Orthopedic Foot & Ankle 2026 MCQs: Board Review

Question 1

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

Explanation

1b 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 2

A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint. He denies any history of similar symptoms. What is the first step in evaluation?

Explanation

The patient's symptoms are typical for gouty arthropathy, and the diagnosis can only be confirmed with aspiration and visualization of the crystals. A concomitant infection also must be ruled out; therefore, it is important to obtain a cell count and culture. Colchicine may have a role in gouty management, but the diagnosis must be confirmed. Allopurinol is not effective in acute gouty arthropathy. Measurement of serum uric acid levels is often not helpful in making a definitive diagnosis. Steroid injections should be deferred until cell count and culture results indicate no accompanying infection. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Question 3

A 7-year-old boy sustained an acute puncture wound of the foot after stepping barefoot on a piece of glass 1 day ago. His mother states that she is not sure if she got the piece of glass out; however, she reports that his immunizations are up-to-date. Examination reveals that the wound is slightly erythematous, less than 1 mm in length on the heel, and is not currently draining. What is the next most appropriate step im management?

Explanation

The child has an up-to-date tetanus; therefore, a booster is not recommended. Pseudomonas coverage is most likely not needed because the child was barefoot. It is too early to evaluate for abscess or osteomyelitis with MRI, and a formal debridement is rarely indicated without signs of an abscess or a retained foreign body. Radiographs with soft-tissue penetration should be obtained to check for a retained foreign body. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 199-205.

Question 4

Figures 2a and 2b show the clinical photograph and radiograph of a 16-year-old cheerleader who fell on her left lower extremity while performing a pyramid. Following adequate sedation, closed reduction is performed, but an incomplete reduction is noted. What structure is most likely preventing a reduction?

Explanation

2b The stretched peroneus brevis muscle and tendon follow anterior to the fibula and are most likely incarcerated with reduction. The anterior talofibular ligament is too small to prevent reduction of the ankle joint itself. The extensor digitorum brevis originates from the talus; therefore, it is not involved in the tibiotalar joint. The posterior tibial tendon lies medially and would not be interposed into the ankle joint. Similarly, the anterior tibialis tendon also would not be involved. Pehlivan O, Akmaz I, Solakoglu C, et al: Medial peritalar dislocation. Arch Orthop Trauma Surg 2002;122:541-543.

Question 5

Figures 3a and 3b show the current radiographs of a 59-year-old woman who has pain and deformity after undergoing bunion surgery 1 year ago. Nonsurgical management has failed to provide relief. Treatment should now consist of

Explanation

3b The hallux varus seen in this patient is most likely the result of a combination of causes. Based on the degenerative changes and the significant shortening of the first metatarsal relative to the second metatarsal, a metatarsophalangeal arthrodesis is the treatment of choice. The other surgical approaches are not expected to provide a satisfactory result. Coughlin MJ, Mann RA: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby-Year Book, 2000, pp 150-269.

Question 6

A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot. He reports success with stretching exercises, but he catches his toes when his foot tires. Examination reveals that the foot is plantigrade and supple. What is the next most appropriate step in management?

Explanation

The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes. Tendon transfer should not be considered until the patient has undergone bracing. Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible. Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present. Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

Question 7

Removal of both hallucal sesamoids should be reserved as a salvage procedure because of the high incidence of which of the following postoperative complications?

Explanation

Removal of both sesamoids is associated with a high incidence of postoperative hallux valgus and cock-up deformity of the great toe because of weakening of the flexor hallucis brevis tendon. The sesamoids lie within these tendons and require meticulous repair following excision. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 17-25.

Question 8

A 35-year-old man who snowboards sustained the injury shown in Figures 4a through 4c. What is the mechanism of injury?

Explanation

4b 4c Fractures of the lateral process of the talus in snowboarders have been thought to result from pure dorsiflexion, inversion, and axial loading. In a cadaveric study, 10 cadavers were placed in fixed dorsiflexion and inversion with an axial load. This was combined with or without external rotation. No fractures occurred after axial loading in the dorsiflexed-inverted position. Fractures of the lateral process of the talus occurred in 75% of the specimens with the addition of external rotation. Boon AJ, Smith J, Zobitz ME, et al: Snowboarder's talus fracture: Mechanism of injury. Am J Sports Med 2001;29:333-338.

Question 9

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?

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 10

A 40-year-old man has a painful mass on his anterior ankle joint with limited range of motion. A radiograph, MRI scan, a gross specimen, and a hematoxylin/eosin biopsy specimen are shown in Figures 5a through 5d. What is the most likely diagnosis?

Explanation

5b 5c 5d Synovial chondromatosis results from chondroid metaplasia within the synovium. Male to female ratio is 2:1, with a peak incidence in early adult life. Radiographs can show speckled cal

Question 11

A 63-year-old woman with a history of poliomyelitis has a fixed 30-degree equinus contracture of the ankle, rigid hindfoot valgus, and normal knee strength and stability. She reports persistent pain and has had several medial forefoot ulcerations despite a program of stretching, bracing, and custom footwear. What is the next most appropriate step in management?

Explanation

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee. Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.

Question 12

What is the most common foot deformity associated with myelomeningocele?

Explanation

All of the above can be associated with myelomeningocele, but talipes equinovarus occurs in 50% to 90% of patients with myelomeningocele. Congenital vertical talus is rarely associated with any neuromuscular diseases other than myelomeningocele but is not the most common deformity in myelomeningocele. Stans AA, Kehl DK: The pediatric foot, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials. New York, NY, Thieme, 1999, pp 702-703.

Question 13

Where is the watershed zone for tarsal navicular vascularity?

Explanation

The central one third has been established as the watershed zone by angiographic studies, and has been borne out in clinical conditions involving the navicular, such as stress fractures and osteonecrosis. These findings account for the susceptibility to injury at this level. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 239-242.

Question 14

A 37-year-old woman has had intermittent paresthesias and numbness in the plantar foot for the past 6 months. She reports that the symptoms are worse with activity, and the paresthesias are beginning to awaken her at night. MRI scans are shown in Figures 6a and 6b. What is the most likely diagnosis?

Explanation

6b The symptoms are consistent with tarsal tunnel syndrome. Ganglion cysts are a well-known cause of tarsal tunnel syndrome. The MRI scans show a high intensity, well-circumscribed mass in the tarsal tunnel that is consistent with a fluid-filled cyst. Patients usually respond well to excision of the ganglion and resolution of the tarsal tunnel symptoms. The surrounding fat is a different signal intensity on the MRI scans, which rules out a lipoma. Synovial cell sarcoma has a heterogeneous appearance on an MRI scan. Metastatic tumors are most commonly found in the osseous structures of the foot, not the soft tissues. Rozbruch SR, Chang V, Bohne WH, et al: Ganglion cysts of the lower extremity: An analysis of 54 cases and review of the literature. Orthopedics 1998;21:141-148. Llauger J, Palmer J, Monill JM, et al: MR imaging of benign soft-tissue masses of the foot and ankle. Radiographics 1998;18:1481-1498.

Question 15

Figure 7 shows the CT scan of a 25-year-old soccer player who has had posterior ankle pain with plantar flexion for the past 2 years. Immobilization has failed to provide relief. He is ambulatory. Management should consist of

Explanation

An os trigonum is usually asymptomatic, but this accessory bone has been associated with persistent posterior ankle pain, which has been described as os trigonum syndrome. This usually affects athletes and ballerinas. Forced plantar flexion leads to impingement of the os trigonum against the posterior tibial plafond, and flexor hallucis tendinitis may develop. It may be difficult to differentiate a fractured trigonal process from the os trigonum. MRI may reveal bone marrow edema that may aid in the diagnosis of os trigonum syndrome. Steroid injections may lead to tendon rupture. The results of excision of a symptomatic os trigonum through a posteromedial or lateral approach are favorable, with a rapid return to full function. The main complication of this procedure is sural nerve injury with a lateral approach. Hedrick MR, McBryde AM: Posterior ankle impingement. Foot Ankle Int 1994;15:2-8.

Question 16

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

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 17

An elite skier training for the Olympics sustains an isolated traumatic dislocation of the peroneal tendons that have spontaneously reduced. The games are 9 months away and the athlete does not want to miss them. Treatment should consist of

Explanation

Most of these injuries occur in young, active patients. Success rates for nonsurgical management are only marginally better than 50%. The treatment of choice is early surgery for patients who desire a quick return to a sport or active lifestyle. Subluxation of the peroneal tendons leads to longitudinal tears over time. McLennan JG: Treatment of acute and chronic luxations of the peroneal tendons. Am J Sports Med 1980;8:432-436.

Question 18

What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

Explanation

Achilles tendon tension is not affected by knee position when the ankle is in 20 degrees to 25 degrees of plantar flexion. Skin perfusion overlying the Achilles tendon is maximal in 20 degrees of plantar flexion and is reduced beyond 20 degrees of plantar flexion. Neutral flexion or any amount of dorsiflexion compromises the repair.

Question 19

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

Explanation

The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief. Therefore, the treatment of choice is midfoot arthrodesis. Shock wave treatment has not been shown to be beneficial for arthritis. An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint. Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury. Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc's tarsometatarsal joints by arthrodesis. Foot Ankle 1990;10:193-200.

Question 20

The Lisfranc ligament connects the base of the

Explanation

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. Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 21

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies any history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of

Explanation

The patient has the classic symptoms, examination findings, and radiographs for a painful accessory navicular. Initial treatment should always be nonsurgical, specifically cast immobilization. Surgery should be reserved for those patients who fail nonsurgical management. Corticosteroids should not be injected into a posterior tibial tendon or insertion point because they can weaken the tendon and possibly cause tendon rupture. Triple arthrodesis and biopsy have no role in the management of a painful accessory navicular.

Question 22

Figures 9a and 9b show the radiographs of a 28-year-old woman who sustained a head injury and a closed injury, without soft-tissue compromise, to her right lower extremity in a motor vehicle accident. Appropriate management of the foot injury should include

Explanation

9b The displaced talar neck fracture should be treated with open reduction and internal fixation using screws. Closed reduction and casting will not maintain position, and percutaneous pinning is not able to maintain reduction to allow union. External fixation and amputation are not necessary for this injury unless there is severe soft-tissue loss.

Question 23

An active 47-year-old woman with rheumatoid arthritis reports forefoot pain and deformity and has difficulty with shoe wear. Examination reveals hallux valgus and claw toes. A radiograph is shown in Figure 10. What is the most appropriate surgical treatment?

Explanation

Rheumatoid arthritis commonly affects the metatarsophalangeal joints, which become destabilized with time resulting in hallux valgus and dislocated lesser claw toes. The result is metatarsalgia as the dislocated claw toes "pull" the fat pad distally. Severe hallux valgus reduces first ray load, which compounds the metatarsalgia because the load is transferred to the lesser metatarsal heads. First metatarsophalangeal arthrodesis restores weight bearing medially and corrects the painful bunion. Metatarsal head resection slackens the toe tendons to allow correction of the claw toes by whatever means necessary and decreases plantar load over the forefoot. Rheumatoid arthritis in the first metatarsophalangeal joint will continue to progress if osteotomies or a Lapidus procedure are performed. Keller resection arthroplasty increases transfer metatarsalgia and reduces push-off power during gait. Flexor-to-extensor tendon transfer of the lesser toes does not address the metatarsalgia and does not correct the dislocation of the 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 572.

Question 24

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

Explanation

The dislocation is between the medial and middle cuneiform. Although the first and second tarsometatarsal joints are aligned, there is a gap between the cuneiforms. The radiograph shows a Lisfranc dislocation variant. In a healthy active individual, open reduction and internal fixation yields the best results. The reestablishment of the normal arch and medial column support with anatomic reduction is critical to obtaining the best possible outcome from these injuries. Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of the tarsal-metatarsal fracture dislocation. Foot Ankle Int 2002;23:922-926.

Question 25

A 32-year-old woman has left second toe dactylitis (sausage toe). Radiographs show a "pencil in cup" distal interphalangeal joint deformity. Examination reveals that subtalar motion is markedly reduced. What is the most likely diagnosis?

Explanation

The patient's clinical picture is considered the classic presentation for psoriatic arthritis. The other answers are not applicable for the constellation of findings. Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA, WB Saunders, 1991, pp 1691-1693.

Question 26

A 55-year-old female presents with medial ankle pain and progressive flattening of the foot. On examination, she is unable to perform a single heel raise on the affected side. Her hindfoot is in valgus but is passively correctable. Radiographs demonstrate uncovering of the talonavicular joint (30%) but no arthritic changes. Which of the following is the most appropriate surgical management if conservative treatment fails?

Explanation

This patient has Stage II posterior tibial tendon dysfunction (flexible flatfoot, inability to perform a single heel raise, correctable deformity, and no arthritis). The gold standard surgical management for Stage II involves a joint-sparing procedure such as an FDL transfer (tendon substitution) and a medial displacement calcaneal osteotomy (bony realignment). Triple arthrodesis is reserved for Stage III (rigid/fixed deformity) or when clinically significant arthritis is present.

Question 27

A 32-year-old male sustains a high-impact motor vehicle accident and presents with a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of the blood supply to the talus and the associated expected rate of avascular necrosis (AVN)?

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body from both the subtalar and tibiotalar joints. This results in the disruption of all three major sources of blood supply to the talar body: the artery of the tarsal canal (from the posterior tibial artery), the artery of the tarsal sinus (from branches of the anterior tibial and peroneal arteries), and the deltoid branches. The risk of avascular necrosis (AVN) is historically reported to be extremely high, approaching 100%.

Question 28

A 45-year-old female undergoes a proximal crescentic osteotomy and distal soft tissue realignment for severe hallux valgus. Six months postoperatively, she complains of medial forefoot pain and difficulty wearing shoes. Examination reveals the great toe is deviated medially, and weight-bearing radiographs show a negative hallux valgus angle. Which of the following intraoperative maneuvers most likely contributed to this complication?

Explanation

The complication described is iatrogenic hallux varus (medial deviation of the great toe following hallux valgus surgery). The most common intraoperative causes include excessive resection of the medial eminence ('staking the metatarsal head'), over-tightening of the medial joint capsule, and excessive release of the lateral structures (lateral collateral ligament and adductor hallucis) combined with over-correction of the intermetatarsal angle.

Question 29

A 35-year-old construction worker sustains an axial load to a plantarflexed foot. Weight-bearing radiographs show a 4mm gap between the 1st and 2nd metatarsal bases with no associated fractures. When comparing open reduction and internal fixation (ORIF) to primary arthrodesis for this specific injury pattern, primary arthrodesis is associated with:

Explanation

This is a purely ligamentous Lisfranc injury. Prospective randomized trials (e.g., Ly and Coetzee, JBJS 2006) have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis yields superior functional outcomes and a significantly lower rate of unplanned secondary surgeries (such as hardware removal and salvage arthrodesis for post-traumatic arthritis) compared to standard ORIF.

Question 30

A 42-year-old male presents with a palpable gap in his Achilles tendon 4 cm proximal to its insertion after feeling a 'pop' while playing basketball. He opts for non-operative management. Which of the following rehabilitation protocols has been shown to produce functional outcomes and re-rupture rates most comparable to operative management?

Explanation

Recent high-level evidence has demonstrated that non-operative management with an early functional rehabilitation protocol (early weight-bearing in a functional orthosis/boot with heel lifts and early range of motion) results in clinical outcomes and re-rupture rates that are not significantly different from operative management. This approach avoids surgical complications such as wound breakdown and nerve injury.

Question 31

A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, erythematous, and painless left foot. He has no fevers. Radiographs show fragmentation of the midfoot with subluxation of the tarsometatarsal joints, but no distinct osteomyelitis. In this acute phase (Eichenholtz stage I), what is the most appropriate initial management?

Explanation

The patient presents with acute Charcot neuroarthropathy (Eichenholtz Stage I: fragmentation phase characterized by erythema, edema, heat, joint subluxation, and bony fragmentation). The mainstay of treatment in the acute phase is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC), to prevent further deformity while the bones coalesce (Stage II) and consolidate (Stage III). Surgery in the acute phase is generally contraindicated due to the high risk of hardware failure in hyperemic, osteopenic bone.

Question 32

A 38-year-old roofer falls 15 feet, sustaining a closed, displaced, intra-articular calcaneus fracture (Sanders type II). He is scheduled for open reduction and internal fixation via an extensile lateral approach. To minimize the risk of wound healing complications and skin flap necrosis, which of the following principles should be strictly adhered to during the surgical approach?

Explanation

The extensile lateral approach to the calcaneus carries a significant risk of wound complications. To minimize this risk, the flap must be elevated as a single, full-thickness subperiosteal layer containing the sural nerve, peroneal tendons, and calcaneofibular ligament. 'No-touch' retraction should be employed, typically by placing K-wires into the talus and cuboid to hold the flap open, avoiding the use of hand-held or self-retaining retractors on the skin edges which cause pressure necrosis.

Question 33

A 21-year-old collegiate basketball player sustains an acute fifth metatarsal fracture. Radiographs show a transverse fracture located 2 cm distal to the tuberosity, extending into the fourth-fifth intermetatarsal articulation, with no intramedullary sclerosis. Which of the following is the most appropriate treatment for this athlete?

Explanation

The patient has an acute Jones fracture (Zone 2: metaphyseal-diaphyseal junction extending into the 4th-5th intermetatarsal articulation). Because this occurs in a vascular watershed area, it has a higher risk of delayed union or nonunion. In elite or high-level athletes, early surgical intervention with intramedullary screw fixation is recommended as it significantly decreases time to union, lowers the nonunion rate, and allows a faster return to sports compared to non-operative management.

Question 34

A 28-year-old female presents with chronic deep ankle pain following a severe ankle sprain 2 years ago. MRI reveals a 1.2 cm x 1.0 cm osteochondral lesion on the medial talar dome. The overlying cartilage is intact but there is subchondral cystic change. She has failed 6 months of conservative treatment. What is the most appropriate first-line surgical intervention?

Explanation

For primary osteochondral lesions of the talus (OLT) that are small to medium-sized (< 1.5 cm diameter or < 150 mm^2 area), arthroscopic bone marrow stimulation (e.g., microfracture) is considered the first-line surgical treatment. It provides excellent clinical outcomes for lesions of this size and preserves future surgical options. Structural grafts (OATS) or cellular techniques (ACI) are generally reserved for larger lesions, massive cystic bone loss, or failed primary bone marrow stimulation.

Question 35

A 22-year-old marathon runner complains of progressive bilateral anterolateral leg pain that reliably begins 3 miles into her run and resolves after 30 minutes of rest. She occasionally experiences numbness on the dorsum of her foot. Resting compartment pressures are 12 mmHg. Five minutes post-exercise, the anterior compartment pressure is 35 mmHg. What is the most appropriate next step in management if she wishes to continue long-distance running?

Explanation

The patient's clinical presentation and diagnostic compartment pressures confirm Chronic Exertional Compartment Syndrome (CECS) of the anterior and lateral compartments. The Pedowitz criteria for CECS include one or more of the following: pre-exercise pressure >= 15 mmHg, 1-minute post-exercise pressure >= 30 mmHg, or 5-minute post-exercise pressure >= 20 mmHg. Given her desire to continue running and failure to modify activities, the definitive treatment is an elective fasciotomy of the involved compartments. Transitioning to a forefoot strike (not heel-strike) is sometimes recommended to lower anterior pressures, but is not the best definitive option here.

Question 36

A 55-year-old female presents with progressive medial foot pain and a flatfoot deformity. Clinical examination reveals a flexible pes planovalgus deformity, an inability to perform a single heel rise, and tenderness directly along the course of the posterior tibial tendon. Radiographs show a talonavicular uncoverage angle of 20 degrees. Following a failed 6-month trial of conservative management with customized orthotics and physical therapy, which of the following is the most appropriate surgical intervention?

Explanation

This patient presents with Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot deformity and the inability to perform a single heel rise. When conservative management fails, joint-sparing flatfoot reconstruction is indicated. The standard of care includes soft tissue reconstruction (FDL transfer to the navicular to replace the incompetent PTT) combined with bony procedures to correct the deformity (medial displacement calcaneal osteotomy) and addressing equinus contracture (gastrocnemius recession or Achilles tendon lengthening). Triple arthrodesis is reserved for rigid deformities (Stage III) or significant arthritic changes.

Question 37

A 42-year-old man undergoes minimally invasive, percutaneous repair of an acute midsubstance Achilles tendon rupture. Postoperatively, he complains of new-onset numbness and tingling over the lateral aspect of his heel and the lateral border of his foot. Iatrogenic injury to which of the following anatomic structures is the most likely cause of his symptoms?

Explanation

The sural nerve provides sensation to the lateral aspect of the heel and the lateral border of the foot. It typically courses from midline to lateral, crossing lateral to the Achilles tendon in the distal third of the leg. The nerve is at significant risk of iatrogenic injury or entrapment during percutaneous or minimally invasive Achilles tendon repairs, particularly during the passage of lateral sutures. The saphenous nerve supplies the medial aspect of the leg and ankle. The superficial peroneal nerve supplies the dorsum of the foot. The medial calcaneal nerve supplies the medial heel.

Question 38

A 25-year-old professional rugby player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs and a subsequent MRI confirm an isolated, complete rupture of the primary stabilizing ligament of the Lisfranc complex without associated fractures. This primary stabilizing interosseous ligament anatomically connects which of the following two osseous structures?

Explanation

The Lisfranc ligament is an oblique interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It is the strongest and most critical ligament for maintaining the stability of the tarsometatarsal (Lisfranc) complex. Note that there is no intermetatarsal ligament connecting the bases of the first and second metatarsals, making this articulation highly dependent on the Lisfranc ligament.

Question 39

A 30-year-old male is brought to the trauma bay following a high-speed motorcycle collision. Plain radiographs reveal a displaced fracture of the talar neck with complete dislocation of both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the grade of this injury and its historically associated risk of avascular necrosis (AVN) of the talar body?

Explanation

The Hawkins classification is used for talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I is non-displaced (0-10% AVN). Type II involves subtalar subluxation or dislocation (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints, historically carrying an AVN rate approaching 100%, though modern fixation techniques have slightly reduced this. Type IV (added by Canale and Kelly) includes subtalar, tibiotalar, and talonavicular dislocation.

Question 40

A 55-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally red, hot, and swollen foot. Radiographs demonstrate periarticular fragmentation, bony debris, and early subluxation at the midfoot tarsometatarsal joints. The skin is intact with no ulcerations, and laboratory inflammatory markers (ESR, CRP) are within normal limits. What is the most appropriate initial management?

Explanation

This patient is presenting with acute Eichenholtz Stage 1 (Development/Fragmentation phase) Charcot neuroarthropathy. The absence of ulceration and normal inflammatory markers make acute infection unlikely, distinguishing it from osteomyelitis or septic arthritis. The gold standard of treatment in the acute, active inflammatory phase is rigid offloading and immobilization, most effectively achieved with a total contact cast (TCC) and non-weight bearing. Surgical reconstruction in the acute inflammatory phase carries high failure rates and is generally contraindicated unless severe instability threatens the soft tissue envelope.

Question 41

A 60-year-old female presents with a painful bunion that restricts her shoe wear. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. Based on these findings, which of the following surgical procedures is most indicated to minimize the risk of recurrence?

Explanation

The patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13 degrees) complicated by clinically demonstrable hypermobility of the first ray (first TMT joint). The Lapidus procedure (first TMT joint arthrodesis) is the most appropriate procedure as it provides powerful correction for large intermetatarsal angles and inherently addresses the hypermobility of the first ray, significantly lowering the risk of recurrence. Distal or proximal osteotomies alone do not stabilize the hypermobile first TMT joint.

Question 42

A 28-year-old female runner presents with persistent deep anterior ankle pain 8 months after a severe inversion injury. An MRI demonstrates a 1.2 cm by 1.0 cm osteochondral lesion on the medial aspect of the talar dome. The overlying articular cartilage appears intact on imaging, but conservative treatment including immobilization and physical therapy has failed. What is the standard first-line surgical management?

Explanation

For primary, symptomatic osteochondral lesions of the talus (OLT) that are small to medium-sized (less than 1.5 cm in diameter or 1.5 cm^2 in area) and have failed conservative management, the gold standard first-line surgical treatment is arthroscopic debridement and bone marrow stimulation (microfracture or drilling). This technique promotes the formation of fibrocartilage. OATS and MACI are typically reserved for larger lesions (> 1.5 cm^2), cystic lesions, or lesions that have failed primary microfracture.

Question 43

A 45-year-old construction worker falls from a ladder and sustains a displaced, intra-articular calcaneal fracture (Sanders Type III). The surgeon plans for an open reduction and internal fixation via an extensile lateral approach. To critically minimize the risk of wound edge necrosis and postoperative wound complications, which of the following techniques must be employed during the surgical exposure?

Explanation

The extensile lateral approach to the calcaneus is notorious for high rates of wound breakdown and infection. To mitigate this risk, the surgeon must create a full-thickness, subperiosteal flap that includes the periosteum, peroneal tendons, and sural nerve within the flap. This 'no-touch' technique preserves the delicate microvascular supply to the corner of the L-shaped flap, primarily fed by the lateral calcaneal artery. Dissecting through subcutaneous tissue or separating the tendons/nerve compromises this blood supply.

Question 44

A 22-year-old elite collegiate basketball player sustains an acute foot injury during a game. Radiographs confirm a transverse fracture through the metaphyseal-diaphyseal junction of the fifth metatarsal base (Zone 2). To minimize the risk of nonunion and facilitate an accelerated return to competitive play, what is the recommended definitive management?

Explanation

A fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal is defined as a Jones fracture (Zone 2). This area represents a vascular watershed zone, predisposing these fractures to delayed union and nonunion. In high-level, elite athletes, surgical management with early percutaneous intramedullary screw fixation is strongly recommended. This approach yields significantly higher union rates and allows for a faster return to sport compared to conservative management (casting or booting).

Question 45

During the operative fixation of an unstable pronation-external rotation (PER) ankle fracture, the surgeon completes rigid fixation of the medial and lateral malleoli. Suspecting an associated syndesmotic injury, the surgeon performs the intraoperative 'Cotton test'. Which of the following best describes the execution of this test?

Explanation

The Cotton test is an intraoperative maneuver used to evaluate the integrity of the distal tibiofibular syndesmosis after malleolar fixation. It is performed by placing a bone hook or clamp around the fibula and applying a strong lateral (and slightly posterior) pulling force. The surgeon simultaneously views the ankle under AP or mortise fluoroscopy; widening of the tibiofibular clear space indicates syndesmotic instability requiring fixation. Squeezing the calf is the Thompson test for the Achilles tendon.

Question 46

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals no hypermobility at the first tarsometatarsal joint. What is the most appropriate surgical management?

Explanation

For a moderate to severe hallux valgus deformity (IMA 14-20 degrees, HVA < 40 degrees) without first tarsometatarsal (TMT) joint hypermobility or arthritis, a proximal metatarsal osteotomy (e.g., crescentic, Ludloff) combined with a distal soft-tissue procedure is indicated. A distal chevron osteotomy is reserved for mild deformities (IMA < 13 degrees). The Lapidus procedure is indicated if there is TMT hypermobility. MTP arthrodesis is preferred for severe deformity with arthritis or in patients with rheumatoid arthritis. A Keller arthroplasty is reserved for older, low-demand patients.

Question 47

A 35-year-old male sustains an acute Achilles tendon rupture while playing tennis. He opts for non-operative management with a functional rehabilitation protocol. Compared to operative treatment, which of the following is true regarding non-operative management utilizing early functional rehabilitation?

Explanation

High-level evidence demonstrates that non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol results in similar rerupture rates compared to operative management. Operative treatment is associated with higher risks of soft tissue complications, infection, and iatrogenic sural nerve injury. Long-term functional outcomes and strength are comparable between the two groups.

Question 48

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing structure of the Lisfranc joint complex that is most likely injured?

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the thickest, strongest, and primary stabilizer of the Lisfranc complex. Notably, there is no direct ligamentous connection between the first and second metatarsals.

Question 49

A 55-year-old female presents with progressive flattening of her left foot, medial-sided pain, and an inability to perform a single-leg heel raise. Clinical examination demonstrates a flexible hindfoot valgus and forefoot abduction. Which of the following is the most appropriate surgical treatment?

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and an inability to perform a single-leg heel raise. The gold standard surgical management for Stage II is a soft tissue transfer (FDL to navicular or medial cuneiform) combined with a bony procedure to correct the deformity, most commonly a medial displacement calcaneal osteotomy (MDCO). Stage I is treated with conservative care or tenosynovectomy. Stage III involves a rigid deformity requiring triple or isolated hindfoot arthrodesis.

Question 50

A 22-year-old elite collegiate basketball player sustains an acute, non-displaced fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. He wishes to return to play as safely and quickly as possible. What is the most appropriate management?

Explanation

Acute fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fractures) occur in a vascular watershed area, predisposing them to a higher rate of nonunion. In a young, high-demand athlete, early intramedullary screw fixation is recommended to decrease the time to union, lower the risk of nonunion, and facilitate an earlier return to sports compared to conservative management.

Question 51

A 30-year-old male is involved in a motor vehicle collision and sustains a displaced talar neck fracture with subluxation of the subtalar joint. The ankle joint remains reduced (Hawkins Type II). Which of the following vascular supplies to the talar body is most likely preserved?

Explanation

The talus has a tenuous, retrograde blood supply. The artery of the tarsal canal (from the posterior tibial artery) is the dominant supply to the body. In a Hawkins II fracture (subtalar subluxation/dislocation), the artery of the tarsal canal and the artery of the tarsal sinus are typically disrupted. The deltoid branches (supplying the medial body) are the most consistently preserved vascular supply, provided the medial malleolus and deltoid ligament are intact.

Question 52

A 60-year-old male with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot of 3 weeks' duration. He denies ulceration, fevers, or chills. Laboratory studies show normal WBC and CRP. Radiographs demonstrate early fragmentation and periarticular debris at the tarsometatarsal joints. What is the initial treatment of choice?

Explanation

The presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy. The absence of an ulcer and normal inflammatory markers make osteomyelitis unlikely. The initial treatment of choice for acute Charcot arthropathy is strict immobilization and offloading, best achieved with a total contact cast (TCC). This prevents further architectural collapse while allowing the acute inflammatory process to consolidate. Surgery is generally contraindicated in the acute inflammatory phase.

Question 53

During operative fixation of a pronation-external rotation ankle fracture, the syndesmosis is found to be unstable after rigid fixation of the medial and lateral malleoli. Which of the following is true regarding syndesmotic screw fixation?

Explanation

Syndesmotic screws are typically placed 2-3 cm proximal to the tibial plafond, parallel to the joint line, and angled 20-30 degrees anteriorly from posterolateral to anteromedial to align with the anatomic position of the fibula relative to the tibia. Engaging 3 or 4 cortices shows no significant difference in outcomes. Current evidence does not support routine screw removal, and position of the ankle (neutral vs. plantarflexion) during insertion does not significantly alter final dorsiflexion. Suture-button constructs actually have a lower rate of hardware removal.

Question 54

A 28-year-old professional football player hyperextends his great toe on artificial turf. He has severe pain, swelling, and ecchymosis at the first MTP joint. MRI reveals a complete rupture of the plantar plate and flexor hallucis brevis from the base of the proximal phalanx, with proximal retraction of the sesamoids. What is the recommended treatment?

Explanation

A complete rupture of the plantar plate with proximal retraction of the sesamoids constitutes a Grade 3 turf toe injury. In high-level athletes, non-operative management of a Grade 3 injury often results in chronic pain, push-off weakness, and a cock-up deformity. Surgical repair of the plantar plate and capsuloligamentous structures is indicated to restore anatomy and function.

Question 55

A 42-year-old male construction worker who smokes 1 pack per day falls from a ladder, sustaining a closed, displaced, intra-articular calcaneal fracture (Sanders Type II). Which of the following surgical approaches carries the lowest risk of wound complications for this patient?

Explanation

The sinus tarsi approach is a minimally invasive lateral approach for the treatment of intra-articular calcaneal fractures. It has been shown to significantly reduce the risk of soft-tissue and wound healing complications compared to the traditional extensile lateral approach. It is particularly beneficial in high-risk patients such as smokers or diabetics, while providing adequate visualization for articular reduction in less complex fracture patterns like Sanders Type II.

Question 56

A 45-year-old active male sustains an acute Achilles tendon rupture while playing tennis. He opts for non-operative management. Which of the following is the most significant advantage of utilizing a functional rehabilitation protocol with early dynamic weight-bearing compared to traditional rigid immobilization?

Explanation

Non-operative management with early functional rehabilitation for acute Achilles tendon ruptures has been shown in recent high-quality randomized controlled trials to have a re-rupture rate comparable to that of operative repair, while eliminating surgical complications such as wound breakdown and infection. Historically, non-operative management was thought to have a much higher re-rupture rate, but the incorporation of early dynamic weight-bearing protocols has altered this paradigm.

Question 57

A 30-year-old male sustains a purely ligamentous Lisfranc injury after a fall from a horse. The first and second tarsometatarsal joints are widely displaced. What is the most appropriate definitive management for this specific injury pattern?

Explanation

In purely ligamentous Lisfranc injuries, the interosseous and plantar ligaments are disrupted without substantial bony avulsions, rendering the healing potential poor with simple stabilization. High-level evidence has demonstrated that primary arthrodesis of the medial and middle columns (1st, 2nd, and 3rd tarsometatarsal joints) yields superior functional outcomes, a higher rate of return to pre-injury activity levels, and significantly lower rates of reoperation or hardware failure compared to ORIF. The 4th and 5th TMT joints should be left mobile.

Question 58

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and inability to perform a single-leg heel raise. Examination reveals a flexible hindfoot valgus and forefoot abduction. Radiographs show uncovering of the talonavicular joint but no arthritic changes. What is the best surgical management if prolonged conservative care fails?

Explanation

The patient presents with Stage IIA adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity without significant arthritic changes in the hindfoot. The standard of care for a symptomatic flexible deformity that fails conservative management is a joint-sparing flatfoot reconstruction. This typically consists of transferring the FDL to substitute for the deficient posterior tibial tendon, combined with an MDCO to correct the mechanical axis of the hindfoot.

Question 59

A 28-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT reveal a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of blood supply in this injury?

Explanation

A Hawkins Type III talar neck fracture involves a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. The talus relies on a tenuous retrograde blood supply, primarily from the artery of the tarsal canal, the artery of the tarsal sinus, and the deltoid branches. In a Type III injury, the severe displacement and dislocation disrupt all three of these primary vascular sources, resulting in a risk of avascular necrosis (AVN) of the talar body approaching 90-100%.

Question 60

A 62-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and obvious clinical hypermobility of the first tarsometatarsal (TMT) joint. No degenerative changes are noted at the metatarsophalangeal (MTP) joint. What is the most appropriate surgical intervention?

Explanation

The patient presents with a severe hallux valgus deformity accompanied by hypermobility of the first TMT joint. An isolated distal or proximal osteotomy is prone to failure and high recurrence rates in the setting of first ray hypermobility. A first TMT arthrodesis (Lapidus procedure) allows for powerful correction of the severe intermetatarsal angle and stabilizes the medial column, preventing recurrence.

Question 61

A 40-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. He smokes 1 pack of cigarettes per day and has a BMI of 32. If an extensile lateral approach is chosen for open reduction and internal fixation, which of the following is the most significant independent risk factor for wound complications?

Explanation

Smoking is a profoundly significant independent risk factor for wound complications following the extensile lateral approach for calcaneus fractures. Studies have consistently shown that smokers have an exponentially higher rate of marginal skin necrosis, deep infection, and the need for secondary soft tissue coverage procedures compared to non-smokers. Smoking cessation and waiting for the wrinkle sign are critical preoperative optimization steps.

Question 62

A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. He denies trauma. X-rays show extensive fragmentation, debris, and subluxation of the midfoot joints. There are no skin ulcers. What is the most appropriate initial management?

Explanation

The patient's clinical and radiographic presentation is classic for Eichenholtz Stage I (acute fragmentation stage) Charcot arthropathy. The gold standard of treatment at this stage is immediate offloading and immobilization to prevent further mechanical destruction of the midfoot while the severe inflammatory process resolves. This is most effectively achieved with a total contact cast (TCC) and strict non-weight-bearing. Surgery during the acute inflammatory phase is highly discouraged due to the extreme risk of hardware failure.

Question 63

A 21-year-old elite collegiate basketball player sustains an acute zone 2 fracture of the proximal fifth metatarsal (Jones fracture). What is the recommended treatment to minimize the risk of nonunion and allow the fastest return to competitive play?

Explanation

A zone 2 proximal fifth metatarsal fracture (Jones fracture) involves the vascular watershed area, putting it at high risk for delayed union or nonunion. In high-level athletes, conservative management is associated with unacceptably high rates of nonunion and prolonged time away from sports. Early intramedullary screw fixation has been shown to significantly increase the union rate, decrease the time to union, and facilitate a much faster return to play.

Question 64

A 25-year-old male sustains a severe twisting injury to his ankle. Radiographs reveal a medial clear space of 6 mm and a tibiofibular clear space of 7 mm on the AP view. A fracture of the proximal third of the fibula is also noted. What is the diagnosis and most appropriate management?

Explanation

A pronation-external rotation injury resulting in a proximal fibular fracture and disruption of the tibiofibular syndesmosis is known as a Maisonneuve fracture. The widening of the medial clear space indicates associated rupture of the deltoid ligament. This highly unstable injury pattern necessitates surgical reduction and stabilization of the syndesmosis, typically achieved with either syndesmotic screws or a dynamic suture-button construct.

Question 65

A 24-year-old professional football player sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI demonstrates a complete tear of the plantar plate with proximal retraction of the sesamoids. He has profound weakness with resisted hallux plantarflexion. What is the most appropriate management?

Explanation

This describes a Grade 3 turf toe injury, characterized by complete disruption of the plantar capsuloligamentous complex. In an elite athlete, conservative management of a Grade 3 injury with significant instability and proximal retraction of the sesamoids leads to chronic pain and decreased push-off strength. Surgical repair of the plantar complex is indicated to restore anatomy, ensure joint stability, and maximize the likelihood of returning to pre-injury performance levels.

Question 66

A 45-year-old woman presents with a severe, painful bunion deformity. She reports a long history of wearing narrow-toed shoes. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?

Explanation

The patient has severe hallux valgus (HVA > 40 degrees, IMA > 13 degrees) combined with first TMT joint hypermobility. A Lapidus procedure (first TMT arthrodesis) is the most appropriate choice to provide powerful correction of the high intermetatarsal angle and address the apex of the deformity (the hypermobile TMT joint). Distal chevron osteotomies are indicated for mild to moderate deformities. First MTP fusion is typically reserved for severe deformities with concurrent first MTP osteoarthritis or in cases of rheumatoid arthritis. The Keller procedure is historically used in low-demand, elderly patients.

Question 67

A 50-year-old woman presents with progressive medial ankle pain and a severe flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side. Examination reveals a flexible hindfoot with significant forefoot abduction. Weight-bearing radiographs show greater than 40% uncoverage of the talonavicular joint on the AP view. What is the most appropriate operative treatment?

Explanation

This patient has Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible deformity, whereas Stage III is rigid. Stage IIB is distinguished from IIA by the presence of significant forefoot abduction (clinically seen as 'too many toes' and radiographically as >30-40% talonavicular uncoverage). To adequately address the forefoot abduction in Stage IIB, a lateral column lengthening (such as an Evans calcaneal osteotomy) is required in addition to a medial displacement calcaneal osteotomy and FDL transfer.

Question 68

A 34-year-old man sustains an acute Achilles tendon rupture while playing basketball. He is discussing treatment options with his surgeon. If he chooses non-operative management utilizing an accelerated functional rehabilitation protocol (early weight-bearing in a functional brace) compared to operative repair, which of the following outcomes is supported by current literature?

Explanation

Recent high-quality level I evidence (such as the meta-analysis by Soroceanu et al. and the Willits et al. RCT) demonstrates that when functional rehabilitation protocols (early weight-bearing and mobilization in an orthosis) are utilized, non-operative management of acute Achilles tendon ruptures yields functional outcomes and re-rupture rates that are not significantly different from operative management, but with a substantially lower risk of complications such as infection, wound breakdown, and iatrogenic sural nerve injury.

Question 69

A 58-year-old man with poorly controlled type 2 diabetes and profound peripheral neuropathy presents with a red, hot, swollen unilateral foot. He denies any prior trauma or fevers. Pulses are palpable and laboratory markers (WBC, CRP) are within normal limits. Radiographs demonstrate periarticular debris, fragmentation of the tarsometatarsal joints, and early subluxation.

What is the most appropriate initial management?

Explanation

The clinical and radiographic picture is pathognomonic for acute Charcot arthropathy (Eichenholtz Stage I - Developmental/Fragmentation phase). There is no clinical or laboratory evidence of acute infection to warrant antibiotics or debridement. The gold standard for initial management of acute active Charcot arthropathy is strict immobilization and offloading, typically achieved with a total contact cast (TCC) to halt the progression of deformity and allow progression to the coalescent and reconstructive phases. CROW boots are utilized in the later, quiescent phases.

Question 70

A 28-year-old man involved in a high-speed motorcycle collision sustains a displaced talar neck fracture with associated dislocations of the subtalar, tibiotalar, and talonavicular joints. According to the classic Hawkins classification and long-term studies, what is the approximate risk of developing avascular necrosis (AVN) of the talar body following this specific injury pattern?

Explanation

The patient has a Hawkins Type IV fracture (displaced talar neck fracture with dislocation of the subtalar, ankle, and talonavicular joints). The blood supply to the talar body (primarily from the artery of the tarsal canal, deltoid branches, and artery of the sinus tarsi) is completely disrupted. AVN rates follow the classification: Type I (nondisplaced) 0-10%; Type II (subtalar subluxation/dislocation) 20-50%; Type III (subtalar and tibiotalar dislocation) and Type IV have an AVN risk of nearly 75-100%.

Question 71

A 22-year-old collegiate offensive lineman sustains an axial load injury to a plantarflexed foot. He presents with midfoot swelling and plantar ecchymosis. Weight-bearing radiographs reveal a 3 mm diastasis between the bases of the first and second metatarsals without any associated fractures (purely ligamentous injury). Which of the following treatments has been shown to provide the most reliable long-term functional outcome and lowest reoperation rate for this specific injury pattern?

Explanation

This is a purely ligamentous Lisfranc injury. Multiple studies, including the landmark prospective randomized trial by Coetzee and Ly, have demonstrated that primary arthrodesis of the affected tarsometatarsal joints (typically the medial three) provides superior functional outcomes, a higher rate of return to pre-injury activity levels, and a significantly lower hardware removal/reoperation rate compared to ORIF in purely ligamentous Lisfranc injuries. ORIF remains a valid option for injuries with significant bony avulsions or fractures.

Question 72

A 20-year-old elite collegiate basketball player presents with lateral foot pain after a sudden pivoting maneuver. Radiographs demonstrate a transverse fracture of the fifth metatarsal located at the metaphyseal-diaphyseal junction, without evidence of intramedullary sclerosis. He wishes to return to play as safely and quickly as possible. What is the most appropriate management?

Explanation

This is an acute Jones fracture (Zone 2 of the proximal fifth metatarsal). Due to the watershed blood supply in this region, these fractures have a higher risk of delayed union or nonunion. In elite athletes, early intramedullary screw fixation is recommended as it significantly decreases the time to clinical and radiographic union and allows for a faster, more predictable return to sport compared to non-operative cast immobilization.

Question 73

Careful patient selection is paramount for the success of Total Ankle Arthroplasty (TAA). Which of the following patients represents the most appropriate candidate for a primary TAA rather than an ankle arthrodesis?

Explanation

The ideal candidate for a total ankle arthroplasty is an older, lower-demand patient with a well-aligned hindfoot, preserved motion, and good bone stock. Contraindications to TAA include active infection, severe peripheral neuropathy/insensate foot (Charcot), substantial avascular necrosis of the talus (poor bone stock for implant seating), severe uncorrectable malalignment, and young age with high physical demands (due to early implant wear and failure).

Question 74

A 40-year-old construction worker falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. Surgery via an extensile lateral approach is planned. To minimize wound healing complications, the surgeon waits until the 'wrinkle test' is positive. During the extensile lateral approach, which nerve is at greatest risk of iatrogenic injury if the vertical limb of the incision is placed too far posteriorly?

Explanation

The extensile lateral approach to the calcaneus involves an L-shaped incision. The vertical limb is placed midway between the posterior border of the fibula and the lateral border of the Achilles tendon. If this vertical limb is placed too far posteriorly or if dissection is not carefully maintained in a full-thickness subperiosteal plane, the sural nerve is at high risk of transection or entrapment. The sural nerve provides sensation to the lateral aspect of the foot.

Question 75

A 45-year-old woman presents with severe burning pain in the plantar aspect of her forefoot, radiating into her third and fourth toes. The pain is exacerbated by wearing narrow-toed, high-heeled shoes. Examination reveals a palpable click when compressing the metatarsal heads while applying plantar pressure to the third webspace (Mulder's sign). If non-operative management fails, surgical excision of the offending structure is planned. Anatomically, where is this structure located relative to the deep transverse metatarsal ligament?

Explanation

The patient is presenting with an interdigital neuroma (Morton's neuroma), most commonly found in the third webspace. Pathophysiologically, it is a perineural fibrosis of the common digital nerve. Anatomically, the common digital nerve runs plantar to the deep transverse metatarsal ligament. Irritation occurs as the nerve is compressed against the unyielding ligament, particularly when the transverse arch is compressed by tight shoes.

Question 76

A 55-year-old woman presents with medial ankle pain and progressive flattening of her left foot over the past year. On examination, she has a flexible flatfoot deformity, is unable to perform a single-leg heel raise on the left, and has >40% of the talar head uncovered on the AP weight-bearing radiograph. There is notable forefoot abduction. What is the most appropriate surgical management for this Stage IIb flatfoot deformity after failure of non-operative treatment?

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). Surgical management for Stage IIb typically involves a combination of soft tissue and bony procedures: gastrocnemius recession (if equinus is present), flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction. A procedure without lateral column lengthening is generally indicated for Stage IIa (minimal to no forefoot abduction). Subtalar and triple arthrodesis are reserved for rigid deformities (Stage III) or when degenerative joint disease is present.

Question 77

A 35-year-old recreational athlete sustains an acute complete Achilles tendon rupture. He opts for nonoperative management with a functional rehabilitation protocol. Compared to operative management, which of the following is true regarding nonoperative treatment with early functional rehabilitation?

Explanation

Recent high-level evidence (Level I randomized controlled trials) has demonstrated that nonoperative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol (early weight-bearing in a functional orthosis) results in a similar rerupture rate compared to operative management. Furthermore, nonoperative management completely avoids surgical complications such as infection, wound breakdown, and iatrogenic sural nerve injury, leading to a lower overall complication rate.

Question 78

A 28-year-old man is involved in a high-speed motor vehicle collision and sustains a Hawkins type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN) of the talar body?

Explanation

The Hawkins classification is used for talar neck fractures. Type I is a nondisplaced fracture (AVN risk 0-10%). Type II involves subtalar subluxation or dislocation (AVN risk 20-50%). Type III involves both subtalar and tibiotalar dislocation, meaning the talar body is extruded from the ankle mortise. The AVN risk for Type III is historically quoted as nearly 100%, though modern series show it may be slightly lower. Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 79

A 42-year-old woman presents with a painful bunion on her right foot. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is no hypermobility at the first tarsometatarsal (TMT) joint, and no evidence of osteoarthritis in the first metatarsophalangeal (MTP) joint. Which of the following surgical interventions is most appropriate?

Explanation

The patient has a severe hallux valgus deformity (HVA >40 degrees, IMA >13-15 degrees). For severe deformities without first MTP joint arthritis, a proximal first metatarsal osteotomy (e.g., proximal crescentic, Ludloff) or a first TMT fusion (Lapidus procedure) combined with a distal soft tissue reconstruction (modified McBride) is indicated to achieve adequate correction of the large IMA. A distal chevron osteotomy is indicated for mild to moderate deformities. First MTP arthrodesis is generally reserved for hallux valgus with severe first MTP osteoarthritis or rheumatoid arthritis.

Question 80

A 24-year-old collegiate football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs of the foot show a 3 mm diastasis between the base of the first and second metatarsals. He undergoes open reduction and internal fixation (ORIF) of the Lisfranc complex. Which of the following ligaments is the primary stabilizer of the Lisfranc joint complex?

Explanation

The Lisfranc ligament is an interosseous ligament that travels from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and primary stabilizer of the Lisfranc joint complex. There is no direct transverse intermetatarsal ligament connecting the bases of the first and second metatarsals, which contributes to the vulnerability of this articulation. Dorsal ligaments are the weakest, rendering the joint prone to dorsal dislocation.

Question 81

A 58-year-old man with a 15-year history of poorly controlled type 2 diabetes presents with a red, hot, swollen, and painless left foot. He denies any recent trauma, fevers, or chills. Radiographs reveal fragmentation of the tarsal bones, periarticular debris, and subluxation of the midfoot. According to the Eichenholtz classification, what is the current stage of this patient's disease, and what is the gold standard initial treatment?

Explanation

The clinical presentation and radiographic findings of fragmentation, periarticular debris, and subluxation are classic for Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot neuroarthropathy. The gold standard initial treatment for acute Stage I Charcot arthropathy is immobilization and offloading, most effectively achieved with a total contact cast (TCC). Stage 0 (prodromal) presents with erythema and edema but normal radiographs. Stage II (coalescence) shows early healing and sclerosis. Surgery is generally contraindicated in the acute fragmentation phase (Stage I) due to high complication rates, including fixation failure and infection.

Question 82

A 40-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He is scheduled for open reduction and internal fixation (ORIF) via an extensile lateral approach. Which of the following is the most critical technical consideration to minimize the risk of wound complications?

Explanation

Wound complications are a major concern with the extensile lateral approach to the calcaneus, occurring in up to 10-25% of cases. To minimize this risk, it is critical to create a 'no-touch' full-thickness fasciocutaneous flap by subperiosteal dissection directly off the lateral wall of the calcaneus. This preserves the precarious blood supply to the corner of the flap, which is supplied by the lateral calcaneal artery. The sural nerve should be elevated within the flap to prevent injury and devascularization. The vertical limb should be placed midway between the Achilles tendon and the posterior border of the fibula.

Question 83

A 45-year-old woman presents with burning pain in the plantar aspect of her forefoot, which is exacerbated by wearing tight, high-heeled shoes. She describes a sensation of 'walking on a marble.' Examination reveals a positive Mulder's click in the third webspace. Non-operative management has failed. She undergoes surgical excision of the neuroma via a dorsal approach. Which of the following structures must be transected to adequately expose and resect the neuroma?

Explanation

Morton's neuroma is a compressive neuropathy of the common digital nerve, most commonly occurring in the third webspace. When approaching a Morton's neuroma surgically through a dorsal incision, the deep transverse metatarsal ligament must be identified and transected. The neuroma is typically located just plantar to this ligament. Dividing the ligament allows for adequate exposure, mobilization, and proximal resection of the neuroma to prevent a symptomatic stump neuroma.

Question 84

A 21-year-old professional soccer player complains of lateral foot pain after a cutting maneuver. Radiographs demonstrate a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation, without significant sclerosis or medullary obliteration. He wishes to return to play as safely and quickly as possible. Which of the following is the most appropriate management?

Explanation

The patient has a Zone 2 fracture of the fifth metatarsal base (Jones fracture), which involves the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. These fractures have a higher risk of nonunion due to the watershed blood supply in this region. In high-demand or elite athletes, acute intramedullary screw fixation is recommended because it significantly decreases the time to clinical and radiographic union and lowers the risk of nonunion compared to non-operative management, allowing for a quicker return to sports.

Question 85

A 26-year-old man sustains a pronation-external rotation (PER) ankle fracture. Intraoperative stress testing after fibular fixation demonstrates widening of the distal tibiofibular clear space. The surgeon decides to use suture-button fixation instead of traditional screw fixation for the syndesmosis. According to current literature, which of the following is a recognized advantage of flexible suture-button fixation over rigid screw fixation?

Explanation

Suture-button fixation for syndesmotic injuries is a form of dynamic or flexible fixation. One of its primary recognized advantages is that it allows for the maintenance of physiologic motion at the distal tibiofibular joint during weight-bearing and ankle range of motion. Studies have shown it leads to similar or better clinical outcomes compared to screw fixation and avoids the need for routine hardware removal (which is often debated with screw fixation). Suture buttons are generally more expensive, and hardware irritation can still occur from the knot/button.

Question 86

A 32-year-old male sustains a high-energy motor vehicle collision resulting in a displaced talar neck fracture with subtalar subluxation. Open reduction and internal fixation is performed within 24 hours. At 8 weeks postoperatively, a mortise radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The subchondral radiolucent band in the talar dome is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia from an intact vascular supply. Its presence at 6-8 weeks post-injury is a highly reliable indicator that the talar body has not undergone avascular necrosis.

Question 87

A 24-year-old football player presents with midfoot pain after a twisting injury with the foot plantar flexed. Weight-bearing radiographs show 2 mm of widening between the base of the 1st and 2nd metatarsals. Non-weight-bearing radiographs show no widening. MRI confirms a complete rupture of the Lisfranc ligament. What is the most appropriate management?

Explanation

A complete rupture of the Lisfranc ligament with diastasis on weight-bearing radiographs indicates instability. Nonoperative management is reserved for stable injuries (sprains without diastasis). Unstable Lisfranc injuries require anatomic reduction and stabilization. For purely ligamentous injuries with instability, primary arthrodesis or ORIF are both acceptable surgical options.

Question 88

A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity over the last 18 months. On examination, she has a flexible hindfoot valgus, a medial prominence, and is unable to perform a single-limb heel rise on the affected side. Radiographs show a talonavicular uncoverage of 30% and a talocalcaneal angle of 25 degrees. Conservative management has failed. What is the most appropriate surgical intervention?

Explanation

The patient has a Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity and inability to perform a single-limb heel rise. Surgical management typically involves an FDL transfer to replace the diseased posterior tibial tendon and a medializing calcaneal osteotomy to correct the hindfoot valgus. Triple arthrodesis is reserved for Stage III (rigid deformity).

Question 89

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 14 degrees. The first tarsometatarsal (TMT) joint shows no hypermobility or arthritic changes. The distal metatarsal articular angle (DMAA) is normal. What is the most appropriate surgical procedure?

Explanation

The patient has a moderate to severe hallux valgus deformity (IMA between 13 and 20 degrees, HVA between 30 and 40 degrees). Distal chevron osteotomy is generally indicated for mild deformities (IMA < 13 degrees). For an IMA of 14 degrees, a proximal metatarsal osteotomy combined with distal soft-tissue reconstruction (or a diaphyseal osteotomy) is indicated to provide adequate translation and angular correction.

Question 90

A 60-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot for 3 weeks. He reports no trauma and denies systemic symptoms such as fever or chills. White blood cell count and inflammatory markers are mildly elevated. Radiographs show fragmentation and periarticular debris at the tarsometatarsal joints. What is the most appropriate next step in management?

Explanation

The clinical presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy, which is often mistaken for infection. The radiographic findings of fragmentation and debris confirm the diagnosis. The cornerstone of treatment in the acute phase is offloading, typically with a total contact cast (TCC), to prevent further progression of the deformity.

Question 91

A 40-year-old roofer falls from a ladder and sustains a closed, displaced intra-articular calcaneus fracture (Sanders type II). He is a heavy smoker (2 packs per day). He asks about the risks of surgical treatment. Which of the following is the most common complication following open reduction and internal fixation (ORIF) of a calcaneus fracture via an extensile lateral approach?

Explanation

Wound healing complications are the most common and feared complication following ORIF of calcaneus fractures via an extensile lateral approach. The risk is significantly increased in patients who smoke, have diabetes, or are obese. Careful tissue handling, waiting for the 'wrinkle sign', and smoking cessation are crucial.

Question 92

A 35-year-old recreational basketball player presents with a 'pop' in his left posterior ankle followed by pain and weakness in plantarflexion. Clinical examination reveals a positive Thompson test and a palpable gap 4 cm proximal to the calcaneal insertion. He opts for nonoperative management. Which of the following functional outcomes is most likely compared to surgical repair?

Explanation

Recent high-quality studies have shown that nonoperative management of acute Achilles tendon ruptures using early functional rehabilitation and weight-bearing in a functional brace yields functional outcomes and rerupture rates similar to those of surgical repair. Surgery has historically been associated with a slightly lower rerupture rate but higher risks of wound complications.

Question 93

A 14-year-old male presents with recurrent ankle sprains and deep hindfoot pain exacerbated by sports. Examination reveals a rigid, flat foot with decreased subtalar motion and peroneal muscle spasm. Radiographs show a 'C-sign' on the lateral view. CT scan confirms a bony coalition. Which of the following joints is most likely involved?

Explanation

The presentation is typical for a tarsal coalition. The 'C-sign' on a lateral radiograph is a classic finding for a talocalcaneal (subtalar) coalition, representing the continuous outline of the medial outline of the talar dome and the posterior outline of the sustentaculum tali. Calcaneonavicular coalitions often show an 'anteater nose' sign.

Question 94

A 22-year-old wide receiver sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. He presents with severe pain, swelling, and marked instability with a positive Lachman test of the joint. Radiographs show proximal migration of the sesamoids. What is the most appropriate management?

Explanation

This is a Grade III turf toe injury involving a complete tear of the plantar plate complex, resulting in frank instability and proximal migration of the sesamoids. Grade III injuries in high-level athletes with significant instability often require surgical repair of the plantar plate to restore push-off strength.

Question 95

A 28-year-old hockey player sustains an external rotation injury to his ankle. He is tender over the anterior inferior tibiofibular ligament (AITFL). Radiographs show no fractures, but the medial clear space is widened to 6 mm on a gravity stress view. Which of the following is true regarding the management of this injury?

Explanation

Widening of the medial clear space indicates an unstable syndesmosis injury requiring operative reduction and stabilization. Flexible fixation with suture button constructs yields similar or better clinical outcomes than rigid screws, allows earlier weight-bearing, avoids hardware removal, and is associated with a lower rate of syndesmotic malreduction.

Question 96

A 41-year-old man sustains a twisting injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. MRI confirms a purely ligamentous Lisfranc injury. He is treated with primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), which of the following is a recognized advantage of this approach for his specific injury pattern?

Explanation

In purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to yield better functional outcomes and lower rates of subsequent surgeries compared to ORIF. ORIF of ligamentous injuries often requires a second surgery for hardware removal and has a higher rate of secondary post-traumatic arthritis requiring salvage arthrodesis. Both procedures require similar postoperative immobilization protocols. Arthrodesis does not uniquely improve arch restoration over a well-reduced ORIF, nor does it necessarily decrease CRPS rates.

Question 97

A 34-year-old recreational athlete presents with a palpable gap in his posterior ankle following a sudden acceleration during a tennis match. The Thompson test is positive. He is discussing treatment options. According to recent high-quality evidence regarding acute Achilles tendon ruptures treated with an early functional rehabilitation protocol, how do the outcomes of nonoperative management compare to surgical repair?

Explanation

Recent randomized controlled trials and meta-analyses (such as those by Willits et al.) have demonstrated that when an early functional rehabilitation protocol (incorporating early weight-bearing and range of motion in a functional brace) is utilized, the rerupture rates between nonoperative and operative management of acute Achilles tendon ruptures are statistically similar. Functional outcomes and strength are also equivalent, while operative management carries a higher risk of soft tissue complications and infection.

Question 98

A 60-year-old woman with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a red, hot, swollen right foot that has been present for 3 weeks. She denies any trauma or systemic symptoms. She has palpable pedal pulses and severe peripheral neuropathy. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Her ESR is 18 mm/hr and CRP is 4 mg/L. Which of the following is the most appropriate next step in management?

Explanation

The patient presents with acute Eichenholtz stage I Charcot neuroarthropathy. The classic presentation includes a red, hot, swollen foot in a patient with profound neuropathy, often mimicking infection. Normal inflammatory markers and absence of a skin breach or ulcer make osteomyelitis highly unlikely. The gold standard for initial management of acute Charcot arthropathy is offloading via total contact casting to prevent progressive deformity while the acute inflammatory stage resolves. Surgical intervention in the acute stage is generally contraindicated due to profound hyperemia, poor bone quality, and a high risk of failure.

Question 99

A 55-year-old woman presents with progressive, painful deformity of her great toe. Clinical examination reveals severe hallux valgus with an overarching second toe and significant first ray hypermobility in the sagittal plane. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 20 degrees, and no signs of degenerative joint disease at the first metatarsophalangeal joint. Which of the following procedures is most appropriate?

Explanation

The patient has a severe hallux valgus deformity (Intermetatarsal Angle > 15°, Hallux Valgus Angle > 40°) accompanied by first ray hypermobility. The Lapidus procedure (first tarsometatarsal joint arthrodesis) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and addresses the underlying hypermobility by stabilizing the medial column. Distal chevron is indicated for mild-to-moderate deformity. First MTP arthrodesis is typically reserved for hallux valgus with concurrent severe degenerative changes (hallux rigidus) or in recurrent/salvage situations.

Question 100

A 48-year-old woman complains of progressive medial ankle pain and flattening of her right foot arch over the past year. She is unable to perform a single-leg heel raise on the right side. Examination reveals a flexible pes planovalgus deformity with 'too many toes' visible from behind. Radiographs of the foot show increased talonavicular uncoverage but no arthritic changes in the subtalar, talonavicular, or calcaneocuboid joints. Nonoperative management with a custom orthosis has failed. What is the most appropriate surgical intervention?

Explanation

This patient presents with Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible flatfoot deformity, inability to perform a single-leg heel rise, and the absence of significant degenerative arthritis in the hindfoot. The standard surgical treatment for Stage II disease that has failed conservative management includes a soft tissue procedure (such as FDL transfer to the navicular to replace the dysfunctional posterior tibial tendon) combined with a bony procedure to correct the deformity and protect the transfer (most commonly a medial displacement calcaneal osteotomy). Triple arthrodesis is indicated for Stage III disease, which presents with a rigid deformity and arthritic changes.

AAOS & ABOS Foot & Ankle Board Review MCQs (Set 2): Ankle Fractures, Lisfranc, Diabetic Foot

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index