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Midfoot & Hindfoot MCQs

Practice Set 9 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 161

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise, has forefoot abduction with a 'too many toes' sign, and flexible hindfoot valgus. Which of the following surgical procedures is most appropriate?

. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (greater than 30-40% uncoverage of the talar head). This requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 162

Topic: Midfoot & Hindfoot
A 25-year-old female sustains a closed Hawkins Type III fracture of the talar neck after a fall from a height. She undergoes prompt open reduction and internal fixation. What is the approximate expected rate of avascular necrosis (AVN) of the talar body for this specific fracture pattern?
. 0 to 15%
. 20 to 50%
. 80 to 100%
. 100% only if the fracture is open
. Generally non-existent if fixed within 6 hours

Correct Answer & Explanation

. 80 to 100%

Explanation

The Hawkins classification for talar neck fractures is highly prognostic for avascular necrosis (AVN). Type I (undisplaced) has an AVN rate of 0-15%. Type II (subluxation or dislocation of the subtalar joint) has a rate of 20-50%. Type III (dislocation of both subtalar and tibiotalar joints) has an extremely high AVN rate, traditionally reported between 80-100%. Type IV (Type III plus talonavicular subluxation/dislocation) also carries a near 100% risk.

Question 163

Topic: Midfoot & Hindfoot

A 22-year-old collegiate athlete sustains a purely ligamentous Lisfranc injury. Based on level I prospective randomized literature comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for this specific injury type, what is a documented advantage of primary arthrodesis?

. Significantly lower rate of early deep infection
. Better short-term range of motion at the midfoot
. Decreased rate of secondary surgeries and hardware removal
. Faster time to full weight-bearing by 4 weeks
. Superior preservation of the subtalar joint mechanics

Correct Answer & Explanation

. Decreased rate of secondary surgeries and hardware removal

Explanation

Multiple studies (e.g., Ly and Coetzee, JBJS Am 2006) have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial 2 or 3 rays yields better functional outcomes (higher AOFAS scores) and significantly lower rates of secondary procedures compared to ORIF. Patients treated with ORIF often require hardware removal and later salvage arthrodesis due to post-traumatic arthritis.

Question 164

Topic: Midfoot & Hindfoot

In the management of Lisfranc injuries, prospective randomized trials have demonstrated that primary arthrodesis provides superior functional outcomes and lower reoperation rates compared to open reduction and internal fixation (ORIF) for which specific subset of patients?

. Bony Lisfranc injuries with large fracture fragments
. Purely ligamentous Lisfranc injuries of the first, second, and third tarsometatarsal joints
. Lisfranc injuries in pediatric patients
. Lisfranc injuries involving the fourth and fifth tarsometatarsal joints exclusively
. Lisfranc injuries presenting greater than 24 hours after trauma

Correct Answer & Explanation

. Purely ligamentous Lisfranc injuries of the first, second, and third tarsometatarsal joints

Explanation

Multiple landmark studies (e.g., Ly and Coetzee) have shown that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields significantly better functional outcomes and lower rates of secondary surgeries (for hardware removal or salvage arthrodesis due to post-traumatic arthritis) compared to ORIF. The 4th and 5th TMT joints should remain mobile.

Question 165

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with medial foot pain and a progressive flatfoot deformity. On examination, she has a flexible hindfoot valgus and is unable to perform a single-leg heel raise. Weight-bearing radiographs reveal 50% uncoverage of the talar head on the AP view. Which of the following surgical interventions is most appropriate for this patient?

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Gastrocnemius recession and isolated talonavicular arthrodesis
. Triple arthrodesis
. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Primary subtalar arthrodesis with spring ligament repair

Correct Answer & Explanation

. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has Stage IIB adult acquired flatfoot deformity, distinguished from Stage IIA by >40% talonavicular uncoverage (forefoot abduction). The addition of a lateral column lengthening to the FDL transfer and medial calcaneal osteotomy addresses this abduction deformity.

Question 166

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Clinical examination reveals an inability to perform a single-leg heel rise and forefoot abduction with "too many toes" visible from behind. Weight-bearing radiographs show greater than 50% talonavicular uncoverage but no arthritic changes in the hindfoot or midfoot. Which of the following is the most appropriate surgical management?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer to the navicular, MDCO, and a lateral column lengthening
. Gastrocnemius recession and isolated FDL transfer
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer to the navicular, MDCO, and a lateral column lengthening

Explanation

This patient has Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by flexible hindfoot valgus and significant forefoot abduction (>40% or >50% talonavicular uncoverage). Surgical correction requires FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to address the abduction.

Question 167

Topic: Midfoot & Hindfoot

In a purely ligamentous Lisfranc injury, which of the following treatments has been shown in prospective randomized trials to yield superior functional outcomes and lower reoperation rates?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF)
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Conservative management in a non-weight-bearing cast
. Primary arthrodesis of all five tarsometatarsal joints

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Prospective randomized trials have demonstrated that primary arthrodesis of the medial column (1st-3rd TMT joints) for purely ligamentous Lisfranc injuries provides superior long-term functional outcomes compared to ORIF. ORIF has a higher rate of hardware failure and post-traumatic arthritis in purely ligamentous variants.

Question 168

Topic: Midfoot & Hindfoot

A 24-year-old male sustains a purely ligamentous Lisfranc injury and is considering surgical intervention. Compared to primary arthrodesis, which of the following statements accurately characterizes open reduction and internal fixation (ORIF) for this specific injury pattern?

. Lower rate of subsequent hardware removal procedures
. Higher rate of return to pre-injury elite sporting activity
. Higher rate of post-traumatic osteoarthritis requiring secondary fusion
. Superior anatomical alignment on postoperative weight-bearing CT
. Shorter necessary period of postoperative immobilization

Correct Answer & Explanation

. Higher rate of post-traumatic osteoarthritis requiring secondary fusion

Explanation

Prospective studies (such as Coetzee and Ly) have shown that purely ligamentous Lisfranc injuries treated with ORIF have a high rate of post-traumatic arthritis requiring secondary midfoot fusion. Primary arthrodesis is increasingly favored for purely ligamentous variants to improve long-term outcomes and limit secondary surgeries.

Question 169

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive medial foot pain and a flatfoot deformity. Examination reveals a flexible hindfoot valgus and an inability to perform a single-leg heel rise. Weight-bearing radiographs demonstrate talonavicular uncoverage of 60%. Which of the following surgical strategies is most appropriate?

. FDL transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II indicates a flexible deformity. Stage IIa has minimal forefoot abduction, typically managed with FDL transfer and MDCO. Stage IIb is characterized by significant forefoot abduction (talonavicular uncoverage > 40-50%). Addition of a lateral column lengthening (e.g., Evans osteotomy) to the FDL transfer and MDCO is necessary to correct the severe forefoot abduction.

Question 170

Topic: Midfoot & Hindfoot

A 30-year-old female sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following is true regarding the surgical management of this specific injury pattern compared to open reduction and internal fixation (ORIF)?

. Primary arthrodesis is associated with superior functional outcomes and a lower rate of secondary surgeries.
. ORIF has a significantly lower rate of hardware removal.
. Primary arthrodesis results in a higher rate of deep infection.
. ORIF allows for earlier return to impact sports.
. There is no difference in outcomes between ORIF and primary arthrodesis for purely ligamentous injuries.

Correct Answer & Explanation

. Primary arthrodesis is associated with superior functional outcomes and a lower rate of secondary surgeries.

Explanation

Level I evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial two or three tarsometatarsal joints for purely ligamentous Lisfranc injuries yields superior functional outcomes and requires fewer secondary surgeries compared to ORIF. ORIF in purely ligamentous injuries frequently fails or requires secondary hardware removal, often eventually necessitating a salvage arthrodesis.

Question 171

Topic: Midfoot & Hindfoot

A 32-year-old male sustains a purely ligamentous Lisfranc injury during a football game. Based on prospective randomized data comparing open reduction internal fixation (ORIF) to primary arthrodesis for purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to have a lower reoperation rate and equivalent or better functional outcomes. If primary arthrodesis is performed, which joints are typically fused?

. Tarsometatarsal joints 1 through 3
. Tarsometatarsal joints 1 through 5
. Naviculocuneiform and calcaneocuboid joints
. Tarsometatarsal joints 2 through 4
. Tarsometatarsal joints 4 and 5

Correct Answer & Explanation

. Tarsometatarsal joints 1 through 3

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries typically involves the medial and middle columns (tarsometatarsal joints 1, 2, and 3). The lateral column (TMT 4 and 5) must be preserved and left unfused (or stabilized temporarily with K-wires) to maintain essential forefoot mobility and accommodate uneven ground during the gait cycle.

Question 172

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing poorly controlled type 2 diabetes and peripheral neuropathy presents with a red, hot, swollen foot for 3 weeks. He denies any trauma or fever. Radiographs show periarticular osteopenia, fragmentation of the talonavicular joint, and subluxation, but no osteomyelitis. What Eichenholtz stage of Charcot arthropathy is this, and what is the standard initial treatment?

. Stage 0; Immediate open reduction and internal fixation
. Stage 1; Total contact casting and non-weight bearing
. Stage 2; Custom Charcot Restraint Orthotic Walker (CROW) boot
. Stage 3; Midfoot arthrodesis with a beaming technique
. Stage 1; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

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

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by periarticular osteopenia, fragmentation, debris formation, and subluxation. The standard of care for acute active Charcot (Stage 0 and Stage 1) is immobilization with a total contact cast (TCC) and restricted weight-bearing to prevent further deformity until the acute inflammatory phase resolves (transition to Stage 2/3).

Question 173

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a flexible, acquired flatfoot deformity secondary to Stage IIb posterior tibial tendon dysfunction. Radiographs demonstrate >40% talonavicular uncoverage and severe forefoot abduction. The planned procedure includes a flexor digitorum longus (FDL) transfer to the navicular. To optimally address the severe transverse plane deformity (forefoot abduction), which structural osteotomy is most commonly indicated?
. Medializing calcaneal osteotomy (MCO)
. Lateral column lengthening (Evans osteotomy)
. Plantarflexion opening wedge medial cuneiform osteotomy (Cotton)
. Closing wedge cuboid osteotomy
. First metatarsal corrective osteotomy

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage on AP radiograph). A lateral column lengthening (Evans osteotomy) effectively corrects the severe transverse plane deformity by pushing the forefoot into adduction. A medializing calcaneal osteotomy (MCO) primarily corrects hindfoot valgus (coronal plane) but has limited effect on severe transverse plane abduction.

Question 174

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing diabetes presents with a warm, swollen, and erythematous left foot. Radiographs demonstrate periarticular debris, fragmentation of the navicular, and subluxation of the midtarsal joints. There are no systemic signs of infection. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and non-weight-bearing
. Primary arthrodesis of the midfoot
. Custom orthotic shoe wear and weight-bearing as tolerated
. Percutaneous pinning of the midtarsal joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in the acute fragmentation phase (Eichenholtz Stage I) of Charcot arthropathy. The gold standard of initial treatment is strict offloading and immobilization using a total contact cast until the acute inflammatory phase resolves.

Question 175

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male with severe peripheral neuropathy presents with a globally swollen, erythematous, and warm right foot. He denies fevers, chills, or an open wound. Radiographs reveal prominent subchondral osteopenia, bony fragmentation, joint debris, and subluxation of the midfoot. According to the Eichenholtz classification, what is the appropriate stage of this Charcot arthropathy and the most appropriate initial management?

. Stage 0; Intravenous antibiotics and surgical debridement
. Stage 1; Total contact casting and strictly non-weight bearing
. Stage 2; Corrective midfoot arthrodesis
. Stage 3; Custom accommodating footwear and bracing
. Stage 4; Below-knee amputation

Correct Answer & Explanation

. Stage 1; Total contact casting and strictly non-weight bearing

Explanation

The clinical and radiographic presentation defines Stage 1 (Developmental/Fragmentation) of the Eichenholtz classification for Charcot arthropathy. It is characterized by erythema, swelling, warmth, osteopenia, fragmentation, joint subluxation, and debris. The gold standard for initial management of Stage 1 Charcot is immobilization and offloading, most effectively achieved with a total contact cast (TCC). Surgery is generally contraindicated during this acute, hyperemic phase.

Question 176

Topic: Midfoot & Hindfoot
A 52-year-old female presents with stage IIB acquired adult flatfoot deformity (posterior tibial tendon dysfunction). Clinical and radiographic evaluation demonstrates a flexible hindfoot valgus and severe forefoot abduction with >40% talonavicular uncoverage on the weight-bearing AP view. Which of the following surgical combinations is most appropriate to comprehensively correct her deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and a medializing calcaneal osteotomy (MCO) only
. FDL transfer to the navicular, MCO, and a lateral column lengthening (e.g., Evans osteotomy)
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Isolated subtalar arthrodesis
. Tibialis anterior tendon transfer and first tarsometatarsal arthrodesis

Correct Answer & Explanation

. FDL transfer to the navicular, MCO, and a lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with profound forefoot abduction (indicated by >40% talonavicular uncoverage). To correct this multi-planar deformity, an FDL transfer and medializing calcaneal osteotomy (which correct the hindfoot valgus) must be combined with a lateral column lengthening (Evans osteotomy) or a medial cuneiform osteotomy (Cotton) to definitively correct the forefoot abduction. Stage IIA (no significant abduction) may be treated with FDL transfer and MCO alone. Stage III (rigid) requires a triple or double arthrodesis.

Question 177

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and is unable to perform a single-leg heel rise. Examination shows a flexible hindfoot valgus and greater than 40% uncovering of the talonavicular joint on a weight-bearing AP foot radiograph. Which of the following surgical strategies is most appropriate for this stage of deformity?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Talonavicular arthrodesis alone
. Gastrocnemius recession and subtalar arthroereisis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with significant forefoot abduction (>30-40% talonavicular uncoverage). Treatment requires FDL transfer, an MDCO (to correct hindfoot valgus), and a lateral column lengthening (such as an Evans calcaneal osteotomy) to correct the severe forefoot abduction. Stage IIa lacks the severe abduction and can be treated without the lateral column lengthening.

Question 178

Topic: Midfoot & Hindfoot
A 52-year-old diabetic male with severe peripheral neuropathy presents with a red, hot, swollen right foot mimicking cellulitis. Radiographs reveal extensive periarticular debris, fragmentation of the subchondral bone, and subluxation of the tarsometatarsal joints. Based on the Eichenholtz classification, what stage is this?
. Stage 0; pre-fragmentation
. Stage I; fragmentation
. Stage II; coalescence
. Stage III; remodeling
. Stage IV; ulceration

Correct Answer & Explanation

. Stage I; fragmentation

Explanation

Eichenholtz Stage I is the developmental or fragmentation phase of Charcot arthropathy. It is characterized clinically by a red, hot, swollen foot and radiographically by subchondral fragmentation, debris formation, and joint subluxation/dislocation. Stage II (coalescence) shows absorption of fine debris and early fusion. Stage III (remodeling) shows rounding of bone ends and sclerosis.

Question 179

Topic: Midfoot & Hindfoot

In a patient with Stage II posterior tibial tendon dysfunction (PTTD), tearing or attenuation of the spring ligament complex is frequently observed. Which component of the spring ligament complex is the thickest, most frequently torn, and acts as the primary static stabilizer of the talonavicular joint?

. Plantar calcaneonavicular ligament
. Superomedial calcaneonavicular ligament
. Inferocalcaneonavicular ligament
. Bifurcate ligament
. Dorsal talonavicular ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex (calcaneonavicular ligament) has three main components: superomedial, inferoplantar, and medioplantar. The superomedial calcaneonavicular ligament is the thickest and most crucial static stabilizer of the talar head. It is the component most frequently attenuated or torn in conjunction with posterior tibial tendon dysfunction (acquired flatfoot deformity).

Question 180

Topic: Midfoot & Hindfoot

A 26-year-old male presents with a grossly deformed foot after a fall from a ladder. Radiographs reveal a medial subtalar dislocation without associated fractures. Which of the following structures is most likely to block closed reduction of this specific dislocation pattern?

. Posterior tibial tendon
. Flexor hallucis longus
. Extensor digitorum brevis
. Peroneus brevis tendon
. Anterior tibial tendon

Correct Answer & Explanation

. Extensor digitorum brevis

Explanation

In a medial subtalar dislocation, the foot is displaced medially, forcing the talar head to protrude laterally. The structures that commonly block closed reduction of a medial subtalar dislocation include the extensor digitorum brevis (EDB) muscle, the extensor retinaculum, or the talonavicular joint capsule impinging on the talar head. Conversely, in a lateral subtalar dislocation, the posterior tibial tendon (PTT) frequently blocks reduction by looping around the medially prominent talar neck.

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