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 1941
Topic: 8. Foot and Ankle
A 60-year-old male with end-stage post-traumatic ankle osteoarthritis is being evaluated for surgical options. Which of the following conditions is considered an absolute contraindication to a total ankle arthroplasty (TAA)?
Correct Answer & Explanation
. Body mass index of 32 kg/m2
Explanation
Active Charcot neuroarthropathy, neuromuscular disease resulting in absent motor function or sensation, avascular necrosis of the talar body (greater than 50%), and active infection are considered absolute contraindications to total ankle arthroplasty. Concomitant subtalar arthritis can be addressed with a subtalar arthrodesis. While obesity and younger age are relative considerations, they are not absolute contraindications.
Question 1942
Topic: 8. Foot and Ankle
When counseling a patient on the expected outcomes of total ankle arthroplasty (TAA) compared to ankle arthrodesis for end-stage ankle osteoarthritis, which of the following statements is most supported by current literature?
Correct Answer & Explanation
. TAA has a lower overall reoperation rate at 10 years
Explanation
Total ankle arthroplasty (TAA) maintains ankle range of motion, which improves sagittal plane gait kinematics and reduces the compensatory stresses on adjacent joints (such as the subtalar and talonavicular joints), thereby lowering the rate of adjacent segment arthritis compared to arthrodesis. However, TAA generally has a higher overall reoperation rate and complication profile over the long term compared to arthrodesis.
Question 1943
Topic: 8. Foot and Ankle
A 58-year-old patient with end-stage post-traumatic ankle arthritis and a rigid 20-degree coronal plane varus deformity is scheduled for a total ankle arthroplasty (TAA). To minimize the risk of premature implant failure and edge loading, which adjunctive procedure should most likely be performed?
Correct Answer & Explanation
. Achilles tendon lengthening
Explanation
A successful TAA requires a plantigrade, well-balanced foot. A rigid varus hindfoot deformity cannot be corrected by the ankle replacement alone and will lead to asymmetric edge loading and early failure of the implant. A lateralizing calcaneal osteotomy (frequently combined with lateral ligament reconstruction or medial release) corrects the hindfoot varus and centers the mechanical axis beneath the tibia.
Question 1944
Topic: 8. Foot and Ankle
A 55-year-old patient presents with end-stage ankle osteoarthritis and is scheduled for a Total Ankle Arthroplasty (TAA).
Preoperative evaluation includes a weight-bearing CT scan. Which of the following findings on weight-bearing CT would most strongly indicate the need for a concomitant subtalar arthrodesis at the time of the TAA?
Correct Answer & Explanation
. Large anterior tibial osteophytes
Explanation
Total ankle arthroplasty preserves ankle motion, but if the patient has concurrent advanced, symptomatic subtalar osteoarthritis (manifested by severe joint space narrowing, subchondral cysts, and sclerosis), the patient will continue to have significant hindfoot pain postoperatively. Therefore, concomitant end-stage subtalar arthritis is a strong indication to perform a combined TAA and subtalar arthrodesis.
Question 1945
Topic: 8. Foot and Ankle
A 62-year-old male undergoes a primary total ankle arthroplasty (TAA). Postoperatively, he develops severe medial gutter pain. Radiographs demonstrate impingement between the talar component and the medial malleolus. Which technical error during the index procedure is the most likely cause of this complication?
Correct Answer & Explanation
. Excessive internal rotation of the tibial component
Explanation
Internal rotation of the tibial component causes the talus to externally rotate relative to the mortise, leading to impingement of the talar component on the medial malleolus. Proper rotational alignment is critical to avoid gutter impingement in TAA.
Question 1946
Topic: 8. Foot and Ankle
A 55-year-old female presents with severe lateral ankle pain and a rigid hindfoot 5 years after an ORIF of a pilon fracture. She is diagnosed with end-stage post-traumatic ankle arthritis. She has a BMI of 42 and absent protective sensation in a stocking-glove distribution due to diabetes. Which of the following is the most appropriate definitive management?
Correct Answer & Explanation
. Total ankle arthroplasty
Explanation
Neuropathy (Charcot risk) and morbid obesity are considered absolute contraindications to total ankle arthroplasty. A tibiotalocalcaneal arthrodesis is the most robust and appropriate option for this patient.
Question 1947
Topic: 8. Foot and Ankle
A patient is evaluated for an isolated ankle arthrodesis versus total ankle arthroplasty (TAA). Which of the following long-term kinematic changes is most typically observed following an isolated ankle arthrodesis compared to a successful TAA?
Correct Answer & Explanation
. Increased sagittal plane motion at the first metatarsophalangeal joint
Explanation
Ankle arthrodesis abolishes tibiotalar motion, leading to compensatory increased stresses and motion at adjacent joints. This significantly elevates the long-term risk of developing symptomatic subtalar and talonavicular osteoarthritis.
Question 1948
Topic: 8. Foot and Ankle
A 62-year-old male with end-stage post-traumatic ankle osteoarthritis and a rigid 15-degree varus deformity is undergoing total ankle arthroplasty (TAA). Intraoperatively, after making the bony cuts and placing trial components, the ankle remains tight medially and fails to correct to a neutral coronal alignment. Which of the following is the most appropriate next step in management?
Correct Answer & Explanation
. Perform a lateral ligament reconstruction
Explanation
In a varus ankle undergoing TAA, residual medial tightness after bony resection should be addressed with a stepwise soft tissue release. The deep deltoid ligament is the primary tether and must be released to achieve coronal balance and prevent premature edge-loading and implant failure.
Question 1949
Topic: 8. Foot and Ankle
A 55-year-old heavy manual laborer with severe end-stage ankle osteoarthritis opts for a tibiotalar arthrodesis over arthroplasty. To optimize his postoperative gait mechanics and minimize adjacent joint arthritis, what is the ideal position for the ankle fusion?
Correct Answer & Explanation
. 5 degrees of dorsiflexion, 5 degrees of varus, 15 degrees of external rotation
Explanation
The ideal position for ankle arthrodesis is neutral dorsiflexion (0 degrees), slight valgus (5 degrees), and slight external rotation (5 to 10 degrees). This position closely mimics the normal foot progression angle and minimizes the lever arm stress on the midfoot and knee.
Question 1950
Topic: 8. Foot and Ankle
Total ankle arthroplasty (TAA) provides excellent outcomes in appropriately selected patients but relies on specific structural and neurologic prerequisites. Which of the following represents an absolute contraindication for TAA?
Correct Answer & Explanation
. Age under 50 years
Explanation
Severe peripheral neuropathy, such as Charcot arthropathy, is an absolute contraindication for TAA due to the high risk of catastrophic failure, collapse, and dislocation. Ankle arthrodesis is the preferred salvage in these patients.
Question 1951
Topic: 8. Foot and Ankle
A 62-year-old patient with rheumatoid arthritis has severe end-stage ankle osteoarthritis alongside symptomatic, radiographically advanced subtalar arthritis. The patient is undergoing preoperative planning for a total ankle arthroplasty (TAA). What is the recommended management approach for the subtalar joint?
Correct Answer & Explanation
. Staged subtalar arthrodesis performed 6 months after TAA
Explanation
Simultaneous TAA and subtalar arthrodesis is a proven, highly successful approach for concomitant severe ankle and subtalar arthritis. It preserves ankle kinematics while resolving subtalar pain and reduces overall patient rehabilitation time.
Question 1952
Topic: 8. Foot and Ankle
In the evaluation of Lisfranc injuries, which radiographic studies should routinely be obtained?
Correct Answer & Explanation
. Bilateral weight-bearing anteroposterior and lateral views of the foot with obliques
Explanation
DISCUSSION: It is estimated that as many as 20% of Lisfranc injuries are missed on initial radiographic examination. Weight-bearing bilateral radiographs should be performed routinely. CT scan, MRI, and stress radiographs performed under anesthesia may be needed in select cases. The Lisfranc ligament stabilizes the midfoot and consists of the dorsal and plantar oblique ligaments and the strong interosseous ligaments. All 3 extend from the base of the second metatarsal to the medial cuneiform. The โfleck sign" is a small avulsion fracture at the medial base of the second metatarsal, representing an avulsion of the Lisfranc ligament. The current treatment recommendation for displaced Lisfranc subluxations and dislocations is to perform ORIF with rigid fixation using either screws or plates and screws. Kirschner wire fixation may lead to recurrence after pin removal. Closed reduction and casting alone cannot permanently reduce the dislocation. RECOMMENDED READINGS: Clanton TO, Waldrop III NE. Athletic injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. Vol 2. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014:1531-1687. Karges DB. Foot trauma. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:631-643.
Question 1953
Topic: Forefoot
A 13-year-old girl with hallux valgus reports pain after playing basketball. Radiographs show a hallux valgus angle of 20 degrees, an intermetatarsal angle of 11 degrees, a distal metatarsal articular angle of 10 degrees, and a congruent joint. Management should consist of
Correct Answer & Explanation
. shoe wear modification.
Explanation
DISCUSSION: Shoe wear modification is the most appropriate management based on the patientโs age, high activity level, and relatively minor symptoms. She also has a mild hallux valgus. Normal radiographic measurements are an intermetatarsal angle of less than 9 degrees, a hallux valgus angle of less than 15 degrees, and a distal metatarsal articular angle of less than 9 degrees. Surgical procedures should be reserved for patients with more severe or progressive deformities. REFERENCES: Stephens HM: Bunions, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1510-1519. Donley BG, Richardson GE: Disorders of the first ray, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1718-1731.
Question 1954
Topic: 8. Foot and Ankle
A 67-year-old woman has had pain in the area of the metatarsal heads and toes bilaterally for the past 18 months. She describes a diffuse discomfort and a constant burning sensation. She notes that the area feels swollen. Examination reveals that her pulses are normal, and there is no frank swelling or focal tenderness. What is the most likely diagnosis?
Correct Answer & Explanation
. Peripheral neuropathy
Explanation
DISCUSSION: Patients with peripheral neuropathy will often initially see an orthopaedic surgeon and report symptoms of burning, numb, dead, or wooden feet. A simple diagnostic evaluation with a tuning fork (to test vibratory sensibility) or use of the Semmes-Weinstein monofilaments will help make the diagnosis. REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-121. Gorson KC, Ropper AH: Idiopathic distal small fiber neuropathy. Acta Neurol Scand 1995;92:376-382.
Question 1955
Topic: 8. Foot and Ankle
A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position). Examination does not elicit the pain with forced passive plantar flexion. A radiograph is shown in Figure 8. What is the most likely cause of the pain?
Correct Answer & Explanation
. Os trigonum entrapment syndrome
Explanation
DISCUSSION: The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome. Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe. The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation. Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion. The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus. REFERENCES: Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500. Khan K, Brown J, Way S, et al: Overuse injuries in classical ballet. Sports Med 1995;19:341-357.
Question 1956
Topic: 8. Foot and Ankle
maximize physical capacity and 4) obtain local control of the disease. Other trivia from the references include: After the lung and liver the skeletal system is the third most common site of metastasis. The spine is the most common site of skeletal metastasis. 60% of all skeletal lesions and 36% are asymptomatic. Breast, prostate, lung and renal carcinoma comprise 80% of the carcinomatous skeletal metastasis. 70% metastasis occur in the thoracic and thoracolumbar regions. 21% had involvement of the lumbar and sacral regions. 8% involved the cervical and cervicothoracic regions together. As many as 90% of patients who die of cancer may have Spinal metastasis at autopsy, and only half of patients who die from cancer will have symptoms from spinal mets. Fewer than 10% with spinal mets are treated surgically. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL., American academy of orthopaedic surgeons, 2002, pp 723-736. back to this question next question 03 What is the most frequently encountered complication following juvenile hallux valgus correction?
Correct Answer & Explanation
. Recurrence of the deformity
Explanation
Coglinโs referenced paper is a study out of Idaho. 11 year retrospective study of 45 patients (60 feet). A multiprocedural approach was used to surgically correct the deformity. There were 6 recurrences of the deformities and eightcomplications (6 cases of hallux varus, one case of wire breakage and one case of undercorrection.) So according to their reference this question has two correct answers.Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with ajuvenile hallux valgus deformity.OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.back to this question next question
Question 1957
Topic: 8. Foot and Ankle
Radiographs of a 20-year-old college athlete who sustained an injury to the ankle reveal no fractures or widening of the ankle mortise. Examination shows swelling at the ankle region and pain with medial lateral compression of the distal tibiofibular joint. Which of the following studies would best help in confirming a diagnosis?
Correct Answer & Explanation
. Inversion stress radiograph
Explanation
Pain with medial-lateral compression of the distal tib-fib joint, swelling in the area and history of injury indicate disruption of the syndesmosis. External rotation stress of the ankle will open the joint space medially confirming the diagnosis.2 and 3 are occasionally utilized when there is questionable involvement of surrounding bone or tendons. 4 rarely indicated for acute ankle sprain but can help in the diagnosis of RSD following ankle injury.
Question 1958
Topic: 8. Foot and Ankle
-Figure 19 is the lateral weight-bearing radiograph of a 28-year-old man with a 3-week history of unrelenting heel pain after increasing his marathon training intensity. The pain never improves throughout the day. Each step he takes is painful. Examination reveals pain with medial-to-lateral compression of the
Correct Answer & Explanation
. calcaneal tuberosity. What is the most likely diagnosis?
Explanation
Question 1959
Topic: 8. Foot and Ankle
A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and Weinstein monofilament is normal. Tibialis anterior and peroneus brevis are weak but present. What is the most appropriate management?
Correct Answer & Explanation
. Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation
Explanation
The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot.
Question 1960
Topic: 8. Foot and Ankle
Figures 9a and 9b are the radiographs of a 19-year-old woman with a painful juvenile bunion. The pathologic findings associated with this deformity include a
Correct Answer & Explanation
. Laterally deviated distal metatarsal articular surface, a
Explanation
DISCUSSIONThe radiographs show a hallux valgus deformity with a laterally deviated distal metatarsal articular surface, a large intermetatarsal angle with medial deviation at the first metatarsocuneiform joint, an elongated medial collateral ligament, and a contracted lateral collateral ligament. There is no distal 1-2 transverse intermetatarsal ligament. The distal transverse ligament in the first interspace extends from the second metatarsal to the lateral (fibular) sesamoid, remains intact, and keeps the sesamoids in a lateral position as the first metatarsal head migrates medially.RECOMMENDED READINGSCoughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995 Nov;16(11):682-97. PubMed PMID: 8589807.View Abstract at PubMedCoughlin MJ, Mann RA. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:183-226.
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