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8. Foot and Ankle MCQs

Practice Set 83 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 1641

Topic: 8. Foot and Ankle

40A B Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

. Instability on unlevel ground
. Ankle pain and swelling
. Anterior laxity on lateral radiographs
. Osteochondral lesion of the talus on MR imaging

Correct Answer & Explanation

. Instability on unlevel ground

Explanation

DISCUSSIONAnkle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearingas tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.RECOMMENDED READINGSColville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):368-77. Review. PubMed PMID: 9826420.View Abstract at PubMedDiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006 Oct;27(10):854-66. Review. PubMed PMID: 17054892.View Abstract at PubMedMaffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604.View Abstract at PubMed

Question 1642

Topic: 8. Foot and Ankle

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

. Traumatic neuroma tethered by plantar neural branches
. Regeneration of the transverse intermetatarsal ligament
. Development of an intermetatarsal synovial cyst
. Complex regional pain syndrome
. Metatarsophalangeal joint synovitis

Correct Answer & Explanation

. Traumatic neuroma tethered by plantar neural branches

Explanation

DISCUSSION: When a recurrent neuroma forms at the end of the resected nerve, it does not retract far enough because either the transection was not proximal enough or it is tethered by plantar neural branches.  The transverse intermetatarsal ligament may reform, but it is not associated with pathology.  Synovial cysts and synovitis are part of the differential diagnosis but are not associated with neuroma excision.  Complex regional pain syndrome may result from neuroma excision, but this is rare and the symptoms are different.REFERENCES: Beskin JL: Recurrent interdigital neuromas, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction: Foot and Ankle.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 481-484.Amis JA, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton’s neuroma excision.  Foot Ankle 1992;13:153-156.

Question 1643

Topic: 8. Foot and Ankle

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, and heel cord lengthening

Explanation

DISCUSSION: 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.REFERENCES: 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.Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot.  Foot Ankle Int 2003;24:530-534.

Question 1644

Topic: 8. Foot and Ankle

A 10-month-old infant has a deformity of the right foot. Radiographs, including simulated weight-bearing AP and lateral views and a maximum plantar flexion lateral view, are shown in Figures 57a through 57c. Initial management of the foot should consist of Review Topic

. manipulation and cast application.
. basic orthopaedic shoes with a scaphoid pad and reinforced medial counter.
. open reduction of the talonavicular joint and Achilles tendon lengthening.
. lateral column lengthening osteotomy.
. observation.

Correct Answer & Explanation

. manipulation and cast application.

Explanation

The radiographs show a congenital vertical talus. This is confirmed on the maximum plantar flexion lateral view which shows failure of the long axis of the first metatarsal to align with the long axis of the talus. This finding is caused by a fixed dorsal dislocation of the navicular on the head of the talus. The initial treatment should consist of manipulation and serial cast application in an attempt to elongate the contracted dorsolateral tendons, joint capsules, and skin. Surgery is always required to complete the correction. Traditionally, surgical treatment consisted of lengthening of the dorsolateral tendons, release of the talonavicular joint capsule, and lengthening of the Achilles tendon. Recently, Dobbs and associates reported the successful use of manipulation and cast immobilization, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. There are no studies documenting the effectiveness of orthoses for the treatment of this condition. Lateral column lengthening may be indicated in older individuals with a symptomatic flexible flatfoot, especially those with neurologic conditions. Observation may be indicated in a young child with a painless flexible flatfoot.

Question 1645

Topic: 8. Foot and Ankle

Figure 33 shows the oblique radiograph of an 11-year-old boy who has a mild left flatfoot deformity. Examination reveals that subtalar motion is limited and painful. Despite casting for 6 weeks, the patient reports foot pain that limits participation in sport activities. A CT scan shows no subtalar joint abnormalities. Management should now include

. manipulation of the foot under general anesthesia.
. peroneal lengthening.
. coalition resection with interposition of fat or muscle.
. distal calcaneal lengthening osteotomy.
. triple arthrodesis.

Correct Answer & Explanation

. manipulation of the foot under general anesthesia.

Explanation

DISCUSSION: The radiograph shows an incompletely ossified calcaneonavicular coalition.  When symptomatic, a trial of cast immobilization is reasonable.  If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition.  Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle.  Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion.  When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary.  Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints.  Peroneal lengtheninghas been described for treatment of the peroneal spastic flatfoot without demonstrabletarsal coalition.REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle.  J Bone Joint Surg Am 1990;72:71-77.Vincent KA: Tarsal coalition and painful flatfoot.  J Am Acad Orthop Surg 1998;6:274-281.Luhmann SJ, Rich MM, Schoenecker PL: Painful idiopathic rigid flatfoot in children and adolescents.  Foot Ankle Int 2000;21:59-66.

Question 1646

Topic: 8. Foot and Ankle

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

. Chevron bunionectomy
. Cheilectomy and removal of loose body
. MTP arthrodesis
. Resection of proximal phalanx

Correct Answer & Explanation

. Chevron bunionectomy

Explanation

DISCUSSIONThe radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.RECOMMENDED READINGSMcNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.View Abstract at PubMedDeland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.View Abstract at PubMedCLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.A B

Question 1647

Topic: 8. Foot and Ankle

Figures 20a and 20b show the radiographs of a 14-year-old boy who sustained a twisting injury to his ankle. If attempted closed reduction is unsuccessful, what is the primary reason to proceed with surgical treatment?

. Decreased risk of posttraumatic arthritis
. Avoid growth arrest
. Minimize risk of osteonecrosis
. Prevent clinical internal rotation deformity
. Prevent development of a late tarsal tunnel syndrome

Correct Answer & Explanation

. Decreased risk of posttraumatic arthritis

Explanation

DISCUSSION: Triplane fractures generally occur in children who are near skeletal maturity.  The injury is generally caused by a supination external rotation mechanism.  The number of fracture fragments present (two or three) depends on what part of the physes is closed at the time of injury.  Articular congruity is the major concern in the management of these injuries since the patient has almost reached skeletal maturity.  The goal is to restore articular congruity to minimize the development of posttraumatic arthritis.REFERENCES: Vaccaro A (ed): Orthopaedic Knowledge Update 8.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction.  J Bone Joint Surg Am 1984;66:647-657.Spiegel PG, Mast JW, Cooperman DR, et al: Triplane fractures of the distal tibial epiphysis.Clin Orthop Relat Res 1984;188:74-89.

Question 1648

Topic: 8. Foot and Ankle

82 • American Academy of Orthopaedic Surgeons A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

. No treatment is required because spontaneous healing is common.
. Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
. Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
. Hyperbaric oxygen treatment is helpful.
. Ankle fusion is frequently necessary.

Correct Answer & Explanation

. No treatment is required because spontaneous healing is common.

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 1649

Topic: 8. Foot and Ankle

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

. Lack of ankle dorsiflexion
. Lack of ankle plantarflexion
. Lack of knee extension
. Loss of bowel and/or bladder control
. Lack of great toe extension

Correct Answer & Explanation

. Lack of ankle dorsiflexion

Explanation

DISCUSSION: This question is a simple review of anatomy and nerve innervation. The L5 root is at risk with an "in-out-in" screw, as described in the question, as the nerve root is just anterior to the sacral ala as it enters the true pelvis. L5 is primarily evaluated by extensor hallucis longus function. L4 is tested with tibialis anterior function and S1 by gastroc-soleus function (ankle plantarflexion).

Question 1650

Topic: 8. Foot and Ankle

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

. cheilectomy.
. extra-depth shoes.
. steroid injection.
. arthrodesis.
. joint replacement arthroplasty.

Correct Answer & Explanation

. cheilectomy.

Explanation

DISCUSSION: Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis.  This patient’s symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear.REFERENCES: Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study.  Foot Ankle Int 2000;21:906-913.Shereff MJ, Baumhauer JF: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint.  J Bone Joint Surg Am 1998;80:898-908.

Question 1651

Topic: 8. Foot and Ankle

Which of the following is considered the most important factor in eliminating infection in chronic osteomyelitis?

. Antibiotic use
. Complete debridement of the compromised bone and soft tissue
. Immobilization of the infected joint
. Irrigation of the tissues
. Arthrodesis of the adjacent joint

Correct Answer & Explanation

. Antibiotic use

Explanation

DISCUSSION: The most important factor in eliminating infection in chronic osteomyelitis is a complete debridement of the compromised bone and soft tissue.  Antibiotics should be used in conjunction with surgical debridement.  However, the foundation of treating infected bone is removal of the diseased tissue.REFERENCES: Cierny G III, Cook WG, Mader JT: Ankle arthrodesis in the presence of ongoing sepsis: Indications, methods, and results.  Orthop Clin North Am 1989;20:709-721.Cierny G, Zorn EZ: Arthrodesis of the tibiotalar joint for sepsis.  Foot Ankle Clin 1996;1:177-197.Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Osterman PA: Arthrodesis of the infected ankle and subtalar joint: Technique, indications and results of 45 consecutive cases.  J Trauma 1999;47:1072-1078.

Question 1652

Topic: 8. Foot and Ankle

A 20-year-old football player sustains a dorsiflexion external rotation injury to his right ankle. During sideline evaluation, which of the following findings best indicates a syndesmosis ankle sprain without diastasis?

. Tenderness over the anterior talofibular and calcaneofibular ligaments
. A positive dorsiflexion external rotation test
. Loss of passive range of motion
. Positive squeeze test
. Inability to single leg hop

Correct Answer & Explanation

. Tenderness over the anterior talofibular and calcaneofibular ligaments

Explanation

DISCUSSION: The inability to single leg hop is considered the best indicator of a syndesmosis ankle sprain without diastasis.  Tenderness along the syndesmosis, the deltoid, or over the anterior talofibular ligament or anterior distal tibia/fibula may present later, following the initial injury.  The squeeze test and tenderness with dorsiflexion and external rotation may be positive but often are not present initially.  The best determinant for prediction of return to play is the amount of tenderness along the syndesmosis, measured from the distal fibula up the syndesmosis.REFERENCES: Nussbaum ED, Hosea TM, et al: Prospective evaluation of syndesmosis ankle sprains without diastasis.  Am J Sports Med 2001;29:31-35.Miller CD, Shelton WR, Barrett GR, et al: Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 1985;23:746-750.Amendola A: Controversies in diagnosis and management of syndesmosis injuries of the ankle.  Foot Ankle 1992;13:44-50.

Question 1653

Topic: 8. Foot and Ankle

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

. excision of the base of the phalanx of the great toe with dorsiflexion osteotomy of the second metatarsal.
. osteotomy of the proximal phalanx of the great toe.
. distal first metatarsal osteotomy with soft-tissue realignment of the great toe.
. fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.
. joint replacement arthroplasty of the first metatarsophalangeal joint.

Correct Answer & Explanation

. excision of the base of the phalanx of the great toe with dorsiflexion osteotomy of the second metatarsal.

Explanation

DISCUSSION: The patient has a significant hallux valgus and instability of the first ray, causing transfer metatarsalgia to the second metatarsal head.  Therefore, the best procedure is fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.  This procedure provides the best chance of relieving symptoms under the second metatarsal head, as well as correcting the hallux valgus.REFERENCE: Sangeorzan BJ, Hansen ST Jr: Modified Lapidus procedure for hallux valgus.  Foot Ankle 1989;9:262-266.

Question 1654

Topic: 8. Foot and Ankle

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

. Ibuprofen
. Fluoroquinolones
. Bisphosphonates
. Metoprolol
. Simvistatin

Correct Answer & Explanation

. Ibuprofen

Explanation

DISCUSSION: Fluoroquinolones have been associated with increased rates of tendinitis, with special predilection for the Achilles tendon.  Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration.  Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7.  The other listed drugs have no known increase in tendon rupture rates nor tendinitis.REFERENCES: van der Linden PD, van de Lei J, Nab HW, et al: Achilles tendinitis associated with fluoroquinolones.  Br J Clin Pharmacol 1999;48:433-437.Bernard-Beaubois K, Hecquet C, Hayem G, et al: In vitro study of cytotoxicity of quinolones on rabbit tenocytes.  Cell Biol Toxicol 1998;14:283-292.Maffulli N: Rupture of the Achilles tendon.  J Bone Joint Surg Am 1999;81:1019-1036.

Question 1655

Topic: 8. Foot and Ankle

What is the most common long-term complication of the fracture shown in Figure 32?

. Nonunion
. Ankle arthritis
. Subtalar arthritis
. Talonavicular arthritis
. Posterior tibial tendinitis

Correct Answer & Explanation

. Nonunion

Explanation

DISCUSSION: The fracture pattern shown in the radiograph involves both a talar neck fracture and a talar body fracture.  The body fracture propagates into the subtalar joint, with significant risk for the development of arthritis in that surface even with an anatomic reduction.  In addition, Canale and Kelly reported a 25% incidence of malunion of talar neck fractures, with varus angulation occurring most frequently.  Of these patients, 50% required a secondary surgical procedure because of the development of degenerative joint disease of the subtalar joint.REFERENCES: Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases.  J Bone Joint Surg Am 1978;60:143-156.Higgins TF, Baumgaertner MR: Diagnosis and treatment of fractures of the talus: A comprehensive review of the literature. Foot Ankle Int 1999;20:595-605.

Question 1656

Topic: 8. Foot and Ankle

The Coleman block test is used to test for Review Topic

. flexibility of the forefoot.
. flexibility of the hindfoot.
. valgus deformity of the hindfoot.
. tightness of tendo Achilles.

Correct Answer & Explanation

. flexibility of the forefoot.

Explanation

The Coleman block test is used to determine the flexibility of the hindfoot. When a block is placed under the lateral border of the foot, the medial column is unsupported. As a result, the first metatarsal drops off the side of the block. If the subtalar joint is flexible, there is no fixed varus deformity of the hindfoot. The hindfoot will no longer be in varus from behind. The varus deformity of the hindfoot will be corrected. If there is no subtalar motion, the varus deformity remains fixed.

Question 1657

Topic: 8. Foot and Ankle

Back pain and ipsilateral knee pain are common long-term sequelae of hip arthrodesis. To limit these problems, what position should be avoided during fusion of the hip?

. Flexion
. Abduction
. Adduction
. External rotation
. Internal rotation

Correct Answer & Explanation

. Flexion

Explanation

DISCUSSION: The recommended position for a hip fusion is flexion of 20° to 30°, slight adduction (5°) or neutral, and 10° of external rotation.  In long-term follow-up, patients who underwent fusion in abduction had more ipsilateral knee and low back pain than patients who were positioned in adduction.  Internal rotation should be avoided to prevent interference with the opposite foot during gait.  External rotation facilitates the application of shoe wear.REFERENCES: Callaghan JJ, Brand RA, Pederson DR: Hip arthrodesis: A long-term follow-up.  J Bone Joint Surg Am 1985;67:1328-1335.Callaghan JJ, McBeath AA: Arthrodesis, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip.  Philadelphia, PA, Lippincott-Raven, 1998, pp 749-759.

Question 1658

Topic: 8. Foot and Ankle

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

. Autologous osteochondral transplantation
. Arthroscopic bone marrow stimulation
. Chondroplasty
. Osteochondral allograft transplantation

Correct Answer & Explanation

. Autologous osteochondral transplantation

Explanation

DISCUSSIONAutologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.RECOMMENDED READINGSSchachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005 May-Jun;13(3):152-8. Review. PubMed PMID: 15938604.View Abstractat PubMedMitchell ME, Giza E, Sullivan MR. Cartilage transplantation techniques for talar cartilage lesions. J Am Acad Orthop Surg. 2009 Jul;17(7):407-14. Review. PubMed PMID: 19571296.View Abstract at PubMedMurawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Review. PubMed PMID: 23780543.View Abstract at PubMed

Question 1659

Topic: 8. Foot and Ankle

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

. Open treatment of the metatarsal malunion
. Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis
. Cast application and an external bone stimulator
. Hallux valgus correction
. Hallux metatarsophalangeal arthrodesis

Correct Answer & Explanation

. Open treatment of the metatarsal malunion

Explanation

DISCUSSION: The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes.  To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis.  Cast immobilization and a bone stimulator are unlikely to be beneficial at this time.  Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint.REFERENCES: Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations.  Clin Orthop 1998;347:208-214.McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft.  Orthopedics 1996;19:389-394.Ouzounian TJ: Metatarsophalangeal arthrodesis for salvage of failed hallux valgus surgery.  Foot Ankle Clin 1997;2:741-752.

Question 1660

Topic: 8. Foot and Ankle
The pathophysiology of a claw toe deformity includes muscular imbalance caused by which of the following relatively strong structures?
. Intrinsics overpowering a relatively weak extensor digitorum longus
. Plantar plate overpowering a relatively weak extensor digitorum brevis
. Lumbricals overpowering relatively weak intrinsics
. Extensor digitorum longus overpowering relatively weak intrinsics
. Extensor digitorum longus overpowering a relatively weak extensor digitorum brevis

Correct Answer & Explanation

. Extensor digitorum longus overpowering relatively weak intrinsics

Explanation

DISCUSSION: The dynamic forces acting to maintain the position of the proximal phalanx at the head of the metatarsal are a balance between the extensor digitorum longus and the weaker intrinsic muscles. With hyperextension at the metatarsophalangeal joint, the intrinsic muscles become less efficient as plantar flexors. Consequently, the hyperextension deformity progresses in the metatarsophalangeal joint as the opposition of the intrinsic muscles to the extensor tendon lessens. This is in contrast to the situation in the interphalangeal joints, where the stronger flexors overpower the weaker intrinsic muscles, which act as the extensors. This combination of events leads to hyperextension at the metatarsophalangeal joint and flexion deformities at the interphalangeal joints, resulting in claw toe.

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