ORTHOPEDIC MCQS WITH ANSWERS ONLINE FOOT AND ANKLE 06

1.      Figures 1a and 1b show the clinical photograph and oblique radiograph of a 52-year-old man who has plantar first metatarsal pain.  A felt pad in the shoe proximal to the area of pain has failed to provide relief.  Management should now consist of

 

1-         cryoablation with liquid nitrogen.

2-         topical salicylic acid application.

3-         first metatarsal dorsiflexion osteotomy.

4-         sesamoidectomy.

5-         sesamoid shaving.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has a discrete callus that overlies a prominent medial sesamoid.  Calluses typically occur in response to increased pressure on the skin.  Initial treatment should be directed at reducing local pressure with a felt pad.  Sesamoid shaving is indicated if the felt pad fails to provide relief.  Sesamoidectomy should be reserved for refractory callus given the potential complications of transfer metatarsalgia or callus and hallux valgus.  A first metatarsal dorsiflexion osteotomy is more appropriate for a diffuse callus that fails to respond to nonsurgical management.  Cryoablation and topical salicylic acid are appropriate for plantar warts, which have a rougher appearance with multiple, small black spots in the lesion. 

 

REFERENCES: Mann RA, Wapner KL: Tibial sesamoid shaving for treatment of intractable plantar keratosis.  Foot Ankle 1992;13:196-198.

Mann RA, Mann JA: Keratotic disorders of the plantar skin.  Instr Course Lect 2004;53:287-302.

 

2.      A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint.  He denies any history of similar symptoms.  What is the first step in evaluation?

 

1-         Serum uric acid level studies and administration of indomethacin

2-         Administration of colchicine

3-         Administration of allopurinol

4-         Aspiration with evaluation of crystals, cell count, and culture

5-         Aspiration with evaluation of crystals and steroid injection

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient’s symptoms are typical for gouty arthropathy, and the diagnosis can only be confirmed with aspiration and visualization of the crystals.  A concomitant infection also must be ruled out; therefore, it is important to obtain a cell count and culture.  Colchicine may have a role in gouty management, but the diagnosis must be confirmed.  Allopurinol is not effective in acute gouty arthropathy.  Measurement of serum uric acid levels is often not helpful in making a definitive diagnosis.  Steroid injections should be deferred until cell count and culture results indicate no accompanying infection. 

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Jahss MH: Disorders of the Foot and Ankle, ed 2.  Philadelphia, PA, WB Saunders, 1991,
pp 1712-1718.

 

3.      A 7-year-old boy sustained an acute puncture wound of the foot after stepping barefoot on a piece of glass 1 day ago.  His mother states that she is not sure if she got the piece of glass out; however, she reports that his immunizations are up-to-date.  Examination reveals that the wound is slightly erythematous, less than 1 mm in length on the heel, and is not currently draining.  What is the next most appropriate step im management?

 

1-         Antibiotic coverage for pseudomonas

2-         Tetanus booster

3-         Radiographs of the foot

4-         MRI to evaluate for possible abscess or osteomyelitis

5-         Surgical debridement of the wound

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The child has an up-to-date tetanus; therefore, a booster is not recommended.  Pseudomonas coverage is most likely not needed because the child was barefoot.  It is too early to evaluate for abscess or osteomyelitis with MRI, and a formal debridement is rarely indicated without signs of an abscess or a retained foreign body.  Radiographs with soft-tissue penetration should be obtained to check for a retained foreign body.

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 199-205.

DeCoster TA, Miller RA: Management of traumatic foot wounds.  J Am Acad Orthop Surg 1994;2:226-230.

 

4.      Figures 2a and 2b show the clinical photograph and radiograph of a 16-year-old cheerleader who fell on her left lower extremity while performing a pyramid.  Following adequate sedation, closed reduction is performed, but an incomplete reduction is noted.  What structure is most likely preventing a reduction?

 

1-         Extensor digitorum brevis

2-         Anterior talofibular

3-         Posterior tibial tendon

4-         Anterior tibial tendon

5-         Peroneus brevis tendon

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The stretched peroneus brevis muscle and tendon follow anterior to the fibula and are most likely incarcerated with reduction.  The anterior talofibular ligament is too small to prevent reduction of the ankle joint itself.  The extensor digitorum brevis originates from the talus; therefore, it is not involved in the tibiotalar joint.  The  posterior tibial tendon lies medially and would not be interposed into the ankle joint.  Similarly, the anterior tibialis tendon also would not be involved. 

 

REFERENCES: Pehlivan O, Akmaz I, Solakoglu C, et al: Medial peritalar dislocation.  Arch Orthop Trauma Surg 2002;122:541-543.

Rivera F, Bertone C, De Martino M, et al: Pure dislocation of the ankle: Three case reports and literature review.  Clin Orthop 2001;382:179-184.

 

5.      Figures 3a and 3b show the current radiographs of a 59-year-old woman who has pain and deformity after undergoing bunion surgery 1 year ago.  Nonsurgical management has failed to provide relief.  Treatment should now consist of

 

1-         revision first metatarsal osteotomy.

2-         medial soft-tissue release and lateral plication.

3-         metatarsophalangeal arthrodesis.

4-         transfer of the extensor hallucis longus tendon.

5-         reverse Akin osteotomy of the proximal phalanx.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The hallux varus seen in this patient is most likely the result of a combination of causes.  Based on the degenerative changes and the significant shortening of the first metatarsal relative to the second metatarsal, a metatarsophalangeal arthrodesis is the treatment of choice.  The other surgical approaches are not expected to provide a satisfactory result.

 

REFERENCES: Coughlin MJ, Mann RA: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby-Year Book, 2000, pp 150-269.

Skalley TC, Myerson MS: The operative treatment of acquired hallux varus.  Clin Orthop 1994;306:183-191.

 

6.      A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot.  He reports success with stretching exercises, but he catches his toes when his foot tires.  Examination reveals that the foot is plantigrade and supple.  What is the next most appropriate step in management?

 

1-         Posterior tibial tendon transfer to the cuboid

2-         Anterior tibial tendon transfer to the cuboid

3-         Achilles tendon lengthening

4-         Ankle-foot orthosis with dorsiflexion assist

5-         Nerve grafting

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes.  Tendon transfer should not be considered until the patient has undergone bracing.  Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible.  Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present.

 

REFERENCES: Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

Santi MD, Botte MJ: Nerve injury and repair in the foot and ankle.  Foot Ankle Int
1996;17:425-439.

 

7.      Removal of both hallucal sesamoids should be reserved as a salvage procedure because of the high incidence of which of the following postoperative complications?

 

1-         Hallux rigidus

2-         Hallux varus

3-         Flexion contracture of the hallux metatarsophalangeal joint

4-         Persistent neuritic pain

5-         Cock-up deformity of the great toe and hallux valgus

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Removal of both sesamoids is associated with a high incidence of postoperative hallux valgus and cock-up deformity of the great toe because of weakening of the flexor hallucis brevis tendon.  The sesamoids lie within these tendons and require meticulous repair following excision.

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 17-25.

Richardson EG: Hallucal sesamoid pain: Causes and surgical treatment.  J Am Acad Orthop Surg 1999;7:270-278.

 

8.      A 35-year-old man who snowboards sustained the injury shown in Figures 4a through 4c.  What is the mechanism of injury?

 

1-         Inversion and external rotation

2-         Axial loading and internal rotation

3-         Plantar flexion, axial loading, and inversion

4-         Dorsiflexion and axial loading

5-         Dorsiflexion, axial loading, inversion, and external rotation

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Fractures of the lateral process of the talus in snowboarders have been thought to result from pure dorsiflexion, inversion, and axial loading.  In a cadaveric study, 10 cadavers were placed in fixed dorsiflexion and inversion with an axial load.  This was combined with or without external rotation.  No fractures occurred after axial loading in the dorsiflexed-inverted position.  Fractures of the lateral process of the talus occurred in 75% of the specimens with the addition of external rotation.

 

REFERENCES: Boon AJ, Smith J, Zobitz ME, et al: Snowboarder’s talus fracture: Mechanism of injury.  Am J Sports Med 2001;29:333-338.

Kirkpatrick DP, Hunter RE, Janes PC, et al: The snowboarder’s foot and ankle.  Am J Sports Med 1998;26:271-277.

 

9.         A 63-year-old man with type I diabetes mellitus who underwent open forefoot amputation now has a high fever, and an elevated WBC count and blood glucose levels.  Repeat laboratory studies the day after surgery show a WBC count of 9,500/mm³, a serum albumin level of 1.9 g/dL, and a total lymphocyte count of 1,900/mm³.  Examination reveals that he is afebrile, and his blood glucose level is now normal.  An ultrasound Doppler of the dorsalis pedis artery shows an ankle-brachial index of 0.6.  A transcutaneous partial pressure measurement of oxygen at the ankle joint shows a level of 38 mm Hg.  What is the best course of action?

 

1-         Guillotine transtibial amputation

2-         Standard transtibial amputation with a posterior myocutaneous flap and immediate prosthetic limb fitting

3-         Culture-specific antibiotic therapy, open wound management, and metabolic/nutritional therapy

4-         Culture-specific antibiotic therapy and Syme ankle disarticulation

5-         Two-stage Syme ankle disarticulation

 

PREFERRED RESPONSE: 3

 

DISCUSSION: This patient appears to have adequate blood supply to heal a Syme’s ankle disarticulation but is currently malnourished because of the systemic infection, and is likely to progress to wound failure.   Therefore, the initial management of choice is culture-specific antibiotic therapy, open wound management, and nutritional supplementation.  If his serum albumin rises to a minimum of 2.5 gm/dL, he can undergo elective Syme’s ankle disarticulation.  If the serum albumin does not rise within a short period of time, he should undergo transtibial amputation.

 

REFERENCE: Pinzur MS, Stuck RM, Sage R, et al: Syme ankle disarticulation in patients with diabetes.  J Bone Joint Surg Am 2003;85:1667-1672.

 

10.    A 40-year-old man has a painful mass on his anterior ankle joint with limited range of motion.  A radiograph, MRI scan, a gross specimen, and a hematoxylin/eosin biopsy specimen are shown in Figures 5a through 5d.  What is the most likely diagnosis?

 

1-         Infection

2-         Tuberculosis

3-         Pigmented villonodular synovitis

4-         Synovial chondromatosis

5-         Metastatic adenocarcinoma

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Synovial chondromatosis results from chondroid metaplasia within the synovium.  Male to female ratio is 2:1, with a peak incidence in early adult life.  Radiographs can show speckled calcification.  Multiple cartilaginous bodies are found loose in the joint and embedded in the synovium.  These nodules are composed of cartilage with calcification. Treatment includes synovectomy and removal of loose bodies.

 

REFERENCES: Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 1007-1032.

Hocking R, Negrine J: Primary synovial chondromatosis of the subtalar joint affecting two brothers.  Foot Ankle Int 2003;24:865-867.

 

11.     A 63-year-old woman with a history of poliomyelitis has a fixed 30-degree equinus contracture of the ankle, rigid hindfoot valgus, and normal knee strength and stability.  She reports persistent pain and has had several medial forefoot ulcerations despite a program of stretching, bracing, and custom footwear.  What is the next most appropriate step in management?

 

1-         CROW walker

2-         Hyperbaric oxygen treatment

3-         Triple arthrodesis with Achilles tendon lengthening

4-         Transtibial amputation

5-         Ankle arthrodesis

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening.  Further bracing will not be helpful.  Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity.  Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee.

 

REFERENCES: Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis.  J Bone Joint Surg Am 1995;77:1148-1153.

Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

 

12.     What is the most common foot deformity associated with myelomeningocele?

 

1-         Talipes equinovarus

2-         Congenital vertical talus

3-         Calcaneus valgus

4-         Calcaneus varus

5-         Cavus

 

PREFERRED RESPONSE: 1

 

DISCUSSION: All of the above can be associated with myelomeningocele, but talipes equinovarus occurs in 50% to 90% of patients with myelomeningocele.  Congenital vertical talus is rarely associated with any neuromuscular diseases other than myelomeningocele but is not the most common deformity in myelomeningocele.

 

REFERENCES: Stans AA, Kehl DK: The pediatric foot, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials.  New York, NY, Thieme, 1999, pp 702-703.

Lindseth RE: Myelomeningocele, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5.  Philadelphia, PA, Lippincott, Williams & Wilkins, 2001,
pp 622-628.

 

13.     Where is the watershed zone for tarsal navicular vascularity?

 

1-         Medial one third

2-         Central one third

3-         Lateral one third

4-         Tuberosity

5-         Inferior pole

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis.  These findings account for the susceptibility to injury at this level. 

 

REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 239-242.

Sarrafian SK: Anatomy of the Foot and Ankle.  Philadelphia, PA, JB Lippincott, 1983,
pp 299-302.

 

14.     A 37-year-old woman has had intermittent paresthesias and numbness in the plantar foot for the past 6 months.   She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night.  MRI scans are shown in Figures 6a and 6b.  What is the most likely diagnosis?

 

1-         Lipoma

2-         Giant cell tumor of the tendon sheath

3-         Synovial sarcoma

4-         Metastatic adenocarcinoma

5-         Ganglion cyst

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The symptoms are consistent with tarsal tunnel syndrome.  Ganglion cysts are a well-known cause of tarsal tunnel syndrome.  The MRI scans show a high intensity, well-circumscribed mass in the tarsal tunnel that is consistent with a fluid-filled cyst.  Patients usually respond well to excision of the ganglion and resolution of the tarsal tunnel symptoms. The surrounding fat is a different signal intensity on the MRI scans, which rules out a lipoma.  Synovial cell sarcoma has a heterogeneous appearance on an MRI scan.  Metastatic tumors are most commonly found in the osseous structures of the foot, not the soft tissues.

 

REFERENCES: Rozbruch SR, Chang V, Bohne WH, et al: Ganglion cysts of the lower extremity: An analysis of 54 cases and review of the literature.  Orthopedics 1998;21:141-148.

Llauger J, Palmer J, Monill JM, et al: MR imaging of benign soft-tissue masses of the foot and ankle.  Radiographics 1998;18:1481-1498.

Takakura Y, Kitada C, Sugimoto K, et al: Tarsal tunnel syndrome: Causes and results of operative treatment.  J Bone Joint Surg Br 1991;73:125-128.

 

15.     Figure 7 shows the CT scan of a 25-year-old soccer player who has had posterior ankle pain with plantar flexion for the past 2 years.  Immobilization has failed to provide relief.  He is ambulatory.  Management should consist of

 

1-         a local steroid injection into the flexor hallucis longus tendon sheath.

2-         range-of-motion exercises.

3-         open reduction and internal fixation.

4-         nonsteroidal anti-inflammatory drugs.

5-         excision of the fragment.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: An os trigonum is usually asymptomatic, but this accessory bone has been associated with persistent posterior ankle pain, which has been described as os trigonum syndrome. This usually affects athletes and ballerinas.  Forced plantar flexion leads to impingement of the os trigonum against the posterior tibial plafond, and flexor hallucis tendinitis may develop.  It may be difficult to differentiate a fractured trigonal process from the os trigonum.  MRI may reveal bone marrow edema that may aid in the diagnosis of os trigonum syndrome.  Steroid injections may lead to tendon rupture.  The results of excision of a symptomatic os trigonum through a posteromedial or lateral approach are favorable, with a rapid return to full function. The main complication of this procedure is sural nerve injury with a lateral approach.

 

REFERENCES: Hedrick MR, McBryde AM: Posterior ankle impingement.  Foot Ankle Int 1994;15:2-8.

Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum.  J Bone Joint Surg Am 2003;85:1051-1057.

 

16.     Figure 8 shows the CT scan of an 11-year-old boy who has had a 1-year history of worsening painful flatfeet.  He reports pain associated with physical education at school, especially with running and jumping.  Management consisting of activity restriction, anti-inflammatory drugs, and casting has failed to provide relief.  Treatment should now consist of

 

1-         a subtalar arthroereisis with a titanium implant.

2-         triple arthrodesis.

3-         resection of the accessory navicular and advancement of the posterior tibial tendon bilaterally.

4-         resection of the talocalcaneal middle facet coalition in each foot.

5-         resection of the calcaneonavicular coalition in both feet.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: In most patients with symptomatic talocalcaneal coalition involving less than 50% of the subtalar joint, resection with fat graft interposition is preferred over a subtalar or triple arthrodesis, especially if reasonable range of motion can be achieved.  This patient has a synchondrosis that is partially cartilaginous.  Although patients may have a residual gait abnormality, most report pain relief after surgery.

 

REFERENCES: Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition.  J Bone Joint Surg Am 1987;69:533-539.

Kitaoka HB, Wikenheiser MA, Schaughnessy WJ, et al: Gait abnormalities following resection of talocalcaneal coalition.  J Bone Joint Surg Am 1997;79:369-374.

Vincent KA: Tarsal coalition and painful flatfoot.  J Am Acad Orthop Surg 1998;6:274-281.

 

17.    An elite skier training for the Olympics sustains an isolated traumatic dislocation of the peroneal tendons that have spontaneously reduced.  The games are 9 months away and the athlete does not want to miss them.  Treatment should consist of

 

1-         acute repair of the superior peroneal retinaculum with possible deepening of the fibular groove.

2-         non-weight-bearing cast immobilization for 6 weeks, followed by intensive rehabilitation.

3-         immediate initiation of sport-specific physical therapy modalities.

4-         ankle bracing and taping and resumption of training in 2 weeks.

5-         a steroid injection, followed by cast boot immobilization for 6 weeks.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Most of these injuries occur in young, active patients.  Success rates for nonsurgical management are only marginally better than 50%.  The treatment of choice is early surgery for patients who desire a quick return to a sport or active lifestyle.  Subluxation of the peroneal tendons leads to longitudinal tears over time.

 

REFERENCES: McLennan JG: Treatment of acute and chronic luxations of the peroneal tendons.  Am J Sports Med 1980;8:432-436.

Krause JO, Brodsky JW: Peroneus brevis tendon tears: Pathophysiology, surgical reconstruction, and clinical results.  Foot Ankle Int 1998;19:271-279.

 

18.    What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

 

1-         Ten degrees of dorsiflexion

2-         Ten degrees of plantar flexion

3-         Twenty degrees of plantar flexion

4-         Neutral

5-         Resting equinus

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Achilles tendon tension is not affected by knee position when the ankle is in 20° to 25° of plantar flexion.  Skin perfusion overlying the Achilles tendon is maximal in 20° of plantar flexion and is reduced beyond 20° of plantar flexion.  Neutral flexion or any amount of dorsiflexion compromises the repair.

 

REFERENCE: Poynton AR, O’Rourke K: An analysis of skin perfusion over the Achilles tendon in varying degrees of plantar flexion.  Foot Ankle Int 2001;22:572-574.

 

19.    A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot.  Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief.  Examination reveals swelling and tenderness over the tarsometatarsal joints.  Radiographs show advanced arthrosis of the first and second tarsometatarsal joints.  Management should now include

 

1-         midfoot arthrodesis.

2-         a rocker sole shoe with orthotic inserts.

3-         shock wave or orthotripsy.

4-         an ankle-foot orthosis.

5-         triple arthrodesis.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief.  Therefore, the treatment of choice is midfoot arthrodesis.  Shock wave treatment has not been shown to be beneficial for arthritis.  An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint.  Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury.

 

REFERENCES: Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis.  Foot Ankle 1990;10:193-200.

Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury.  J Bone Joint Surg Am 1996;78:1665-1676.

 

20.    The Lisfranc ligament connects the base of the

 

1-         first metatarsal and the medial cuneiform.

2-         first metatarsal and the base of the second metatarsal.

3-         first metatarsal and the middle cuneiform.

4-         second metatarsal and the medial cuneiform.

5-         second metatarsal and the middle cuneiform.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The Lisfranc ligament arises from the lateral surface of the first (medial) cuneiform and is directed obliquely outward and slightly downward to insert on the medial surface of the second metatarsal base.  It is the strongest of the tarsometatarsal interosseous ligaments. 

 

REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2.  Philadelphia, PA, JB Lippincott, 1993.

Solan MC, Moorman CT III, Miyamoto RG, et al: Ligamentous restraints of the second tarsometatarsal joint: A biomechanical evaluation.  Foot Ankle Int 2001;22:637-641.

 

21.     An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months.  She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief.  She denies any history of trauma.  Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity.  Radiographs show a prominent accessory navicular.  Management should consist of

 

1-         cast immobilization for 4 to 6 weeks.

2-         posterior tibial tendon advancement and repair (Kidner procedure).

3-         corticosteroid injection of the posterior tibial tendon insertion.

4-         triple arthrodesis.

5-         needle biopsy of the trochar.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The patient has the classic symptoms, examination findings, and radiographs for a painful accessory navicular.  Initial treatment should always be nonsurgical, specifically cast immobilization.  Surgery should be reserved for those patients who fail nonsurgical management.  Corticosteroids should not be injected into a posterior tibial tendon or insertion point because they can weaken the tendon and possibly cause tendon rupture.  Triple arthrodesis and biopsy have no role in the management of a painful accessory navicular.

 

REFERENCE: Bordelon RL: Flatfoot in children and young adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby, 1993, pp 717-756.

 

22.    Figures 9a and 9b show the radiographs of a 28-year-old woman who sustained a head injury and a closed injury, without soft-tissue compromise, to her right lower extremity in a motor vehicle accident.  Appropriate management of the foot injury should include

 

1-         external fixation with a circular frame.

2-         open reduction and internal fixation with screws.

3-         closed reduction and percutaneous pinning.

4-         closed reduction and cast immobilization.

5-         amputation.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The displaced talar neck fracture should be treated with open reduction and internal fixation using screws.  Closed reduction and casting will not maintain position, and percutaneous pinning is not able to maintain reduction to allow union.  External fixation and amputation are not necessary for this injury unless there is severe soft-tissue loss.

 

REFERENCE: Adelaar RS: Fractures of the talus.  Instr Course Lect 1990;39:147-156.

 

23.     An active 47-year-old woman with rheumatoid arthritis reports forefoot pain and deformity and has difficulty with shoe wear.  Examination reveals hallux valgus
and claw toes.  A radiograph is shown in Figure 10.  What is the most appropriate surgical treatment?

 

1-         Distal chevron osteotomy bunionectomy with lesser metatarsal head resections

2-         Proximal first metatarsal osteotomy with flexor-to-extensor tendon transfer for the lesser toes

3-         First metatarsophalangeal arthrodesis with lesser metatarsal head resections

4-         First tarsometatarsal realignment arthrodesis (Lapidus procedure) with flexor-to-extensor tendon transfer for the lesser toes

5-         Resection of the base of the hallux proximal phalanx (Keller procedure) with flexor-to-extensor tendon transfer for the lesser toes

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Rheumatoid arthritis commonly affects the metatarsophalangeal joints, which become destabilized with time resulting in hallux valgus and dislocated lesser claw toes.  The result is metatarsalgia as the dislocated claw toes “pull” the fat pad distally.  Severe hallux valgus reduces first ray load, which compounds the metatarsalgia because the load is transferred to the lesser metatarsal heads.  First metatarsophalangeal arthrodesis restores weight bearing medially and corrects the painful bunion.  Metatarsal head resection slackens the toe tendons to allow correction of the claw toes by whatever means necessary and decreases plantar load over the forefoot.  Rheumatoid arthritis in the first metatarsophalangeal joint will continue to progress if osteotomies or a Lapidus procedure are performed.  Keller resection arthroplasty increases transfer metatarsalgia and reduces push-off power during gait.  Flexor-to-extensor tendon transfer of the lesser toes does not address the metatarsalgia and does not correct the dislocation of the metatarsophalangeal joint.

 

REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, p 572.

Abdo RV, Iorio LJ: Rheumatoid arthritis of the foot and ankle.  J Am Acad Orthop Surg 1994;2:326-332.

 

24.    Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago.  Treatment should consist of

 

1-         open reduction and internal fixation.

2-         a short leg weight-bearing cast.

3-         a short leg non-weight-bearing cast.

4-         first tarsometatarsal fusion.

5-         functional brace application and early range of motion.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The dislocation is between the medial and middle cuneiform.  Although the first and second tarsometatarsal joints are aligned, there is a gap between the cuneiforms.  The radiograph shows a Lisfranc dislocation variant.  In a healthy active individual, open reduction and internal fixation yields the best results.  The reestablishment of the normal arch and medial column support with anatomic reduction is critical to obtaining the best possible outcome from these injuries. 

 

REFERENCES: Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of the tarsal-metatarsal fracture dislocation.  Foot Ankle Int
2002;23:922-926.

Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries.  J Bone Joint Surg Am 2000;82:1609-1618.

 

25.    A 32-year-old woman has left second toe dactylitis (sausage toe).  Radiographs show a “pencil in cup” distal interphalangeal joint deformity.  Examination reveals that subtalar motion is markedly reduced.  What is the most likely diagnosis?

 

1-         Rheumatoid arthritis

2-         Lyme disease

3-         Psoriatic arthritis

4-         Crohn’s disease arthropathy

5-         Gout

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient’s clinical picture is considered the classic presentation for psoriatic arthritis.  The other answers are not applicable for the constellation of findings.

 

REFERENCES: Jahss MH: Disorders of the Foot and Ankle, ed 2.  Philadelphia, PA,
WB Saunders, 1991, pp 1691-1693.

Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

 

26.    What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

 

1-         Posterior tibial

2-         Calcaneal

3-         Intermediate branch of the superficial peroneal

4-         Lateral plantar

5-         Sural

 

PREFERRED RESPONSE: 5

 

DISCUSSION: Cadaver and clinical studies have shown that the sural nerve is at the highest risk for injury with a percutaneous repair of the Achilles tendon. 

 

REFERENCE: Hockenbury RT, Johns JC: A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles.  Foot Ankle 1990;11:67-72.

 

27.    Which of the following tendons is the primary antagonist of the posterior tibialis tendon?

 

1-         Anterior tibialis

2-         Achilles

3-         Peroneus brevis

4-         Peroneus longus

5-         Flexor digitorum longus

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle.  The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon.  The primary action of the peroneus longus is plantar flexion of the first ray.  It secondarily everts the posterior tibialis tendon.  The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon.  The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.

 

REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2.  Philadelphia, PA, JB Lippincott, 1993, pp 550-551.

Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 2-36.

 

28.    Which of the following is considered the most common infectious organism causing osteochondritis in pediatric puncture wounds of the foot?

 

1-         Eikenella corrodens

2-         Pseudomonas aeruginosa

3-         Pasteurella multocida

4-         Serratia marcescens

5-         Proteus mirabilis

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Pseudomonas aeruginosa is the most common infectious organism causing osteochondritis in pediatric puncture wounds of the foot.  Eikenella corrodens is found in human bites, and Pasteurella multocida is characteristically seen with animal bites.  Serratia marcescens and Proteus mirabilis have been reported but are much less likely. 

 

REFERENCES: Jacobs RF, Adelman L, Sack CM, et al: Management of pseudomonas osteochondritis complicating puncture wounds of the foot.  Pediatrics 1982;69:432-435.

Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 171-172.

 

29.    An 18-year-old man sustains an injury to his lateral ankle after being kicked while playing soccer.  He reports persistent pain on the lateral ankle as well as a popping sensation with attempted ankle dorsiflexion and eversion.  Which of the following structures anatomically restrains the retracted structure shown in Figure 12?

 

1-         Posterior talofibular ligament

2-         Calcaneofibular ligament

3-         Superior peroneal retinaculum

4-         Inferior peroneal retinaculum

5-         Peroneal tubercle

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The peroneus brevis and peroneus longus muscles are the main evertors of the hindfoot.  As they descend along the posterior fibula, they pass through the retromalleolar sulcus, formed by the concavity of the retromalleolar fibula.  This sulcus is deepened by a fibrocartilaginous rim.  The superior peroneal retinaculum covers the fibular groove and stabilizes the peroneal tendons within the retromalleolar sulcus.  It originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus. 

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 81-89.

Sarrafian S: The Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2.  Philadelphia, PA, JB Lippincott, 1993, pp 113-158.

 

30.    A 22-year-old man who sustained a Gustilo-Anderson grade IIIC open fracture of the right tibia and fibula was treated with an immediate open transtibial amputation.  After two serial debridements, he underwent wound closure with a posterior myocutaneous soft-tissue flap.  What is the preferred method of early rehabilitation?

 

1-         Bulky gauze dressings with no compression of the traumatized tissues and early non-weight-bearing ambulation

2-         Bulky gauze dressings with snug compression of the residual limb and early non-weight-bearing ambulation

3-         Immediate intraoperative prosthetic fitting with a vacuum-formed prosthetic limb, followed by immediate weight bearing

4-         Rigid plaster dressing, a cast change at 5 to 7 days, and partial weight bearing with an attached pylon when the wound shows signs of healing without infection

5-         Compression dressing and delayed application of a weight-bearing pylon until the sutures are removed and the wound is well healed

 

PREFERRED RESPONSE: 4

 

DISCUSSION: There is no evidence that early weight bearing enhances ultimate rehabilitation.  At the other extreme, weight bearing should not be delayed for a prolonged period of time.  In a young, healthy individual, the rigid plaster dressing appears to be the safest method of protecting the wound during the early postoperative period.  If the wound appears to be secure, early partial weight bearing can be safely initiated.

 

REFERENCES: Burgess EM, Romano RL, Zettl JH: The Management of Lower Extremity Amputations.  Washington, DC, US Government Printing Office, 1969, also at: www.prs-research.org. 

Smith DG, McFarland LV, Sangeorzan BJ, et al: Postoperative dressing and management strategies for transtibial amputations: A critical review.  J Rehabil Res Dev 2003;40:213-224.

 

31.     Figure 13 shows the clinical photograph of a 66-year-old man who has had an increasingly painful right foot deformity for the past 3 years.  Examination reveals that the subtalar joint is fixed in 15° of valgus, and forefoot supination can be corrected to 10° from neutral.  Nonsurgical management has failed to provide relief.  Treatment should now consist of

 

1-         medial sliding calcaneal osteotomy with flexor digitorum longus (FDL) transfer.

2-         isolated subtalar arthrodesis.

3-         isolated talonavicular arthrodesis.

4-         triple arthrodesis.

5-         subtalar arthroereisis.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The most important determining factor for correction of an adult flatfoot without an arthrodesis is the flexibility of the subtalar and transverse tarsal joints.  Rigid deformities cannot be corrected with a medial sliding calcaneal osteotomy with FDL transfer or a subtalar arthroereisis.   Isolated subtalar or talonavicular arthrodesis does not correct the deformities entirely.  If the patient has forefoot supination that can be corrected to less than 7°, an isolated subtalar fusion is a possible alternative.

 

REFERENCE: Mann RA: Flatfoot in adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby, 1993, pp 757-784.

 

32.     When evaluating a patient with hallux rigidus, what is the most important clinical factor indicating the need for an arthrodesis as opposed to a cheilectomy?

 

1-         Dorsal foot pain with shoe wear

2-         Pronounced limited motion in the first metatarsophalangeal joint

3-         Pain at the midrange of motion in the first metatarsophalangeal joint

4-         Large dorsal osteophytes clinically and radiographically

5-         Flattened first metatarsal head with periarticular sclerosis

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Cheilectomy has been shown to provide satisfactory pain relief and improved function in long-term studies.  It is important to select patients appropriately when choosing a cheilectomy versus an arthrodesis.  Pain at the midrange of motion and loss of more than 50% of the metatarsal head cartilage are predictors of a poor outcome following cheilectomy, and these patients should receive an arthrodesis.

 

REFERENCES: Coughlin MJ, Shurnas PS: Hallux rigidus: Grading and long-term results of operative treatment.  J Bone Joint Surg Am 2003;85:2072-2088.

Easley ME, Davis WH, Anderson RB: Intermediate to long-term follow-up of medial-approach dorsal cheilectomy for hallux rigidus.  Foot Ankle Int 1999;20:147-152.

 

33.     A patient who has recalcitrant medial plantar heel pain and pain directly over the medial side of the heel undergoes open release of the plantar fascia.  After releasing a portion of the plantar fascia, the deep fascia of the abductor hallucis muscle is released to relieve pressure on which of the following structures?

 

1-         Lateral plantar artery

2-         Tibial nerve

3-         First branch of the lateral plantar nerve

4-         Sural nerve

5-         Flexor hallucis brevis muscle

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The deep fascia of the abductor hallucis muscle is released to relieve pressure on the first branch of the lateral plantar nerve.  The tibial nerve lies more proximal to this area.  The medial plantar nerve has already passed dorsally and medially, while the sural nerve lies on the lateral side of the foot.  The flexor hallucis brevis muscle lies deep to the plantar fascia, not the abductor fascia.

 

REFERENCES: Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 1992;279:229-236.

Davies MS, Weiss GA, Saxby TS: Plantar fasciitis: How successful is surgical intervention?  Foot Ankle Int 1999;20:803-807.

 

34.     A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief.  Examination reveals a severe hallux valgus with dorsal subluxation of the second toe.  Radiographs are shown in Figures 14a and 14b.  The most appropriate management should include

 

1-         hallux metatarsophalangeal arthrodesis.

2-         custom orthotics.

3-         Chevron osteotomy with second toe correction.

4-         Keller resection arthroplasty with second toe correction.

5-         proximal metatarsal osteotomy with second toe correction.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The radiographs do not show significant arthrosis of the hallux metatarsophalangeal joint; therefore, arthrodesis is unnecessary.  Orthotics will not correct the deformity.  A distally based osteotomy will not achieve sufficient correction of the incongruity of deformity, and a Keller resection is not indicated in the younger population.  The treatment of choice is a proximal metatarsal osteotomy with second toe correction.

 

REFERENCE: Mann RA, Rudicel S, Graves SC: Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy: A long-term follow-up.  J Bone Joint Surg Am 1992;74:124-129.

 

35.     What is the most appropriate orthosis for hallux rigidus?

 

1-         Morton’s extension

2-         Metatarsal arch pad

3-         Full-length semi-rigid longitudinal arch support

4-         Full-length semi-rigid longitudinal arch support with medial hindfoot posting

5-         Full-length semi-rigid longitudinal arch support with lateral forefoot posting

 

PREFERRED RESPONSE: 1

 

DISCUSSION: A Morton’s extension limits excursion of the first metatarsophalangeal joint.  It also functions as a ground reaction stabilizer during the toe-off phase of gait and thus reduces torque and joint reaction force at the first metatarsophalangeal joint.  The metatarsal arch pad and full-length semi-rigid longitudinal arch support may help by dorsiflexing the first metatarsal relative to the phalanx and thus decompress the first metatarsophalangeal joint.  However, they are not as biomechanically effective as the Morton’s extension.  Both medial hindfoot and lateral forefoot posting are contraindicated because they increase ground reaction at the first metatarsophalangeal joint.

 

REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, p 611.

Watson AD, Wapner KL: Foot and ankle reconstruction, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials.  New York, NY, Thieme, 1999, p 635.

 

36.     While experts disagree whether the postpolio syndrome is caused by a reactivation of the dormant virus or by an attritional aging phenomena of muscles that have been overworked over a period of time, both groups recommend which of the following guidelines for optimizing function in this population?

 

1-         Refrain from exercise.

2-         Exercise muscles to exhaustion, but allow 1 day in between exercise sessions to allow the muscles to recover.

3-         Exercise muscles to exhaustion, but allow 2 days in between exercise sessions to allow the muscles to recover.

4-         Exercise daily at a subexhaustion level.

5-         Exercise should be limited to postural and antigravity muscles.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Most leaders in orthopaedic surgery support Jacqueline Perry’s theory that the postpolio syndrome is an attritional degenerative process that is the result of overuse of muscles and joints that are unable to adequately tolerate overload, and have little functional reserve.  For that reason, aerobic conditioning and exercise are important.  Overload and exhaustion of involved muscles should be avoided. 

 

REFERENCE: Garrett AL: Poliomyelitis, in Nickel VL (ed): Orthopaedic Rehabilitation.  New York, NY, Churchill Livingston, 1982, pp 449-458.

 

37.    Figures 15a through 15c show the radiographs of a 23-year-old football player who was injured when another player fell on his flexed and planted foot.  He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb.  Examination reveals mild swelling.  Management should consist of

 

1-         casting.

2-         closed reduction, casting, and no weight bearing for 6 weeks.

3-         open reduction and internal fixation.

4-         closed reduction and percutaneous Kirschner wire fixation.

5-         closed reduction and percutaneous screw fixation.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity.  Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms.  Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment.  For patients with third-degree sprains, poor results were obtained with nonsurgical management.  These patients required open reduction and internal fixation for optimal return to function.  The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.

 

REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1.  St Louis, MO, Mosby, 1995,
pp 107-123.

Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete.  Am J Sports Med 1993;21:497-502.

Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries.  J Bone Joint Surg Am 2000;82:1609-1618.

Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex.  J Am Acad Orthop Surg 2003;11:260-267.

 

38.    Which of the following methods best aids in diagnosis of an interdigital neuroma?

 

1-         Ultrasound

2-         MRI

3-         Web space injection

4-         Electromyography and nerve conduction velocity studies

5-         History and physical examination

 

PREFERRED RESPONSE: 5

 

DISCUSSION: History and physical examination are still the gold standard for diagnosis of an interdigital neuroma.  Ultrasound and MRI may be helpful adjuncts but are dependent on equipment and operator expertise.  Web space injection may be helpful for diagnostic and therapeutic purposes.  Electromyography and nerve conduction velocity studies are of little benefit for distal lesions. 

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 145-147.

Bennett GL, Graham CE, Mauldin DM: Morton’s interdigital neuroma: A comprehensive treatment protocol.  Foot Ankle Int 1995;16:760-763.

 

39.    A 58-year-old man has had a 3-year history of recurrent ulcerations of the left ankle and instability despite multiple attempts at custom bracing, contact casting, and surgical debridement.  He has an ankle-brachial index of 0.76.  A clinical photograph and radiographs are shown in Figures 16a through 16c.  Treatment should now consist of

 

1-         transtibial amputation.

2-         a double upright brace.

3-         dressing changes with platelet-derived growth factor.

4-         tibiocalcaneal arthrodesis.

5-         total ankle arthroplasty.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Nonsurgical management has failed to provide relief; therefore, the treatment of choice is arthrodesis with an intramedullary nail.  Amputation may be indicated if the arthrodesis fails.  The patient does have adequate circulation for an attempt at salvage.  Total ankle arthroplasty is not indicated in a neuropathic patient.

 

REFERENCES: Pinzur MS, Kelikian A: Charcot ankle fusion with a retrograde locked intramedullary nail.  Foot Ankle Int 1997;18:699-704.

Herbst SA: External fixation of Charcot arthropathy.  Foot Ankle Clin 2004;9:595-609.

 

40.    Figures 17a and 17b show the radiographs of a 32-year-old professional athlete who sustained an injury to the first metatarsal.  A view of the opposite noninjured side is shown in Figure 17c.  Management of the fracture should consist of

 

1-         open reduction and internal fixation.

2-         a postoperative stiff-soled shoe with weight bearing as tolerated.

3-         a postoperative shoe with no weight bearing for 3 weeks.

4-         a short leg cast with no weight bearing.

5-         percutaneous pinning.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Parameters for first metatarsal fracture management are different than for shaft fractures of the central second, third, and fourth metatarsals.  The first metatarsal carries a greater load and if malunited, can create transfer lesions by virtue of uneven weight distribution; therefore, nonsurgical management is not indicated for this patient.  Percutaneous pinning is not as likely to result in an anatomic reduction as open reduction and internal fixation.  As his livelihood depends on an expeditious return to function, the choice of open reduction and internal fixation allows for earlier motion and rehabilitation.

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 64-65.

Shereff MJ: Compartment syndromes of the foot.  Instr Course Lect 1990;39:127-132.

 

41.     Which of the following are considered appropriate nonsurgical bracing/orthotic options for a supple adult-acquired flatfoot deformity with forefoot abduction, secondary to posterior tibial tendon insufficiency?

 

1-         Rigid orthotic with a lateral post

2-         Custom-molded leather and polypropylene orthosis (Arizona brace)

3-         UCBL with lateral posting

4-         One quarter-inch lateral heel and sole wedge applied to the shoe

5-         Three-quarter heel lift

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The initial stages of posterior tibial tendon insufficiency, where the deformity remains supple, may be treated with bracing or an orthotic for pain relief.  The Arizona brace was introduced in 1988, and assists in pain relief and deformity correction by minimizing hindfoot valgus alignment, lateral calcaneal displacement, and medial ankle collapse.  It is particularly helpful in those patients with advanced disease that cannot tolerate an ankle-foot orthosis.  All other choices are incorrect because of the addition of lateral posting, which is not advantageous in valgus deformities.  The addition of medial posting to any of the above choices would render them correct alternatives.  A heel lift is applicable in Achilles tendon disorders, not posterior tibial tendon disorders.

 

REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction.  Foot Ankle Int 1996;17:736-741.

Imhauser CW, Abidi NA, Frankel DZ, et al: Biomechanical evaluation of the efficacy of external stabilizers in conservative treatment of acquired flat foot deformity.  Foot Ankle Int 2002;23:727-737.

 

42.    A 28-year-old man underwent open reduction and internal fixation of a closed, displaced, intra-articular calcaneal fracture 8 weeks ago.  Examination now reveals that the lateral wound is red and draining purulent material.  Cultures obtained from the wound grow out Staphylococcus aureus.  Radiographs show early healing of the fracture. What is the next most appropriate step in management?

 

1-         Intravenous antibiotics

2-         Debridement of the wound without hardware removal

3-         Debridement of the wound with hardware removal

4-         Vacuum-assisted closure (VAC) and negative pressure therapy

5-         Total calcanectomy

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Intravenous antibiotics alone will not adequately treat this infection.  At 8 weeks after surgery, the hardware must be removed because Staphylococcus aureus is a virulent microbe.  VAC therapy alone is not adequate without debridement and hardware removal, but it may play a role in postoperative wound care.  Calcanectomy is a salvage procedure for calcaneal osteomyelitis or recalcitrant heel ulceration.

 

REFERENCES: Benirschke SK, Kramer PA: Wound healing complications in closed and open calcaneal fractures.  J Orthop Trauma 2004;18:1-6.

Lim EV, Leung JP: Complications of intra-articular calcaneal fractures. Clin Orthop
2001;391:7-16.

Folk JW, Starr AJ, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures.  J Orthop Trauma 1999;13:369-372.

 

43.     A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year.  The pain is worse with weight bearing and is better with rest and the use of an ankle brace.  What findings are shown on the MRI scans shown in Figures 18a through 18c?

 

1-         The flexor digitorum longus tendon is ruptured.

2-         The posterior tibial tendon has a normal appearance.

3-         The posterior tibial tendon has a physiologic amount of fluid in its sheath.

4-         The posterior tibial tendon is completely ruptured and retracted (type III tear).

5-         The posterior tibial tendon has a chronic longitudinal split with enlargement
(type II tear).

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath.  This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.

 

REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction).  Foot Ankle Clin 1997;2:241-260.

Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures.  Foot Ankle 1992;13:208-214.

 

44.    A 60-year-old man reports increasing pain in his right foot with limited ankle dorsiflexion and anterior ankle pain after sustaining a fracture of the calcaneus in a fall several years ago.  Bracing, nonsteroidal anti-inflammatory drugs, and cortisone injections have failed to provide significant relief.  Radiographs are shown in Figures 19a and 19b.  What is the next most appropriate step in management?

 

1-         Subtalar distraction arthrodesis

2-         Subtalar arthroscopy with debridement

3-         Custom orthotics

4-         Ankle arthrodesis

5-         Calcaneal osteotomy

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Following a calcaneal fracture, the patient has severe subtalar arthritis with loss of talar declination and shortening of the heel; therefore, the treatment of choice is subtalar distraction arthrodesis.  Orthotics will not provide significant relief as bracing has failed.  Ankle arthrodesis will not be beneficial because the arthritis is in the subtalar joint.  Subtalar arthroscopy would only be helpful for a small area of arthrosis, and calcaneal osteotomy would not be beneficial given the extent of the arthritis of the subtalar joint.

 

REFERENCE: Robinson TF, Murphy GA: Arthrodesis as salvage for calcaneal avulsions.  Foot Ankle Clin 2002;7:107-120.

 

45.    A 58-year-old woman sustained a ruptured Achilles tendon 1 year ago, and management consisted of an ankle-foot orthosis.  She now reports increasing difficulty with ambulation and increasing pain.  An MRI scan shows a 6-cm defect in the right Achilles tendon.  Management should now consist of

 

1-         continued use of an ankle-foot orthosis.

2-         direct repair of the Achilles tendon.

3-         V-Y repair of the Achilles tendon.

4-         transfer of the plantaris tendon.

5-         Achilles tendon turndown with flexor hallucis longus tendon transfer.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: With a gap of less than 4 cm, a V-Y repair would be appropriate without a tendon transfer.  For gaps greater than 5 cm, a lengthening with augmentation is the most appropriate treatment.  Therefore, the treatment of choice is an Achilles tendon turndown with flexor hallucis longus tendon transfer.  The plantaris tendon is not a strong enough repair, and direct repair is not possible given the large defect in the Achilles tendon.  Continued use of the ankle-foot orthosis will not provide adequate relief for this patient. 

 

REFERENCE: Myerson MS: Achilles tendon ruptures.  Instr Course Lect 1999;48:219-230.

 

46.    A 29-year-old woman reports dysesthesias and burning after undergoing bunion surgery that consisted of a proximal crescentic first metatarsal osteotomy 6 months ago.  Examination reveals a positive Tinel’s sign at the proximal aspect of the healed incision.  What injured nerve is responsible for her continued symptoms?

 

1-         Recurrent branch of the deep peroneal

2-         Recurrent branch of the sural

3-         Terminal cutaneous branch of the saphenous

4-         Dorsomedial cutaneous branch of the superficial peroneal

5-         Medial plantar

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve.  This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux.  Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve.  The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.  

 

REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery.  Foot Ankle 1986;7:110-117.

Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2.  Philadelphia, PA, JB Lippincott, 1993.

 

47.    Figure 20 shows the clinical photograph of a man who has had diabetes mellitus controlled with oral medication for the past 10 years.  He wears soft-soled shoes and only uses leather-soled shoes for important business meetings.  Examination reveals palpable dorsalis pedis and posterior tibial pulses, although they are somewhat diminished.  He is insensate to pressure with the Semmes-Weinstein 5.07 monofilament.  The ulcer heals after treatment with a full contact cast.  What is the best course of action at this time?

 

1-         Referral to his primary care physician

2-         Foot-specific patient education, depth-inlay shoes, custom accommodative foot orthoses, and follow-up observation

3-         Dorsiflexion osteotomy of the first and third metatarsals

4-         Excision of the second and third metatarsal heads

5-         Achilles tendon lengthening and dorsiflexion osteotomy of the first and third metatarsals

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has not undergone a trial of foot-specific patient education and accommodative/therapeutic shoe wear.  He must use therapeutic shoe wear at all times, as even the occasional use of pressure-concentrating shoe wear has a high likelihood of leading to the development of a diabetic foot ulcer.

 

REFERENCES: Pinzur MS, Kernan-Schroeder D, Emmanuele NV, et al: Development of a nurse-provided health system strategy for diabetic foot care.  Foot Ank Int 2001;22:744-746.

Pinzur MS, Shields N, Goelitz B, et al: American Orthopaedic Foot & Ankle Society shoe survey of diabetic patients.  Foot & Ankle Int 1999;20:703-707.

Reiber GE, Smith DG, Wallace CM, et al: Effect of therapeutic footwear on foot reulceration in patients with diabetes: A randomized controlled trial.  JAMA 2002;287:2552-2558.

 

48.    Figures 21a and 21b show the clinical photograph and radiograph of a 15-year-old girl who has a deformity of her feet.  Her parents are concerned because there is a family history of Charcot-Marie-Tooth disease.  The patient reports some mild instability of the ankle and has noticed mild early callosities; however, she is not having any significant pain.  Coleman block testing reveals a forefoot valgus and supple hindfoot.  She has weakness to eversion and dorsiflexion.  Initial management should consist of

 

1-         dorsiflexion osteotomy of the first metatarsal with peroneus longus to brevis transfer.

2-         plantar fasciotomy with dorsiflexion osteotomy of the first metatarsal and calcaneal osteotomy.

3-         a stretching and strengthening physical therapy program and accommodative inserts.

4-         observation.

5-         calcaneal osteotomy, dorsiflexion osteotomy of the first metatarsal, peroneus longus to brevis transfer, plantar fascia release, Achilles tendon lengthening, and midfoot osteotomy.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Initial management of a young patient with a cavovarus deformity of the foot and a family history of Charcot-Marie-Tooth disease should focus on mobilization and strengthening of the weakening muscular units and an accommodative insert.  Surgical intervention should be delayed until progression of the deformity begins to cause symptoms and/or weakness of the muscular units, resulting in contractures of the antagonistic muscle units.

 

REFERENCES: Pinzur MS: Charcot’s foot.  Foot Ankle Clin 2000;5:897-912.

Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease.  Foot Ankle 1993;14:476-486.

Thometz JG, Gould JS: Cavus deformity, in The Child’s Foot and Ankle.  New York, NY, Raven Press, 1992, pp 343-353.

 

49.    A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits.  Palpation of the third web space recreates her symptoms.  Which of the following will most accurately aid in confirming a diagnosis?

 

1-         History and physical examination

2-         Ultrasonography

3-         MRI

4-         Radiographs

5-         Nerve conduction velocity studies

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The diagnosis of an interdigital neuroma is best made by a thorough history and careful physical examination.  Radiographs are helpful in excluding other pathologic processes such as a metatarsal stress fracture.  MRI and ultrasound have both been reported to aid in the diagnosis of an interdigital neuroma.

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 145-151.

Quinn TJ, Jacobson JA, Craig JG, et al: Sonography of Morton’s neuromas.  Am J Roentgenol 2000;174:1723-1728.

 

50.    A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season.  Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first metatarsophalangeal joint that was aggravated by weight bearing.  A removable walker boot partially relieved the pain, and she was able to complete the season.  Her pain has now returned; however, she denies any history of injury.  Examination reveals tenderness over the medial sesamoid but no deformities.  A radiograph and bone scan are shown in Figures 22a and 22b.  What is the best treatment option at this time?

 

1-         Cast immobilization and no weight bearing for 4 to 8 weeks

2-         Immobilization in a walking cast for 4 to 8 weeks

3-         Hard-soled shoe for 4 to 8 weeks

4-         Sesamoid bone grafting

5-         Medial sesamoidectomy

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The radiograph reveals either a fractured or bipartite sesamoid.  The bone scan shows asymmetrically increased uptake over the medial sesamoid.  Given the history and physical examination, a stress fracture is the most likely diagnosis.  Medial sesamoidectomy reliably improves pain, and athletes return to sports on an average of 7 weeks after excision.  Immobilization typically requires more than 4 to 8 weeks and is not always successful; however, it would be appropriate management for a patient who is not an elite athlete.

 

REFERENCES: Sanders R: Fractures of the midfoot and forefoot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 1601-1603.

Saxena A, Krisdakumtorn T: Return to activity after sesamoidectomy in athletically active individuals.  Foot Ankle Int 2003;24:415-419.

 

51.     When performing surgery on a patient with insertional Achilles tendinitis and a Haglund’s deformity, how much of the Achilles tendon insertion can be safely detached without having to consider reattachment with bone anchors?

 

1-         10%

2-         33%

3-         50%

4-         66%

5-         75%

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The Achilles tendon insertion encompasses a broad area on the posterior area of the calcaneus.  A biomechanical study has shown that up to 50% of the Achilles tendon insertion point can be detached before the strength of the attachment point starts to weaken.  It is recommended that if more than this amount is detached to remove the posterior superior calcaneal prominence, consideration should be given to either securing the tendon to the bone with suture anchors or performing a tendon transfer.

 

REFERENCES: Kolodziej P, Glisson RR, Nunley JA: Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendinitis and Haglund’s deformity: A biomechanical study.  Foot Ankle Int 1999;20:433-437.

Sammarco GJ, Taylor AL: Operative management of Haglund’s deformity in the nonathlete: A retrospective study.  Foot Ankle Int 1998;19:724-729.

 

52.    A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability.  Which of the following principles applies to brace management in this individual?

 

1-         A shorter lever arm is more effective in limiting pressure.

2-         Limbs with mild contractures do better with bracing than flaccid limbs through increased force concentration.

3-         Three-point pressure effect works best to prevent the joint from buckling.

4-         Four-point pressure effect works best to prevent the joint from buckling.

5-         Smaller base support provides increased stability.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Bracing for spina bifida paraplegia provides both support and improved function of the movable limb.  An orthosis has value in controlling unstable joints.  The three-point pressure effect applies a force above and below the joint to prevent it from buckling.  A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle).  A longer lever arm brace and a brace with a greater area of support provide better stability.  Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin.

 

REFERENCES: Gage JR: An overview of normal walking.  Instr Course Lect 1990;39:291-303.

Bleck EE: Current concepts review: Management of the lower extremities in children who have cerebral palsy.  J Bone Joint Surg Am 1990;72:140-144.

Harris MB, Banta JV: Cost of skin care in the myelomeningocele population.  J Pediatr Orthop 1990;10:355:361.

 

53.     A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago.  Examination now reveals recent onset erythema, warmth, and swelling of the midfoot.  Radiographs are shown in Figures 23a through 23d.  What is the most likely reason for the swelling of the foot?

 

1-         Infection

2-         Charcot arthropathy

3-         Delayed compartment syndrome

4-         Deep venous thrombosis

5-         Gout

 

PREFERRED RESPONSE: 2

 

DISCUSSION: A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma.  Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout.  A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

 

REFERENCE: Connolly JF, Csencsitz TA: Limb threatening neuropathic complications from ankle fractures in patients with diabetes.  Clin Orthop 1998;348:212-219.

 

54.    When considering a flexor digitorum longus tendon transfer as part of the surgical treatment in patients with symptomatic flatfoot deformity caused by posterior tibial tendon insufficiency, which of the following patients is the most appropriate candidate?

 

1-         A 45-year-old woman with a hypermobile foot

2-         A 45-year-old man with a rigid hindfoot valgus deformity

3-         A thin 55-year-old woman with mild hemiparesis affecting the symptomatic foot from a previous stroke

4-         An active 55-year-old woman with a progressively worsening supple hindfoot valgus

5-         A moderately obese 70-year-old woman with a supple hindfoot

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Transfer of the flexor digitorum longus tendon is a common technique combined with other procedures to treat patients with posterior tibial tendon insufficiency.  However, it is contraindicated in patients with a fixed hindfoot deformity, hypermobility, or neuromuscular compromise.  It is relatively contraindicated in patients who are obese, and those older than age 60 to 70 years.

 

REFERENCES: Pedowitz WJ, Kovatis P: Flatfoot in the adult.  J Am Acad Orthop Surg 1995;3:293-302.

Mann RA: Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby-Year Book, 1993, pp 167-296.

 

55.    What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

 

1-         Traumatic neuroma tethered by plantar neural branches

2-         Regeneration of the transverse intermetatarsal ligament

3-         Development of an intermetatarsal synovial cyst

4-         Complex regional pain syndrome

5-         Metatarsophalangeal joint synovitis

 

PREFERRED RESPONSE: 1

 

DISCUSSION: When a recurrent neuroma forms at the end of the resected nerve, it does not retract far enough because either the transection was not proximal enough or it is tethered by plantar neural branches.  The transverse intermetatarsal ligament may reform, but it is not associated with pathology.  Synovial cysts and synovitis are part of the differential diagnosis but are not associated with neuroma excision.  Complex regional pain syndrome may result from neuroma excision, but this is rare and the symptoms are different. 

 

REFERENCES: Beskin JL: Recurrent interdigital neuromas, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction: Foot and Ankle.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 481-484.

Amis JA, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton’s neuroma excision.  Foot Ankle 1992;13:153-156.

 

56.    A 45-year-old woman has had radiating pain in the medial ankle for the past 3 months.  Examination reveals a small mass in the retromedial ankle region and a positive Tinel’s sign.  An intraoperative photograph and a hematoxylin/eosin biopsy specimen are shown in Figures 24a and 24b.  Treatment should consist of

 

1-         chemotherapy.

2-         radiation therapy.

3-         marginal excision.

4-         wide excision.

5-         above-knee amputation.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Neurilemoma is a benign tumor of nerve sheath origin, and peak incidence is in the third through sixth decades.  The tumor is well encapsulated on the surface of a peripheral nerve.  MRI findings may be significant for a “string sign.”  A positive Tinel’s sign in the distribution of the nerve affected may be present.  Grossly, the lesion is well encapsulated in a nerve sheath.  Microscopically, there are structures referred to as Antoni A (a pattern of spindle cells arranged in intersecting bundles) and Antoni B (areas with less cellularity with loosely arranged cells).  These lesions are benign, and treatment should consist of marginal excision.  Nerve function may be preserved by careful dissection, excising the lesion parallel to the nerve fascicles so the lesion may be extruded.  Recurrence is rare.

 

REFERENCES: Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 1007-1032.

Simon M, Springfield D: Surgery for the Bone and Soft-Tissue Tumors.  Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 530-531.

57.    An 83-year-old woman with a long history of her foot slowly and progressively “turning out” now reports significant ankle pain.  History reveals that she has significant cardiac disease and exercise-induced angina.  Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple.  Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis.  What is the most appropriate orthotic management?

 

1-         Total contact orthotic

2-         UCBL orthotic

3-         Molded articulated ankle-foot orthosis

4-         Molded ankle gauntlet (Arizona brace)

5-         Lateral heel flare

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient will continue to have pain secondary to the ankle arthrosis with both the UCBL and the molded articulated ankle-foot orthosis.  The total contact orthotic does not provide enough hindfoot control to support the progressive collapse of the ankle into valgus positioning.  A molded leather gauntlet will not only control tibiotalar motion but also control hindfoot motion and allow support of the longitudinal arch.

 

REFERENCE: Augustin JF, Lin SS, Berberian WS, et al: Nonoperative treatment of adult acquired flat foot with the Arizona brace.  Foot Ankle Clin 2003;8:491-502. 

 

58.    What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

 

1-         Floating toe

2-         Nonunion

3-         Osteonecrosis

4-         Inadequate shortening

5-         Dorsal displacement

 

PREFERRED RESPONSE: 1

 

DISCUSSION: Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface.  The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or “floating toe.”  Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy.

 

REFERENCES: Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis.  Foot Ankle Int
2001;22:47-50.

Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints.  Foot Ankle Int 1999;20:72-79.

 

59.    What are the five major compartments of the foot?

 

1-         Medial, lateral, central, interosseous, and calcaneal

2-         Medial, lateral, central, interosseous, and dorsal

3-         Medial, lateral, central, dorsal, and calcaneal

4-         Medial, lateral, dorsal, interosseous, and calcaneal

5-         Dorsal, lateral, central, interosseous, and calcaneal

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The five major compartments of the foot are medial, lateral, central, interosseous, and calcaneal.  There is no dorsal compartment in the foot. 

 

REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 262-264.

Shereff MJ: Compartment syndromes of the foot.  Instr Course Lect 1990;39:127-132.

 

60.    Figures 25a and 25b show the radiographs of a 66-year-old man who has had a long history of bilateral painful flatfoot deformities.  Examination reveals that his foot is partially correctable passively, albeit with discomfort, and he has an Achilles tendon contracture.  An ankle-foot orthosis has failed to provide relief.  Treatment should now consist of

 

1-         UCBL orthoses.

2-         triple arthrodesis with Achilles tendon lengthening.

3-         medial calcaneal osteotomy with posterior tibial tendon reconstruction and flexor digitorum longus tendon transfer.

4-         medial calcaneal osteotomy with posterior tibial tendon reconstruction, flexor digitorum longus tendon transfer, and lateral column lengthening.

5-         gastrocnemius lengthening and serial casting.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice.  Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction.  Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help.  Osteotomy procedures are designed for lesser deformities and well-preserved joints. 

 

REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 115-120.

Walling AK: Symposium: Adult acquired flatfoot.  Clin Orthop 1999;365:2-99.

 

61.     A 77-year-old man with diabetes mellitus has had a nonhealing Wagner grade I ulcer under the medial sesamoid for the past 3 months.  He smokes tobacco regularly.  He has undergone several debridements and total contact casting.  Examination reveals no palpable pulses.  He has no erythema or purulence, and he is afebrile.  Radiographs reveal no abnormalities.  What is the best initial diagnostic test to help determine why the ulcer has failed to heal?

 

1-         5.07 Semmes-Weinstein monofilament

2-         Bone scan

3-         Thompson’s test

4-         CT

5-         Noninvasive vascular studies

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The best initial test for this patient is to assess the vascular supply to the foot.  An elderly smoker with diabetes mellitus has a high risk of peripheral vascular disease.  Decreased weight bearing has not been successful.  Although a bone scan might be helpful, it would take secondary consideration to the patient’s vascular supply, especially in the absence of any acute infection.  Monofilament testing would help diagnosis neuropathy, which is a root cause behind the ulcer forming, but does not prevent it from healing. The Thompson’s test is used to diagnosis an Achilles tendon rupture.  

 

REFERENCE: Brodsky JW: Evaluation of the diabetic foot.  Instr Course Lect 1999;48:289-303.

 

62.    A 28-year-old man who sustained an ankle fracture in a motor vehicle accident underwent open reduction and internal fixation 3 months ago.  He continues to report significant ankle pain with ambulation.  Radiographs are shown in Figure 26.  What is the next most appropriate step in management?

 

1-         Articulated ankle-foot orthosis

2-         Revision open reduction and internal fixation of the syndesmosis with debridement of the medial gutter

3-         Ankle arthrodesis

4-         Syndesmosis arthrodesis

5-         Ankle arthroscopy and debridement

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient sustained a bimalleolar ankle fracture with a syndesmosis disruption.  The initial open reduction and internal fixation did not successfully reduce the distal tibiofibular joint.  The patient may need a derotational distraction osteotomy of the fibula to reduce the syndesmosis.  The other procedures do not address the primary problem of the fibular malunion and syndesmosis malreduction.  There is no radiographic evidence of significant arthritis; therefore, ankle arthrodesis is not indicated.

 

REFERENCE: Heier KA, Walling AK: Treatment of ankle fractures.  Foot Ankle Clin 1999;4:521-534.

 

63.     The first branch of the lateral plantar nerve innervates the

 

1-         interossei.

2-         quadratus plantae.

3-         flexor digitorum brevis.

4-         abductor hallucis brevis.

5-         abductor digiti quinti.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The first branch of the lateral plantar nerve innervates the abductor digiti quinti, and more distal branches of the lateral plantar nerve supply the quadratus plantae and the interossei.  The medial plantar nerve supplies the abductor hallucis brevis and the flexor digitorum brevis. 

 

REFERENCES: Pansky B, House EH: Review of Gross Anatomy, ed 3.  New York, NY, Macmillan, 1975, pp 464-476.

Sarrafian SK: Anatomy of the Foot and Ankle.  Philadelphia, PA, JB Lippincott, 1983,
pp 325-328.

 

64.    The radiograph shown in Figure 27 shows measurement of what angle?

 

1-         Hallux valgus

2-         Distal metatarsal articular

3-         Intermetatarsal

4-         Sesamoid divergence

5-         Angle of joint congruence

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The relationship between the distal articular surface of the first metatarsal head and the long axis of the first metatarsal is called the distal metatarsal articular angle.  This angle has been validated by Richardson and associates to measure and determine the congruence of the first metatarsophalangeal joint.  This angle is critical in determining the appropriate surgical procedure to perform on a patient with a bunion deformity because a congruent joint requires a procedure to maintain congruence of the articular surfaces following osteotomy.  Therefore, a chevron becomes a biplanar chevron, and a Lapidus procedure adds a second osteotomy of the distal metatarsal to tilt the metatarsal head into a congruent location.

 

REFERENCES: Coughlin MJ: Juvenile hallux valgus: Etiology and treatment.  Foot Ankle Int 1995;16:682-697.

Steel MW III, Johnson KA, DeWitz MA, et al: Radiographic measurements of the normal foot.  Foot Ankle 1980;1:151-158.

Richardson EG, Graves SC, McClure JT, et al: First metatarsal head-shaft angle: A method of determination.  Foot Ankle 1993;14:181-185.

 

65.    Which of the following orthotic features best reduces pain in patients with hallux rigidus?

 

1-         Plastazote layer to absorb shock

2-         Medial posting to offload the medial forefoot

3-         Rigid shank or forefoot rocker

4-         Metatarsal bar to offload the first metatarsal head

5-         Full length as opposed to three-quarter length

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Nonsurgical care for hallux rigidus involves limiting the motion of the first metatarsophalangeal joint during toe-off and ensuring that there is a deep enough toe box to accommodate dorsal osteophytes.  A rigid shank or forefoot rocker both help to reduce the forces of extension during toe-off.

 

REFERENCES: Beskin JL: Hallux rigidus.  Foot Ankle Clin 1999;4:335-353.

Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 17-25.

 

66.    An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it.  The headstone was removed after 3 minutes.  Radiographs show multiple midfoot fractures.  Examination reveals severe pain that is worse with passive toe motion.  Clinical photographs are shown in Figure 28.  Management should consist of

 

1-         a short leg cast and elevation of the foot.

2-         fasciotomies of the foot.

3-         MRI.

4-         CT.

5-         stress radiographs.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The patient has a classic history and examination for an acute compartment syndrome of the foot.  CT, MRI, or stress radiographs are not necessary prior to emergent fasciotomies of the foot.  These studies can be performed after the initial fasciotomies to determine the best long-term management of the fractures.  There are nine compartments in the foot.  These are decompressed through three incisions (two on the dorsal foot and one medially).  A short leg cast does not address the compartment syndrome and could be limb threatening with excessive swelling in a circumferential cast.  It is preferable to splint severe crush injuries rather than apply a cast.

 

REFERENCES: Fulkerson E, Razi A, Tejwani N: Review: Acute compartment syndrome of the foot.  Foot Ankle Int 2003;24:180-187.

Weber TG, Manoli A II: Compartment syndromes of the foot.  Foot Ankle Clin 1999;4:473-486.

 

67.    A 5-year-old boy has had midfoot pain with activity for the past 3 months.  He has no pain at rest.  Radiographs are shown in Figures 29a and 29b.  Management should
consist of

 

1-         a vascularized pedicle bone graft.

2-         a short leg walking cast.

3-         a custom-molded orthotic.

4-         surgical debridement followed by antibiotics.

5-         a bone stimulator.

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The radiographs show classic findings for Koehler’s disease (osteochondrosis of the navicular).  The patient’s age and clinical history are typical for this self-limiting condition.  Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast.  There is no role for surgery in this disease.

 

REFERENCE: Williams GA, Cowell HR: Koehler’s disease of the tarsal navicular.  Clin Orthop 1981;158:53-58.

 

68.    A 62-year-old man with diabetes mellitus has had a persistent 2-cm ulcer under the third metatarsal head for the past 4 months.  He reports that he has had similar ulcers twice before, and both healed with nonsurgical management.  He has used multiple types of commercial walking braces, shoes, and commercial dressings without resolution.  He is insensate to the Semmes-Weinstein 5.07 monofilament.  When the wound is probed with culture swab, there is no communication with the metatarsal head.  Radiographs, bone scans, and laboratory studies reveal no evidence of osteomyelitis.  What is the most predictable method of accomplishing wound healing without recurrence?

 

1-         Transmetatarsal amputation

2-         Excision of the third metatarsal head

3-         Percutaneous Achilles tendon lengthening and a total contact cast

4-         Viral recombitant growth factor and a commercial removeable walking boot

5-         A non-weight-bearing total contact cast that is changed every week until the ulcer is healed

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has a persistent diabetic foot ulcer without evidence of osteomyelitis.  He has evidence of a sensory peripheral neuropathy and a concomitant motor neuropathy, leading to a dynamic motor imbalance.  Use of a total contact cast would offer a high probability of healing the resistant ulcer but with a high potential for recurrence.  Combining the total contact cast with Achilles tendon lengthening allows wound healing without a high risk for recurrence.  Excision of the noninfected metatarsal head would make the patient vulnerable to the development of a transfer lesion under one of the remaining metatarsal heads.

 

REFERENCES: Robertson DD, Mueller MJ, Smith KE, et al: Structural changes in the forefoot of individuals with diabetes and a prior plantar ulcer.  J Bone Joint Surg Am 2002;84:1395-1404.

Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of Achilles tendon lengthening on neuropathic plantar ulcers.  J Bone Joint Surg Am 2003;85:1436-1445.

 

69.    Figure 30 shows the radiograph of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head.  Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head.  Nonsurgical management has failed to provide relief.  Surgical treatment should include

 

1-         simple lateral eminence resection.

2-         distal chevron osteotomy of the fifth metatarsal.

3-         oblique mid-diaphyseal osteotomy of the fifth metatarsal.

4-         proximal diaphyseal osteotomy of the fifth metatarsal.

5-         excision of the fifth metatarsal head.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has painful lateral and plantar keratoses with metatarsus quintus valgus deformity.  This combination of problems is best addressed with an oblique mid-diaphyseal osteotomy that allows the distal metatarsal to be displaced medially and dorsally.  Lateral eminence resection alone will not address the painful plantar keratosis.  A distal chevron osteotomy has a more limited ability to address the plantar keratosis (if translated medially and slight dorsally).  Proximal diaphyseal osteotomies of the fifth metatarsal are associated with an increased risk of delayed union or nonunion secondary to the relative hypovascularity in the proximal diaphysis.  Excision of the fifth metatarsal head can result in a floppy fifth toe and transfer metatarsalgia. 

 

REFERENCES: Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair.  Foot Ankle 1991;11:195-203.

Moran MM, Claridge RJ: Chevron osteotomy for bunionette.  Foot Ankle Int 1994;15:684-688.

 

70.    An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury.  Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture.  He was discharged with a 3-day prescription of amoxicillin and clavulanate.  The patient now has increasing pain and tenderness at the puncture site.  What is the best course of action?

 

1-         Change the antibiotic to ciprofloxacin

2-         Initiate gentamicin

3-         Resume the prescription for amoxicillin and clavulanate

4-         Observation and follow-up in 48 hours

5-         Surgical debridement

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The initial treatment consisting of oral antibiotics was appropriate but with progressive symptoms, surgical debridement is necessary.  Ciprofloxacin is contraindicated in children, and at this stage, oral antibiotics are inadequate.  Intravenous antibiotics may be necessary, but surgical debridement is paramount.  Failure to respond to the initial management precludes further observation. 

 

REFERENCES: Riegler HP, Routson T: Complications of deep puncture wounds of the foot. 
J Trauma 1979;19:18-22.

Green NE: Musculoskeletal infections in children: Part IV.  Pseudomonas infections of the foot following puncture wounds.  Instr Course Lect 1983;32:43-46.

 

71.    A 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game.  Radiographs are shown in Figures 31a through 31c.  Management should consist of

 

1-         open reduction and internal fixation with a plate and screws.

2-         open treatment with calcaneal bone graft.

3-         percutaneous screw fixation with a 4.5-mm screw.

4-         weight-bearing cast for 8 weeks.

5-         spanning external fixation.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation.  In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity.  One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure.

 

REFERENCES: Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture.  Foot Ankle Int 1996;17:449-457.

Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-252.

 

72.    Which of the following structures are found in the anterior tarsal tunnel?

 

1-         Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve

2-         Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, superficial peroneal nerve

3-         Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve

4-         Extensor hallucis brevis, extensor hallucis longus, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve

5-         Dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The contents of the anterior tarsal tunnel are the extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, and the deep peroneal nerve.  The term “anterior tarsal tunnel syndrome” is used to specifically describe the compression of the deep peroneal nerve under the inferior extensor retinaculum.  With nerve compression, patients report a burning sensation across the dorsum of the foot with paresthesias in the first web space.  There also may be wasting and weakness of the extensor digitorum brevis. 

 

REFERENCES: Kuritz HM: Anterior entrapment syndromes.  J Foot Surg 1976;15:143-148.

Sarrafian S: The Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2.  Philadelphia, PA, JB Lippincott, 1993, pp 113-158.

 

73.    A 55-year-old man who runs on the weekends reports a 1-year history of continued pain directly posteriorly in the heel.  Management consisting of anti-inflammatory drugs, icing techniques, a heel-counter in his shoe split, and physical therapy consisting of stretching, contrast baths, custom orthotics, and iontophoresis has failed to provide relief.  Not only is his lifestyle disrupted with respect to running, but he now has pain with normal ambulation with all forms of shoe wear.  He is not necessarily concerned with returning to running; he is primarily seeking pain relief.  A lateral radiograph and clinical photograph are shown in Figures 32a and 32b.  Treatment should now consist of

 

1-         injection directly into the tendon with triamcinolone or methylprednisolone.

2-         shock wave treatment to the posterior heel to break up calcific deposits.

3-         brisement.

4-         a simple lateral surgical approach to the posterior heel, with resection of the Haglund’s exostosis.

5-         a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The patient has severe calcifications at the insertion of the Achilles tendon.  Failure to address the Haglund’s exostosis and the calcifications will leave the patient with persistent pain.  Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture.  Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund’s exostosis treatment.  Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon.  This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease.  Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology.  The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief.

 

REFERENCES: Clain M, Baxter D: Achilles tendinitis.  Foot Ankle 1992;13:482-487.

Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study.  Am J Sports Med 1994;22:611-619.

Schepsis A, Leach R: Surgical management of Achilles tendinitis.  Am J Sports Med 1987;15:308-315.

Keck S, Kelly P: Bursitis of the posterior part of the heel: Evaluation of surgical treatment of eighteen patients.  J Bone Joint Surg Am 1965;47:267-273.

 

74.    A 45-year-old man who has had recurrent pain and swelling of the left Achilles tendon insertion for the past 10 years reports that physical therapy and activity modification have provided relief in the past.  He now has continued pain despite these efforts.  He also reports occasional bouts of dysuria that he attributes to a history of prostatitis.  He also notes recent eye irritation that he attributes to allergies.  A lateral heel radiograph is shown in Figure 33.  Which of the following laboratory studies would best aid in diagnosis?

 

1-         Glucose tolerance test

2-         CBC count with differential

3-         Urethral swab and culture

4-         HLA-B27

5-         Antiphospholipid antibody

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Reiter’s syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis.  Tendon ensethopathies can also be present.  It is most often seen in men and is associated with a positive HLA-B27 marker.  Rheumatoid arthritis does not usually present with these features; more commonly it causes forefoot pain and synovitis of the metatarsophalangeal joints.  A CBC count with differential would be helpful in a situation of possible infection.  The urethral swab would help to diagnose a gonococcal infection which can cause a monoarticular septic arthritis.  Antiphospholipid antibody is associated with a hypercoaguable state and increased risk of deep venous thrombosis.  

 

REFERENCE: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, vol 1, pp 560-650.

 

75.    A 29-year-old man reports severe knee instability and popliteal pain. History reveals that he had polio of the left lower extremity as a child and has been brace-free his entire life.  Examination reveals that he walks with 40° of knee hyperextension and has a fixed ankle equinus deformity of 30° .  He has no active motors about the knee or ankle.  Which of the following methods will provide knee stability and pain relief?

 

1-         Knee-ankle-foot orthosis with locking joints

2-         Knee and ankle fusion

3-         Soft-tissue release of the ankle and a locked knee orthosis

4-         Soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint

5-         Ankle fusion and a knee-ankle-foot orthosis

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The ankle equinus allows the patient to keep his weight-bearing line anterior to the axis of the hyperextended knee joint.  With time, pain has developed because of continued stretching and now incompetence of the posterior capsule of the knee joint.  Several soft-tissue and bony procedures have been designed to provide knee stability in this situation; however, the results have been either short-lived or inconsistent.  Tenodeses, capsular plications, and bony blocks have had limited success and generally fail over time.  Current orthotic technology makes soft-tissue release and orthotic control the most predictable option.  To decrease the hyperextension moment on the knee joint, the ankle deformity also must be corrected.  The most predictable method of achieving stability and diminished pain during walking is with soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint.

 

REFERENCE: Michael JW: Lower limb orthoses, in Goldberg B, Hsu JD (eds): Atlas of Orthoses and Assistive Devices.  St Louis, MO, Mosby, 1997, pp 209-224.

 

76.    Figures 34a and 34b show the clinical photographs of a 46-year-old woman who has a painful deformity of the second toe.  Surgical treatment consisting of metatarsophalangeal capsulotomy and proximal interphalangeal joint resection arthroplasty resulted in satisfactory correction, but the toe remains unstable at the metatarsophalangeal joint.  What is the next most appropriate step?

 

1-         Flexor digitorum longus tenotomy

2-         Resection of the metatarsal head and pin fixation

3-         Transfer of the flexor digitorum longus to the extensor tendon

4-         Excision at the base of the proximal phalanx and syndactyly with the third toe

5-         Arthrodesis of the second metatarsophalangeal joint

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Crossover second toes are attributed to attenuation or rupture of the plantar plate and lateral collateral ligament and are associated with varying degrees of instability.  Flexor-to-extensor transfer (Girdlestone/Taylor procedure) can provide intrinsic stability to the toe.  Although plantar metatarsal head condylectomy can increase stability by resulting in scarring of the plantar plate, excision of the entire second metatarsal head carries a high risk of transfer metatarsalgia.  Removal of the base of the proximal phalanx destabilizes the toe and should be reserved as a salvage procedure.  Simple flexor tenotomy alone will not improve stability, and arthrodesis of the second metatarsophalangeal joint will limit motion and impair function. 

 

REFERENCES: Coughlin MJ: Crossover second toe deformity.  Foot Ankle 1987;8:29-39.

Thompson FM, Deland JT: Flexor tendon transfer for metatarsophalangeal instability of the second toe.  Foot Ankle 1993;14:385-388.

 

77.    A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b.  Management consists of splinting.  At his 2-week follow-up visit, he clinically passes the wrinkle test.  He agrees to open reduction and internal fixation.  What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

 

1-         Closed reduction and percutaneous pinning

2-         Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin

3-         Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 2.0 cm anterior to the Achilles tendon, and horizontal limb 2.0 cm proximal to the line marking the plantar glabrous skin

4-         Sinus tarsi approach

5-         Ollier approach

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The approach to the calcaneus has evolved from several different patterns, driven by a high wound complication rate of 10%.  The current extensile lateral approach was described by Zwipp and associates in 1988.  The surgical exposure uses an L-shaped incision, with the vertical component positioned one half a finger’s breath anterior to the Achilles tendon and extending distally to the junction of the lateral skin and the plantar skin.  Borrelli and Lashgari mapped the angiosome of the lateral calcaneal flap and found that the major arterial blood supply to this flap consisted of three arteries: the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery. The lateral calcaneal artery appeared to be responsible for most of the blood supply to the corner of the flap.  This was found 1.5 cm anterior to the Achilles tendon.  Division of this artery with inaccurate placement of the vertical limb of the incision can cause ischemia of the lateral skin flap.

 

REFERENCES: Borrelli J Jr, Lashgari C: Vascularity of the lateral calcaneal flap: A cadaveric injection study.  J Orthop Trauma 1999;13:73-77.

Freeman BJC, Duff S, Allen PE, et al: The extended lateral approach to the hindfoot: An anatomical basis and surgical implications.  J Bone Joint Surg Br 1998;80:139-142.

Zwipp H, Tscherne H, Wulker N: Osteosynthesis of dislocated intra-articular calcaneus fractures.  Unfallchirurg 1988;91:507-515.

 

78.    In the treatment of all magnitudes of bunionette deformities, what is the most common complication associated with lateral condylectomy of the fifth metatarsal head?

 

1-         Metatarsophalangeal arthrosis

2-         Transfer metatarsalgia

3-         Recurrent deformity

4-         Overcorrection of the deformity

5-         Dislocation of the metatarsophalangeal joint

 

PREFERRED RESPONSE: 3

 

DISCUSSION: When a lateral condylectomy alone is performed for all bunionette deformities, a high recurrence rate is expected.  Lateral condylectomy should be used alone when the primary deformity is an enlarged lateral condyle of the fifth metatarsal head.  In cases with significant divergence of the fifth metatarsal shaft in relationship to the fourth metatarsal shaft or with lateral bowing of the distal fifth metatarsal shaft, the lateral fifth metatarsal prominence will not be effectively reduced and recurrent symptoms and deformity are expected.  Transfer metatarsalgia and/or dislocation of the metatarsophalangeal joint can infrequently occur with excessive metatarsal head excision.  Arthrosis of the metatarsophalangeal joint has not been frequently reported. 

 

REFERENCES: Coughlin MJ, Mann RA: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby-Year Book, 1993, pp 413-465.

Kelikian H: Deformities of the lesser toe, in Kelikian H (ed): Hallux Valgus, Allied Deformities of the Forefoot and Metatarsalgia.  Philadelphia, PA, WB Saunders, 1965, pp 327-330.

Kitaoka HB, Holiday AD Jr: Lateral condylar resection for bunionette.  Clin Orthop 1992;278:183-192.

 

79.    A 17-year-old patient sustained a closed calcaneal fracture when he jumped off of a roof 2 years ago, and he underwent nonsurgical management at the time of injury.  The patient now reports lateral hindfoot pain that is worse with weight-bearing activities.  Anti-inflammatory drugs and orthoses have failed to provide relief.  Coronal and sagittal CT scans are shown in Figures 36a and 36b.  What is the best course of action?

 

1-         In situ subtalar arthrodesis

2-         Cortisone injection in the subtalar joint followed by casting for 4 to 6 weeks

3-         UCBL insert

4-         Lateral wall exostectomy

5-         Bone block arthrodesis of the subtalar joint

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The CT scans show evidence of a lateral wall blowout and malunion without significant arthrosis of the subtalar joint.  In a young patient, it is preferable to avoid a fusion and allow residual motion by performing an exostectomy that decompresses the lateral subtalar joint and peroneal tendons.

 

REFERENCES: Chandler JT, Bonar SK, Anderson RB, et al: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures.  Foot Ankle Int 1999;20:18-24.

Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, p 52.

 

80.    A 52-year-old woman with diabetes mellitus has had a plantar foot ulcer under the second metatarsal head for the past week.  The patient had a similar ulcer 2 months ago, and total contact casting resulted in healing.  Examination reveals no signs of infection.  What procedure will best prevent recurrence of the ulcer?

 

1-         Flexor hallucis longus transfer to the Achilles tendon

2-         Peripheral vascular bypass

3-         Jones procedure (extensor hallucis longus transfer to the first metatarsal with interphalangeal joint fusion)

4-         Posterior tibial tendon transfer to the anterior tibialis tendon

5-         Achilles tendon lengthening

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The contracted Achilles tendon leads to increased forefoot pressure, thus increasing the risk for ulceration in neuropathic patients.  Several studies have shown the benefit of Achilles tendon lengthening to heal and prevent forefoot ulceration in these patients.  The flexor hallucis longus transfer is used for chronically torn/deficient Achilles tendons, not a contracted Achilles tendon.  The Jones procedure works well for the first ray but does not help to alleviate pressure under the second ray.  Peripheral bypass surgery is unnecessary because the ulcer healed during the initial treatment, indicating that the patient has adequate circulation.  The posterior tibial tendon transfer is used for foot drop or other neuromuscular conditions to correct deformity and increase function.  It is not used for forefoot ulcers in patients with diabetes mellitus.   

 

REFERENCES: Armstrong DG, Stacpoole-Shea S, Nguyen H, et al: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot.  J Bone Joint Surg Am 1999;81:535-538.

Meuller MJ, Sinacore DR, Hastings MK, et al: Effect of Achilles tendon lengthening on neuropathic plantar ulcers: A randomized clinical trial.  J Bone Joint Surg Am
2003;85:1436-1445.

 

81.    Figures 37a and 37b show the clinical photographs of a 43-year-old patient with type I diabetes mellitus who has a stump ulcer after undergoing successful transtibial amputation 1 year ago.  Which of the following is considered the most predictable method of healing the ulcer and preventing recurrent ulceration?

 

1-         Refrain from using the prosthesis until the ulcer heals.

2-         Refrain from using the prosthesis and apply platelet-derived growth factor daily until the ulcer heals.

3-         Have a prosthetist relieve the area of the anterior-distal tibia to eliminate pressure and allow the ulcer to heal.

4-         Replace the prosthetic socket liner with a thick silicone liner.

5-         Perform a wedge resection of the infected tissue, create a soft-tissue envelope with muscle covering the bone, and allow primary healing of the skin.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The ulcer occurred as the result of a mismatch between the shape of the residual limb and the prosthetic socket.  With the mismatch, the residual limb pistoned and the tissue failed because of the applied shear forces.  The most predictable short- and long-term solution is reconstruction of the residual limb.  Refraining from use of the prosthesis will prevent the patient from walking for months.  It is unlikely that prosthetic socket modification will allow resolution of this large ulcer.

 

REFERENCE: Hadden W, Marks R, Murdoch G, et al: Wedge resection of amputation stumps: A valuable salvage procedure.  J Bone Joint Surg Br 1987;69:306-308.

 

82.    A 15-year-old girl who plays high school basketball has had worsening forefoot pain and swelling that is aggravated by activity for the past 5 weeks.  She denies any history of an injury.  Examination reveals no deformities.  A radiograph is shown in Figure 38.  Initial management should consist of

 

1-         no weight bearing.

2-         weight bearing as tolerated in a hard-soled shoe.

3-         a short leg walking cast.

4-         second metatarsophalangeal joint debridement and metatarsal osteotomy.

5-         a longitudinal arch support with metatarsal head relief.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Freiberg’s infraction is believed to be an osteochondrosis of the second metatarsal head.  It is the only osteochondrosis that has a predilection for females.  The typical patient is an athletically active adolescent female.  The radiograph shows stage II disease wherein reossification is occurring; it is at this time that the second metatarsal head is most susceptible to deformation.  Therefore, initial management should consist of a short leg
walking cast.

 

REFERENCE: Mann RA, Coughlin MJ: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 413-415.

 

83.    A 56-year-old woman has a painful mass on the bottom of her left foot, and orthotic management has failed to provide relief.  Examination reveals that the mass is contiguous with the plantar fascia.  An MRI scan shows a homogenous nodule within the plantar fascia.  Resection of the tumor is shown in the clinical photograph in Figure 39.  What type of cell is most likely responsible for the formation of this tumor?

 

1-         Myocyte

2-         T-cell

3-         Synovial cell

4-         Osteocyte

5-         Fibromyoblast

 

PREFERRED RESPONSE: 5

 

DISCUSSION: The history, examination, and surgical findings are most consistent with plantar fibromatosis.  Plantar fibromatosis is a benign tumor of the plantar fascia that consists chiefly of fibromyoblasts.  These cells produce excessive collagen and are similar to the cells found in the palmar fascia of patients with Dupuytren’s contracture of the hand.  The myocyte, synovial cell, and osteocyte all produce their respective individual tissue types but do not contribute to the formation of a plantar fibromatosis.  The T-cell is an important immunologic cell that is most affected in patients with HIV.

 

REFERENCE: Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis.  Foot Ankle Int 2000;21:563-569.

 

84.    A 34-year-old man underwent a transtibial amputation as the result of a work-related injury.  The amputation was performed at the inferior level of the tibial tubercle.  The residual limb has a soft-tissue envelope composed of gastrocnemius muscle that is used as soft-tissue cushioning for the distal tibia.  Despite undergoing several prosthetic fittings, he continues to report pain and instability.  Examination reveals that the prosthesis appears to fit well with no apparent pressure points or areas of skin breakdown.  He is not willing to have any further surgery.  Which of the following modifications will most likely provide relief?

 

1-         Add double metal uprights and a leather corset.

2-         Add a supracondylar suspension to the soft suspension.

3-         Add supracondylar and suprapatellar suspensions to the socket design.

4-         Replace the socket insert with a silicone suction socket with locking bolt suspension.

5-         Replace the prosthetic socket with a negative pressure vacuum system.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: While transtibial amputees can be fitted with a prosthesis with a residual limb as short as 5 cm, or with retention of the insertion of the patellar tendon, this patient has an unstable gait because of the limited ability of the prosthetic socket to maintain a snug and stable fit.  While cumbersome and bulky, double metal uprights and a corset is the only predictable method of gaining stability. The other methods attempt to add an element of stability; however, they are unlikely to be successful. 

 

REFERENCES: Bowker JH, Goldberg B, Poonekar PD: Transtibial amputation: Surgical procedures and postsurgical management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics.  St Louis, MO, Mosby Year Book, 1992, pp 429-452.

Kapp S, Cummings D: Transtibial amputation: Prosthetic management, in Bowker JH, Michael JW (eds): Atlas of Limb Prosthetics.  St Louis, MO, Mosby Year Book, 1992, pp 453-478.

 

85.       A 30-year-old man has had intermittent swelling of his right ankle for the past 6 months.  He denies any history of trauma.  Radiographs reveal osteolytic changes on both sides of the joint.  An axial CT scan and a T₂-weighted MRI scan are shown in Figures 40a and 40b.  He undergoes surgical excision.  An intraoperative photograph and a biopsy specimen are shown in Figures 40c and 40d.  What is the most likely diagnosis?

 

1-         Synovial sarcoma

2-         Infection

3-         Pigmented villonodular synovitis

4-         Malignant fibrous histiocytoma

5-         Synovial chondromatosis

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Pigmented villonodular synovitis often presents with intermittent swelling and minimal pain.  It often occurs around joints but may be found around tendon sheaths and bursal linings.  Periarticular erosions involving both sides of joints are typical, and multiple joint involvement has been described.  Portions of low-signal intensity on T₁- and T₂-weighted images are characteristic of hemosiderin-laden processes.  High-signal content is suggestive of high water content.  The combination of low-signal intensity areas in intra-articular lesions with or without osseous destruction is diagnostic of pigmented villonodular synovitis.  Aspiration reveals bloody or brownish fluid.  The treatment of choice is synovectomy performed arthroscopically or open.  Recurrence is common.

 

REFERENCES: Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 1007-1032.

Simon M, Springfield D: Surgery for the Bone and Soft-Tissue Tumors.  Philadelphia, PA, Lippincott Williams & Wilkins, 1998, p 36.

 

86.    The Coleman block test is used to evaluate the cavovarus foot.  What is the most important information obtained from this test?

 

1-         Determines the patient’s ability to balance

2-         Determines hindfoot flexibility

3-         Determines forefoot flexibility

4-         Assesses the patient for Achilles tendon contractures

5-         Evaluates peroneus longus strength

 

PREFERRED RESPONSE: 2

 

DISCUSSION: Coleman block testing, performed by placing an elevation under the lateral border of the foot, is used to determine if the forefoot and/or plantar flexed first ray is causing a compensatory varus in the hindfoot.  The block is placed under the lateral border of the foot, and therefore does not have any relation to the Achilles tendon and suppleness of the hindfoot.

 

REFERENCES: Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease.  Foot Ankle 1993;14:476-486.

Thometz JG, Gould JS: Cavus deformity, in The Child’s Foot and Ankle.  New York, NY, Raven Press, 1992, pp 343-353.

 

87.    Figures 41a and 41b show the radiographs of a 22-year-old woman who has a bunion on her left foot.  She denies pain in the foot, but she reports increasing difficulty with shoe wear.  Management should consist of

 

1-         distal Chevron osteotomy.

2-         proximal metatarsal osteotomy with soft-tissue release.

3-         shoe wear modifications.

4-         dorsal cheilectomy with Moberg osteotomy.

5-         hallux metatarsophalangeal joint arthroplasty.

 

PREFERRED RESPONSE: 3

 

DISCUSSION: Surgery is not indicated in a patient who has a mild deformity and no pain.  Shoe wear modifications should be recommended.

 

REFERENCE: Mann RA, Coughlin MJ: Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, p 174.

 

88.    A 35-year-old woman has had significant pain and swelling in the left medial ankle inferior to the medial malleolus for the past 8 months.  Physical therapy, brace and orthotic management, and immobilization have failed to provide relief.  She is now requesting a more aggressive option to assist in pain relief.  Clinical photographs and radiographs are seen in Figures 42a through 42f.  Following exposure, a complete rupture of the posterior tibial tendon is visible.  What is the most appropriate surgical reconstruction?

 

1-         Subtalar arthrodesis

2-         Flexor digitorum longus transfer

3-         Flexor digitorum longus tendon transfer, medial slide calcaneal osteotomy, and spring ligament repair

4-         Primary repair of the posterior tibial tendon

5-         Talonavicular arthrodesis

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient has a complete rupture of the posterior tibial tendon with minimal hindfoot valgus deformity.  The deformity is supple, and there is no arthritis in the subtalar, talonavicular, or calcaneocuboid joints; therefore, joint-sparing procedures are appropriate in this patient (avoidance of arthrodeses).  The treatment of choice is flexor digitorum longus tendon transfer, medial slide calcaneal osteotomy, and spring ligament repair.  Primary repair of an incompetent posterior tibial tendon can lead to failure and recurrence of pain and deformity.  Talonavicular arthrodesis corrects the forefoot abduction and elevates a plantar flexed talus; however, the patient does not have this deformity; therefore, the procedure is not indicated.

 

REFERENCES: Myerson MS, Corrigan J, Thompson F, et al:  Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: A radiological investigation.  Foot Ankle Int 1995;16:712-718.

Trnka HJ, Easley ME, Myerson MS: The role of calcaneal osteotomies for correction of adult flat foot.  Clin Orthop 1999;365:50-64.

Jahss MH: Spontaneous rupture of the tibialis posterior tendon: Clinical findings, tenographic studies, and a new technique for repair.  Foot Ankle 1982;3:158-166.

Toolan BC, Sangeorzan BJ, Hansen ST Jr: Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot.  J Bone Joint Surg Am 1999;81:1545-1560.

 

89.    A 48-year-old man reports localized plantar forefoot pain.  Examination reveals a discrete callus (intractable plantar keratosis) with well-localized tenderness beneath the second metatarsal head.  The callus most likely lies beneath what structure?

 

1-         Lateral (fibular) condyle of the second metatarsal head

2-         Second metatarsophalangeal sesamoid

3-         Plantar condyle of the base of the proximal phalanx

4-         Exostosis of the plantar second metatarsal head

5-         Osteochondroma of the second metatarsal distal metaphysis

 

PREFERRED RESPONSE: 1

 

DISCUSSION: A discrete or focal callus is a response to excessive weight-bearing stress beneath the lateral (fibular) condyle of a lesser metatarsal head (most commonly second).  The other structures generally have not been associated with a discrete callus.

 

REFERENCES: Coughlin MJ, Mann RA: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby-Year Book, 1993, pp 413-465.

Cracchiolo A: Surgical procedures of the lateral metatarsals, in Jahss MH (ed): Disorders of the Foot and Ankle, ed 2.  Philadelphia, PA, WB Saunders, 1991, pp 1269-1283.

 

90.    A 65-year-old woman with a history of diabetes mellitus and plantar ulcers has an erythematous and swollen right foot and ankle.  Despite IV antibiotics, the erythema spreads to her lower calf within 24 hours.  She has a systolic blood pressure of 80/55 mm Hg and a pulse rate of 120.  Laboratory studies show a creatinine level of 1.5 mg.  Initial management should consist of

 

1-         continued IV antibiotics and observation.

2-         hyperbaric oxygen treatment.

3-         rapid IV fluid boluses.

4-         surgical debridement.

5-         whirlpool therapy.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Necrotizing fasciitis is an aggressive and rapidly spreading soft-tissue infection, usually caused by group A beta-hemolytic Streptococcus pyogenes.  Presentation is typical of a rapidly ascending cellulitis, recalcitrant to antibiotic treatment.  Differentiation between cellulitis and impetigo is difficult, and success depends on a high level of suspicion.  The skin and subcutaneous tissues are affected, with sparing of the muscles.  Septic shock and multi-organ system failure can be fatal.  Treatment is aggressive surgical debridement with broad-spectrum antibiotics.  Repeat irrigation and debridement may be necessary.  Hyperbaric oxygen studies have shown inconsistent results.

 

REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 199-205.

Fontes RA Jr, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections.  J Am Acad Orthop Surg 2000;8:151-158.

 

91.    A 15-year-old boy has hindfoot pain and very limited subtalar motion.  A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet.  He has no degeneration of the posterior subtalar facet.  Following failure of nonsurgical management, treatment should consist of

 

1-         resection of the coalition with fat graft interposition.

2-         Grice extra-articular subtalar arthrodesis.

3-         subtalar arthroereisis.

4-         intra-articular subtalar fusion.

5-         medial sliding calcaneal osteotomy.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: The CT scan is an important test to help determine the extent of involvement of the talocalcaneal facet in a talocalcaneal coalition.  In a young patient with no arthritis and joint involvement of less than 50%, resection of the coalition and fat pad interposition has been shown to be successful.  A calcaneal osteotomy does not address the coalition.  Subtalar arthroereisis has been used for treatment of a flexible flatfoot; tarsal coalition patients have a rigid-type flatfoot deformity.

 

REFERENCES: Sullivan JA: The child’s foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4.  Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1077-1135.

Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition.  J Bone Joint Surg Am 1987;69:533-539.

 

92.    A 55-year-old patient is seeking a surgical consultation for a painful flatfoot deformity that has failed to respond to nonsteroidal anti-inflammatory drugs, shoe and activity modifications, and orthoses.  The patient is of medium build, a nonsmoker, and has no history of diabetes mellitus.  Radiographs are shown in Figures 43a through 43c.  Based on these findings, treatment should consist of

 

1-         triple arthrodesis.

2-         lateral column lengthening with flexor digitorum longus tendon transfer.

3-         medial calcaneal displacement osteotomy, flexor digitorum longus transfer, and gastrocnemius recession.

4-         midfoot arthrodesis.

5-         subtalar arthroereisis with a Maxwell-Brancheau Arthroereisis titanium implant.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: The patient has a degenerative collapse of the midfoot through the tarsometatarsal joints with significant forefoot abduction; therefore, a midfoot arthrodesis is required to address the arthritic joints and deformity at the tarsometatarsal articulation.  All of the other procedures correct hindfoot deformities and therefore would not be appropriate treatment.

 

REFERENCES: Brage M: Degenerative joint disease of the midfoot.  Foot Ankle Clin 1999;4:355-367.

Mann RA, Prieskorn D, Sobel M: Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma.  J Bone Joint Surg Am
1996;78:1376-1385.

 

93.    A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago.  Initial radiographs revealed no fractures, and the skin remained intact at the time of injury.  Physical therapy, anti-inflammatory drugs, and a serotonin reuptake inhibitor have failed to provide relief.  What is the next most appropriate step in management?

 

1-         Continued physical therapy

2-         Alteration of medication to include an anti-epileptic

3-         Tarsal tunnel release

4-         Sympathetic blocks

5-         Neurostimulation

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Following failure of physical therapy and pharmacologic management in a patient with complex regional pain syndrome, the management of choice is sympathetic blocks.  While continued physical therapy would be assistive, sympathetic blocks allow a more rapid relief of symptoms.  Neurostimulation is not appropriate at this stage because of its invasive nature. 

 

REFERENCES: Cepeda MS, Lau J, Carr DB: Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: A narrative and systematic review.  Clin J Pain 2002;18:216-233.

Perez RS, Kwakkel G, Zuurmond WW, et al: Treatment of reflex sympathetic dystrophy (CRPS type 1): A research synthesis of 21 randomized clinical trials.  J Pain Symptom Manage 2001;21:511-526.

Tran KM, Frank SM, Raja SN, et al: Lumbar sympathetic block for sympathetically maintained pain changes in cutaneous temperatures and pain perception.  Anesth Analg 2000;90:1396-1401.

Stanton-Hicks M, Baron R, Boas R, et al: Complex regional pain syndromes: Guidelines for therapy.  Clin J Pain 1998;14:155-166.

 

94.    What nerve is most likely to develop a traumatic neuroma following open reducation and internal fixation of a talar neck fracture via a posterolateral approach?

 

1-         Dorsal intermediate cutaneous

2-         Sural

3-         Saphenous

4-         Medial plantar

5-         Lateral plantar (Baxter)

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The preferred approach is posterolateral, placing the sural nerve most at risk.  The dorsal intermediate cutaneous nerve is anterolateral to the ankle, and the medial and lateral plantar branches are medial and inferior to the surgical site.  The saphenous nerve is anteromedial and away from the surgical approach.

 

REFERENCES: Swanson TV, Bray TJ, Holmes GB Jr: Fractures of the talar neck: A mechanical study of fixation.  J Bone Joint Surg Am 1992;74:544-551.

Lawrence S, Botte M: The sural nerve of the foot and ankle: An anatomic study with clinical and surgical implications.  Foot Ankle Int 1994;15:490-494.

 

95.    Patients with tarsal tunnel syndrome are most likely to obtain a favorable outcome
from decompression of the posterior tibial nerve if which of the following conditions
is present?

 

1-         A space-occupying lesion is compressing the tarsal tunnel.

2-         Nerve conduction velocity studies reveal slowing across the medial malleolus.

3-         The posterior tibial tendon is ruptured.

4-         The integrity of the posterior tibial tendon is compromised.

5-         The spring ligament is ruptured, resulting in the development of a dynamic flatfoot.

 

PREFERRED RESPONSE: 1

 

DISCUSSION: In one series, only 44% of patients demonstrated good results from tarsal tunnel decompression if they did not have a mass in the tarsal tunnel.  Conditions that produce a traction neuropathy of the posterior tibial nerve are unlikely to respond to neurolysis.  The most favorable condition associated with a good response to decompression is when a compressing anatomic structure can be removed from the tarsal tunnel.

 

REFERENCES: Frey C, Kerr R: Magnetic resonance imaging and the evaluation of tarsal tunnel syndrome.  Foot Ankle 1993;14:159-164.

Garrett AL: Poliomyelitis, in Nickel VL (ed): Orthopaedic Rehabilitation.  New York, NY, Churchill Livingston, 1982, pp 449-458.

Pfeiffer WH, Cracchiolo A III: Clinical results after tarsal tunnel decompression.  J Bone Joint Surg Am 1994;76:1222-1230.

 

96.    A 30-year-old man has chronic pain, joint stiffness, and symmetrical polyarthropathy but no significant synovitis.  Examination reveals enlargement of the second and third metatarsal heads.  Radiographs show chondrocalcinosis of the ankles and bony enlargement of the midfoot; no marginal erosions are evident at the metatarsophalangeal level.  What is the most likely diagnosis?

 

1-         Osteoarthritis

2-         Rheumatoid arthritis

3-         Hemochromatosis

4-         Reiter’s syndrome

5-         Pseudogout (calcium pyrophosphate deposition disease)

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The patient’s clinical picture is considered the classic presentation for hemochromatosis.  Osteoarthritis and pseudogout more commonly affect an older age group.  Rheumatoid arthritis is more common in women and is not commonly associated with chondrocalcinosis.  The radiographic appearance of the forefoot in Reiter’s syndrome is one of a pencil in cup deformity of the metatarsophalangeal joint, not enlargement. 

 

REFERENCES: Stevens FM, Edwards C: Recognizing and managing hemochromatosis and hemochromatosis arthropathy.  J Musculoskeletal Med 2004;4:212-225.

Baker ND, Jahss MH, Levanthal GH: Unusual involvement of the feet in hemochromatosis.  Foot Ankle 1984;4:212-215.

 

97.    The strongest biomechanical construct for open reduction and internal fixation of a talar neck fracture uses what interval and entry point?

 

1-         Anterior tibialis, abductor hallucis; anteromedial head of the talus

2-         Anterior tibialis, extensor hallucis longus; anteromedial head of the talus

3-         Peroneus brevis, flexor hallucis longus; posterolateral tubercle of the talus

4-         Extensor digitorum, peroneus tertius; anterolateral head of the talus

5-         Flexor digitorum longus, flexor hallucis longus; posteromedial tubercle of
the talus

 

PREFERRED RESPONSE: 3

 

DISCUSSION: The strongest biomechanical construct is posterior to anterior fixation with the entry point being at the level of the posterolateral tubercle of the talus.  This uses the interval between the peroneus brevis and the flexor hallucis longus.  The interval between the flexor digitorum longus and the flexor hallucis longus with entry at the posteromedial tubercle of the talus is not an accepted approach for fixation of talar neck fractures. All of the other options use screw placements from anterior to posterior.

 

REFERENCES: Swanson TV, Bray TJ, Homes GB Jr: Fractures of the talar neck: A mechanical study of fixation.  J Bone Joint Surg Am 1992;74:544-551.

Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 37-38.

 

98.    A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain.  Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint.  Treatment should consist of

 

1-         extensor hallus longus lengthening.

2-         midfoot osteotomy.

3-         first metatarsal osteotomy.

4-         transfer of the extensor hallucis longus to the neck of the first metatarsal.

5-         transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.

 

PREFERRED RESPONSE: 5

 

DISCUSSION: In a retrospective study for clawing of the hallux with associated cavus foot deformities, the modified Robert Jones tendon transfer was shown to be effective in relieving symptoms related to clawing of the hallux in 90% of patients but was not reliable in relieving pain under the first metatarsal head, with success in only 43% of patients.  In three patients, pain under the metatarsal head was relieved initially but recurred by 18 months.  The return of symptoms in these cases is the result of stretching of the muscle and tendon of the extensor hallucis longus by the more powerful peroneus longus.  Basal dorsal wedge osteotomy at the time of the modified Robert Jones procedure is recommended.

 

REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 79-100.

Tynan MC, Klenerman L: The modified Robert Jones tendon transfer in cases of pes cavus and clawed hallux.  Foot Ankle Int 1994;15:68-71.

 

99.    A 45-year-old woman with stage II posterior tibial tendinitis has failed to respond to nonsurgical management.  Recommended treatment now includes posterior tibial
tendon debridement and medial calcaneal displacement osteotomy along with transfer
of what tendon?

 

1-         Flexor hallucis longus

2-         Flexor digitorum longus

3-         Flexor digitorum brevis

4-         Peroneus longus

5-         Split anterior tibial tendon

 

PREFERRED RESPONSE: 2

 

DISCUSSION: The flexor digitorium longus is the commonly accepted tendon transfer for posterior tibial tendon insufficiency.  The flexor hallucis longus has to be carefully rerouted to avoid crossing the neurovascular bundle and has not been shown clinically to provide superior results to flexor digitorum longus transfer.  Use of the peroneus longus results in loss of plantar flexion strength of the first metatarsal, contributing to the flatfoot deformity.  The anterior tibial tendon is in the anterior compartment and fires out of phase with the posterior tibial tendon. 

 

REFERENCES: Sitler DF, Bell SJ: Soft tissue procedures.  Foot Ankle Clin 2003;8:503-520.

Guyton GP, Jeng C, Krieger LE, et al: Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: A middle-term clinical follow-up.  Foot Ankle Int 2001;22:627-632.

 

100.  A 38-year-old marathon runner has had Achilles tendon pain for the past 2 months.  Examination reveals that the tendon is thickened and tender proximal to the calcaneal insertion.  The tendon sheath is not thickened or tender.  The pathophysiology of the tendon is best described as

 

1-         acute inflammation.

2-         chronic inflammation.

3-         partial tendon rupture.

4-         anaerobic degeneration.

5-         impaired collagen cross-linking.

 

PREFERRED RESPONSE: 4

 

DISCUSSION: Atraumatic Achilles tendon disease can be differentiated into Achilles tendinosis and peritendinitis.  Thickening and tenderness of the Achilles tendon are present in both, but thickening and tenderness of the tendon sheath indicates peritendinitis.  Histologic examination of Achilles tendinosis reveals an absence of acute and chronic inflammatory cells.  Radiologists often diagnose partial tendon rupture by MRI and there may be microscopic longitudinal tears present, but there is no mechanical compromise as would be implied by a partial rupture.  The thickening typically occurs in the portion of the tendon with the poorest blood supply, and biochemical analysis detects high levels of lactate and other products of anaerobic glycolysis.

 

REFERENCES: Astrom M, Rausing A: Chronic Achilles tendinopathy: A survey of surgical and histopathologic findings.  Clin Orthop 1995;316:151-164.

Ohberg L, Lorentzon R, Alfredson H: Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: An ultrasonographic investigation.  Knee Surg Sports Traumatol Arthrosc 2001;9:233-238.

Alfredson H, Bjur D, Thorsen K, et al: High intratendinous lactate levels in painful chronic Achilles tendinosis: An investigation using microdialysis technique.  J Orthop Res
2002;20:934-938.