement</li></ol>

Answer 20

C. NEVER DO TENDON TRANSFER IN ISOLATION - NEEDS MDCO

Question 21

RC 2012 - Middle age female with severe flat foot deformity acquired over last 2 years. What is the cause? <ol> <li>Tarsal coalition</li> <li>Posterior tibial tendon dysfunction</li> <li>Charcot foot</li> <li>Ryan operated on it 2 years ago</li> </ol> <div></div>

Answer 21

2.<div><div>Charcot foot is possible with the right history, but two years is a long time course for this and PTTD is much more likely</div></div><div><br></br></div><div>PEDS DDX:</div><div><ul> <li>Tarsal coalition</li> <li>Tarsal coalition</li> <li>Tarsal coalition</li> <li>Poorly corrected club foot with midfoot break</li> <li>Congenital vertical talus</li> <li>Congenital oblique talus</li> <li>Spastic diplegia (hemiplegia is spared for some reason)</li></ul></div>

Question 22

RC 2016, 2014 - A patient with flexible flat feet undergoes lateral column lengthening through the anterior calcaneus. Which of the following is a complication of lateral column lengthening? <ol> <li>Calcaneocuboid arthritis</li> <li>Subtalar instability</li> <li>Increased pressures and stress fracture of the sesamoids</li> <li>Pronation of the forefoot</li></ol>

Answer 22

A.<div><ul> <li>JAAOS - Adult Acquired Flatfoot</li> <ul> <li>Lateral column lengthening provides correction to the abducted talonavicular joint and raises the arch</li> <li>It also decreases eversion and increases the pressure along the plantar lateral border of the foot</li> <li>Lengthening may result in lateral foot overload, fifth metatarsal stress fracture and significant stiffness</li></ul></ul> <ul> <li>Roche and Calder. Foot Ankle Clin N Am. 2012.</li> <ul> <li>Evans suggested preserving the joint through his osteotomy; however, studies have shown that the contact pressure generated across the calcaneocuboid joint after lengthening may actually rise, raising concerns that this may predispose to early degenerative change…They found that joint contact pressures were increased from baseline levels after Evans procedures by 111%. The addition of a medializing calcaneal osteotomy reduced this pressure increase to 93%. </li> <ul> <li>Lots of biomechanical evidence for CC arthritis, little clinical evidence</li> </ul> </ul> <li>Neufeld SK (Foot and Ankle Clin 2001)</li> <ul> <li>Calcaneal lengthening osteotomies can result in over correction and result in excessive and fixed SUPINATION, thought to be a cause of lateral foot pain</li> <li>Overlengthening can cause metatarsocuboid arthritis or instability</li></ul></ul> <ul> <li>Moseir-LaClair S, Pomeroy G, Manoli II A. Intermediate follow-up on the double osteotomy and tendon transfer for stage II posterior tibial tendon insufficiency. Foot Ankle Int 22:283-291, 2001</li> <ul> <li>14% CC arthritis (but 50% of cases had pre-existing arthritis) </li> </ul></ul></div>

Question 23

<div>RC 2011 - Advantage of lateral column lengthening over medial calc osteotomy for stage 2 PTTD? </div>

<ol> <li>better forefoot abduction</li> <li>improved restoration of hindfoot alignment</li> <li>better fusion</li> <li>Less non-union</li></ol>

Answer 23

A.<div><ul> <li>Jer: I’m guessing ‘A’ should say ‘better forefoot abduction correction’?</li><li>Bolt PM (FAI 2007) A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot</li> <ul> <li>Lateral column lengthening had greater initial and final re-alignment</li> <li>Lateral column lengthening had higher non-union</li> <ul> <li>High radiographic prevalence of OA</li> </ul> <li>Rate of repeat surgery was 2x higher with osteotomy than lengthening</li> </ul><ul> </ul></ul></div>

Question 24

RC 2015 - 55yo lady presents 6mos following a minor ankle inversion injury with progressive pain and swelling posterior to the medial malleolus. What would you expect to find on exam? <div> a. Positive anterior drawer test</div> <div> b. Rigid subtalar motion</div> <div> c. Positive Coleman block test</div> <div> d. Unable to do single limb heel raise</div>

Answer 24

D.<div><ul> <li>I think they’re getting at PTTD possibly…</li> <li>Anterior drawer should have corresponding pain at anterolateral ankle</li> <li>Rigid subtalar motion indicates subtalar coalition or end stage disease, unlikely with this presentation and age group</li> <li>Possible to do Coleman block</li></ul></div>

Question 25

RC 2016 - Question regarding pediatric flatfoot comparing the triple-C osteotomy to an Evans lateral column lengthening. Which is true? <ol> <li>The Evans procedure is better at correcting talar head coverage or talonavicular coverage </li> <li>Triple C has is associated with higher complications than Evans</li> <li>A complication of Triple C is CC joint subluxation</li></ol>

Answer 25

A.

Question 26

RC 2017 - What are 8 surgical considerations in the management of severe hallux valgus?

Answer 26

“<ul> <li>‘Severe’ Deformity requires proximal osteotomy and DSTP</li> </ul><ol> <li>Lateral release of adductor hallucis tendon and intermetatarsal ligament</li> <li>Medial tightening = medial capsule plication</li> </ol> <li>MTP congruency (ie if incongruent-> must restore congruency)</li> <li>MTP Fusion for</li> <ul> <li>OA</li> <li>Inflamm arthropathy</li> <li>Neuromusc disease</li> <li>Severe OP</li> <li>Revision surgery</li> <li>Multiple lesser toe deformites</li> </ul> <li>Proximal: TMT joint hypermobility (fuse if needed)</li> <li>Distal: Hallux valgus interphalengeus (do Akin if needed)</li><div>ORDER</div><div>-DSTP</div><div>-proximal osteotomy</div><div>-bunionectomy</div>”

Question 27

<div>RC 2018, 2014 - A 64yo female presents with a painful bunion. X-rays demonstrate hallux valgus with an inter-metatarsal angle (IMA) of 20 degrees and a hallux valgus angle (HVA) of 45 degrees, with an incongruent 1st MTP joint. She has failed non-op treatment. What is the best treatment?</div>

<ol> <li>Buncionectomy and chevron osteotomy</li> <li>Distal soft tissue release and Akin osteotomy</li> <li>Fusion of the 1st MTP</li> <li>Fusion of the first metatarsal-medial cuneiform joint</li></ol>

Answer 27

3. severe bunion = mtp fusion is good procedure<div><ul> <li>#4 - Lapidus (first TMT fusion + distal soft tissue procedure) would likely be the best option, however, a TMT fusion alone is not ideal. A first MTP fusion is an appropriate treatment option for a severe bunion – especially in an elderly patient. <b>ie would require a soft tissue procedure distally to address the INCONGRUENCE of the joint</b></li> </ul> <div>Disorders of the first metatarsal phalangeal joint. Mann. JAAOS. 1995.</div> <ul> <li>Incongruent deformities are classified as mild (hallux valgus angle less than 30 degrees and IM angle less than 13 degrees), moderate (hallux valgus angle less than 40 degrees and IM angle greater than 13 degrees), and severe (hallux valgus angle greater than 40 degrees and IM angle greater than 20 degrees). </li> <li>For advanced moderate and severe deformities, a distal soft-tissue procedure with a proximal osteotomy will give a reproducible satisfactory result in most cases, although it is technically demanding. The MTP arthrodesis is an excellent procedure for treating a severe hallux valgus deformity, particularly in older patients and those with rheumatoid arthritis, spasticity, or arthrosis. arthrodesis is used along with the complete distal soft-tissue procedure.</li></ul></div>

Question 28

<div>RC 2015, 2011 - 23 yo female with hallux valgus, painful, IMA 15, HVA, 40. Partially correctable. Xray shows bunion. Appropriate treatment?</div>

<ol> <li>Proximal osteotomy</li> <li>Distal osteotomy</li> <li>Proximal phalanx osteotomy</li> <li>MTP fusion</li></ol>

Answer 28

1.<div><div>ANSWER: A (previous years chose D because they thought you always need to do a DSTP as well…but they are assuming this</div><ul> <li>Group discussion - argument that since it is incongruent, would need a distal soft tissue procedure with your proximal osteotomy, controversial</li></ul></div>

Question 29

<div>RC 2012 - Juvenile hallux valgus different than adult</div>

<ol> <li>Decreased HV angle</li> <li>increased DMAA</li> <li>increased incongruity</li> <li>decreased IM angle</li></ol>

Answer 29

“2.<div><ul> <li>A – Early onset have increased HV (1st mt is in VARUS)</li> <li>B – 48% - The defining characteristic of a juvenile bunion</li> <li>C – Can have subluxation or not</li> <li>D – No they can have a variety of IM a</li> </ul> <div></div> <div>Differences between adult and juvenile hallux valgus. Juvenile exhibits the following characteristics:</div> <ul> <li>Often is bilateral with a family history</li> <li>Usually presents with cosmetic concern, not pain</li> <li>The deformity often is associated with flexible flatfoot or metatarsus adductus</li> <li>The 1st metatarsal is in varus with a resultant increased intermetatarsal angle between the 1st and 2nd metatarsal</li> <li>There is an increased distal metatarsal articular angle with a congruent joint</li> <li>Much higher recurrence rate (up to 50%)</li> <ul> <li>Coughlin MJ (FAI 1995) Juvenile Hallux Valgus: etiology and treatment</li> <ul> <li>Retrospective study of 45 patients with 60 feet</li> <li>Early onset was characterized by increased deformity and an increased DMAA</li> <li>72% had maternal transmission</li> <li>"”an increased DMAA may be the defining characteristics of juvenile hallux valgus””</li> </ul> </ul></ul></div>”

Question 30

<div>RC 2014 - List 4 causes for hallux varus deformity after correction of hallux valgus.</div>

Answer 30

<ul> <li>Over-correction of IMA through osteotomy</li> <li>Excessive medial eminence resection</li> <li>Excessive medial capsular tightening</li> <li>Excessive lateral release</li> <li>Excision fibular sesamoid</li></ul>

Question 31

<div>RC 2012 - Congenital Hallux varus (all except):</div>

<ol> <li>If Bony procedure required, need osteotomy</li> <li>Polydactyly is frequently noted</li> <li>30% recover non-op</li> <li>medial column defect</li></ol>

Answer 31

“C. these are SURGICAL<div><ul> <li>Belthur MV (JPO 2011) The Spectrum of Preaxial polydactyly of the Foot</li> <ul> <li>20/28 feet with polydactyly had hallux varus</li> </ul> <li>Lovell and Winter’s Pediatric Orthopedics:</li> <ul> <li>Often associated with short first metatarsal, bracket epiphysis of the first MT, pre and post-axial polydactyly and fibrous band that acts as a tether along medial side of great toe</li> <li>"”mild forms of hallux varus with a flexible deformity generally resolve spontaneously, but that condition should be differentiated from congenital hallux varus””</li> <li>Treatment:</li> <ul> <li><b>There is no role for conservative management</b></li> <li>McElvenny –> soft tissue release and resection</li> <li>Resection and grafting of physeal bridge = bracket epiphysis</li> <li>Opening wedge osteotomy</li> <li>Amputation</li> </ul> </ul></ul></div>”

Question 32

<div>RC 2013 - Rheumatoid forefoot reconstruction, all are true except (bad memory, McGill)</div>

<ul> <li>A. Fuse 1st MTP at 30o dorsiflexion to MT</li> <li>B. Release all lesser toe extensors and capsule</li> <li>C. Perform less toe MT osteotomies from proximal-dorsal to distal-plantar</li> <li>D. Do not recreate the lesser MTP cascade</li></ul>

Answer 32

D. you WANT to recreate cascade.<div><br></br></div><div><div>fusion position: neutral rotation, 10 deg valgus, 25 deg dorsiflexion</div></div>

Question 33

RC 2008 - 39 y.o, with RA, has evidence of erosion and degenerative disease of talonavicular joint with associated pain. Her subtalar and calcaneocuboid joints are not affected and painless. She also has mild subluxation and RA of her metatarsocuneiform joints. What is the most appropriate treatment? <ul> <li>A. Triple arthrodesis</li> <li>B. Subtalar and talonavicular arthrodesis</li> <li>C. Talonavicular arthrodesis</li> <li>D. Talonavicular resection</li></ul>

Answer 33

“C.<ul> <li>I think you could argue for B quite strongly. </li> <li>JAAOS 1994 - Rheumatoid foot and ankle</li> <ul> <li>"”Occasionally, isolated involvement of the talonavicular joint will occur without deformity. Formation of cysts and joint destruction can sometimes be extensive. In these circumstances, isolated TN arthrodesis has been recommended. However, progression of arthritis destruction in adjacent joint is possible. We have found SPECT useful before proceeding with TN arthrodesis….some authors advocate double arthrodesis or TN and CC joints for younger more active patients””</li> </ul></ul>”

Question 34

RC 2012 - 20 yr F with foot JRA and pain. TT joint normal. TN joint trashed and dislocated. ST joint and CC joints trashed. Orthotic didn’t help. Best option? <ul> <li>A. AFO</li> <li>B. Triple</li> <li>C. Subtalar</li> <li>D. TN</li> </ul> <div></div>

Answer 34

B. dont be dumb.

Question 35

<div>RC ORAL - Dead toe after RA forefoot reconstruction. tx?</div>

Answer 35

<ul> <li>Release dressing</li> <li>Remove tourniquet</li> <li>Dangle Foot</li> <li>Warm foot</li> <li>Skewer toe onto K-wire and rotate</li> <li>Remove Pin</li></ul>

Question 36

<div>RC 2018 - What is the current recommended standard for the perioperative management of rheumatologic biologic/ TNF-alpha antagonist medications?</div>

<div>a.Stop 2 weeks before surgery and restart immediately after surgery</div>

<div>b.Stop 2 weeks before surgery, and restart 2 weeks after surgery</div>

<div>c.Continue all preoperative medications</div>

<div>d.Stop 2 months before surgery, and restart 3 months after surgery</div>

Answer 36

“B.<div><br></br></div><div><img></img><br></br></div>”

Question 37

<div>RC 2014, 2011 - What is true regarding hallux rigidus?</div>

<ol> <li>Increased plantar pressures </li> <li>Intraoperatively, 10 degrees of dorsiflexion is all that is needed for normal gait</li> <li>The instantaneous center of rotation remains the same</li> <li>Dorsal osteophyte limits plantarflexion</li></ol>

Answer 37

A.<div>fuse at neutral, 5 deg valgus, 10-15 deg DF<br></br><div><ul> <li>Kinematic analysis of the first metatarsophalangeal joint in patients who have hallux rigidus reveals a decrease in the total arc of motion, with relatively normal plantar flexion but markedly restricted dorsiflexion. </li> <li>Motion analysis reveals instant centers of rotation that are displaced and located eccentrically about the metatarsal head.</li> <li><b>Patients who have symptomatic hallux rigidus have been found to have higher-than-normal dynamic plantar pressures of the first ray. </b></li> <ul> <li>Decreased plantar pressures of the first ray have been reported after resection arthroplasty and implant arthroplasty.</li> </ul> <li>The minimum physiological dorsiflexion of the first metatarsophalangeal joint that is necessary for a normal gait is unknown; however, the values that have been reported in the literature have ranged from 15 to approximately 90 degrees</li></ul></div></div>

Question 38

<div>RC 2016, 2014, 2011 - 40 year old male laborer with hallux rigidus. What is the best treatment? </div>

<ol> <li>Custom orthotic </li> <li>1st MTP fusion </li> <li>Keller’s resection </li> <li>Proximal phalanx osteotomy</li></ol>

Answer 38

<b>B.</b><div><ul> <li>Shoe modifications, such as a Morton extension orthosis</li> <ul> <li>Often poorly tolerated</li> </ul> <li>Cheilectomy and Proximal Phalanx Osteotomy</li> <li>Arthrodesis</li> <ul> <li>Favorable and time-tested procedure for managing late and end stage hallux rigidus</li> </ul> <li>Keller Resection Arthroplasty</li> <ul> <li>Better choice for patients > 70 years, less active</li> </ul></ul></div>

Question 39

<div>RC 2015, 2011 - 25 yr old female with a severe bunionette and high 4-5 angle ? What are 3 surgical treatment components?</div>

Answer 39

“<ol> <li>JAAOS 2007 - Bunionette Deformity</li> <ol> <li>Metatarsal head translated dorso-medial (relieve callosities)</li> <li>Lateral eminence resection</li> <li>Medial soft-tissue release of 5th MTP</li> </ol></ol><div><div>Radiographs:</div> <ul> <li>4-5 IM angle:</li> <ul> <li>Normal < 6.5-8o</li> <li>Average symptomatic bunionette 9.6o</li> </ul> <li>Lateral deviation angle:</li> <ul> <li>Average is 2.6o (0-7o)</li> <li>Average of 8o with symptomatic bunionette</li> </ul> <li>5th MTP angle:</li> <ul> <li>Usually <14o</li> </ul> <li>Normal width of metatarsal head is <13mm</li></ul></div><div><img></img><br></br></div>”

Question 40

<div>RC 2018, 2015, 2011 - What is the last bone to ossify in the foot:</div>

<ol> <li>Cuboid</li> <li>Medial cuneiform</li> <li>Navicular</li> <li>Base of 5th phalanx</li></ol>

Answer 40

“C. navicular<div><br></br></div><div><img></img><br></br></div>”

Question 41

<div>RC 2008 - Within the foot and ankle, where do accessory ossicles NOT occur and are subsequently indicative of a fracture at that site?</div>

<ol> <li>Tip of fibula</li> <li>Posterior talus</li> <li>FHL insertion</li> <li>Insertion of peroneus brevis</li></ol>

Answer 41

C. sesamoids are in FHB not FHL.

Question 42

<div>RC 2017 - Which was true regarding total ankle arthroplasty and anticoagulation</div>

<div>A. Doesn’t need anticoagulation if healthy</div>

<div>B. Should be anti-coagulated if previous PE</div>

<div>C. Everyone should get it</div>

Answer 42

“B. (group consensus)<div>(A is also true, but B is best)<br></br><div><br></br></div><div><div><img></img></div> <ul> <li>Chart review of 637 patients (664 ankles) who received a TAA between May 2007 and January 2014 and had a minimum follow-up of 3 months. </li> <li>Chemoprophylaxis was prescribed only in the setting of a history of VTE or active coagulopathy. Patients were continued on chemoprophylactic agents if they were taking these medications preoperatively</li> <li>Our results suggest that clinically detectable VTE after TAA is uncommon. Patients without identifiable risk factors do not appear to require chemoprophylaxis following TAA. We recommend continuation of antiplatelet oranticoagulationtherapy in patients who are taking these medications preoperatively and the initiation of chemoprophylaxis postoperatively in patients with known risk factors for VTE.</li> </ul> <div><img></img></div> <ul> <li>The incidence of symptomatic DVT aftertotalankle replacementand use of low-molecular-weight heparin is comparable with that in patients undergoingtotalknee or hipreplacement</li> <li>we identified obesity, a previous venous thromboembolic event and the absence of full post-operative weight-bearing as independent risk factors for developing a symptomatic DVT</li> <li>Our results indicate that we do not have the evidence to advocate the routine use of LMWH in this patient group</li></ul></div></div>”

Question 43

RC 2017 - (1) Regarding a recent study on ankle arthroplasty and arthrodesis as compared to unaffected controls, which of the following is NOT true? <ol> <li>arthroplasty has a closer gait pattern to controls </li> <li>Arthroplasty and arthrodesis have equivalent patient satisfaction </li> <li>plantarflexion with arthroplasty is equal to control </li> <li>Gait power is greater with arthrodesis vs arthroplasty (?)</li> </ol> <div>(2) When comparing the outcomes of ankle arthrodesis and ankle arthroplasty with those of a control group, all of the following are true except</div> <ol> <li>Ankle arthroplasty group has same plantar flexion strength as the control group</li> <li>Both Ankle arthroplasty and ankle arthrodesis demonstrate a weaker gait than the control group</li> <li>Arthrodesis and ankle arthroplasty patients report similar patient reported outcomes</li> <li>Ankle athroplasty gives a range of motion that is similar to that of the control group</li></ol>

Answer 43

(1) C/D<div>(2) A/D</div><div><br></br></div><div>FACTS</div><div>-PF ROM/power decreased in TAA and fusion compared to controls</div><div>-gait power: control»TAA>Fusion</div><div>-TAA>fusion for gait pattern</div><div>-equivalent satisfaction</div><div>-DF same between arthroplasty and control</div><div><br></br></div><div><ul> <li>Plantar flexion motion was not equivalent to normal in either group</li> <li>Improvements in patient-reportedAnkleOsteoarthritis Scale and Short Form-36 scores were similar for both treatment groups</li> <li>Thegaitpatterns of patients following three-component, mobile-bearing totalanklearthroplastymore closely resemblednormalgaitwhencomparedwith thegaitpatterns of patients followingarthrodesis</li></ul></div>

Question 44

RC 2016 - What is the MOST common reason for revision in a 3 component total ankle replacement? <ol> <li>Infection</li> <li>Loosening and osteolysis</li> <li>Medial malleolus fracture</li> <li>Ipsilateral hindfoot/subtalar arthritis</li></ol>

Answer 44

B.<div><ul> <li>Haddad (JBJS 2007) Component loosening and/or subsidence (28%) were the primary reasons for revision</li> <li>Reported rates of infection after TAA range from 1-3.5%</li></ul></div>

Question 45

RC 2011 - Ankle fusion. What kind of orthotic? <ul> <li>A. double rocker bottom</li> <li>B. heel to toe rocker bottom</li> <li>C. Forefoot rocker</li> <li>D. negative rocker bottom</li></ul>

Answer 45

B.<div><ul> <li>Heel to toe orthoses reduce need for ankle motion</li> <li>Other Options:</li> <ul> <li>Double Rocks accommodate for midfoot pathology</li> <li>Toe only rocker –> increase weightbearing proximal to MT heads (forefoot problems)</li> <li>Negative Rocker –> foot in fixed dorsiflexion</li> </ul></ul></div>

Question 46

RC 2009 - Post ankle fusion, get: <ul> <li>A. Knee OA</li> <li>B. Ipsilateral hindfoot OA</li> <li>C. Back OA</li> <li>D. Contra-lateral ankle OA</li></ul>

Answer 46

B. Subtalar arthrosis (50% at 10 years)

Question 47

<div>RC 2017 -</div>

<div><br></br></div>

<div>YYC - 50 year old dude comes with severe radiographic arthritis (of what?) and deformity but no pain. No previous medical care. All are options to discuss with patient except. </div>

<ol> <li>Hemoglobin A1C</li> <li>Discuss fusion</li> <li>Discuss total ankle arthroplasty</li> <li>Order patient supportive orthosis </li> </ol>

<div></div>

<div>McGILL STEM: 50yo guy comes to your clinic, otherwise healthy with no other medical issues. Found to have ankle OA which is very severe but patient has no pain at all. All of the following will be included in your work up and discussion except:</div>

<ol> <li>Neurology consult</li> <li>Discuss TAA</li> <li>Discuss fusion</li> <li>orthotics</li> </ol>

<div></div>

Answer 47

YYC: C.<div>McGill: B.</div><div><br></br></div><div>Dont do TAA in this guy</div><div><br></br></div><div><div>JAAOS 2016: Ankle Arthritis: You Can’t Always Replace it</div> <div>Patients with acute or chronic joint infections, an insensate foot, severe multiplanar deformity, Charcot arthropathy, osteonecrosis of the talus, and compromised soft tissues are often poor candidates for this procedure</div></div>

Question 48

RC 2017 - When performing a supra-malleolar extra-articular osteotomy for ankle OA, all are true except: <div>A. Dome osteotomy is preferred for >15 degrees deformity</div> <div>B. Aim to overcorrect by 4 degrees</div> <div>C. A medial calcaneus slide may also be required for varus ankle OA</div> <div>D. May need fibular osteotomy >10 degrees deformity</div> <div></div>

Answer 48

C. MCDO will put you in more varus…<div><ul> <li>Slight overcorrection is necessary to balance the ankle. In general, the distal tibial surface angle is overcorrected to 2 to 4 degrees of valgus to compensate for the loss of cartilage in the medial tibiotalar joint.</li> <li>In our experience, deformity >10 degrees generally necessitates fibular correction.</li></ul></div>

Question 49

RC 2012, 2011, 2010 - Christina at age of 50 needs ankle fused, and can’t remember how to do it. She should fuse the foot in? <ol> <li>10 degrees dorsiflexion, neutral rotation, 5 degrees valgus</li> <li>neutral flexion, neutral rotation, 5 degrees varus</li> <li>neutral flexion, 5 degrees external rotation, 5 degree varus</li> <li>neutral flexion, 10 degrees ER, 5 degrees valgus</li></ol>

Answer 49

D.<div><ul> <li>JAAOS 2000- Ankle Arthrodesis</li> <ul> <li>The foot should be externally rotated 20-30o relative to the tibia</li> <li>The ankle joint in neutral flexion, 5-10o external rotation and slight valgus (5o)</li> </ul></ul></div>

Question 50

RC 2011 - What is the best position of the hindfoot with subtalar fusion <ol> <li>15 ER, 5 valgus, neutral dorsiflexion</li> <li>5 IR, 5 valgus, neutral dorsiflexion</li> <li>5 plantarlexion, neural varus-valgus, no rotation</li> <li>no rotation, 5 dorsiflexion, 5 varus</li> </ol> <div></div>

Answer 50

A.

Question 51

RC 2017 - Which of following is a poor prognosticator during Cheilectomy for anterior ankle impingement <div>A. Size of medial mal spur</div> <div>B. Decrease joint space</div> <div>C. Size of tibia osteophyte</div> <div>D. Tibial and talar osteophyte formation</div>

Answer 51

“B.<div><ul> <li>AAI is distinguished from early ankle OA in that the tibiotalar joint space is maintained</li> <li>Nothing in article about size of osteophytes and severity of symptoms</li> <li>Obviously decreased joint space = OA and therefore would have poor outcomes if treated with cheilectomy alone… </li> </ul> <div><img></img></div> <ul> <li>Results showed that the degree of osteoarthritic changes is a betterprognosticfactor for theoutcomeofarthroscopic surgeryforanteriorankleimpingementthan size and location of the spurs. The hypothesis is that osteophytes withoutjoint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those withoutjointspace narrowing had good or excellent results, and 50% of those withjointspace narrowing had good or excellent results. At the 2-year followup, the group withoutjointspace narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports</li></ul></div><div><br></br></div>”

Question 52

RC 2011 - In regards to ankle scope, all are indications except? <ul> <li>A. Loose body</li> <li>B. asymmetric joint space narrowing</li> <li>C. osteochondral lesion less than 1cm</li> <li>D. anterior lipping of distal tibia</li></ul>

Answer 52

B.

Question 53

<div>RC 2011 - Active volleyball player suffers an inversion ankle injury. Underwent course of PT and now has pain with ankle dorsiflexion. NO symptoms of instability. Symptoms of his anterior ankle impingement can be caused by all except:</div>

<ol> <li>CN coalition</li> <li>Medial talar osteophyte</li> <li>Scarring and fibrosis of tissue in lateral gutter of ankle</li> <li>Hypertrophy of terminal aspect if AITFL</li> </ol>

<div></div>

Answer 53

A.<div><ul> <li>Anterior bony impingement of the ankle is the osteophytic impingement of the anterior rim of the tibia and the sulcus of the talus</li> <li>The recurrent inversion ankle sprain creates chronic inflammation and hypertrophic changes of the synovial tissue between the talus and the anterior tibia. An accumulation of synovitis and scar tissue is entrapped in the anterolateral gutter of the ankle usually following inversion injuries. The patient will have swelling after activity and limited ankle dorsiflexion and supination as well</li> <li>Bassett’s ligament, a thickened distal fascicle of the anterior inferior tibiofibular ligament (AITFL) that extends distally on the lateral malleolus, is believed to be an independent accessory ligament and the cause of anterolateral soft tissue impingement when the ankle is plantar flexed</li></ul><div><br></br></div><div><br></br></div></div>

Question 54

<div>RC 2015 - What is associated with anterior ankle impingement with tibial and talar osteophytes:</div>

<ol> <li>Lateral ankle instability</li> <li>Anterolateral OCD</li> <li>Posteromedial OCD</li> <li>Full thickness chondral defect of the talus</li></ol>

Answer 54

“A (group consensus over D)<div><br></br></div><div><div>JAAOS 2014 - Anterior Ankle Impingement: Diagnosis and Treatment</div> 14-26% of patients undergoing modified Brostrom procedures have anterior ankle impingement Described ““tram track lesions”” cartilage lesions on the talus, but didn’t comment on thickness Tibial spurs are lateral on CT, so PM OCD doesn’t make sense –> AL OCD is possible but not mentioned in the article<br></br></div>”

Question 55

RC 2016, 2014, 2012 - Patient with flatfoot, 10 degree equinus contracture with knee straight, able to dorsiflex to 10 degrees with knee flexed <ol> <li>Achilles tendon is tight</li> <li>Tibialis posterior is tight</li> <li>Gastrocnemius is tight</li> <li>Subtalar joint is stiff</li></ol>

Answer 55

C. gastrocs is tight - knee flexion relaxes it.<div><br></br></div><div><ul> <li>The Silverskiold test differentiates an isolated gastrocnemius contracture from combine gastrocnemius and soleus contractures by assessing passive ankle dorsiflexion with the knee both flexed and extended</li></ul><div><br></br></div></div>

Question 56

RC 2015 - Contraction of the gastroc results in: <ul> <li>A. Plantarflexion</li> <li>B. Flexion of the knee and ankle</li> <li>C. Flexion of the knee and ankle and subtalar supination</li> <li>D. Flexion of the knee and ankle and subtalar pronation</li></ul>

Answer 56

C.<div><ul> <li>Uquilas CA (JBJS 2015) Everything Achilles</li> <ul> <li>The Achilles tendon is part of a msculotendinous unit that spans three joints, producing knee flexion, tibiotalar flexion, and subtalar inversion</li> </ul></ul></div>

Question 57

<div>RC 2014 - Which of the following are associated with a gastroc-soleus/achilles contracture?</div>

<ul> <li>A. Plantar fasciitis, hallux rigidus, neuropathic foot ulcers</li> <li>B. Hallux rigidus, neuropathic foot ulcer, plantar fasciitis</li> <li>C. Plantar fasciitis, Morton’s neuroma, neuropathic foot ulcers</li> <li>D. Plantar fasciitis, neuropathic foot ulcers, charcot midfoot collapse</li></ul>

Answer 57

D.<div><ul> <li>“Strong association with metatarsalgia, neuropathic ulceration, plantar fasciitis, Charcot midfoot breakdown”</li> <li>“Lesser degree PTTD, Achilles tendinopathy, ankle sprain and fracture, MTP synovitis, hallux valgus, claw toes and toe walking”</li></ul></div>

Question 58

<div>RC 2017 - 45yo active male, feels a pop in the back of his heel when pushing off while skating. Has an Achilles rupture. Comes to see you in clinic 6 weeks after injury. He has been walking on it. What do you recommend?</div>

<div>A. Plantar flexion casting x6 weeks</div>

<div>B. Surgical repair</div>

<div>C. Physiotherapy</div>

<div>D. Functional rehabilitation and walking boot</div>

Answer 58

“B.<div><br></br></div><div><div>JAAOS Jan 2009, Reddy et al Surgical treatment for chronic disease and disorders of the achilles tendon</div> <div><img></img></div> <div></div> <div></div> <div>FAI 2017, Kraeutler et al. Chronic Achilles Tendon Ruptures</div> <div><img></img></div></div>”

Question 59

RC 2011 - List 3 complications of performing an open repair of an Achilles tendon rupture vs. closed treatment

Answer 59

<ul> <li>Incision issues: Hypertrophic Scar, Wound breakdown, Infection</li> <li>Sural nerve injury</li> <li>Tethering of Achilles to skin</li></ul>

Question 60

RC 2013 - When treating an acute Achilles tendon rupture surgically, what are 5 conditions that would make you approach surgical treatment with caution?

Answer 60

<ul> <li>Diabetes</li> <li>Obese (BMI > 30)</li> <li>smoker</li><li>Neuropathy</li></ul>

<ul> <li>Immunocompromised states</li> <li>Age > 65</li> <li>Sedentary life</li> <li>Peripheral vascular disease</li></ul>

Question 61

RC 2016, 2013, 2010 - Debriding an Achilles tendon for intra-substance tendinopathy and remove >50%. Which tendon transfer? <ol> <li>FHL</li> <li>FDL</li> <li>Tibial Posterior </li> <li>Plantaris</li></ol>

Answer 61

A.<div><ul> <li>FHL tendon transfer –> FHL is stronger than FDL and peroneals</li> <ul> <li>Similar axis of force to Achilles</li> <li>In phase transfer</li> </ul> </ul> <div></div></div>

Question 62

RC 2017, 2012 - 45 y.o male Patient has acute achilles tendon rupture. What is appropriate to tell him? <ol> <li>He will get more passive ROM with non-surgical treatment</li> <li>He will have larger diameter calf with surgery</li> <li>If treated non-op, this includes early weight-bearing</li> <li>Re-rupture rate at 2 years is significantly less in operative group</li></ol>

Answer 62

C.<div><div>Soroceanu A (JBJS 2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials</div><ul><li>10 studies</li><li><b>Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included</b></li><li>Surgery had 15.8% increased risk for complications other than re-rupture</li></ul></div><div><div><br></br></div><div>Willits K (JBJS 2010) Operative versus Non-operative Treatment of Acute Achilles Tendon Ruptures</div> <ul> <li>Mohtadi Study</li> <li>144 patients randomized to operative vs non-operative</li> <li><b><u>Both groups had early WB and ROM</u></b></li> <li>No difference in re-rupture rates, higher soft tissue complications in operative group</li> </ul> <div></div> <div>Wong (AJSM 2002) </div> <ul> <li>Wound complications: 14.6% vs 0.5%</li> <li>Re-rupture: 10.7% casting, 1.4% open, 1.5% functional brace</li> <li>Overall complication rates:</li> <ul> <li>6.7% in open repair with early mobilization</li> <li>15.6% perc repair and early mobilization</li> </ul> </ul> <div></div> <div>Khan (JBJS 2005)</div> <ul> <li>12 studies with 800 patients</li> <li>Once again higher rate of re-rupture with non-op and higher rate of complications with OR</li> <li>Functional brace had re-rupture rate of 2.4% vs 12.6% in casting group</li> </ul> <div></div> <div><br></br></div></div>

Question 63

RC 2012 - Old Man Spence running and suffers Achilles rupture. Unfortunately not smart enough to get checked out for a month. MRI shows there is a 7cm gap. What to do? <ol> <li>FHL </li> <li>V-Y</li> <li>Synthetic graft</li></ol>

Answer 63

A.<div><br></br></div><div>VY - only for 2-5cm (7cm of excursion requires 14cm of width - not possible)</div><div>synthetic graft would be asking a lot</div>

Question 64

NON-OP ACHILLES protocol

Answer 64

<div>0-2 weeks<br></br></div>

<ul> <li>Cast/bulky splint in plantarflexion</li> <li>Non-WBing with crutches</li> </ul>

<div>2-4 weeks</div>

<ul> <li><b>Transition to aircast boot with 2cm heel lift</b></li> <li><b>Protected WBing with crutches</b></li> <li>Allowed to do active plantarflexion, eversion/inversion out of aircast below neutral</li> </ul>

<div>4-6 weeks</div>

<ul> <li>Advance to WBAT in aircast boot with 2cm heel lift</li> <li>May continue exercises as above</li> </ul>

<div>6-8 weeks</div>

<ul> <li><b><u>Start removing heel lift</u></b>, 1 lift/week</li> <li>Continue WBAT in boot, no crutches</li> <li>May continue exercises as above</li> </ul>

<div>8-12 weeks</div>

<ul> <li>Wean out of boot, using crutches initially for wean</li> <li>Progress ankle ROM, strength (including calf raises), proprioception</li> </ul>

<div>>12 weeks</div>

<ul> <li>Continue rehab including sport-specific retraining</li> </ul>

<div>>6 months</div>

<ul> <li>Eccentric heel drop program</li></ul>

Question 65

JBJS Summary for Achilles Rupture?

Answer 65

<ul> <li>Soroceanu A (JBJS 2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials</li> <ul> <li>10 studies</li> <li>Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included</li> <li>Surgery had 15.8% increased risk for complications other than re-rupture</li> <li>Surgical patients returned to work 19.16 days sooner (p = 0.0014). </li> <li>There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).</li> </ul></ul>

Question 66

<div>RC 2012, 2009 - All of the following are good to assess ankle stability except?</div>

<ol> <li>MRI </li> <li>Anterior drawer test in plantarflexion </li> <li>CT of the syndesmosis</li> <li>Arthrogram showing dye extending to peroneal tendon sheath</li></ol>

Answer 66

C<div><br></br></div><div><div>Sugimoto K (CORR 2002) </div> Subtalar arthrography for recurrent ankle instability 93% sensitivity and 85% specificity for CFL ligament if contrast leakage from ankle joint, into peroneal sheath or into lateral recess<br></br></div>

Question 67

<div>RC 2015 - What is not associated with ankle instability?</div>

<ol> <li>Peroneal tendonitis</li> <li>Posterior tibialis subluxation/dislocation</li> <li>Occult fracture of anterior process of talus (is this actually supposed to be lateral process?)</li> <li>OCD of the talus</li></ol>

Answer 67

“B.<div><ul> <li>JAAOS 2009 - Commonly missed peri-talar injuries</li> <ul> <li>Osteochondral injuries of the talar dome often accompany the ankle sprain/fracture</li> <li>Lateral talar process fractures</li> <ul> <li>"”Commonly misdiagnosed as an ankle sprain because the the location of maximal tenderness 1cm inferior to tip of lateral malleolus””</li> </ul> </ul> <li>JAAOS 2009 - Peroneal Tendon Injuries</li> <ul> <li>Peroneal subluxation and dislocation associated with ligamentous ankle injuries</li> </ul> <li>JAAOS 2005 - Process and Tubercle Fractures of the Hindfoot</li> <ul> <li>Lateral talar process fractures mimic ankle sprains</li> <li>Fractures of the anterior calcaneal process also occur after inversion of the plantarflexed ankle</li> </ul></ul></div>”

Question 68

RC 2014 - A 20yo female presents to your clinic with a history of multiple ankle inversion injuries. She now has tenderness over the peroneal tendons and lateral ankle joint, and has a positive anterior drawer test. X-rays are normal. What investigation should be ordered to help with pre-op planning? <ol> <li>Stress radiographs</li> <li>Arthrogram</li> <li>MRI</li> <li>CT</li> </ol> <div></div>

Answer 68

C<div><br></br></div><div><div>JAAOS 2008 - Acute and Chronic Ankle Instability</div> <ul> <li>Stress radiographs may be useful in establishing a tear of the lateral ligamentous complex….. but the present lack of clinical usefulness of this information…do not recommend the routine use of stress radiographs</li> <li>MRI imaging evaluation can be useful, particularly in demonstrating associated causes of ankle pain, such as chondral injury, bone bruising, radiographically occult fractures, sinus tarsi injury, periarticular tendon tears, degeneration, and impingement syndrome</li></ul></div>

Question 69

JAAOS 2018 - ankle instability summary

Answer 69

<ul> <li>Surgical options</li> <ul> <li>Non anatomic repair- falling out of favour due to wound complications and recurrent instability</li> <li>Anatomic direct repair of ATFL and CFL </li> <li>Anatomic reconstruction with graft (allo = auto) </li> <ul> <li>Indications: obese, poor tissue quality, failed repair</li> <li>Autograft options</li> <ul> <li>Local (P. longus, EDB) </li> <li>Free (Achilles, hamstrings, bone patellar tendon bone) </li> </ul> <li>Allograft options</li> <ul> <li>Toe flexors/extensors, fascia lata, hamstrings, p. longus described </li> </ul> </ul> <li>Open vs arthroscopic -> 2 RCTs show equivalent outcomes at 1 year</li> <ul> <li>Arthroscopic risks SPN and sural nerve</li> </ul> </ul> <li>Complications higher for non-anatomic repair</li> <ul> <li>Instability</li> <li>Wound complications</li> </ul> <li>Risk factors for recurrence </li> <ul> <li>Patient factors:</li> <ul> <li>Pre-disposing: ligamentous laxity, long-standing instability, high functional demand, and cavovarus deformity </li> <li>Re-injury</li> <li>Functional instabliity</li> </ul> <li>Surgical Factors: inadequate anatomic reconstruction (ie anatomic reconstruction have less instability)</li> </ul> <li>Arthroscopic complications</li> <ul> <li>“relatively high” complication rate (no numbers mentioned) </li> <li>most often nerve damage </li> <ul> <li>Communicating branch b/t SPN and sural (avg distance 4.7 cm from lateral malleolus) à”Safe Zone” of 1.5cm from lateral malleolus</li> </ul> </ul></ul>

Question 70

RC 2014 - What orthotic will you prescribe for a 16yo boy with a subtle cavus foot

Answer 70

<ul> <li>Custom, full length, semi-rigid orthotic</li> <li>Recessed first ray</li> <li>Lateral hindfoot wedge or post</li> <li>Lowered medial arch</li> <li>Heel cushion</li></ul>

Question 71

<div>RC 2012 - 20 yr F with 8 mm Anterolateral talar OCD cystic lesion. No intact cartilage rim. What should be done?</div>

<ul> <li>A. Micro # with MM osteotomy</li> <li>B. Microfracture with arthroscopy</li> <li>C. Retrograde drilling</li> <li>D. Transplant ipsilateral knee</li></ul>

Answer 71

B.<div><br></br></div><div><ul> <li>JAAOS 2010 - Osteochondral Lesions of the Talus</li> <ul> <li>Retrograde drilling if cartilage cap is intact</li> <li>MM osteotomy not needed for microfracture, only needed if placing grafts/need appropriate angle for plugs</li> <li>OATS generally only if > 1-1.5cm</li> </ul></ul></div>

Question 72

RC 2018 - What is the most common location of an atraumatic osteochondral lesion of the talus? <ol> <li>Anteromedial</li> <li>Posteromedial</li> <li>Posterolateral</li> <li>Anterolateral</li></ol>

Answer 72

B.<div><br></br></div><div><br></br></div>

Question 73

RC 2015 - What is part of every surgical procedure for plantar fasciitis? <ul> <li>A. Partial release of the plantar fascia</li> <li>B. Skin incision and inspection of the plantar fascia</li> <li>C. Release of the tarsal tunnel</li> <li>D. Full release of the plantar fascia</li></ul>

Answer 73

A.<div><br></br></div><div>JAAOS</div><div><ul> <li>Plantar fasciotomy, either partial or complete, is the common surgical procedure chosen for treating recalcitrant cases</li> <li>Biomechanical and finite-elements studies have shown that release of >40% of the plantar fascia has detrimental effects on other ligamentous and bony structures in the foot; therefore, releases should be limited</li> <li>Release of tarsal tunnel only indicated if tarsal tunnel symptoms present</li></ul></div>

Question 74

<div>RC 2013 - List 4 components of the syndesmosis</div>

Answer 74

“<ul> <li>Anterior inferior tibfib ligament</li> <li>Posterior inferior tibfib ligament</li> <li>Interosseous Ligament</li> <li>Inferior Transverse Ligament</li></ul><div><img></img><br></br></div>”

Question 75

RC 2012 - 4 nerves to block for ankle block (2012)

Answer 75

<div><ul> <li>Tibial Nerve</li> <li>Superficial Peroneal Nerve</li> <li>Deep Peroneal Nerve</li> <li>Sural Nerve</li> <li>Saphenous Nerve</li></ul></div>

Question 76

RC 2018 - Anticoagulation in ankle surgery – no evidence and not recommended <ol> <li>Dalteparin is provided to prevent DVT and recommended as prophylaxis</li> <li>No evidence for DVT and prophylaxis is not recommended</li> <li>Venous doppler showed 10-40% DVT below knee following TAA and prophylaix is recommended</li></ol>

Answer 76

“B.<div><ul><li><div>DVT prevalence is 20-40% in ankle fracture surgery</div></li><li><div>No difference in rates of DVT with prophylaxis or not</div></li><li><div>Recommend against use of prophylaxis, uness 3+ RFs</div></li><ul><li><div>obesity</div></li><li><div>history of VTE</div></li><li><div>history of trauma</div></li><li><div>use of hormonal replacement or oral contraception therapy</div></li><li><div>anatomic location of surgery</div></li><li><div>procedure duration 60 minutes or more</div></li><li><div>general anesthesia</div></li><li><div>postoperative nonweightbearing immobilization greater than 2 weeks</div></li></ul></ul>and use of anticoagulation.<br></br></div><div><br></br></div><div><br></br></div><div><div><a>FootAnkleInt.</a>2019 Jan;40(1):98-104. doi: 10.1177/1071100718794851. Epub 2018 Sep 7.</div> <div>Incidence and Risk Factors of Symptomatic Venous Thromboembolism Following Foot andAnkleSurgery.</div> <div><a>Richey JM</a>1,<a>Ritterman Weintraub ML</a>2,<a>Schuberth JM</a>3.</div> <div></div> <div>The overall low incidence of VTE following foot andanklesurgerydoes not support routine prophylaxis for all patients. Among patients with 3 or more risk factors, the use of chemoprophylaxis may be warranted.</div></div>”

Question 77

<div>RC 2016 - Which of the following is true regarding a typical gait cycle?</div>

<ol> <li>Maximal vertical displacement at mid stance</li> <li>Maximal vertical displacement occurs at the same time as maximal horizontal displacement</li> <li>50% kinetic energy becomes ….</li> <li>Stance phase takes up 70% of gait cycle</li></ol>

Answer 77

“A.<div><div>Center of gravity (COG)</div> <ul> <li>in standing position is 5cm anterior to S2 vertebral body</li> <li>vertical displacement</li> <ul> <li>during gait cycle COGdisplaces vertically in a rhythmic pattern</li> <ul> <li>the highest point is during midstance phase</li> <li>lowest point occurs at the time of double limb support</li> </ul> </ul> <li>horizontal displacement</li> <ul> <li>COG displaces 5cm horizontally during adult male step</li> </ul></ul><div><br></br></div><div><img></img><br></br></div></div>”

Question 78

<div>RC 2014, 2015 - What muscles are firing during mid-swing phase of gait?</div>

<ol> <li>only tib-ant</li> <li>psoas and tib-ant</li> <li>psoas, hamstrings, tib-ant</li> <li>psoas, quads, tib-ant</li> </ol>

<div></div>

<div><br></br></div>

Answer 78

“<div>ANSWER - C (group consensus)</div><ul><li>Jer: based on table below - would suggest C - psoas and tib ant are concentric and hamstring eccentric</li></ul><div><img></img><br></br></div>”

Question 79

Medializing calcaneal osteotomy described as having a “safe zone” what is true about it? (RC 2019)<div><div>a. Osteotomy inside the safe zone decreases rate of all nerve injuries to < 10%</div> <div>b. Medial and lateral plantar nerves are still at risk even with osteotomy in the safe zone</div> <div>c. Sural nerve injury > 10%</div> <div>d. Some shit about medial vs lateral plantar nerve always at risk</div></div>

Answer 79

“B<div><br></br></div><div><img></img><br></br></div><div><br></br><div><div>• <b><span>Results: </span></b></div> <div>• <span>The safe zone was determined to be within the area </span><b><span><span>11.2 </span></span></b><b><span><span>± </span></span></b><b><span><span>2.7 mm anterior to the landmark line.</span></span></b><span> </span></div> <div>• <span>After </span><b><span>open osteotomy</span></b><span>, lacerations were found in 3 of 10 <b>Medial Calcaneal (</b></span><b><span>MC</span></b><b><span>)</span></b><span> nerves and 3 of 10 <b>Lateral Calcaneal (</b></span><b><span>LC</span></b><b><span>)</span></b><span> nerves. </span></div> <div>• <span>After <b>percutaneous osteotomy</b>, lacerations were found in 2 of 10 MC nerves and 1 of 10 LC nerves. </span></div> <div>• <span>No lacerations of the S</span><span>ural, </span><span>Medial Plantar, or Lateral Plantar nerves were found with either osteotomy.</span><span><br></br> </span></div> <div>• <b><span>Conclusions:</span></b><b><span></span></b><span></span><b></b></div> <div>• <span>The safe zone extended 11.2 </span><span>± </span><span>2.7 mm anterior to the described landmark line. </span></div> <div>• <span>P</span><span>rovides reliable clearance of the medial plantar, lateral plantar, and sural nerves. </span></div> <div>• <b><span><span>The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy</span></span></b><b><span><span></span></span></b><b><span></span></b></div> <div>• <span>There were more injuries to the MC & LC nerves using a traditional open approach compared to a percutaneous osteotomy with a side-cutting burr.</span></div> <div>• <span>O</span><span>pen technique </span><span>= 30% risk to MC & LC nerves.</span></div></div></div>”

Question 80

All the following increase the rate of DVT in ankle surgery except?<div>A. BMI >30</div><div>B. Age >40</div><div>C. Tourniquet use</div><div>D. TXA</div>

Answer 80

Answer: D<div><br></br></div>

Question 81

“<div><span>Hallux valgus to varus what is most common cause? (RC 2019)</span></div><div>A.Correcting IMA to 2</div><div>B. Full release of adductor hallucis</div><div>C. Lateral sesamoidectomy</div><div>D. Release abductor from medial side</div>”

Answer 81

“<div>Answer: C</div> <div><br></br></div><div>Varies between 2-14% after corrective surgery for hallux valgus deformities.</div> <div><br></br></div><div>Pathoanatomy</div> <ul> <li>Loss of osseous support</li> <li>Excessive resection of the medial eminence</li> <li>Excision of lateral sesamoid</li> <ul> <li>Formerly done in the classical description of the McBride</li> </ul> <li>Overrelease of lateral capsular structures</li> <ul> <li>Release or transfer of the <span>adductor hallucis alone is not sufficient </span>to produce dynamic hallux varus</li> </ul> <li>Overplication of medial capsule</li> <li>Overtranslation of intermetatarsal angle or hallux valgus interphalangeus</li> </ul> <div>Two types of iatrogenically induced hallux varus have been described.</div> <ol> <li>The <span>static type</span> results from osseous disruption at the MTP joint following overcorrection (aggressive medial eminence resection or overcorrection of the IMA) during osteotomy procedures.</li> <li>The <span>dynamic type</span> is a result of disruption of muscle balance at the base of the proximal phalanx.</li> </ol> <div><span>Ref: Donley BG. Acquired hallux varus. Foot Ankle Int 1997;18(9):586–92.</span></div> <ul> <li><b>Although hallux varus can occur due to a combination of intraoperative procedures, it is most commonly reported, and perhaps best explained, after a McBride procedure with fibular sesamoid excision.</b></li></ul>”