Foot & Ankle 2014

Question 1

Question 1

Figures 1a and 1b are the radiographs and angular measurements of a 38-year-old woman who has bunion pain with all types of shoe wear that now limits her activiites. The first metatarsophalangeal joint is mobilie and can be passively overcorrected into varus. There is no pain with range of motion. Surgical correction should consist of

1. simple bunionectomy.
2. distal metatarsal osteotomy.
3. proximal phalanx osteotomy.
4. proximal metatarsal osteotomy.
5. tarsometatarsal realignment fusion.

Answer 1

2. distal metatarsal osteotomy.

RECOMMENDED READINGS

Perera AM, Mason L, Stephens MM. The pathogenesis of hallux valgus. J Bone Joint Surg Am. 2011 Sep 7;93(17):1650-61. doi: 10.2106/JBJS.H.01630. Review. PubMed PMID: 21915581.

Coughlin MJ, Anderson RB. Hallux valgus. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann’s Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA:Saunders;2014:155-321.

Question 2

Question 16

Figures 16a and 16b are the MR and ultrasound images of a healthy, active 64-year-old man who has anterior ankle pain, difficulty ambulating, and an abnormal gait. These symptosm developed insideously 2 weeks ago and worsened after a recent misstep while walking. What is the best treatment option?

1. Cast immobilization
2. Ankle-foot orthosis
3. Posterior tibialis tendon transfer
4. Physical therapy and eccentric strengthening
5. Primary tendon repair and possible graft augmentation

Answer 2

5. Primary tendon repair and possible graft augmentation

RECOMMENDED READINGS

Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Surgical repair of acute and chronic tibialis anterior tendon ruptures. J Bone Joint Surg Am. 2009 Feb;91(2):325-32. doi: 10.2106/JBJS.G.01386. PubMed PMID: 19181976.

Kopp FJ, Backus S, Deland JT, O’Malley MJ. Anterior tibial tendon rupture: results of operative treatment. Foot Ankle Int. 2007 Oct;28(10):1045-7. PubMedPMID: 17923052.

Question 3

Question 31

A 24-year-old marathon runner twisted her ankle 6 weeks ago. Her pain and swelling have largely resolved, but her ankle feels unsteady. She has not had any recurrence of giving-way episodes. Examination reveals mild tenderness to palpation over the lateral ankle, mild anterior drawer laxity with a solid end point, and minimally decreased strength of the entire ankle and hindfoot. Treatment should consist of

1. cast immobilization.
2. ankle ligament repair.
3. corticosteroid injection.
4. proprioceptive retraining.
5. peroneal tendon tenodesis.

Answer 3

4. proprioceptive retraining.

RECOMMENDED READINGS

Haskell A, Mann RA. Foot and ankle. In: DeLee JC, Drez D, Miller MD, eds. DeLee and Drez’s Orthopaedic Sports Medicine. 3rd ed. Philadelphia, PA:Saunders;2010:1865-2205.

Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604.

Question 4

Question 46

What is the etiology of the second-toe deformity seen in Figures 46a and 46b?

1. Hallux varus
2. Normal aging
3. Narrow-toed shoes
4. Plantar plate rupture
5. Diabetic neuropathy

Answer 4

4. Plantar plate rupture

RECOMMENDED READINGS

Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser toe deformities. J Am Acad Orthop Surg. 2011 Aug;19(8):505-14. Review. PubMed PMID: 21807918.

Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA:Saunders;2014:322-424.

Question 5

Question 54

A 55-year-old diabetic with peripheral neuropathy has had severe foot pain associated with redness and swelling for 1 month. It is difficult to tell if the early findings on the radiograph are due to Charcot arthropathy, infection, or both. What is the best way to make that determination?

1. PET scan
2. Serial radiographs
3. MR image alone
4. Indium 111 scan alone
5. Combined MR image and indium 111 scan

Answer 5

5. Combined MR image and indium 111 scan

RECOMMENDED READINGS

Anakwenze OA, Milby AH, Gans I, Stern JJ, Levin LS, Wapner KL. Foot and ankle infections: diagnosis and management. J Am Acad Orthop Surg. 2012 Nov;20(11):684-93. doi: 10.5435/JAAOS-20-11-684. Review. PubMed PMID: 23118134.

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS; Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004 Oct 1;39(7):885-910. Epub 2004 Sep 10. PubMed PMID: 15472838.

Question 6

Question 69

With respect to stride length, cadence, and velocity, gait after ankle arthroplasty–vs gait after ankle arthrodesis–reveals

1. increased stride length, cadence, and velocity in ankle arthroplasty.
2. increased stride length and cadence and decreased velocity in ankle arthrodesis.
3. decreased stride length, increased cadence, and increased velocity in ankle arthroplasty.
4. decreased stride length, increased cadence, and decreased velocity in ankle arthrodesis.
5. no differences in any parameters.

Answer 6

1. increased stride length, cadence, and velocity in ankle arthroplasty.

RECOMMENDED READINGS

Flavin R, Coleman SC, Tenenbaum S, Brodsky JW. Comparison of gait after total ankle arthroplasty and ankle arthrodesis. Foot Ankle Int. 2013 Oct;34(10):1340-8. doi: 10.1177/1071100713490675. Epub 2013 May 13. PubMed PMID: 23669163.

Snedeker JG, Wirth SH, Espinosa N. Biomechanics of the normal and arthritic ankle joint. Foot Ankle Clin. 2012 Dec;17(4):517-28. doi:10.1016/j.fcl.2012.08.001. Epub 2012 Oct 2. Review. PubMed PMID: 23158367.

Question 7

Question 80

A 45-year-old woman has had heel pain for 8 months. The pain is usually worse in the morning and often is associated with pain at the base of the fifth metatarsal. Stretching exercises, a night splint, 2 corticosteroid injections, and orthotics have not provided any relief. Examination reveals tenderness along the plantar medial heel and origin of the abductor hallucis muscle. THere is no significant Achilles or gastrocnemius tightness. There is no pain with manual compression of the calcaneus. There is no Tinel sign with percussion of the tibial nerve. Radiographic findings are normal. What is the most likely diagnosis?

1. Plantar fasciitis
2. Heel spur syndrome
3. Tarsal tunnel syndrome
4. Calcaneal stress fracture
5. Compression of the lateral plantar nerve

Answer 7

5. Compression of the lateral plantar nerve

RECOMMENDED READINGS

Oztuna V, Ozge A, Eskandari MM, Colak M, Gölpinar A, Kuyurtar F. Nerve entrapment in painful heel syndrome. Foot Ankle Int. 2002 Mar;23(3):208-11. PubMed PMID: 11934062.

DiGiovanni BF, Dawson LK, Baumhauer JF. Plantar heel pain. In: Coughlin MJ, Saltzman CL, Anderson RB. Mann’s Surgery of the Foot and Ankle. 9th ed. Philadelphia, PA:Saunders;2014:685- 701.

Question 8

Question 93

Figures 93a through 93c are the radiographs of a 26-year-old woman who fell 4 feet and sustained an injury to the left ankle. With regard to the medial malleolus, what is the most appropriate surgical fixation method?

1. Tension band with figure-of-eight 18-gague wire
2. Percutaneous partially threaded cancellous screws
3. Precontoured locking plate with bicortical locking screws
4. Bicortical screws exiting at the proximal tibial metaphysis
5. Buttress plate with screws parallel to the articular surface

Answer 8

5. Buttress plate with screws parallel to the articular surface

Question 9

Question 105

A 32-year-old woman has had dorsal foot pain for 6 months. The pain is exacerbated when wearing tight shoes and especially when wearing ski boots. She has reproduction of the pain with palpation over the second metatarsal bases. Additional clinical findings likely will reveal

1. clawing of the hallux.
2. numbness in the first webspace
3. pain exasturbated with dorsiflexion
4. weakness of the abductor halluces.
5. weakness of the extensor digitorum communis.

Answer 9

2. numbness in the first webspace

RECOMMENDED READINGS

Liu Z, Zhou J, Zhao L. Anterior tarsal tunnel syndrome. J Bone Joint Surg Br. 1991 May;73(3):470-3. PubMed PMID: 1670452.

Eibel P. The anterior tarsal syndrome. J Bone Joint Surg Am. 1985 Jan;67(1):170. PubMed PMID: 3968100.

Question 10

Question 117

For the ankle fracture seen in Figures 117a and 117c, what is the most rigid fixation construct for the fibula?

1. Intramedullary fixation
2. Transsyndesmotic screws
3. Locking semitubular plate
4. Nonlocking semitubular plate
5. Interfragmentary screw compression

Answer 10

3. Locking semitubular plate

RECOMMENDED READINGS

Siegel J, Tornetta P 3rd. Extraperiosteal plating of pronation-abduction ankle fractures. Surgical technique. J Bone Joint Surg Am. 2008 Mar;90 Suppl 2 Pt1:135-44. doi: 10.2106/JBJS.G.01138. PubMed PMID: 18310692.

Bottlang M, Doornink J, Lujan TJ, Fitzpatrick DC, Marsh JL, Augat P, von Rechenberg B, Lesser M, Madey SM. Effects of construct stiffness on healing of fractures stabilized with locking plates. J Bone Joint Surg Am. 2010 Dec;92 Suppl 2:12-22. doi: 10.2106/JBJS.J.00780. PubMed PMID: 21123589; PubMed Central PMCID: PMC2995582.

Question 11

Question 130

Figures 130a and 130b are the standing radiographs of a 57-year-old woman who has a chronic draining anterior ankle wound. She underwent a total ankle arthroplasty 3 years ago, which was complicated by a wound dehiscence immediately following surgery. She has had 2 incision and drainage procedures since surgery and has been taking intermittent antibiotics during the last year. She denies fevers or other constitutional signs but has persistent pain with weight bearing. Treatment should consist of

1. staged revision total ankle arthroplasty.
2. incision and drainage with free-flap coverage
3. staged ankle arthrodesis with structural autograft.
4. single-stage prosthesis explantation and hindfoot arthrodesis.
5. polyethylene exchange and long-term antibiotic suppression.

Answer 11

3. staged ankle arthrodesis with structural autograft.

Question 12

Question 147

Figures 147a through 147d are the MR images of a 28-year-old woman who twisted her ankle 6 months ago. Her pain initially subsided over 6 weeks, but recurred and worsened starting 2 months ago. She has not experienced any giveing way, but lacks confidence in her ankle. The pain is worse on uneven ground. Examination reveals tenderness to palpation over the posterolateral fibula and pain with resisted eversion of the foot. There is no laxity of the lateral ankle ligaments. Surgery should consist of

1. ankle ligament repair.
2. peroneal tendon repair.
3. osteochondral lesion repair.
4. osteochondral lesion excision.
5. ankle arthroscopy and anterolateral debridement.

Answer 12

2. peroneal tendon repair.

RECOMMENDED READINGS

Philbin TM, Landis GS, Smith B. Peroneal tendon injuries. J Am Acad Orthop Surg. 2009 May;17(5):306- 17. Review. PubMed PMID: 19411642.

Wukich DK, Tuason DA. Diagnosis and treatment of chronic ankle pain. Instr Course Lect. 2011;60:335- 50. Review. PubMed PMID: 21553785.

Question 13

Question 158

Figures 158a through 158c are the MR images of a 23-year-old man who was running barefoot and felt acute pain in the plantar aspect of his foot. Examination revealed ecchymosis and pain plantarly. Initial treatment should consist of

1. cast immobilization.
2. a corticosteroid injection.
3. supervised physical therapy.
4. an eccentric stretching program.
5. placement in a semirigid orthotic device.

Answer 13

1. cast immobilization.

RECOMMENDED READINGS

Salzler MJ, Bluman EM, Noonan S, Chiodo CP, de Asla RJ. Injuries observed in minimalist runners. Foot Ankle Int. 2012 Apr;33(4):262-6. doi: 10.3113/FAI.2012.0262. PubMed PMID: 22735197.

Kim C, Cashdollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec. 2010 Dec;3(6):335-7. doi: 10.1177/1938640010378530. Epub 2010 Sep 3. PubMed PMID: 20817847.

Question 14

Question 200

Figures 200a through 200c are the MR images of a 36-year-old former professional baseball player who felt an acute pop in his Achilles whiel playing recreational softball 2 days ago. His history is significant for “chronic tendonitis” during his playing career, for which he received multiple steroid injections. He exhibits a positive Thompson test result and plantar flexion weakness. Treatment should consist of

1. percutaneous minimally invasive repair.
2. calcaneal ostectomy and insertional repair.
3. open debridement with fascial turndown.
4. nonsurgical treatment with functional rehabilitation.
5. midsubstance debridement and flexor hallicus longus transfer

Answer 14

2. calcaneal ostectomy and insertional repair.

RECOMMENDED READINGS

Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int. 2011 Apr;32(4):394-9. doi: 10.3113/FAI.2011.0394. PubMed PMID: 21733442.

Reddy SS, Pedowitz DI, Parekh SG, Omar IM, Wapner KL. Surgical treatment for chronic disease and disorders of the achilles tendon. J Am Acad Orthop Surg. 2009 Jan;17(1):3-14. Review. PubMed PMID: 19136422.

Question 15

Question 211

Figures 211a and 211b are the standing anteroposterior and lateral radiographs of a 52-year-old woman who has pain at the hallux metatarsophalangeal joint. She has pain with joint range of motion, over a prominent medial eminence, and with midrange motion of the hallux metatarsophalangeal joint. No significant platnar pain is noted. After failing surgical treatment, what is the best option for surgical treatment?

1. Cheilectomy
2. Cheilectomy with proximal phalanx osteotomy
3. Metatarsophalangeal arthrodesis
4. Distal chevron bunionectomy with cheilectomy
5. Implant arthroplasty for hallux of the metatarsophalangeal joint

Answer 15

3. Metatarsophalangeal arthrodesis

RECOMMENDED READINGS

O’Malley MJ, Basran HS, Gu Y, Sayres S, Deland JT. Treatment of advanced stages of hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am. 2013 Apr 3;95(7):606-10. doi: 10.2106/ JBJS.K.00904. PubMed PMID: 23553295.

Question 16

Question 216

Figures 216a and 216b are the radiographs of a 28-year-old man who is seen 3 days after falling down a flight of stairs. Which intervention or technincal consideration is most important to maximize functional outcome?

1. Suture button device
2. Deltoid ligament repair
3. Quadricortical syndesmosis screws
4. Open reduction of the syndesmosis
5. Ankle in neutral position for implant placement

Answer 16

4. Open reduction of the syndesmosis

RECOMMENDED READINGS

Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012Jul;26(7):439-43. doi: 10.1097/ BOT.0b013e31822a526a. PubMed PMID: 22357084.

Question 17

Question 222

Figures 222a and 222b are the standing radiographs of a 53-year-old obese man who has a 1-year history of a nonhealing plantar midfoot wound that is refractory to serial dressing changes, hyperbaric treatment, and offloading. He has a long history of insulin-dependent diabetes mellitus and had a 2-month period of severe swelling in the involved foot 2 years ago. The wound is 2 cm in maximum diameter and a probe-to bone test result is negative. He denies fevers or any constitutional signs. Treatment should include

1. transmetatarsal amputation.
2. debridement and vacuum-assisted closure.
3. Achilles lengthening and total contact casting.
4. plantar exostectomy and Achilles lengthening.
5. ringed fixator immobilization and extended offloading

Answer 17

4. plantar exostectomy and Achilles lengthening.

RECOMMENDED READINGS

Hastings MK, Johnson JE, Strube MJ, Hildebolt CF, Bohnert KL, Prior FW, Sinacore DR. Progression of foot deformity in Charcot neuropathicosteoarthropathy. J Bone Joint Surg Am. 2013 Jul 3;95(13):1206-13. doi: 10.2106/JBJS.L.00250. PubMed PMID: 23824389; PubMed Central PMCID: PMC3689259.

Question 18

Question 232

Figures 232a and 232b are the weight-bearing radiographs of a 44-year-old, self-employed general contractor who has ankle pain that limits his occupational and recreational activities. Nonsteroidal anti-inflammatory medication, bracing, and corticosteroid injections no longer provide relief. Examination reveals very limited ankle motion, normal hindfoot motion, and diffuse tenderness to palpation. Treatment should consist of

1. ankle arthrodesis.
2. total ankle arthroplasty.
3. distraction arthroplasty.
4. interposition arthroplasty.
5. ankle arthroscopy and debridement.

Answer 18

1. ankle arthrodesis.

RECOMMENDED READINGS

Labib SA, Raikin SM, Lau JT, Anderson JG, SooHoo NF, Carette S, Pinney SJ. Joint preservation procedures for ankle arthritis. Foot Ankle Int. 2013 Jul;34(7):1040-7. doi: 10.1177/1071100713496385. Review. PubMed PMID: 23821012.

Coetzee JC, Hurwitz SR, eds. Arthritis and Arthroplasty: The Foot and Ankle. Philadelphia, PA:Saunders;2010, pp. 3-12, 62-81, 85-94.

Question 19

Question 245

Figure 245 is the radiograph of a 62-year-old woman who had recalcitrant posterior heel pain. Examination revealed she had 10 degrees of dorsiflexion with her knee extended. After failing nonsurgical management, treatment should now consist of

1. endoscopic debridement of Haglund’s deformity.
2. injection platelet-rich plasma and cast immobilization.
3. Achilles tendon debridement with calcaneal exostectomy.
4. Achilles tendon debridement with gastrocnemius recession.
5. Achilles tendon debridement with calcaneal exostectomy and flexor digitorum longus tendon transfer.

Answer 19

3. Achilles tendon debridement with calcaneal exostectomy.

RECOMMENDED READINGS

Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int. 2012 Jun;33(6):487-91. doi:10.3113/FAI.2012.0487. PubMed PMID: 22735321.

Nunley JA, Ruskin G, Horst F. Long-term clinical outcomes following the central incision technique for insertional Achilles tendinopathy. Foot Ankle Int. 2011 Sep;32(9):850-5. PubMed PMID: 22097159.

Question 20

Question 251

Figures 251a and 251b are the weight-bearing radiographs of a 62-year-old man who has a progressive flatfoot deformity. He is unable to perform a single-leg heel rise because of pain, but generates normal inversion strength against resistance without pain. His hindfoot is flexible. Surgical treatment of the deformity should include

1. triple arthrodesis and Achilles lengthening.
2. midfoot arthrodesis and Achilles lengthening.
3. flexor digitorum longus transfer, posterior tibial tendon debridement, and Achilles lengthening
4. medial displacement calcaneal osteotomy, flexor digitorum longus tendon transfer, and Achilles lengthening
5. lateral column lengthening, medial displacement calcaneal osteotomy, spring ligament reconstruction, flexor digitorum longus tendon transfer, and Achilles lengthening

Answer 20

2. midfoot arthrodesis and Achilles lengthening.

Question 21

Question 260

Figures 260a through 260c are the MR images and diagnostic ankle arthroscopy of a 14-year-old soccer player who has a 4-month history of anteromedial ankle pain from a twisting injury. Her symptoms have persisted despite cast immobilization and offloading. She exhibits a stable end point with lateral ligment testing. What is the best next treatment step?

1. Retrograde drilling
2. Osteochondral mosaicplasty
3. Osteochondral allograft transfer
4. Arthroscopic microfracture surgery
5. Autologous chondrocyte implantation

Answer 21

1. Retrograde drilling

RECOMMENDED READINGS

Anders S, Lechler P, Rackl W, Grifka J, Schaumburger J. Fluoroscopy-guided retrograde core drilling and cancellous bone grafting in osteochondral defects of the talus. Int Orthop. 2012 Aug;36(8):1635-40. doi: 10.1007/s00264-012-1530-9. Epub 2012 Apr 11. PubMed PMID: 22491802; PubMed Central PMCID: PMC3535023.

Question 22

Question 268

Figures 268a through 268c are the weight-bearing radiographs of a 28-year-old woman who has an 8-month history of intermittent activity-related pain along the lateral midfoot and peroneal tendons. Her pain, which developed insidiously, primarily occurs with running activities. Which foot orthosis is most appropriate for this patient?

1. Carbon shank with Morton’s extension
2. University of California at Berkeley Laboratory orthosis
3. Full-length steel shank
4. Full-length semirigid insert with arch support and a medial post
5. Full-length insert with a first metatarsal head recess and later hell and sole wedge

Answer 22

5. Full-length insert with a first metatarsal head recess and later hell and sole wedge

RECOMMENDED READINGS

Chilvers M, Manoli A 2nd. The subtle cavus foot and association with ankle instability and lateral foot overload. Foot Ankle Clin. 2008 Jun;13(2):315-24, vii. Doi: 10.1016/j.fcl.2008.01.003. Review. PubMed PMID: 18457776.

Manoli A 2nd, Graham B. The subtle cavus foot, “the underpronator”. Foot Ankle Int. 2005 Mar;26(3):256-63. Review. PubMed PMID: 15766431.