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8. Foot and Ankle MCQs

Practice Set 139 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2761

Topic: 8. Foot and Ankle

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 27

. an extra-depth shoe with an accommodative orthosis.
. surgical debridement and metatarsal head resection.
. posterior tibial tendon transfer through the interosseous membrane.
. Achilles tendon lengthening and total contact casting.
. hyperbaric oxygen therapy.

Correct Answer & Explanation

. Achilles tendon lengthening and total contact casting.

Explanation

Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration. In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective. Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained. Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996;19:465-475.

Question 2762

Topic: 8. Foot and Ankle

Figures 4a through 4c show the clinical photographs and radiographs of a 12-month-old boy who has progressive difficulty wearing shoes because of the length of the second toe, as well as width of the forefoot. Management should consist of

. form-fitted shoes.
. amputation of the second toe at the metatarsophalangeal joint.
. amputation of the first ray and amputation of the second toe.
. amputation of the second ray.
. an MRI scan of the foot, a CT scan of the chest, and a biopsy of the foot with the possibility of ankle disarticulation amputation.

Correct Answer & Explanation

. amputation of the second ray.

Explanation

The patient has macrodactyly involving the second ray, with significant enlargement of the width and height of the foot. The radiographs show widening of the interval between the first and second metatarsal and between the second and third metatarsal. With this degree of involvement, amputation of the second ray with excision of the overgrowth of affected soft tissue provides the most consistent desired reduction in foot size. A threaded Steinmann pin should be inserted across the remaining metatarsals until healing has occurred. Patients with macrodactyly should be examined to exclude neurofibromatosis type 1 and Klippel-Trenaunay-Weber syndrome.

Question 2763

Topic: 8. Foot and Ankle

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?

. History and physical examination
. Ultrasonography
. MRI
. Radiographs
. Nerve conduction velocity studies

Correct Answer & Explanation

. History and physical examination

Explanation

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

Question 2764

Topic: 8. Foot and Ankle

A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsiflexion at the ankle and no other foot deformities or ulcers. Which of the following is considered appropriate shoe wear for this patient?

. Snug fitting shoe to block side-to-side motion that is common after this procedure
. Leather sole shoe to prevent catching the shoe on carpet which is common with crepe-soled shoes
. Lateral wedge on the shoe to offset the external rotation during the toe-off phase of gait commonly seen after this procedure
. Steel shank to extend the foot lever and prevent deformity at the toe break
. Custom-made shoe to provide the best possible fit and function

Correct Answer & Explanation

. Steel shank to extend the foot lever and prevent deformity at the toe break

Explanation

The steel shank is a flat 1-inch steel strip placed between layers of the shoe to extend the foot lever and prevent deformity at the toe break seen following a partial first ray amputation. A rocker sole may be added as well to facilitate transition from foot flat to the toe-off phase of gait. Proper shoe fit is important, but "snug" fitting shoes in a patient with peripheral neuropathy and likely fluctuations in volume from intermittent swelling are to be avoided. A custom shoe is an unnecessary expense. The patient has at least 10 degrees of dorsiflexion at the ankle with an intact anterior tibialis muscle; therefore, catching the sole on carpeting should not be a problem. Philbin TM, Leyes M, Sferra JJ, et al: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.

Question 2765

Topic: 8. Foot and Ankle

A 12-year-old boy has had progressive pain and flatfeet for the past year. Pain is increased with weight-bearing activities. Examination reveals that subtalar motion is absent. On standing, the patient has obvious hindfoot valgus and loss of the normal arch bilaterally. Plain radiographs are shown in Figures 43a through 43c, and a CT scan is shown in Figure 43d. What is the most likely diagnosis?

. Peroneal spastic flatfoot
. Flexible flatfoot with a short Achilles tendon
. Calcaneonavicular coalition
. Talocalcaneal coalition
. Posterior tibial tendon dysfunction

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The axial views show fusion of the talus and calcaneus at the medial facet (talocalcaneal coalition). Peroneal spastic flatfoot is a descriptive term applying to the symptoms of painful flatfoot associated with apparent peroneal spasm and is sometimes caused by tarsal coalition; however, this is not the most appropriate diagnosis for this patient. Flexible flatfoot with a short Achilles tendon often causes symptoms similar to the ones listed above, but subtalar motion should be normal. A diagnosis of calcaneonavicular coalition can be made based on plain oblique views of the foot but is not seen in these views. Posterior tibial tendon dysfunction in the absence of other pathology is uncommon in children. Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.

Question 2766

Topic: 8. Foot and Ankle
A 26-year-old man with chronic lateral ankle instability underwent a modified Broström procedure 8 months ago. He reports persistent pain and swelling of the lateral ankle. Examination reveals lateral ankle tenderness and swelling and a negative anterior drawer test. Laboratory studies show a WBC count of 6,500/mm3 and an erythrocyte sedimentation rate of 15 mm/h. Radiographs of the ankle are normal. What is the most likely cause of this problem?
. Deep infection
. Failure of repair
. Peroneus longus tear
. Peroneus brevis tear
. Tibiotalar arthritis

Correct Answer & Explanation

. Peroneus brevis tear

Explanation

Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop.

Question 2767

Topic: 8. Foot and Ankle

A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient's symptoms?

. Nonunion
. Tarsal tunnel syndrome
. Degenerative arthritis of the hindfoot joints
. Sinus tarsi syndrome
. Chronic osteomyelitis of the distal tibia

Correct Answer & Explanation

. Degenerative arthritis of the hindfoot joints

Explanation

The patient has a solid ankle fusion radiographically. With a tibiotalar arthrodesis, the adjacent joints (subtalar and transverse tarsal) take additional stress. Over time, progressive degenerative arthritis will occur in these adjacent joints, often necessitating further surgery. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.

Question 2768

Topic: 8. Foot and Ankle

A 28-year-old professional football player reports painless loss of ankle motion after sustaining a "severe" ankle sprain 12 months ago. A mortise radiograph is shown in Figure 1. Surgical treatment should be reserved for which of the following conditions?

Sports Medicine 2007 Practice Questions: Set 1 (Solved) - Figure 2

. Chronic ankle instability
. Persistent pain
. Progressive loss of ankle plantar flexion
. Development of ankle arthritis
. Instability of the proximal tibiofibular joint

Correct Answer & Explanation

. Persistent pain

Explanation

The radiograph shows posttraumatic tibiofibular synostosis. This condition typically follows an eversion (high) ankle sprain that results in disruption of the interosseous membrane. Ossification usually develops within 6 to 12 months after the injury. Return to sports is possible despite the lack of normal ankle dorsiflexion and mobility between the tibia and fibula. Surgical excision is reserved for persistent pain that fails to respond to nonsurgical management once the ossification is "cold" on bone scintigraphy. Whiteside LA, Reynolds FC, Ellsasser JC: Tibiofibular synostosis and recurrent ankle sprains in high performance athletes. Am J Sports Med 1978;6:204-208. Henry JH, Andersen AJ, Cothren CC: Tibiofibular synostosis in professional basketball players. Am J Sports Med 1993;21:619-622.

Question 2769

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 2770

Topic: 8. Foot and Ankle

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?

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 14

. Guillotine transtibial amputation
. Standard transtibial amputation with a posterior myocutaneous flap and immediate prosthetic limb fitting
. Culture-specific antibiotic therapy, open wound management, and metabolic/nutritional therapy
. Culture-specific antibiotic therapy and Syme ankle disarticulation
. Two-stage Syme ankle disarticulation

Correct Answer & Explanation

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

Explanation

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.

Question 2771

Topic: 8. Foot and Ankle

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?

. Subtalar arthrodesis
. Flexor digitorum longus transfer
. Flexor digitorum longus tendon transfer, medial slide calcaneal osteotomy, and spring ligament repair
. Primary repair of the posterior tibial tendon
. Talonavicular arthrodesis

Correct Answer & Explanation

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

Explanation

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. 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.

Question 2772

Topic: 8. Foot and Ankle

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

. cryoablation with liquid nitrogen.
. topical salicylic acid application.
. first metatarsal dorsiflexion osteotomy.
. sesamoidectomy.
. sesamoid shaving.

Correct Answer & Explanation

. sesamoid shaving.

Explanation

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

Question 2773

Topic: 8. Foot and Ankle

A 59-year-old woman underwent open reduction and internal fixation (ORIF) of her ankle 6 months ago, with subsequent hardware removal 3 months later. She now reports persistent, diffuse ankle pain, swelling, and limited range of motion. Figure 48 shows an oblique radiograph of the ankle. What is the next most appropriate step in management?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 4) - Figure 28

. Physical therapy
. Hardware removal
. Repeat placement of a syndesmotic screw
. Deltoid ligament reconstruction
. Revision ORIF with exploration of the syndesmosis and medial ankle

Correct Answer & Explanation

. Revision ORIF with exploration of the syndesmosis and medial ankle

Explanation

The radiographs demonstrate persistent widening of the medial clear space with an ossicle. This represents soft-tissue interposition-scar tissue, the deltoid ligament, or the posterior tibialis tendon. Physical therapy will not improve the symptomatic malalignment. Hardware removal would be indicated for pain localized to the lateral fibula. Repeat syndesmotic screw fixation alone will not reduce the malalignment. Deltoid ligament repair may be necessary but will need to be combined with debridement of the medial ankle and syndesmosis, as well as repeat placement of one or more syndesmotic screws to maintain the reduction. Weening B, Bhandari M: Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 2005;19:102-108.

Question 2774

Topic: 8. Foot and Ankle

An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?

Foot & Ankle 2000 Practice Questions: Set 3 (Solved) - Figure 16

. MRI to rule out a complete rupture
. Ultrasound of the tendon apposition
. Open reduction and internal fixation of the calcaneal fracture
. Symptomatic care and physical therapy
. Surgical repair with tendon debridement and flexor hallucis longus transfer

Correct Answer & Explanation

. Surgical repair with tendon debridement and flexor hallucis longus transfer

Explanation

The patient's long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury. Myerson MS, McGarvey W: Disorders of the Achilles tendon: Insertion and Achilles tendinitis. Instr Course Lect 1999;48:211-218. Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.

Question 2775

Topic: 8. Foot and Ankle

What is the most appropriate orthosis for hallux rigidus?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 10

. Morton's extension
. Metatarsal arch pad
. Full-length semi-rigid longitudinal arch support
. Full-length semi-rigid longitudinal arch support with medial hindfoot posting
. Full-length semi-rigid longitudinal arch support with lateral forefoot posting

Correct Answer & Explanation

. Morton's extension

Explanation

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

Question 2776

Topic: 8. Foot and Ankle

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of

. a short leg cast with the ankle in slight plantar flexion.
. a corticosteroid injection into the retrocalcaneal bursa.
. excision of the os trigonum.
. excision of the superior tuberosity of the calcaneus.
. ankle arthroscopy with loose body removal.

Correct Answer & Explanation

. excision of the os trigonum.

Explanation

The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic. 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. Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.

Question 2777

Topic: 8. Foot and Ankle

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

. casting.
. closed reduction, casting, and no weight bearing for 6 weeks.
. open reduction and internal fixation.
. closed reduction and percutaneous Kirschner wire fixation.
. closed reduction and percutaneous screw fixation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

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. 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.

Question 2778

Topic: 8. Foot and Ankle

A 25-year-old competitive skier sustains a twisting injury to the right ankle while skiing. She is unable to continue the activity secondary to severe lateral ankle pain. Examination reveals ecchymosis and fullness over the lateral malleolus with pain and weakness on active ankle dorsiflexion and external rotation. There is no medial-sided pain. Neurovascular examination is normal. An AP radiograph and MRI scan are shown in Figures 17a and 17b, respectively. Management should consist of

. ice, elevation, and progressive weight bearing as tolerated.
. a walking boot for 6 weeks.
. a short leg non-weight-bearing cast for 6 weeks.
. temporary syndesmotic screw fixation.
. repair of the peroneal retinaculum.

Correct Answer & Explanation

. repair of the peroneal retinaculum.

Explanation

The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice. Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670-672. Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.

Question 2779

Topic: 8. Foot and Ankle

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

. physical therapy and bracing.
. reassurance that these problems will resolve with time.
. posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.
. Achilles tendon lengthening, and flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot.
. flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion.

Correct Answer & Explanation

. posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.

Explanation

This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes. Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213. Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.

Question 2780

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.

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