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Midfoot & Hindfoot MCQs

Practice Set 12 of 39

This practice set contains high-yield board review questions covering key concepts in Midfoot & Hindfoot. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 221

Topic: Midfoot & Hindfoot

A 40-year-old man with amyloidosis injured his left knee while walking. Figure 17a shows an AP radiograph that was obtained 2 weeks after the injury. The radiograph shown in Figure 17b was obtained after the patient wore a hinged knee brace for 3 months. A clinical photograph is shown in Figure 17c. What is the most likely diagnosis?

. Pyarthrosis
. Pigmented villonodular synovitis
. Synovial osteochondromatosis
. Charcot arthropathy
. Spontaneous osteonecrosis

Correct Answer & Explanation

. Charcot arthropathy

Explanation

The patient has a Charcot arthropathy of the knee, which is associated with amyloidosis. The rapid joint destruction shown in the radiographs is most consistent with that diagnosis. Drennan D, Fahey J, Maylahn D: Important factors in achieving arthrodesis of the Charcot knee. J Bone Joint Surg Am 1971;53:1180-1193. Soudry M, Binazzi R, Johanson N, et al: Total knee arthroplasty in Charcot and Charcot like joints. Clin Orthop 1986;208:199-204.

Question 222

Topic: Midfoot & Hindfoot

A 47-year-old woman has had medial ankle pain and swelling for the past 3 months. She recalls no specific injury, and casting and nonsteroidal anti-inflammatory drugs have failed to provide relief. Examination reveals a pes planus with heel valgus that is passively correctable. Radiographs show no evidence of arthritis. An MRI scan is shown in Figure 16. What is the most appropriate surgical procedure to alleviate her pain?

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 3

. Triple arthrodesis
. Isolated flexor digitorum longus transfer
. Flexor digitorum longus transfer with medial displacement calcaneal osteotomy
. Debridement and direct repair of the posterior tibial tendon
. Repair of the spring ligament

Correct Answer & Explanation

. Flexor digitorum longus transfer with medial displacement calcaneal osteotomy

Explanation

The patient has a stage II posterior tibial tendon tear with a supple foot; therefore, the treatment of choice is flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Triple arthrodesis is not indicated, and isolated tendon transfer will stretch out in the face of persistent heel valgus. Direct repair of the posterior tibial tendon or repair of the spring ligament is not sufficient to correct the deformity. Myerson MS, Corrigan J: Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics 1996;19:383-388.

Question 223

Topic: Midfoot & Hindfoot

A 20-year-old man sustains the injury shown in Figures 1a and 1b in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by

. a subtalar arthrodesis.
. screw fixation of the talar neck.
. repair of the medial subtalar capsule.
. temporary transarticular pin fixation.
. evaluation for and excision or fixation of osteochondral fractures.

Correct Answer & Explanation

. evaluation for and excision or fixation of osteochondral fractures.

Explanation

Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.

Question 224

Topic: Midfoot & Hindfoot

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 degrees of valgus, and forefoot supination can be corrected to 10 degrees from neutral. Nonsurgical management has failed to provide relief. Treatment should now consist of

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 6

. medial sliding calcaneal osteotomy with flexor digitorum longus (FDL) transfer.
. isolated subtalar arthrodesis.
. isolated talonavicular arthrodesis.
. triple arthrodesis.
. subtalar arthroereisis.

Correct Answer & Explanation

. triple arthrodesis.

Explanation

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 degrees, an isolated subtalar fusion is a possible alternative.

Question 225

Topic: Midfoot & Hindfoot

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

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 25

. a subtalar arthroereisis with a titanium implant.
. triple arthrodesis.
. resection of the accessory navicular and advancement of the posterior tibial tendon bilaterally.
. resection of the talocalcaneal middle facet coalition in each foot.
. resection of the calcaneonavicular coalition in both feet.

Correct Answer & Explanation

. resection of the calcaneonavicular coalition in both feet.

Explanation

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. 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.

Question 226

Topic: Midfoot & Hindfoot

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?

. Tendon transfer, lateral column lengthening, and heel cord lengthening
. Triple arthrodesis and heel cord lengthening
. Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening
. Tendon transfer, spring ligament repair, and heel cord lengthening
. Tendon repair, medial displacement calcaneal osteotomy, and heel cord lengthening

Correct Answer & Explanation

. Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening

Explanation

The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs. Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.

Question 227

Topic: Midfoot & Hindfoot

A 62-year-old man has a severe pes planus and pain in the hindfoot. Radiographs show advanced degenerative changes at the talonavicular and subtalar joints with good preservation of the ankle joint. What is the most appropriate surgical procedure to alleviate his pain?

. Flexor digitorum longus transfer with calcaneal osteotomy
. Lateral column lengthening with tendon transfer
. Subtalar arthrodesis
. Triple arthrodesis
. Isolated talonavicular fusion

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Once degenerative changes have occurred, soft-tissue procedures are not indicated. Triple arthrodesis is the treatment of choice for adult-acquired flatfoot. Isolated fusion of the subtalar or talonavicular joint will not be sufficient to correct the problem. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 269-282.

Question 228

Topic: Midfoot & Hindfoot

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

. Quicker return to activities
. Quicker return to work
. Increased subtalar joint range of motion
. Decreased risk of nonunion
. Decreased risk of posttraumatic arthritis

Correct Answer & Explanation

. Decreased risk of posttraumatic arthritis

Explanation

The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 229

Topic: Midfoot & Hindfoot

A 54-year-old male with long-standing diabetes presents with a swollen, warm, and erythematous left foot. Radiographs reveal fragmentation and periarticular debris at the tarsometatarsal joints. Which classification system is commonly used to stage the anatomical location of this disease process?

. Eichenholtz classification
. Brodsky classification
. Sanders classification
. Tscherne classification
. Hardinge classification

Correct Answer & Explanation

. Brodsky classification

Explanation

The Brodsky classification describes the anatomic location of Charcot arthropathy. Type 1 is the tarsometatarsal (Lisfranc) joint, which is the most common. Type 2 involves the Chopart/subtalar joints. Type 3A involves the ankle (tibiotalar), and Type 3B involves the calcaneal tuberosity. The Eichenholtz classification describes the clinical and radiographic progression (development, coalescence, consolidation).

Question 230

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive flatfoot deformity, lateral hindfoot pain, and inability to perform a single-leg heel rise. Clinical exam shows a flexible hindfoot valgus and forefoot abduction. Radiographs show >40% uncoverage of the talonavicular joint. Diagnosis of Stage IIB posterior tibial tendon dysfunction (PTTD) is made. Which of the following surgical interventions is most critical to correct the specific forefoot abduction deformity in this stage?
. Medial displacement calcaneal osteotomy (MDCO)
. Flexor digitorum longus (FDL) transfer to the navicular
. Lateral column lengthening (Evans osteotomy)
. Spring ligament reconstruction
. Triple arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

Stage IIB PTTD is characterized by a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage). While an FDL transfer replaces the function of the diseased posterior tibial tendon, and a medial displacement calcaneal osteotomy (MDCO) corrects hindfoot valgus, the lateral column lengthening (Evans osteotomy) is specifically required to correct the forefoot abduction deformity by lengthening the lateral column and pivoting the navicular back over the talar head.

Question 231

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a Hawkins Type III talar neck fracture following a high-speed motor vehicle collision. Which of the following accurately describes the displacement pattern and the approximate historical risk of avascular necrosis (AVN) for this specific injury type?
. Displaced talar neck fracture with subtalar dislocation; 20-50% risk of AVN.
. Displaced talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN.
. Displaced talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN.
. Nondisplaced talar neck fracture; 0-10% risk of AVN.
. Displaced talar neck fracture with talonavicular dislocation only; 50% risk of AVN.

Correct Answer & Explanation

. Displaced talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN.

Explanation

Hawkins Type III is a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The risk of AVN in Type III fractures is exceptionally high, historically reported as up to 100% (though modern series may show ~85-90%). Type I is nondisplaced (~0-15% AVN). Type II has subtalar dislocation (~20-50% AVN). Type IV involves the talonavicular joint in addition to the subtalar and tibiotalar joints.

Question 232

Topic: Midfoot & Hindfoot
A 55-year-old patient with long-standing, poorly controlled diabetes mellitus presents with an acute, red, hot, and swollen right foot. Radiographs demonstrate extensive osteopenia, periarticular fragmentation, bony debris, and midfoot subluxation. According to the Eichenholtz classification of Charcot neuroarthropathy, which stage does this represent?
. Stage 0 (High risk/Inflammatory)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation/Reconstruction)
. Stage IV (Ulceration/Infection)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes the radiographic evolution of Charcot arthropathy. Stage I (Development or Fragmentation) is characterized by acute inflammation clinically, and radiographs showing osteopenia, periarticular fragmentation, subluxation/dislocation, and bony debris. Stage 0 lacks radiographic findings but has clinical swelling. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Consolidation) shows remodeling and fixed deformity.

Question 233

Topic: Midfoot & Hindfoot
A 60-year-old diabetic patient presents with a warm, swollen, erythematous foot. Radiographs reveal fragmentation of bone, periarticular debris, subluxation, and joint dislocation. There is no active consolidation. Which stage of the Eichenholtz classification for Charcot arthropathy does this represent?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot neuroarthropathy. Stage I (Developmental/Fragmentation) is characterized by acute inflammation, osteopenia, joint subluxation/dislocation, bone fragmentation, and intra-articular debris. Stage II (Coalescence) shows decreased inflammation and early absorption of debris. Stage III (Consolidation) shows remodeling and robust bony fusion. Stage 0 was later added (Shibata) to denote the acute inflammatory phase prior to radiographic fragmentation.

Question 234

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type II diabetes presents with a red, hot, swollen right foot. Inflammatory markers are normal and an MRI confirms no osteomyelitis. Radiographs reveal prominent periarticular osseous debris, fragmentation of the navicular and cuneiforms, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this clinical and radiographic picture represent?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage 0 is the acute inflammatory stage without radiographic changes. Stage I (Development/Fragmentation) is characterized clinically by a hot, swollen foot and radiographically by osteopenia, periarticular fragmentation, bony debris, and subluxation/dislocation. Stage II (Coalescence) shows absorption of fine debris, fusion of larger fragments, and early sclerosis. Stage III (Consolidation) shows remodeling, rounding of bone ends, and stable deformity.

Question 235

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a severe inversion injury resulting in a displaced fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar joint remains congruous. According to the Hawkins classification, what type of injury is this and what is the approximate rate of avascular necrosis (AVN)?
. Type I, 0-10%
. Type II, 20-50%
. Type III, 80-100%
. Type IV, 100%
. Type II, 80-100%

Correct Answer & Explanation

. Type III, 80-100%

Explanation

Hawkins Classification of talar neck fractures: Type I is nondisplaced (0-10% AVN). Type II involves displacement with subtalar subluxation/dislocation (20-50% AVN). Type III involves displacement with both subtalar and tibiotalar dislocation (nearly 100% AVN). Type IV adds talonavicular subluxation/dislocation.

Question 236

Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris at the midfoot. According to the Eichenholtz classification, this presentation is most consistent with which stage?
. Stage 0
. Stage I (Development)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Resolution)

Correct Answer & Explanation

. Stage I (Development)

Explanation

The Eichenholtz classification of Charcot arthropathy: Stage 0 (pre-fragmentation) - erythema, edema, normal radiographs. Stage I (Development/Fragmentation) - severe edema, erythema, bony fragmentation, joint subluxation/dislocation, debris. Stage II (Coalescence) - decreased edema, absorption of fine debris, early fusion. Stage III (Reconstruction) - remodeling and consolidation of bone.

Question 237

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm right foot without open ulcerations. He is afebrile with a normal WBC count. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints.

According to the Eichenholtz classification, what is the best initial management?

. Intravenous antibiotics and emergent irrigation and debridement
. Total contact casting and restricted weight-bearing
. Primary midfoot arthrodesis with robust internal fixation
. Surgical exostectomy of prominent bone to prevent ulceration
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and restricted weight-bearing

Explanation

This patient is in the acute fragmentation phase (Stage 1) of Eichenholtz Charcot arthropathy. The classic presentation mimics infection (red, hot, swollen), but the absence of systemic signs and an intact skin envelope point toward Charcot. The mainstay of treatment in the acute fragmentation stage is immobilization and offloading, typically achieved via a total contact cast (TCC). Surgery during the acute inflammatory phase carries a high risk of failure and is generally contraindicated unless severe instability threatens the soft tissue envelope.

Question 238

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Assuming radiographs initially revealed midfoot fragmentation and subluxation, and follow-up radiographs 4 months later demonstrate absorption of fine bone debris and early fusion of large fragments. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (Inflammatory)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Remodeling/Consolidation)
. Stage IV (Chronic Deformity)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot neuroarthropathy. Stage 0 is the inflammatory phase (erythema, edema, warmth, normal radiographs or mild osteopenia). Stage I (Fragmentation) is characterized by joint subluxation, debris formation, and fragmentation. Stage II (Coalescence) is marked by the absorption of fine debris, early sclerosis, and fusion of larger fragments as the acute inflammation subsides. Stage III (Consolidation/Remodeling) shows remodeling of the bone ends, decreased sclerosis, and a stable (though often deformed) joint.

Question 239

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs reveal periarticular fragmentation, bony debris, and early subluxation of the midfoot joints. Laboratory markers for infection are negative. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy and the most appropriate initial management?

. Stage 0; rigid internal fixation
. Stage 1; total contact casting and non-weight-bearing
. Stage 2; custom orthotic shoe wear
. Stage 3; midfoot arthrodesis
. Stage 1; immediate operative debridement

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight-bearing

Explanation

Eichenholtz Stage 1 is the developmental or fragmentation stage of Charcot arthropathy. It is clinically characterized by a hot, red, swollen foot. Radiographically, there is bony fragmentation, joint subluxation/dislocation, and debris. The cornerstone of treatment in the acute fragmentation stage is immediate offloading and immobilization, typically achieved with a total contact cast (TCC) to halt the progression of deformity until the joint coalesces.

Question 240

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. On examination, she has a flexible flatfoot, valgus hindfoot that corrects on a toe-raise, and she is unable to perform a single-limb heel rise on the affected side. According to the Johnson and Strom classification (modified by Myerson), what stage of Posterior Tibial Tendon Dysfunction (PTTD) does she have?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

Stage I PTTD involves tenosynovitis with mild pain but no deformity; the patient can still perform a single heel rise. Stage II involves a flexible flatfoot deformity, and the patient is unable to perform a single heel rise. Stage III involves a rigid, fixed flatfoot deformity. Stage IV involves deltoid ligament incompetence with a rigid flatfoot and ankle valgus tilt.

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