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8. Foot and Ankle MCQs

Practice Set 74 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 1461

Topic: 8. Foot and Ankle

A 20-year-old patient with severe right external tibial torsion (45 degrees) needs a full-length standing AP radiograph to plan a femoral osteotomy. How should the radiology technician position the patient's right leg to ensure accurate analysis of the mechanical axis and joint orientation angles?

. Feet pointing straight ahead (0 degrees foot progression angle)
. Patella facing straight forward
. Leg externally rotated to 45 degrees
. Leg internally rotated to 45 degrees
. Patient supine with the knee in 15 degrees of flexion

Correct Answer & Explanation

. Patella facing straight forward

Explanation

To accurately assess the mechanical axis and frontal plane joint orientation angles, the patella must be facing strictly forward. If the foot is pointed straight in the presence of tibial torsion, the knee will be rotated, producing spurious frontal plane measurements.

Question 1462

Topic: 8. Foot and Ankle
A 5-year-old boy has had pain in the right foot for the past month. Examination reveals tenderness and mild swelling in the region of the tarsal navicular. Radiographs are shown in Figure 30. Management should consist of:
. biopsy of the tarsal navicular.
. curettage and bone grafting of the tarsal navicular.
. CBC count, C-reactive protein level, erythrocyte sedimentation rate, blood cultures, and IV antibiotics.
. symptomatic treatment with restriction of weight bearing or application of short leg cast.
. medial column lengthening of the foot through the tarsal navicular.

Correct Answer & Explanation

. symptomatic treatment with restriction of weight bearing or application of short leg cast.

Explanation

The child has the classic findings of Kohler’s disease or osteochondrosis of the tarsal navicular. The cause of this condition is not known, but osteonecrosis and mechanical compression have been proposed. Children generally report midfoot pain over the tarsal navicular and limping. Physical findings include tenderness, swelling, and occasionally redness in the region of the tarsal navicular. Radiographs show sclerosis and narrowing of the tarsal navicular. The natural history of the condition is spontaneous resolution and reconstitution of the navicular. Symptomatic treatment with restriction of weight bearing or casting is recommended.

Question 1463

Topic: 8. Foot and Ankle
A 24-year-old professional basketball player reports the gradual onset of pain that is poorly localized to the left midfoot for the past 2 months. Examination reveals diffuse tenderness to palpation, full range of motion of the ankle and subtalar joint, and a normal neurovascular examination to the foot. An AP radiograph is shown in Figure 10. Definitive treatment should include
. a custom-molded orthotic and anti-inflammatory drugs.
. partial weight-bearing ambulation with crutches.
. weight bearing as tolerated with a walking boot.
. casting for 6 weeks with bone stimulation.
. internal fixation.

Correct Answer & Explanation

. internal fixation.

Explanation

DISCUSSION: The imaging studies reveal a navicular stress fracture. This condition is secondary to chronic overuse (often running on hard surfaces) and results in vague, ill-defined pain in the midfoot. These fractures can be missed on radiographs but are well-defined on CT or MRI. Tarsal navicular fractures are typically oriented in the sagittal plane. Surgery is typically indicated for the high-level athlete because of the high risk for nonunion and persistent symptoms following nonsurgical management. Internal fixation is the treatment of choice. REFERENCES: Torg JS, Pavlov H, Cooley JH, et al: Stress fractures of the tarsal navicular. J Bone Joint Surg Am 1982;64:700-712. Brodsky JW, Krause JO: Stress fractures of the foot and ankle, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2391-2409.

Question 1464

Topic: 8. Foot and Ankle
A 45-year-old woman with grade II adult-acquired flatfoot deformity has pain on the lateral side of her foot just distal to the tip of the fibula. Which component of a comprehensive flatfoot reconstruction most likely will address the deformity responsible for this pain?
. Spring ligament reconstruction
. Lateral column lengthening
. Medial-displacing calcaneal osteotomy
. Medial cuneiform opening-wedge osteotomy

Correct Answer & Explanation

. Medial-displacing calcaneal osteotomy

Explanation

DISCUSSION: Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide. RECOMMENDED READINGS: Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May;31(5):361-71. doi: 10.3113/FAI.2010.0361. PubMed PMID:

Question 1465

Topic: 8. Foot and Ankle
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?
. Glucose tolerance test
. CBC count with differential
. Urethral swab and culture
. HLA-B27
. Antiphospholipid antibody

Correct Answer & Explanation

. HLA-B27

Explanation

DISCUSSION: Reiter’s syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis. Tendon enthesopathies 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 hypercoagulable 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.

Question 1466

Topic: 8. Foot and Ankle
A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?
. Metatarsophalangeal joint arthrodesis
. Medial capsular release with lengthening of the abductor hallucis
. Medial capsular release with lateral sesamoid excision
. Proximal phalangeal lateral closing wedge osteotomy
. Medial capsular lengthening and split extensor hallucis longus tendon transfer

Correct Answer & Explanation

. Medial capsular lengthening and split extensor hallucis longus tendon transfer

Explanation

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint. REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32. Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 1467

Topic: 8. Foot and Ankle
The Lisfranc ligament connects the base of the
. first metatarsal and the medial cuneiform.
. first metatarsal and the base of the second metatarsal.
. first metatarsal and the middle cuneiform.
. second metatarsal and the medial cuneiform.
. second metatarsal and the middle cuneiform.

Correct Answer & Explanation

. first metatarsal and the base of the second metatarsal.

Explanation

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.

Question 1468

Topic: 8. Foot and Ankle

A patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the site of the tenderness, about 7 cm above the lateral heel, provided temporary relief of the pain. What is the recommended course of management for the persistent burning pain?

. Subtalar fusion
. Neuroplasty of the superficial peroneal nerve
. Neuroplasty of the sural nerve and implant removal
. Excision and burial of the sural nerve in deep muscle or vein
. Electromyography/nerve conduction velocity studies to evaluate local nerve entrapment versus radiculopathy

Correct Answer & Explanation

. Excision and burial of the sural nerve in deep muscle or vein

Explanation

The patient has a sural nerve neuroma, which is a known complication of the extensile lateral approach. Of the available choices, excision and burial of the sural nerve in muscle or vein is the best choice because it gives better pain relief due to the better blood supply in muscle than bone. Recent authors advocate burying the nerve in vein as the best option. Neuroplasty is a possibility (but not of the superficial peroneal nerve), but the sural nerve is usually very sensitive and often pain relief with a release is incomplete. Additionally, implant removal is not indicated because of the patient's complaints; also, the implants should not be removed at 6 months. A subtalar fusion is the choice for posttraumatic arthritis from the calcaneus fracture. Electromyography/nerve conduction velocity studies are reasonable choices if there was an indication the pain could be coming from the back or there was no clear evidence of a sural nerve neuroma.

Question 1469

Topic: 8. Foot and Ankle
A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of
. extensor digitorum longus tenotomy.
. extensor digitorum longus tenotomy with dorsal fifth metatarsophalangeal (MTP) joint capsulotomy.
. dorsal V-Y plasty for skin contracture, combined with extensor digitorum longus tenotomy and dorsal fifth MTP capsulotomy.
. a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).
. plantar proximal phalangeal resection.

Correct Answer & Explanation

. a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).

Explanation

DISCUSSION: The major obstacle to overcome in the surgical treatment of this cock-up deformity is recurrence. Dorsal releases can be performed; however, chronic dislocation of the fifth MTP joint usually needs to be addressed with plantar release as well. Chronic dorsal soft-tissue contractures may be overcome with translation of the toe into a plantar-based incision, as described originally by Cockin and accredited to Butler. This is the treatment of choice. Resection of the proximal phalanx improves symptoms but induces a secondary deformity; this procedure is usually reserved for skeletally mature individuals. REFERENCES: Black GB, Grogan DP, Bobechko WP: Butler arthroplasty for correction of adducted fifth toe: A retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441. Paton RW: V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249. Coughlin MJ, Mann RA: Lesser toe deformities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 5. St Louis, MO, Mosby, 1986, pp 132-157.

Question 1470

Topic: 8. Foot and Ankle
Which of the following tendons is the primary antagonist of the posterior tibialis tendon?
. Anterior tibialis
. Achilles
. Peroneus brevis
. Peroneus longus
. Flexor digitorum longus

Correct Answer & Explanation

. Peroneus brevis

Explanation

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.

Question 1471

Topic: 8. Foot and Ankle
A 17-year-old high school athlete comes in with a 6-month history of right midfoot pain. She has been treated with cast immobilization, crutches, and physical therapy. She still has significant pain with activities and cannot participate in sports. Her radiograph is shown in Figure 93a, and MR images are shown in Figures 93b and 93c. What is the most appropriate next step?
. Repeat treatment with a nonweight-bearing cast
. Percutaneous lag screw fixation
. Addition of a bone stimulator
. Injection of bone morphogenic protein

Correct Answer & Explanation

. Percutaneous lag screw fixation

Explanation

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury. RECOMMENDED READINGS: Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. View Abstract at PubMed Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 1472

Topic: 8. Foot and Ankle

A 24-year-old male presents with bilateral progressive cavovarus feet. On examination, a Coleman block test is performed by placing his heel and lateral border of the foot on a block while allowing the first metatarsal to drop off the edge. During the test, his hindfoot varus corrects completely to neutral. What is the primary anatomic driver of his deformity, and what is the most appropriate initial bony surgical intervention?

. Fixed hindfoot varus; treated with a lateralizing calcaneal osteotomy
. Plantarflexed first ray; treated with a dorsiflexion osteotomy of the first metatarsal
. Weak peroneus longus; treated with a peroneus longus to brevis tendon transfer
. Spastic tibialis posterior; treated with Z-lengthening of the posterior tibial tendon
. Achilles contracture; treated with percutaneous Achilles tendon lengthening

Correct Answer & Explanation

. Plantarflexed first ray; treated with a dorsiflexion osteotomy of the first metatarsal

Explanation

The Coleman block test distinguishes between flexible and rigid hindfoot varus in a cavovarus foot. If the hindfoot corrects to neutral when the plantarflexed first ray is allowed to drop off the block, the hindfoot deformity is flexible and primarily driven by the rigid, plantarflexed first metatarsal. The appropriate bony treatment addresses the forefoot driver with a dorsiflexion osteotomy of the first metatarsal.

Question 1473

Topic: Midfoot & Hindfoot

A 55-year-old female presents with severe medial ankle pain and a progressively flattening arch. She cannot perform a single-leg heel rise. Radiographs demonstrate advanced flatfoot deformity with talonavicular uncoverage of 45%. The subtalar joint shows no degenerative changes. Based on this Stage IIb Adult Acquired Flatfoot Deformity, what is the most appropriate surgical reconstruction?

. Tenosynovectomy of the posterior tibial tendon
. FDL transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) / adult acquired flatfoot deformity is characterized by flexible deformity but with significant forefoot abduction (typically defined as >30-40% talonavicular uncoverage). While an FDL transfer and MDCO address the medial and hindfoot components, the severe forefoot abduction requires a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) to adequately restore the foot's shape.

Question 1474

Topic: 8. Foot and Ankle

You are treating a patient with severe hallux valgus (Intermetatarsal Angle = 18 degrees). You opt to perform a proximal crescentic osteotomy of the first metatarsal. Compared to diaphyseal osteotomies like the Scarf or Ludloff, what is a specific, well-known biomechanical risk associated with the proximal crescentic osteotomy?

. Higher rate of avascular necrosis of the metatarsal head
. Greater shortening of the first ray
. Dorsal elevation of the first metatarsal head leading to transfer metatarsalgia
. Significantly higher rate of nonunion compared to diaphyseal osteotomies
. Inability to correct associated pronation of the first metatarsal

Correct Answer & Explanation

. Dorsal elevation of the first metatarsal head leading to transfer metatarsalgia

Explanation

The proximal crescentic osteotomy is powerful for correcting large IM angles but is technically demanding in the sagittal plane. Due to the orientation of the osteotomy and weight-bearing forces, there is a high risk of dorsal malunion (dorsal elevation of the first metatarsal head). This unloads the first ray during the propulsive phase of gait, leading to transfer metatarsalgia under the lesser metatarsal heads.

Question 1475

Topic: 8. Foot and Ankle

Total ankle arthroplasty (TAA) has become a common alternative to arthrodesis for end-stage ankle osteoarthritis. Which of the following conditions is considered an absolute contraindication to performing a TAA?

. Age greater than 70 years
. End-stage bilateral ankle osteoarthritis
. Charcot neuroarthropathy with severe sensory neuropathy
. Avascular necrosis of the talar dome involving 20% of the body
. Concomitant subtalar osteoarthritis

Correct Answer & Explanation

. Charcot neuroarthropathy with severe sensory neuropathy

Explanation

Charcot neuroarthropathy, loss of protective sensation, active infection, and severe uncorrectable malalignment are absolute contraindications for Total Ankle Arthroplasty (TAA). Older age, bilateral disease, minor AVN, and adjacent joint arthritis are often indications rather than contraindications (adjacent joint arthritis actually favors TAA over arthrodesis to preserve motion).

Question 1476

Topic: Midfoot & Hindfoot

A 25-year-old male sustains a midfoot injury. Weight-bearing radiographs reveal 2mm of widening between the first and second metatarsal bases. MRI confirms a rupture of the dorsal Lisfranc ligament and a sprain of the plantar Lisfranc ligament. Which statement regarding the biomechanics of the Lisfranc ligament complex is most accurate in guiding treatment?

. The dorsal Lisfranc ligament provides the primary stability to the TMT joint
. Rupture of the interosseous Lisfranc ligament alone leads to multiplanar instability
. The plantar Lisfranc ligament is thicker and provides the majority of the biomechanical strength
. Operative fixation is only required if the 1st metatarsocuneiform joint is involved
. Non-operative management is indicated for any diastasis less than 4mm

Correct Answer & Explanation

. The plantar Lisfranc ligament is thicker and provides the majority of the biomechanical strength

Explanation

The Lisfranc ligament complex consists of dorsal, interosseous, and plantar components connecting the medial cuneiform to the second metatarsal base. The plantar Lisfranc ligament is the thickest and biomechanically strongest of the three. Disruption of the plantar ligament leads to significant instability requiring operative stabilization. Diastasis > 2mm on weight-bearing films is generally an indication for surgery.

Question 1477

Topic: 8. Foot and Ankle

Based on recent large multicenter randomized controlled trials (e.g., Willits et al.) comparing operative versus non-operative management for acute Achilles tendon ruptures utilizing modern early functional rehabilitation protocols, what is the primary conclusion regarding re-rupture rates?

. Significantly lower re-rupture rates in the operative group
. Significantly higher rates of DVT in the non-operative group
. No significant difference in re-rupture rates between the two groups
. Superior plantarflexion strength in the non-operative group at 2 years
. Higher rates of sural nerve injury in the non-operative group

Correct Answer & Explanation

. No significant difference in re-rupture rates between the two groups

Explanation

Historically, operative treatment of Achilles tendon ruptures was favored due to lower re-rupture rates compared to prolonged cast immobilization. However, modern high-quality RCTs have demonstrated that when early weight-bearing and functional rehabilitation (using an active motion protocol) are employed, there is no statistically significant difference in re-rupture rates between operatively and non-operatively treated patients.

Question 1478

Topic: 8. Foot and Ankle
A 30-year-old male sustains a high-energy Hawkins Type III talar neck fracture. This fracture pattern involves a talar neck fracture with dislocation of the talar body from both the subtalar and tibiotalar joints. Which of the following best describes the disruption of the vascular supply to the talar body in this specific injury?
. Artery of the tarsal canal is disrupted, but deltoid branches remain intact
. Disruption of blood supply from the capsular vessels, artery of the tarsal canal, and deltoid branches
. Solely disruption of the anterior tibial artery branches
. The sinus tarsi vessels are the only intact supply
. Blood supply is maintained through the retrograde intraosseous anastomosis

Correct Answer & Explanation

. Disruption of blood supply from the capsular vessels, artery of the tarsal canal, and deltoid branches

Explanation

The talus receives blood from 3 main sources: the artery of the tarsal canal (branch of posterior tibial artery, supplies majority of the body), artery of the tarsal sinus, and deltoid branches. A Hawkins Type III fracture implies dislocation of the talar body from both the subtalar and ankle joints, tearing all three major extraosseous blood supplies, which explains the very high rate of avascular necrosis (AVN), historically up to 100%.

Question 1479

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity. Examination shows an inability to perform a single-limb heel rise, 'too many toes' sign, and severe forefoot abduction. Weight-bearing radiographs reveal greater than 40% uncoverage of the talonavicular joint and a talonavicular fault, but flexible hindfoot and midfoot joints. In addition to a flexor digitorum longus (FDL) transfer and medial calcaneal slide osteotomy, which of the following procedures is most strongly indicated to correct her specific multiplanar deformity?

. Spring ligament reconstruction only
. Medial column fusion (naviculocuneiform arthrodesis)
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), differentiated from Stage IIa by significant forefoot abduction (typically >30-40% talonavicular uncoverage). To effectively correct the severe forefoot abduction and restore the arch in a flexible foot, a lateral column lengthening (Evans osteotomy) is indicated in conjunction with soft tissue reconstruction (FDL transfer) and hindfoot alignment (medializing calcaneal osteotomy).

Question 1480

Topic: 8. Foot and Ankle

A 62-year-old male undergoes surgical treatment for severe insertional Achilles tendinopathy with a large retrocalcaneal exostosis. During the extensive debridement of calcific tendinosis and bone, approximately 60% of the Achilles tendon insertion is detached from the calcaneus. What is the most appropriate next step in management?

. Primary repair of the Achilles tendon using suture anchors only
. V-Y fractional lengthening of the gastrocnemius
. Augmentation with a flexor hallucis longus (FHL) tendon transfer
. Augmentation with a peroneus brevis tendon transfer
. Application of a bridging external fixator in plantarflexion

Correct Answer & Explanation

. Augmentation with a flexor hallucis longus (FHL) tendon transfer

Explanation

When debridement of insertional Achilles tendinopathy requires detachment of more than 50% of the tendon insertion, the repair is structurally compromised, and the risk of rupture is high. Augmentation is indicated. Flexor hallucis longus (FHL) transfer is the gold standard because it provides a strong, vascularized tendon that fires in phase with the gastrocsoleus complex.

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