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Z MCQ Of OrthoBullets > Foot & Ankle (2008-2019) > Flashcards

Foot & Ankle (2008-2019) Flashcards

1
Q
  1. 5 causes of adult cavovarus foot (2012, 2014)
A

(JAAOS - Adult Cavovarus Foot)

  • CNS: CP, TBI, Stroke, MS, Tumors
  • Spine/PNS: Myelomeningocele, syrinx, Diastematomyelia, polio, tumor, SMA, Hereditary neuropathy (CMT)
  • Other: MD, Arthrogryposis, Compartment Syndrome, Burns
  • Post traumatic
  • Clubfoot residual
  • Idiopathic
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2
Q
  1. What orthotic will you prescribe for a 16yo boy with a subtle cavus foot (4 points)? (2015)
A

o JAAOS 2014 - Subtle cavus foot: diagnosis and management

· Custom, full length, semi-rigid orthotic

· Recessed first ray

· Lateral hindfoot wedge or post

· Lowered medial arch

· Heel cushion

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3
Q
  1. List 6 clinical / pathoanatomic findings in the flexible adult flatfoot. (2016)
A

o JAAOS 1999 - Posterior Tibial Tendon Insufficiency

· Inability to perform single heel raise

· “too many toes” sign

· Excessive hindfoot valgus

· Loss of longitudinal arch

· Forefoot abduction

· Equinus contracture

· Pain and tenderness along medial border of foot

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4
Q
  1. List 4 inverters of the subtalar joint. (2014)
A

o Tib post

o Tib Ant

o FDL

o FHL

o Achilles

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5
Q
  1. Patient with flatfoot, 10 degree equinus contracture with knee straight, able to dorsiflex to 10 degrees with knee flexed

A) Achilles tendon is tight

B) Tibialis posterior is tight

C) Gastrocnemius is tight

D) Subtalar joint is stiff

A

ANSWER: C (Gastroc tight)

· 2008, 2013, 2016

· JAAOS 2014 - Triceps surae contracture

· 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

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6
Q
  1. Flexible Pes Planovalgus with no abduction. She is unable to do a single stance heel raise. What operation:

A) TN fusion

B) Triple fusion

C) FDL transfer with medializing calcaneal osteotomy

D) TP advancement

A

ANSWER: C (FDL transfer with med calc osteotomy)

· 2013

· JAAOS 2008 - Adult Acquired Flatfoot Deformity

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7
Q
  1. Middle age female with severe flat foot deformity acquired over last 2 years. What is the cause?
    a. Tarsal coalition
    b. Posterior tibial tendon dysfunction
    c. Charcot foot
    d. Ryan operated on it 2 years ago
A

B. Posterior tibial tendon dysfunction

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8
Q
  1. 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?
    a. Calcaneocuboid arthritis
    b. Subtalar instability
    c. Increased pressures and stress fracture of the sesamoids
    d. Pronation of the forefoot Lateral Column Lengthening Osteotomies.
A

ANSWER: A

· 2014, 2016

· JAAOS - Adult Acquired Flatfoot

· Lateral column lengthening provides correction to the abducted talonavicular joint and raises the arch

· It also decreases eversion and increases the pressure along the plantar lateral border of the foot

· Lengthening may result in lateral foot overload, fifth metatarsal stress fracture, and significant stiffness

· Roche and Calder. Foot Ankle Clin N Am. 2012.

· 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%.

§ Lots of biomechanical evidence for CC arthritis, little clinical evidence

· Neufeld SK (Foot and Ankle Clin 2001)

· Calcaneal lengthening osteotomies can result in over correction and result in excessive and fixed SUPINATION, thought to be a cause of lateral foot pain

· Overlengthening can cause metatarsocuboid arthritis or instability

· 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

· 14% CC arthritis (but 50% of cases had pre-existing arthritis)

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9
Q
  1. Advantage of lateral column lengthening over medial calc osteotomy for stage 2 PTTD?
  2. better forefoot abduction
  3. improved restoration of hindfoot alignment
  4. better fusion
  5. Less non-union
A

ANSWER: A

2011

  • ®Lateral column lengthening addresses uncoverage of the navicular (Evans) à corrects forefoot abduction
    • Bolt PM (FAI 2007) A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot
  • Lateral column lengthening had greater initial and final re-alignment
  • Lateral column lengthening had higher non-union
  • Rate of osteotomy was 2x higher with osteotomy than lengthening
  • High radiographic prevalence of OA
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10
Q
  1. 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?
    a. Positive anterior drawer test
    b. Rigid subtalar motion
    c. Positive Coleman block test
    d. Unable to do single limb heel raise
A

ANSWER: D

2015

Anterior drawer should have corresponding pain at anterolateral ankle

Rigid subtalar motion indicates subtalar coalition or end stage disease, unlikely with this presentation and age group

Possible to do Coleman block

Probably referring to postmed talar dome OC lesion or posteromedial impingement post sprain

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11
Q
  1. 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?
  2. Stress radiographs
  3. Arthrogram
  4. MRI
  5. CT
A

ANSWER: C

2014

  • JAAOS 2008 - Acute and Chronic Ankle Instability
  • 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
  • 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
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12
Q
  1. What is not associated with ankle instability?
  2. Peroneal tendonitis
  3. Posterior tibialis subluxation/dislocation
  4. Occult fracture of anterior process of talus (is this actually supposed to be lateral process?)
  5. OCD of the talus
A

ANSWER: B

2015

JAAOS 2009 - Commonly missed peri-talar injuries

Osteochondral injuries of the talar dome often accompany the ankle sprain/fracture

Lateral talar process fractures

“Commonly misdiagnosed as an ankle sprain because the location of maximal tenderness 1cm inferior to tip of lateral malleolus”

JAAOS 2009 - Peroneal Tendon Injuries

Peroneal subluxation and dislocation associated with ligamentous ankle injuries

JAAOS 2005 - Process and Tubercle Fractures of the Hindfoot

Lateral talar process fractures mimic ankle sprains

Fractures of the anterior calcaneal process also occur after inversion of the plantarflexed ankle

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13
Q
  1. All of the following are good to assess ankle stability except?
  2. MRI
  3. Anterior drawer test in plantarflexion
  4. CT of the syndesmosis
  5. Arthrogram showing dye extending to peroneal tendon sheath
A

ANSWER: C

2009, 2012

Sugimoto K (CORR 2002)

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

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14
Q
  1. In a Chopart amputation, what 2 things can you do to prevent equinus contracture? (2015)
A
  • Soft tissue procedures:
  • Tenodesis of tib ant to dorsum of talus
  • Recession of gastrocs/Achilles
  • Boney procedures:
  • TTC fusion
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15
Q
  1. DM is a common cause of Charcot arthropathy of the foot and ankle. List 3 other causes. (2011)
A

JAAOS 2009 Charcot Neuroarthropathy of the Foot and Ankle

Alcoholism, Leprosy, myelomeningocele, spinal cord injury, syphilis (Tabes dorsalis), brain injury, congenital insensitivity to pain

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16
Q
  1. Symes amputation due to diabetic toes. Which is an important part of the operation:
  2. Attach fat pad to posterior tibia
  3. Attach fat pad to anterior tibia
  4. Resect fat pad
  5. Attach Tibialis Posterior to anterior tibia
A

ANSWER: B

2011, 2013

Campbell’s 11th Edition

“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”

Drill several holes through the anterior edge of the tibia and fibula, and suture the deep fascial lining the heel flap to the bones”

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17
Q
  1. Patient has a Symes. All of the following except
  2. Rigid socket not needed for success
  3. Lift often needed on contralateral side
  4. Heel pad migration may preclude weight bearing
  5. The long lever arm is an advantage
A

ANSWER - A 

2012, 2014

  • Rigid SOCKET is necessary to prevent fat pad migration; rigid prosthesis (aka. foot) is NOT necessary (can use carbon fiber energy storing foot) (rigid socket bears weight up the whole lower leg instead of being an end loading stump)
  • Carroll K - Prosthetics and Patient Management: A Comprehensive Clinical Approach
  • With a symes prothesis the amputated limb actually becomes longer thus the opposit leg requires a lift.
  • Connection between socket and foot must be rigid
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18
Q
  1. 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?
  2. Total contact cast
  3. ORIF
  4. Midfoot fusion
  5. Amputation
A

ANSWER: A

2013

  • JAAOS 2009 - Charcot Neuroarthropathy of the Foot and Ankle
  • Presents as hot swollen foot with bounding pulses.
  • Eichenholtz Classification:
  • Inflammatory –> treatment total contact casting
  • Fragmentation —> total contact casting
  • Coalescence –> total contact casting
  • Reconstruction
  • Indications for surgery:
  • Ulceration from exostoses/dislocations
  • Fusions in reconstructive phase
  • Amputation for recurrent ulcerations/OM
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19
Q
  1. Diabetic guy, with what sounds like a Charcot foot in the stem with medial arch collapse. What would you find on exam?
  2. Pain doing a single heel rise
  3. Warm dry foot with prominence along medial talar head, increase callosities
  4. Decreased eversion and normal inversion
A

ANSWER: B

2012

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

JAAOS 2009 - Charcot Neuroarthropathy of the Foot and Ankle

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20
Q
  1. What is the cause of osteopenia in a neuropathic (Charcot) joint?
  2. Increased blood flow
  3. Non-weight-bearing due to treatment
  4. Neuropathy
  5. Cannot remember the last option
A

ANSWER - A

2009, 2014

  • Charcot Neuroarthropathy of the Foot and Ankle. van der Van, Chapman and Bowker. JAAOS 2009.
  • The neurovascular theory proposes that autonomic dysfunction leads to increased blood flow via arteriovenous shunting, resulting in bone resorption and weakening.
  • Inflammation also responsible for osteoclast stimulation
  •  
  • Charcot Neuroarthropathy of the Foot and Ankle: A Review. Varma. Journal of Foot and Ankle Surgery. 2013
  • This causes about 30% to 60% increased blood flow into the bone, which causes the minerals to be washed off and also stimulates the osteoclasts. These, in their turn, cause increased bone destruction, leading to osteopenia….It is the uncontrolled inflammation that results in the final common pathway for the decreased bone density in CN with an osteoclast and osteoblast imbalance. 
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21
Q
  1. Regarding diabetic healing, what is predictive of good healing?
  2. Transcutaneous oxygen pressure > 30mmHg
  3. ABI of 1.5
  4. Toe pressure of 20 mmHg
A

ANSWER: A

2008, 2013

JAAOS 2010 - Evolving Techniques in Foot and Ankle Amputation

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22
Q
  1. What Transcutaneous O2 is needed for wound healing in diabetics?
  2. 15 mm
  3. 30 mm
  4. 50 mm
  5. 70 mm
A

ANSWER: B

2012

JAAOS 2010 - Evolving Techniques in Foot and Ankle Amputations

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23
Q
  1. What is the most important predictor of healing in a diabetic ulcer?
  2. severity of DM
  3. blood supply
  4. peripheral neuropathy
  5. chronicity of the ulcer
A

ANSWER: B

  • 2009, 2015
  • Peripheral neuropathy is a risk factor for development of ulceration
  • Predictors of non-healing:
  • ABI < 0.45
  • Transcutaneous pressure < 30mmHg
  • Serum albumin < 2.5g/dl
  • Absolute lymphocyte count < 1,500
  • JAAOS 2008 - Complications of Fracture in Patients with Diabetes
  • The most important factor in maintaining a proper milieu for wound healing in patients with diabetes is physiologic blood glucose control - Doesn’t this suggest A? (Clay)
  • McNeely (Diabetes Care 1995)
  • Independent predictors of foot ulceration –> absence of Achilles reflex, insensate to 5.07 Semmes-Weinstein monofilament, transcutaneous oxygen tension <30 mmHg
  • Transcutaneous oxygenation was found to be strongest risk factor for foot ulceration
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24
Q
  1. 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?
  2. Gastrocsoleus stretching exercises and referral for specialized diabetic footwear
  3. Medial calcaneal slide osteotomy
  4. Dorsiflexion osteotomy of the 5th metatarsal
  5. Percutaneous lengthening of the Achilles tendon
A

ANSWER: A - Think A is still right

2009, 2014, 2016 (variants)

Variations in 2016 question (poorly remembered) included improved glycemic control and ulcer debridement

Would not be B because cavus feet need a lateralizing slide osteotomy

Would not be C because it wouldn’t off load anything

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25
Q
  1. List 4 causes for hallux varus deformity after correction of hallux valgus. (2014)
A

AAOS Core Review:

Over-correction of IMA through osteotomy <0

Excessive medial eminence resection

Excessive medial capsular tightening

Excessive lateral release

Excision fibular sesamoid

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26
Q
  1. 25 yr old female with a severe bunionette and high 4-5 angle ? What are 3 surgical treatment components?
A

2010, 2015

JAAOS 2007 - Bunionette Deformity

Metatarsal head translated dorso-medial (relieve callosities)

Lateral eminence resection

Medial soft-tissue release of 5th MTP

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27
Q
  1. What is true regarding the sesamoid bones in the foot?
  2. They are supplied by a single artery
  3. Together they receive 50% of weight during normal gait
  4. The fibular sesamoid is larger than the tibial
  5. Both sesamoids lie within the 2 muscle bellies of the flexor hallucis brevis
A

ANSWER: B

2008, 2013, 2016

JAAOS 2006 – The Hallucal Sesamoids

  • Sesamoid complex transmits as much as 50% of body weight
  • The larger tibial sesamoid lies within the medial head of the flexor halluces brevis, the smaller fibular sesamoid lies within the lateral head
  • Usually a single artery per sesamoid, but up to 2-3 per sesamoid have been described
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28
Q
  1. Question on lesser toes, which is true
  2. on ground 75% during stance phase
  3. max peak pressure of MT head is significantly larger
  4. equal distribution across lesser toes
  5. don’t provide stability in stance phase
A

ANSWER: A

2008

  • Hughes J (JBJS Br 1990) The importance of the toes in walking
  • 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
  • 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%.  
  • 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.
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29
Q
  1. Congenital Hallux varus (all except):
  2. If Bony procedure required, need osteotomy
  3. Polydactyly is frequently noted
  4. 30% recover non-op
  5. medial column defect
A

ANSWER: C

2012

  • Belthur MV (JPO 2011) The Spectrum of Preaxial polydactyly of the Foot
  • 20/28 feet with polydactyly had hallux varus
  • Lovell and Winter’s Pediatric Orthopedics:
  • 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
  • “mild forms of hallux varus with a flexible deformity generally resolve spontaneously, but that condition should be differentiated from congenital hallux varus”
  • Treatment:
  • There is no role for conservative management
  • McElvenny –> soft tissue release and resection
  • Resection and grafting of physeal bridge
  • Opening wedge osteotomy
  • Amputation
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30
Q
  1. Juvenile hallux valgus different than adult
  2. Decreased HV angle
  3. increased DMAA
  4. increased incongruity
  5. decreased IM angle
A

ANSWER: B

2012

  • Coughlin MJ (FAI 1995) Juvenile Hallux Valgus: etiology and treatment
  • Retrospective study of 45 patients with 60 feet
  • Early onset was characterized by increased deformity and an increased DMAA
  • 72% had maternal transmission
  • “an increased DMAA may be the defining characteristics of juvenile hallux valgus”
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31
Q
  1. 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?
  2. Bunionectomy and chevron osteotomy
  3. Distal soft tissue release and Akin osteotomy
  4. Fusion of the 1st MTP
  5. Fusion of the first metatarsal-medial cuneiform joint
A

ANSWER: C

2008, 2014

  • 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.  
  • Disorders of the first metatarsal phalangeal joint. Mann. JAAOS. 1995.
  • 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).
  • 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.
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32
Q
  1. 23 yo female with hallux valgus, painful, IMA 15, HVA, 40. Partially correctable. Xray shows bunion. Appropriate treatment?
  2. Proximal osteotomy
  3. Distal osteotomy
  4. Proximal phalanx osteotomy
  5. MTP fusion
A

ANSWER: A (old answer D)

2011, 2015

  • Group discussion - argument that since it is incongruent, would need a distal soft tissue procedure with your proximal osteotomy, controversial
  • Charles:Too young for MTP fusion, better correction with proximal base osteotomy and ST release
  • Miller’s = IMA > 13 OR HVA > 40 = proximal MT osteotomy
  • IMA <13 AND HVA < 40 = dital MT osteotomy (chevron)
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33
Q
  1. What is true regarding hallux rigidus?
  2. Increased plantar pressures
  3. Intraoperatively, 10 degrees of dorsiflexion is all that is needed for normal gait
  4. The instantaneous center of rotation remains the same
  5. Dorsal osteophyte limits plantarflexion
A

ANSWER - A

2008, 2014

  • Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint (J Bone Joint Surg Am, 1998 Jun; 80 (6): 898 -908) 
  • 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.
  • Motion analysis reveals instant centers of rotation that are displaced and located eccentrically about the metatarsal head.
  • Patients who have symptomatic hallux rigidus have been found to have higher-than-normal dynamic plantar pressures of the first ray.
  • Decreased plantar pressures of the first ray have been reported after resection arthroplasty and implant arthroplasty.
  • 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
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34
Q
  1. 40 year old male laborer with hallux rigidus. What is the best treatment?
  2. Custom orthotic
  3. 1st MTP fusion
  4. Keller’s resection
  5. Proximal phalanx osteotomy
A

ANSWER: B

2011, 2014, 2016

  • JAAOS 2012 - Surgical Management of Hallux Rigidus
  • Shoe modifications, such as a Morton extension orthosis
  • Often poorly tolerated
  • Cheilectomy and Proximal Phalanx Osteotomy
  • Arthrodesis
  • Favorable and time-tested procedure for managing late and end stage hallux rigidus
  • Keller Resection Arthroplasty
  • Better choice for patients > 70 years, less active
35
Q
  1. Christina at age of 50 needs ankle fused, and can’t remember how to do it. She should fuse the foot in?
  2. 10 degrees dorsiflexion, neutral rotation, 5 degrees valgus
  3. neutral flexion, neutral rotation, 5 degrees varus
  4. neutral flexion, 5 degrees external rotation, 5 degree varus
  5. neutral flexion, 10 degrees ER, 5 degrees valgus
A

ANSWER: D

2008, 2010, 2011, 2012

JAAOS 2000- Ankle Arthrodesis

The foot should be externally rotated 20-30o relative to the tibia

The ankle joint in neutral flexion, 5-10o external rotation and slight valgus (5o)

36
Q
  1. What is the best position of the hindfoot with subtalar fusion
  2. 15 ER, 5 valgus, neutral dorsiflexion
  3. 5 IR, 5 valgus, neutral dorsiflexion
  4. 5 plantarlexion, neural varus-valgus, no rotation
  5. no rotation, 5 dorsiflexion, 5 varus
A

ANSWER: A

2011

37
Q
  1. What is associated with anterior ankle impingement with tibial and talar osteophytes:
  2. Lateral ankle instability
  3. Anterolateral OCD
  4. Posteromedial OCD
  5. Full thickness chondral defect of the talus 
A

ANSWER: D (old answer A… A is associated but D is straight from article)

2015

  • JAAOS 2014 - Anterior Ankle Impingement: Diagnosis and Treatment
  • 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
  • Kim SH (Arthroscopy 1999) Tram track lesion of the talar dome:
  • Describes 6 lesions in talar dome
  • Full thickness lesions in the anterior half of the medial aspect of the talar dome,
  • longitudinal defects of variable width
  • No patients had ankle instability
  • Moon JS (Arthroscopy 2010):
  • 57 patients treated arthroscopically
  • 26% had chronic ankle instability
  • No correlation between instability and spur severity
  • 80% of ankles had cartilage lesions
  • Mainly in anterior half of talar dome, corresponding to the mediolateral location of tibial spurs
  • 61% of those with tram-track lesions had lesions on both tibia and talus
  • Presence of instability didn’t correlate with cartilage lesions
38
Q
  1. 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?
  2. FDL
  3. EDM
  4. FHL
  5. Tib post
A

ANSWER: C

2012, 2016

Discussed with LaMothe:

If POSTERIOR to middle facet then FHL

If ANTERIOR to middle facet the FDL as FHL under sustentaculum

39
Q
  1. What is the MOST common reason for revision in a 3 component total ankle replacement?
  2. Infection
  3. Loosening and osteolysis
  4. Medial malleolus fracture
  5. Ipsilateral hindfoot/subtalar arthritis
A

ANSWER: B

2016

JAAOS 2015 – Evaluation of the Painful TAA

Haddad (JBJS 2007) Component loosening and/or subsidence (28%) were the primary reasons for revision

Reported rates of infection after TAA range from 1-3.5%

Glazebrook:

40
Q
  1. Question regarding pediatric flatfoot comparing the triple-C osteotomy to an Evans lateral column lengthening. Which is true?
  2. The Evans procedure is better at correcting talar head coverage or talonavicular coverage
  3. Triple C has is associated with higher complications than Evans
  4. A complication of Triple C is CC joint subluxation
A

ANSWER: A

2016

  • JAAOS 2014 - Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management
  • “CLO (calc length osteo) produced significantly better correction of the subluxed navicular on the head of the talus, but the procedure was associated with a marginally higher rate of complications. Most of these complications were related to subluxation of the calcaneocuboid joint and can be avoided with proper stabilization of the joint, as described in the literature
  • Comparison of the Calcaneo-Cuboid-Cuneiform
  • Osteotomies and the Calcaneal Lengthening Osteotomy
    in the Surgical Treatment of Symptomatic Flexible Flatfoot
  • Rathjen and Mubarak11 modified this procedure, per- forming a sliding-closing medial calcaneal osteotomy, aplantar-closing wedge osteotomy of the medial cunei-form, and an opening wedge osteotomy of the cuboid (triple C osteotomy). The other osteotomy, described byEvans,12 consists of an opening wedge calcaneal osteot-omy to lengthen the lateral column. Mosca13 modified Evans’ procedure and added a plantar-medial closing wedge osteotomy of the medial cuneiform to correct the supination of the forefoot
41
Q
  1. What is a complication of lateral column lengthening?
  2. Degeneration of CC joint
  3. Subtalar Instability
  4. Pronation of the forefoot
  5. Sesamoid stress fracture
A

ANSWER: A 

2014, 2016

JAAOS - Adult Acquired Flatfoot

  • Lateral column lengthening provides correction to the abducted talonavicular joint and raises the arch
  • It also decreases eversion and increases the pressure along the plantar lateral border of the foot
  • Lengthening may result in lateral foot overload, fifth metatarsal stress fracture and significant stiffness
  •  
  • Roche and Calder. Foot Ankle Clin N Am. 2012.
  • 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%.
  • Lots of biomechanical evidence for CC arthritis, little clinical evidence
  •  
  • Neufeld SK (Foot and Ankle Clin 2001)
  • Calcaneal lengthening osteotomies can results in over correction and result in excessive and fixed SUPINATION, thought to be a cause of lateral foot pain
  • Overlengthening can cause metatarsocuboid arthritis or instability
  •  
  • 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
  • 14% CC arthritis (but 50% of cases had pre-existing arthritis) 
42
Q
  1. Ankle fusion. What kind of orthotic?
  2. double rocker bottom
  3. heel to toe rocker bottom
  4. Forefoot rocker
  5. negative rocker bottom
A

ANSWER: B

2011

JAAOS 2008 - Shoe Wear and Orthoses

Heel to toe orthoses reduce need for ankle motion

Other Options:

Double Rocks accommodate for midfoot pathology

Toe only rocker –> increase weightbearing proximal to MT heads (forefoot problems)

Negative Rocker –> foot in fixed dorsiflexion

43
Q
  1. Post ankle fusion, get:
  2. Knee OA
  3. Ipsilateral hindfoot OA
  4. Back OA
  5. Contra-lateral ankle OA
A

ANSWER: B

2009

Coester (JBJS 2001) Long-term results following ankle arthrodesis for post-traumatic arthritis

More OA of ipsilateral subtalar, talonavicular, CC, NC, TMT and fist MTP joints

No worse knee OA

44
Q
  1. 20 yr F with 8 mm Anterolateral talar OCD cystic lesion. No intact cartilage rim. What should be done?
  2. Micro # with MM osteotomy
  3. Microfracture with arthroscopy
  4. Retrograde drilling
  5. Transplant ipsilateral knee
A

ANSWER: B

2012

JAAOS 2010 - Osteochondral Lesions of the Talus

Retrograde drilling if cartilage cap is intact

MM osteotomy not needed for microfracture, only needed if placing grafts/need appropriate angle for plugs

OATS generally only if > 1-1.5cm

45
Q
  1. What is part of every surgical procedure for plantar fasciitis?
  2. Partial release of the plantar fascia
  3. Skin incision and inspection of the plantar fascia
  4. Release of the tarsal tunnel
  5. Full release of the plantar fascia
A

ANSWER: A

2015

JAAOS 2008 - Plantar Fasciitis

  • Plantar fasciotomy, either partial or complete, is the common surgical procedure chosen for treating recalcitrant cases
  • 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
  • Release of tarsal tunnel only indicated if tarsal tunnel symptoms present
46
Q
  1. In regards to ankle scope, all are indications except?
  2. Loose body
  3. asymmetric joint space narrowing
  4. osteochondral lesion less than 1cm
  5. anterior lipping of distal tibia
A

ANSWER: B

2011

47
Q
  1. Contraction of the gastroc results in:
  2. Plantarflexion
  3. Flexion of the knee and ankle
  4. Flexion of the knee and ankle and subtalar supination
  5. Flexion of the knee and ankle and subtalar pronation
A

ANSWER: C

2015

Uquilas CA (JBJS 2015) Everything Achilles

The Achilles tendon is part of a musculotendinous unit that spans three joints, praducing knee flexion, tibiotalar flexion, and subtalar inversion

48
Q
  1. Which of the following are associated with a gastroc-soleus/achilles contracture?
  2. Plantar fasciitis, hallux rigidus, neuropathic foot ulcers
  3. Hallux rigidus, neuropathic foot ulcer, plantar fasciitis
  4. Plantar fasciitis, Morton’s neuroma, neuropathic foot ulcers
  5. Plantar fasciitis, neuropathic foot ulcers, charcot midfoot collapse
A

ANSWER: D

2014

JAAOS 2013 – Triceps Surae Contracture

  • “Strong association with metatarsalgia, neuropathic ulceration, plantar fasciitis, Charcot midfoot breakdown”
  • “Lesser degree PTTD, Achilles tendinopathy, ankle sprain and fracture, MTP synovitis, hallux valgus, claw toes and toe walking”
  • Coughlin MJ (FAI 2003) Hallux Rigidus
  • Case series of 114 patients
  • “there was no evidence of an Achilles or gastrocnemius tendon contracture”
49
Q
  1. 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?
  2. AFO
  3. Triple
  4. Subtalar
  5. TN
A

ANSWER: B

2012

50
Q
  1. Rheumatoid forefoot reconstruction, all are false except
  2. Fuse 1st MTP at 30o dorsiflexion to MT
  3. Release all lesser toe extensors and capsule
  4. Perform less toe MT osteotomies from proximal-dorsal to distal-plantar
  5. Do not recreate the lesser MTP cascade
A

Answer: A

2013

D: You should reestablish the cascade

C: should be distal dorsal to plantar proximal

JAAOS 1994 – Rheumatoid Arthritis of the Foot and Ankle

B: Advanced deformity often requires extensor brevis tenotomy (little toe = no EDB), EDL tendon Z-lengthening and resection of the base of the proximal phalanx.

  • ®Dorsal Approach to Lesser MT Head Resection in RA Foot:
  • -Modified technique involves metatarsal head trimming or resection thru a dorsal incision with or w/o excision of all or part of the proximal phalanx may resolve the symptoms
  • -Two longitudinal incisions are made in the 2nd and 4th interspaces
  • -Collateral ligaments, the dorsal aspect of the capsule, the plantar plate, and the interossei are released in a circumferential fashion around the base of the proximal phalanx and the head and metaphysis of the metatarsal
  • -Long extensor tendon is left intact (EDB is released)
  • -Metatarsal head resection:
  • -Improve exposure of metatarsal head by clearing the base of the proximal phalanx and by distracting on the phalanx
  • -Bone cutter is used to transect the second metatarsal in the region of the distal metaphysis
  • -It is essential that the metatarsal heads be transected in a distal-dorsal to plantar proximal direction
  • -Larger amount of bone needs to be resected with more severe overlap of proximal phalanx on the metatarsal head
  • -Goal is to create about 1 cm of space between the metatarsal neck and base of proximal phalanx
  • -After resection of the second metatarsal, remaining metatarsals should be progressively shorter by several mm (from 2nd to the 5th)
  • -Failure to achieve a nice cascading of the metatarsal, may result in metatarsalgia
  • -Attempt to preserve the base of the proximal phalanx at the MP joint (preserves the alignment and relocation of the lesser MP joints)
  • -Subsequent in the operative procedure the hammertoe deformities are fixed with a K wire that is also driven across the relocated MTP joint, which provides stability
  • -Another technique involves longitudinal “Y” incisions between the 2nd and 3rd and between the 4th and 5th metatarsal heads, so that a Webbing procedure can be performed on the lesser toes
  • -With more severe deformity, (with dislocation of the metatarsal heads) it may be necessary to resect the proximal bases of the lesser toes
  • -With more severe deformity, a more extensive Webbing procedure may have to be performed, usually past the region of phalangeal resection, to prevent drifting of the digits
  • ®Wheeless:
  • ®Position of 1st MTP Arthrodesis:
  • -Toe is placed in approx 25 to 30° of dorsiflexion in relation to first metatarsal and approximately 10-15° of valgus in a first MP joint arthrodesis
  • -First toe should end up resting comfortably against the second toe
  • -Toe should be in 15° of dorsiflexion from the floor (although during surgery it is not possible to make this determination)
  • -This places the least amount of stress on the interphalangeal joint of great toe & provides patient w/ smoother gait pattern.
  • -Remember the angle of inclination to the floor helps fine tune the dorsiflexion; angle of MTP arthrodesis
  • -A flat foot will need less dorsiflexion while a high arched foot will need more dorsiflexion
  • -Following arthrodesis, reduction of intermetatarsal angle will occur in proportion to the preoperative intermetatarsal angle
    • Abdo et al. Rheumatoid Arthritis of the Foot and Ankle. JAAOS November 1994 ; 2:326-332.
  • The forefoot is commonly the most painful area and it is usually the first to be operated upon, but if the forefoot and hindfoot are equally involved the hindfoot should be corrected first.
  • The typical rheumatoid forefoot has hallux valgus, plantar displacement of the metatarsal heads and a varus position of the little toe. Subluxation or dislocation of the proximal phalanges dorsally on the metatarsal heads is common.
  • MTP Fusion, resection arthroplasty MT heads, PIP fusion
  • Retrospective study of 43 consecutive patients; average F/U 74 months
  • High percentage of successful results at 6 years
  • fusion of the first ray maintained alignment and protected the hallux and the lesser metatarsophalangeal joints from recurrent deformity and subsequent metatarsalgia
  • Avoid excessive shortening
  • Position of the hallux is assessed fluoroscopically and clinically with a flat surface to simulate weight bearing.
  • Proper positioning includes valgus of 10 to 15 degrees, dorsiflexion of 25 to 30 degrees relative to the metatarsal shaft (or 15 degrees relative to the sole of the foot), and neutral rotation.
  • Clinically, the hallux should not impinge on the second toe and the nail plate should be aligned with the same plane as the lesser toes.
51
Q
  1. 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?
  2. Triple arthrodesis
  3. Subtalar and talonavicular arthrodesis
  4. Talonavicular arthrodesis
  5. Talonavicular resection
A

ANSWER: B or C

2008

  • B better but described as Tn and CC fusion in young active
  • C is better for early disease
  • JAAOS 1994 - Rheumatoid foot and ankle
  • “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”
52
Q
  1. A fisherman sustained an open medial malleolus fracture and sharp laceration to tib post tendon. How should you manage the Tib-post tendon injury?
  2. Repair primarily
  3. UCBL orthosis
  4. Tenodesis the distal part to FHL
  5. Reconstruct the deficit with FDL to navicular
A

ANSWER: A

2008

JAAOS 2005 - Nerve and tendon lacerations about the foot and ankle

Acute repair of a tibialis posterior tendon laceration can lead to a good result

Small case series of these

53
Q
  1. List 3 complications of performing an open repair of an Achilles tendon rupture vs. closed treatment. (2011)
A
  • Hypertrophic Scar
  • Sural nerve injury
  • Infection
  • Wound breakdown
  • Tethering of Achilles to skin
54
Q
  1. When treating an acute Achilles tendon rupture surgically, what are 5 conditions that would make you approach surgical treatment with caution? (2013)
A

JAAOS 2010 - Diagnosis and Treatment of Acute Achilles Tendon Rupture

“….although surgical treatment is an option, it should be approached more cautiously in patients with:

  • Diabetes
  • Neuropathy
  • Immunocompromised states
  • Age > 65
  • Use Tobacco
  • Sedentary life
  • Obese (BMI > 30)
  • Peripheral vascular disease”
55
Q
  1. Debriding an Achilles tendon for intra-substance tendinopathy and remove >50%. Which tendon transfer?
  2. FHL
  3. FDL
  4. Tibial Posterior
  5. Plantaris
A

ANSWER: A

2010, 2013, 2016

FHL tendon transfer –> FHL is stronger than FDL and peroneals

Similar axis of force to Achilles

In phase transfer

56
Q
  1. 45 y.o male Patient has acute achilles tendon rupture. What is appropriate to tell him?
  2. He will get more passive ROM with non-surgical treatment
  3. He will have larger diameter calf with surgery
  4. If treated non-op, this includes early weight-bearing
  5. Re-rupture rate at 2 years is significantly less in operative group
A

ANSWER: C

2012

  • Willits K (JBJS 2010) Operative versus Non-operative Treatment of Acute Achilles Tendon Ruptures
  • Mohtadi Study
  • 144 patients randomized to operative vs non-operative
  • Both groups had early WB and ROM
  • No difference in re-rupture rates, higher soft tissue complications in operative group
  • Wong (AJSM 2002)
  • Wound complications: 14.6% vs 0.5%
  • Re-rupture: 10.7% casting, 1.4% open, 1.5% functional brace
  • Overall complication rates:
  • 6.7% in open repair with early mobilization
  • 15.6% perc repair and early mobilization
  • Khan (JBJS 2005)
  • 12 studies with 800 patients
  • Once again higher rate of re-rupture with non-op and higher rate of complications with OR
  • Functional brace had re-rupture rate of 2.4% vs 12.6% in casting group
  • Soroceanu A (JBJS 2012) Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials
  • 10 studies
  • Re-rupture rates between operative and non-operative groups equal if functional rehabilitation included
  • Surgery had 15.8% increased risk for complications other than re-rupture
57
Q
  1. 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?
  2. FHL
  3. V-Y
  4. Synthetic graft
A

ANSWER: A

2012

JBJS 2015 - Everything Achilles: Knowledge update and current concepts

Chiodo CP (FAI 2006) Current Concepts Review: Acute Ruptures of the Achilles Tendon

V-Y turndown –> gaps of 3-5 cm (because need twice the length of the turn down of the gap, so for 5cm would need 10cm length)

FHL tendon transfer

Synthetic grafts described but no long term evidence (Lamothe says remove synthetic from your algorithm).

58
Q
  1. When evaluating the syndesmosis which is normal?
  2. > 6 mm something
  3. < 6 mm of tib-fib clear space on the mortise
  4. > 10 mm of tib-fib overlap on the AP
  5. Another measurement of some sort that was wrong
A

ANSWER: B

2009, 2016

  • JBJS 2014 - Current Concepts: Injuries to the Ankle Syndesmosis
  • Three radiographic parameters have been defined for the diagnosis of syndesmotic injury including:
  • Tibiofibular overlap: > 6mm in the AP radiograph, >1mm in mortise
  • Tibiofibular clear space <6mm in both AP and mortise at 1cm proximal to plafond
  • Medial clear space: should be less than or equal to the clear space between the talar dome and tibial plafond
  • (C also true in older other source – but Millers’s, Sagars, orthobullets, etc…all say > 6 not >10)
59
Q
  1. When doing a right syndesmotic stress test?
  2. Abduct and ER
  3. Varus and ER
  4. Left Lateral decubitus position and allow foot hang over end of bed
A

ANSWER: B (old answer A – wrong… Charles)

2016

  • Hastie (FAI 2015) WB radiographs facilitate functional treatment of ankle fractures of uncertain stability
  • Gravity stress test - ipsilateral side down (foot externally rotates with gravity) –> therefore C incorrect
  • JAAOS 2009 Stress Radiographs in Orthopedic Surgery
  • Manual stress tests should be done with ankle in neutral DF and 10o ER
  • Femino JE (FAI 2013) Varus ER stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption
  • Conclusions: Varus external rotation stress was more effective than valgus external rotation stress in demonstrating displacement of markers at the medial gutter and on AP and mortise radiographs for both DDL and DDL with syndesmotic instability
  • Left lateral decubitus position (LLDP) would mean that the patient is lying on his or her left side.
  • This is fucking stupid….no evidence of abduct and ER, just that varus ER is better to detect deltoid AND syndesmosis injury, most important is dorsiflexing and ER
    *
60
Q
  1. All of the following regarding TMT injuries are true except:
  2. 25% risk of arthritis despite good reduction
  3. Dorsal plating is superior to trans-articular screws
  4. 20% initially missed
  5. Short 2nd MT and shallow 2nd TMT recess are risk factors for Lisfranc injury
A

ANSWER: B

2019

  • JAAOS 2010 – Treatment of Lisfranc Joint Injury: Current Concepts
  • Nearly 20% of these injuries are misdiagnosed or missed on initial radiographic assessment
  • Anatomic variances frequently predispose to injury. Peicha et al14 showed that persons with Lisfranc injury had a shallower medial mortise depth compared with control subjects. They suggested that adequate mortise depth provides for greater stability by allowing for a stronger Lisfranc ligament.
  • For more obvious Lisfranc fracture-dislocation, screw fixation has been shown to have lower rates of redisplacement7,27,34 and faster return to weight bearing27,34 postoperatively compared with Kirschner wire (K-wire) fixation. Small-fragment (3.5 mm) cortical screw fixation is recommended for the first, second, and third TMT joints. The fourth and fifth joints may be pinned with K-wires. 
  • We consider using dorsal plating for bridging fixation of comminuted fractures with bony fragments in the TMT joints (Figure 6) and total ligamentous injuries (Figure 7), and as an alternative surgical treatment in certain cases, such as joint damage and loss of fixation. We use dorsal plating in approximately 10% of patients with comminuted joint injuries
  • 25% OA even after fixation
  • JBJS 2018 - Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes.
  • Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique
  • In fact, a shallow second TMT joint mortise is considered a risk factor for suffering a Lisfranc injury - Lisfranc fracture-dislocations: current management EFFORT reviews 2019
  • Edmonton:
  • Lisfranc fractures.  All true except

  • Decreased length of 2nd metatarsal and keystone shallower leads to higher risk of injury

  • 25% go on to arthritis despite good reduction

  • Plates have better outcomes than screws

  • 20% commonly missed injuries
  • Answer:C?
  • A is true, B is true, C questionable, D is true (Sask picked C)
    • JAAOS 2017 article-sites cadaver model that no difference between dorsal plating and screws—paper below states differently.
  • Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes.
  • Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique.
  • Two randomized studies directly compared the results of primary arthrodesis with those of ORIF for TMT joint complex injuries. Ly and Coetzee6 randomly assigned 41 patients to either open reduction or primary arthrodesis for ligamentous injury patterns. The arthrodesis group had substantially improved functional outcomes, higher returns to preinjury activity levels, lower rates of revision surgery, and less pain at final follow-up. In the group that underwent open reduction, 25% of patients required conversion to arthrodesis for symptomatic posttraumatic arthritis
  • Abbasian et al40 found no substantial difference in functional outcome, pain, return to activity, or rates of posttraumatic arthritis following ORIF in matched cohorts of 29 patients each with ligamentous injuries or osseous injury patterns. Radiographic arthritis was seen in 27% of ligamentous injuries compared with 31% of osseous injuries; however, only one patient in each treatment group (3%) required conversion to arthrodesis during the study period.
  • Keystone: the importance of this osseous configuration has been emphasized in a study that reported that subjects with a shallower recess are more prone to injuries at this articulation
61
Q
  1. Regarding the 1cm safe zone that has been described for medializing calcaneus osteotomy to decrease neural injury. If you stay within this safe zone, which of the following is true:
  2. >10% sural nerve injury
  3. medial plantar nerve injury <10%, but lateral plantar nerve injury >10%
  4. There is a <10% risk of all nerve injuries
  5. Medial and plantar nerve injury are still possible even if you stay within the safe zone
A

ANSWER: D

2019

  • calcaneal nerve always at risk, but provides reliable clearance of the medial plantar, lateral plantar, and sural nerves. The medial and lateral calcaneal nerves were always at risk regardless of the location of the osteotomy.
  • Low risk to sural & plantar nerves, but not calcaneal nerves ???
  • Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy: A Cadaveric and Radiographic Investigation - 2013
  • Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction? – 2018
  • SAFE ZONE: On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the “landmark line.” A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique.
  • In a recent cadaveric article, Talusan et al11 attempted to identify the ideal osteotomy location and define a “safe zone” for calcaneal osteotomies that may be referenced to decrease the risk of iatrogenic neurologic injury.
  • The authors define their “safe zone” as an area on the lateral foot radiograph extending 11.2 mm anterior from a line connecting the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia.11 
  • They conclude that their safe zone would reliably spare the medial plantar, lateral plantar, and sural nerves during a calcaneal osteotomy.11
  • The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line.
  • The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy
62
Q
  1. Best view for hindfoot alignment
  2. Saltzman
  3. Canale
  4. Broden
  5. Mortise
A

ANSWER: A

2019

Saltzman (aka hindfoot alignment view) but they say axial view is better

Canale – Talar neck view

Broden – subtalar view

Mortise – no

63
Q
  1. Volleyball player. Ankle sprain 6 months ago. Impingement in dorsiflexion, especially when landing. Regarding anterior ankle impingement. All of the following can lead to anterior impingement except: REPEAT
  2. Calcaneonavicular coalition
  3. Hypertrophied AITFL
  4. Lateral gutter fibrosis
  5. Medial talar spur
A

ANSWER: A

2019

  • https://www.podiatrytoday.com/article/7485
  • JAAOS 2014 - Anterior Ankle Impingement: Diagnosis and Treatment
  • At the time of surgery, the authors found that a distal portion of the AITFL was impinging on the anterolateral talus.
  • talar spur lies medial to the midline, whereas the tibial spur lies lateral to the midline; typically, the spurs do not overlap. Neither were the spurs found to overlap in the cadaver study by Tol and van Dijk.13 Soft-tissue inflam- mation and cartilage lesions may cause pain.3,13,14,18-22 A triangular- shaped area of soft tissue consisting of synovium, collagen, blood vessels, and adipose is located in the anterior
  • joint space between the talus and tibia; in a normal ankle, these tissues are compressed between the talus and tibia on 15 of dorsiflexion.13 In pa- tients with AAI syndrome, pain may be secondary to impingement of this soft tissue3,18,20 (Figure 1).
64
Q
  1. In treatment of ankle arthritis, all of the following are true except?

  2. Gait pattern in arthroplasty is closer to controls than arthrodesis.

  3. Arthroplasty leads to equivalent plantarflexion range of motion compared to controls
  4. Reported patient outcomes are similar between arthroplasty and arthrodesis

  5. Plantarflexion strength in arthroplasty and arthrodesis is lower than controls.
A

ANSWER: B

2019

Edmonton

  • arthrodesis has long been an option for this condition, but leads to noticeably altered gait mechanics and velocity, decreased range of motion, and resultant osteoarthritis of the adjacent joints.
  • Patients who had undergone arthroplasty, when compared with patients who had undergone arthrodesis, demonstrated greater postoperative total sagittal plane motion (18.1° versus 13.7°; p < 0.05), dorsiflexion (11.9° versus 6.8°; p < 0.05), and range of tibial tilt (23.1° versus 19.1°; p < 0.05). Plantar flexion motion was not equivalent to normal in either group. Ankle moments and power in both treatment groups remained significantly lower compared with the control group (p < 0.05 between each treatment group and the control group for both variables). Gait patterns in both treatment groups were not completely normalized. Improvements in patient-reported Ankle Osteoarthritis Scale and Short Form-36 scores were similar for both treatment groups.
65
Q
  1. What is the best method to assess the stability of the syndesmosis intraoperatively
  2. ER stress test
  3. Cotton Test
  4. Gravity stress
  5. Dorsiflexion
A

ANSWER: A (newest evidence favors ER stress test over Cotton) (B old answer)

Intraoperative Assessment of the Stability of the Distal Tibiofibular Joint in Supination-External Rotation Injuries of the Ankle Sensitivity, Specificity, and Reliability of Two Clinical Tests Harri Pakarinen, MD, Tapio Flinkkila, MD, PhD, Pasi Ohtonen, MSc, Pekka Hyv ¨ onen, MD, PhD, ¨ Martti Lakovaara, MD, Juhana Leppilahti, MD, PhD, and Jukka Ristiniemi, MD, PhD

The hook test had a sensitivity of 0.25 (95% confidence interval, 0.12 to 0.45) and a specificity of 0.98 (95% confidence interval, 0.94 to 1.0) for the detection of the same instabilities. The external rotation stress test had a sensitivity of 0.58 (95% confidence interval, 0.39 to 0.76) and a specificity of 0.96 (95% confidence interval, 0.90 to 0.98).

Matuszewski PE, Dombroski D, Lawrence JTR, Esterhai JL, Mehta S. Prospective Intraoperative Syndesmotic Evaluation During Ankle Fracture Fixation: Stress External Rotation Versus Lateral Fibular Stress. J Orthop Trauma. 2015;29(4):4.

The difference in widening with stress external rotation was significantly greater than lateral fibular stress and appreciable on standard fluoroscopic views. Stress external rotation radiographs are a more reliable indicator of mortise instability than traditional lateral fibular stress.

2019

  • http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.904.9905&rep=rep1&type=pdf
  • JAAOS management of ankle fractures – can create wider medial space widening with cotton test
  • JWO - Diagnosing syndesmotic instability in ankle fracture – cotton better
  • Pre-op – best is ER or gravity
  • On the basis of a biomechanical cadaveric study, Stoffel et al[28] concluded that use of the lateral (bone hook) stress test or Cotton test[32] and examination of the tibio fibular clear space on stress radiographs intra-operatively is more reliable, because of the greater displacement when per- forming this test, than the exorotation stress test.
  • The “Hook” or “Cotton” test is more reliable than the exorotation stress test
66
Q
  1. Which of the following is a risk factor for hallux varus
  2. Complete Medial FHB release
  3. Lateral sesamoidectomy
  4. Reducing the IMA to 2 deg
  5. Complete release of the adductor brevis
A

ANSWER: B

2019

Charles – Miller’s says IMA < 0 causes hallux varus and the Modified part of McBride is that they dont do lateral sesamoidectomy

Risk Factors for Iatrogenic Hallux Varus (after Hallux valgus surgery)

  • 2-10% incidence following HV surgery
  • Over tightening of medial capsule
  • Excessive resection of medial eminence
  • Overcorrection of IMA / HVA
  • Excessive lateral capsular release (McBride) – taking down the collateral ligament
  • Excision of fibular sesamoid
67
Q
  1. REPEAT, For a 3-component Total ankle arthroplasty at 8 years, what is the most common cause of failure? 
  2. malleolar fracture 
  3. Poly wear and osteolysis 
  4. Infection 
  5. Subtalar arthritis 
A

ANSWER: B

2019

In a systematic review of 49 primary studies that evaluated TAA and ankle arthrodesis, Haddad et al27 reported

implant survival rates of 78% and 77% at 5 years and 10 years, respectively. The revision rate for TAA was 7%. Component loosening and/or subsidence (28%) were the primary reasons for revision (Figure 1).

68
Q
  1. Regarding transmetatarsal amputations in diabetic patients, what is the most predictive of healing? 
  2. Vascularity 
  3. Glycemic control 
  4. Smoking 
  5. Duration of ulcer treatment 
A
  • ANSWER: B

2019

Risk factors for failure of transmetatarsal amputation in diabetic patients: a cohort study. CANADIAN study

  • Blood glucose control as measured by HbA1c was the most important single factor predicting the success of TMA. Need for debridement after TMA was also found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups.
    •  primary factor determining the success of a TMA was the quality of glucose control. As a result of this study we currently do not perform any elective, trauma or emergency surgery on diabetic patients with an HbA1c of over 8 unless the need for surgery is to save life or limb.
69
Q
  1. All of the following are true regarding os trigonum except: 
  2. Can be due to a fracture of the Stieda process 
  3. Rarely associated with FHL tendonitis 
  4. Presents with decreased plantarflexion 
  5. Surgery is a consideration in athletes after 3-6 months of failed non-operative treatment.  
A

ANSWER: B

2019

  • The Stieda process is an elongation of the lateral tubercle of the posterior process of the talus (Fig 1). It is larger than the medial tubercle and is considered the most variable aspect of hindfoot anatomy. This process is the insertion point of the posterior talofibular ligament.
  • A would def be wrong, fracture of stieda process looks like os trigonum but IS NOT (os trigonum is failure a a secondary ossification centre to fuse) like all the other os in the body. - prob not well remembered
  • Os trigonum syndrome often coexists with FHL tenosynovitis in thes ame patient population.

JAAOS 2019 Ankle injuries in Dancers

  • Pain with hyperplantar flexion, doesnt mention decrease plantar flexion
  • Associated with FHL tenditinitis
  • mention one study suggesting surgery after 4 months nonop but no clear guidelines
70
Q
  1. With respect to supramalleolar osteotomy in the treatment of deformities around the ankle, all of the following are true EXCEPT
  2. An anterior dome osteotomy is preferred to treat deformity > 15 degrees
  3. In performing corrections of varus deformity > 10 degrees, a concurrent fibular osteotomy is usually required
  4. In the setting of varus deformity, a medializing calcaneal osteotomy is frequently required
  5. The goal should be to overcorrect deformity by 4 degrees
A

Answer: C (2017) – Would be lateralizing.

JAAOS 2016 – Supramalleolar Osteotomies for the treatment of ankle arthritis

71
Q
  1. All of the following are possible causes of recurrent ankle instability except:
  2. Peroneal tendonitis
  3. Posterior tibialis subluxation/dislocation
  4. Occult fracture of anterior process of calc
  5. OCD of the talus

A

Answer: B (2017)

A - yes
B – prob no

C - yes

D – OCD can def cause it

  • Aside ankle sprains: most common reason for missed athletic participation. Associated injuries: OCD, peroneal tendon injuries, subtle cavovarus foot, deltoid ligament injury, 5th MT fracture, anterior process of calcaneus, lateral process of talus. ATFL is most commonly injured. After treatment, the most common cause of chronic pain is a missed injury.
72
Q
  1. In a study comparing the gait of patients with total ankle replacement, ankle arthrodesis and normal ankle joints, which of the following is true?
  2. Total ankle arthroplasty results in equal plantarflexion as a normal ankle
  3. TAR and fusion result in equal push-off strength than normal ankle
  4. Total ankle replacement better approximates a normal gait compared to ankle fusion
  5. Patients with total ankle arthroplasty have the same gait speed as patients with a normal ankle joint
A

Answer: C

2017

  • Tim Daniel’s paper 2014
  • Same gait speed
  • Same cadence
  • Same stance phase
  • TAR – BETTER total sagittal ROM (mostlydorsiflexion)
  • Same plantar flexion
  • TAR – more tibial tilt at heel-off
  • Same power/ heel rise
  • *** compared to normal ankle: worst plantar flexion (TAR and fusion), worst power (TAR and fusion), coronal plane motion same in all groups, gait speed SAME in all groups
    • The gait patterns of patients following three-component, mobile-bearing total ankle arthroplasty more closely resembled normal gait when compared with the gait patterns of patients following arthrodesis. 
  • Ankle arthroplasty and ankle arthrodesis: gait analysis compared with normal controls.
  • Singer S1, Klejman S2, Pinsker E1, Houck J3, Daniels T1.
    • Comparison of gait after total ankle arthroplasty and ankle arthrodesis
  • Robert Flavin 1, Scott C Coleman, Shay Tenenbaum, James W Brodsky
  • . 2013 Oct;34(10):1340-8.
  • doi: 10.1177/1071100713490675. Epub 2013 May 13.
    • Baseline parameters showed comparability among the treatment and control groups. Temporospatial analysis, using time as the main effect, showed that compared with ankle arthrodesis, patients with total ankle arthroplasty had higher walking velocity attributable to both increases in stride length and cadence as well as more normalized first and second rockers of the gait cycle
    • Conclusions: Patients in both the arthrodesis and arthroplasty groups had significant improvements in various parameters of gait when compared with their own preoperative function. Neither group functioned as well as the normal control subjects. Neither group was superior in every parameter of gait at 1 year postoperatively. However, the data suggest that the major parameters of gait after ankle arthrodesis in deformed ankle arthritis are comparable to gait function after total ankle arthroplasty in nondeformed ankle arthritis.
73
Q
  1. What is an indicator of poor prognosis following ankle arthroscopy for anterior impingement?
  2. Anterior tibial osteophytes
  3. Joint space narrowing
  4. Decreased pre-op dorsiflexion
  5. Pain only in dorsiflexion
A

Answer: B (2017) – joint space narrowing

  • The hypothesis is that osteophytes without joint 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 without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally
74
Q
  1. A young basketball player has recurrent ankle instability. What is the least likely cause?
  2. CN coalition
  3. Synovitis in lateral gutter
  4. Posterior tibial tendon dysfunctions
  5. Subtle cavovarus foot
A

Answer: C (2017)

A – yes. Rigid flatfoot. Tx takedown vs subtalar fusion

B – yes JAAOS

C- not likely.

D – yes recurrent sprains with cavovarus foot is a common presentation. Get Peroneal tendon pathology

75
Q
  1. You see a patient in your office with severe ankle arthritis. He has limited ROM and loss of joint space on imaging but NO pain. All of the following are reasonable next steps in management except:

A) Counsel the patient on an ankle arthrodesis.

B) Refer the patient for an AFO

C) Counsel the patient for a total ankle

D) Refer the patient for a neurology consult.

A

Answer: C (2017) - Shit question but sounds like he has charcot joint thus no total ankle.

Remembered different in other exams where it’s clear patient has charcot joint.

76
Q
  1. In patient undergoing total ankle arthroplasty, which is true regarding the role of DVT prophylaxis
  2. All patients require DVT prophylaxis
  3. DVT prophylaxis is only indicated in patients with active venous thromboemboli
  4. Patients treated in a cast post-operatively will require DVT prophylaxis
  5. DVT prophylaxis is only required in patients who are at high risk of embolic events
A

Answer: D (2017) – high risk only.

  • Prophylaxis Overview
  • prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is most important factor in decreasing morbidity and mortality
  • prophylaxis treatment should be determined by weighing risk of bleeding vs risk of pulmonary embolus
  • AAOS risk factors for major bleeding
  • bleeding disorders
  • history of a recent gastrointestinal bleed
  • history of a recent hemorrhagic stroke
  • AAOS risk factors for pulmonary embolus
  • hypercoagulable state
  • previous documented pulmonary embolism
  • DVT prophylaxis is recommended for all arthroplasty patients; for standard patients, not recommended for upper extremity procedures, arthroscopic, and isolated fractures at knee and below
  • the use of pharmacologic prophylaxis and mechanical compression received a moderate strength recommendation from the AAOS
    • F&A Surgery Prophylaxis
  • the risk of VTE was not found to be lowered by thromboprophylaxis in a study of 20,043 adult patients
    • Note: no increase in DVT has been associated with the use of tranexamic acid (TXA)
77
Q
  1. A healthy, 35 year old male suffers an ankle injury and is diagnosed with an ankle sprain. He undergoes 6 weeks of physiotherapy, and is still experiencing pain. His physiotherapist requests an orthopaedics consult, and you diagnose him with an Achilles tendon tear. What is the most appropriate next step?
  2. Continued physiotherapy
  3. Casting in plantarflexion for 6 weeks
  4. Casting in dorsiflexion for 6 weeks
  5. Achilles tendon repair +/- FHL transfer
A

Answer: D (2017)

A – no needs specific rehab for Achilles protocal.

B – no needs early ROM

C – No, plantar flexion but not for 6 weeks

D – you could. Assume its chronic.

  • Fowler protocol for accelerated achilles rehab
  • 0-6 w
  • Air cast WBAT WITH 2 CM lift (plantar flex)
  • At 2 weeks start physio, ROM to 0 degrees of dorsi
  • 6-8 w
  • Remove lift
  • 8-12 w
  • Transition out of boot

I don’t really like this question/answer – If he’s completing physiotherapy with only pain being his complaint – perhaps it’s just a partial tear. Don’t think I’d jump in with a chronic tear reconstruction. Would start non-op tx protocol.

78
Q
  1. 30 F has a foot injury 6 months ago. She was treated as a “sprain”. It is still hurting her. You are shown a clinical image (shows talonavicular dislocation with CT slices showing depressed talar head fragment and navicular perched on the depressed portion and pristine subtalar joint). How should you manage this?
  2. Triple arthrodesis
  3. Continue with observation
  4. Fix the talar head fragment and ORIF
  5. Isolate TN fusion
A

ANSWER: D

2018

  • States pristine subtalar joint so no triple also doesn’t involve CC jt, too old for ORIF, failed observation
  • Based on a high percentage of good results, retrospective studies strongly suggest that isolated talonavicular arthrodesis provides efficient pain relief and functional improvement in case of talonavicular arthritis in rheumatoid arthritis, primary or posttraumatic arthritis, flexible acquired flatfoot deformity, residual dorsolateral subluxation of the talonavicular joint after surgical treatment of clubfoot, and some neurologic disorders.
  • Depends on the actual question
  • Better chance of fusion of TN if double or triple
79
Q
  1. 65 female has had bunion surgery but comes back with recurrence, complaining of pain and rubbing in her shoes. Xrays show a K wire in the joint and 1st MTP arthritis. What should you do
  2. refer her back to the original surgeon
  3. remove hardware
  4. remove hardware and 1t MTP fusion
  5. Lapidus with 1st MT realignment
A

ANSWER: C

2018

80
Q
  1. Older (?50, 65?) type 1 diabetic comes with a red warm swollen foot. The skin is intact. You are shown an image (there is a midfoot dislocation with the middle cuneiform hanging out in the medial part of the foot…like completely dislocated). They did not mention any acute injury (an may have said it’s been like that for about 3 weeks). Has been weight bearing on it. What is the best management?
  2. Total contact casting
  3. Midfoot ORIF
  4. Midfoot fusion
  5. IV antibiotics
A

ANSWER: A

2018

81
Q
  1. What is the most common location of an atraumatic osteochondral lesion of the talus?
  2. Anteromedial
  3. Posteromedial
  4. Posterolateral
  5. Anterolateral
A

ANSWER: B

2018

PM = atraumatic

AL = traumatic

82
Q
  1. All of the following are associated with plantar fasciitis EXCEPT
  2. Pes planus
  3. Cavus foot
  4. Calcaneal spur
  5. Tight achilles
A

ANSWER: C

  • 2018
  • Tricky question
  • Associated conditions:
  • calcaneal apophysitis
  • gastrocnemius-soleus contracture
  • heel pain triad
  • plantar fasciitis
  • posterior tibial tendon dysfunction
  • tarsal tunnel syndrome
  • anatomic variations
  • femoral anteversion
  • pes cavus
  • pes planus
    • Plantar fasciitis can lead to calcaneal spur
    • Usually non op or ESWT
    • Surgical release with plantar fasciotomy
  • approach
  • can be done open or arthroscopically
  • open procedure is indicated if tarsal tunnel syndrome is present as well
  • release
  • release medial one-third to two-thirds
  • avoid complete release as it may lead to
  • destabilization of the longitudinal arch
  • overload of the lateral column
  • dorsolateral foot pain
  • consider simultaneous release of Baxter’s nerve
  • release the deep fascia of abductor hallucis
  • may improve outcomes
83
Q
  1. Which of the following is true regarding anticoagulation in ankle surgery? (This question was worded this stupidly and I still am not sure what each stem was exactly getting at)
  2. Venographic evidence of DVT is present in 30-40% of patients and anticoagulation is indicated.
  3. There is no evidence that Daltaparin reduces DVT and it is not indicated
  4. There is evidence that Daltaparin reduces DVT and it is indicated
  5. There is no evidence that Daltaparin reduces DVTS but it is recommended for routine prophylaxis.
A

ANSWER: B

2018

84
Q
  1. A diabetic patient comes. He has a non healing forefoot ulcer under the fifth metatarsal which he has tried a lot of skin trimming and wound care for. He has bilateral subtle cavus. What is the best treatment?
  2. Percutaneous tendoachilles lengthening
  3. Medializing calcaneal osteotomy
  4. Achilles stretching and referral for diabetic shoewear
  5. Dorsiflexion osteotomy of the fifth MT
A

ANSWER: A /C

2018

OITE = C

Can do non op first. Depends on question, if cavus and clear achilles tight then perc lengthening

Z MCQ Of OrthoBullets (27 decks)

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