ORTHOPEDICS HYPERGUIDE 2022 MCQ-1301-1350

1301. (3342) Q3-4204:

Patients sustaining a crushing injury to the foot with midfoot tenderness but without any radiographic signs of fracture or dislocation:

1) Should be managed with a postoperative shoe and early physical therapy until the tenderness resolves

3) Should be protected in a cast boot with early weight bearing to tolerance

2) Should be splinted and kept non-weight bearing until nontender

5) C an be discharged with no further follow-up

4) Requires open reduction internal fixation to prevent long-term arthritis

Patients who sustain a foot injury and have clinical midfoot tenderness should be assumed to have a serious midfoot sprain until proven otherwise. These patients should be protected non-weight bearing until the tenderness is gone before weight-bearing and physical therapy begins.

■Correct Answer: Should be splinted and kept non-weight bearing until nontender

1302. (3343) Q3-4206:

The calcaneal compartment of the foot contains all of the following structures except:

1) Quadratus plantae muscle

3) Lateral plantar nerve, artery, and vein

2) Posterior tibial nerve, artery, and vein

5) 1st dorsal metatarsal artery

4) Interossei muscles

The four interossei muscles are contained in their respective interosseous compartments. The calcaneal compartment may also variably contain the medial plantar nerve. The remaining compartments of the foot are the adductor, medial, lateral, and superficial.

■Correct Answer: Interossei muscles

1303. (3344) Q3-4211:

Time to radiographic fusion following arthroscopic ankle arthrodesis is:

1) Longer than following an open technique arthrodesis

3) The same as open technique

2) Shorter than following an open technique arthrodesis

5) Is affected by whether two-screw or three-screw fixation is utilized

4) Is affected by whether external bone stimulation is utilized

Time to radiographic fusion following arthroscopic ankle arthrodesis is shorter than following open ankle arthrodesis. Theoretically, the decreased dissection and soft-tissue stripping contributes to greater vascular inflow to heal the fusion site.

■Correct Answer: Shorter than following an open technique arthrodesis

1304. (3345) Q3-4213:

Neighboring joint arthritis following ankle arthrodesis has not been found in the:

1) Knee joint

3) First metatarsophalangeal joint

2) Naviculocuneiform joint

5) Hindfoot joint

4) Subtalar joint

Long-term follow-up of ankle fusions show that nearly all patients develop arthritis in the hindfoot, midfoot, and 1st metatarsophalangeal joint. There is no evidence to show that the hip or knee is at greater risk for developing arthritis following ankle fusion.

■Correct Answer: Knee joint

1305. (3346) Q3-4214:

Range of motion following total ankle replacement is closely correlated with:

1) Amount of osteophytes resected during surgery

3) Level of tibial and talar saw cuts

2) Meticulous ligament balancing

5) Size of implant

4) Preoperative range of motion

A radiographic study comparing preoperative to postoperative tibio-talar range of motion as measured by radiographs showed that the amount of motion that patients had following ankle replacement was most dependent upon the motion they had before surgery.

■Correct Answer: Preoperative range of motion

1306. (3347) Q3-4215:

Take-down of ankle arthrodesis and conversion to total ankle replacement:

1) Is impossible if the fibula has been resected

3) Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

2) Is a dependable procedure with a rate of complications similar to primary ankle replacement

5) Requires custom made prosthetic implants

4) Results in minimal gains in ankle range of motion

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patientâs pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.

■Correct Answer: Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

1307. (3348) Q3-4216:

Development of hindfoot arthritis following total ankle replacement is seen in:

1) 0% of patients

3) 50% of patients

2) <25% of patients

5) >75% of patients

4) 75% of patients

Although it is felt that the retention of some degree of ankle motion with ankle replacement can help prevent the development of hindfoot arthritis, in a 9-year follow-up study nearly 25% of patients still had radiographic signs of arthritis.

■Correct Answer: <25% of patients

1308. (4062) Q3-4217:

C linical improvement following ankle distraction arthroplasty:

1) Typically reaches its maximal improvement by the end of 1 year

3) C an take up to 5 years to reach maximal improvement

2) Is accompanied by major gains in ankle range of motion

5) Is usually realized within the first month following removal of the frame

4) Is not accompanied by improvement in radiographic joint space

Distraction arthroplasty with an Ilizarov external fixator is usually associated with half of the clinical improvement occurring within the first year, and the other half happening over the next 5 years.

■Correct Answer: C an take up to 5 years to reach maximal improvement

1309. (3349) Q3-4222: Isolated subtalar arthrodesis:

1) Increases transverse tarsal joint over time

3) Decreased talonavicular joint motion but increases calcaneocuboid joint motion

2) Decreases talonavicular motion less than calcaneocuboid motion

5) Increases subtalar motion

4) Decreases talonavicular motion more than calcaneocuboid motion

Subtalar fusion decreased talonavicular motion more so than calcaneocuboid motion in this cadaver study. Isolated talonavicular fusion is the most influential of the hindfoot joints, locking hindfoot motion.

■Correct Answer: Decreases talonavicular motion more than calcaneocuboid motion

1310. (3350) Q3-4225:

Which injury is likely to have a worse clinical outcome:

1) A purely ligamentous Lisfranc injury

2) A Lisfranc fracture-dislocation

Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.

■Correct Answer: A

purely ligamentous Lisfranc injury

1311. (3443) Q3-4368:

C urrently recommended indications for surgical management of hallux rigidus with an arthrodesis include:

1) Positive axial grind test on preoperative clinical examination

3) Osteophytes over the dorsolateral head of the first metatarsal

2) >50% of the cartilage on the metatarsal head remaining

5) Normal first metatarsophalangeal joint motion

4) Osteophytes over the dorsal aspect of the proximal phalanx

C oughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.

■Correct Answer: Positive axial grind test on preoperative clinical examination

1312. (3452) Q3-4380:

The main blood supply to the talar body is from the:

1) Peroneal artery

3) Artery of the tarsal canal

2) Dorsalis pedis artery

5) 1st dorsal metatarsal artery

4) Artery of the sinus tarsi

The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. The dorsalis pedis and the artery of the sinus tarsi supply the talar head.

■Correct Answer: Artery of the tarsal canal

1313. (3460) Q3-4392:

How many weeks following open reduction and internal fixation of a right ankle fracture can patients resume driving with normal braking times:

1) 6 weeks

3) 12 weeks

2) 9 weeks

5) 18 weeks

4) 16 weeks

Total braking time following open reduction and internal fixation of right ankle fractures was tested at 6, 9, and 12 weeks postoperatively. These patients were managed with a functional brace, non-weight bearing, and early range of motion in the postoperative period. Braking time was significantly slower than normal at 6 weeks, but had returned to near normal by 9 weeks postoperatively.

■Correct Answer: 9 weeks

1314. (3467) Q3-4404:

When using external fixation in the treatment of tibial pilon fractures, distal transfixation wires:

1) Should always traverse the distal tibia-fibula joint to get optimal fixation

3) Are not at risk for causing joint infection

2) Should remain >12.2 mm above the subchondral plate of the distal tibia

5) C annot be olive wires because of a higher risk for pin-tract infection

4) Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle

In cadaver specimens, the anterolateral capsular reflection of the ankle joint extended proximally the highest with an average of

9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.

■Correct Answer: Should remain >12.2 mm above the subchondral plate of the distal tibia

1315. (3470) Q3-4407:

Treatment of significant loss of height and posttraumatic arthritis following nonoperative treatment of calcaneus fractures should include:

1) Subtalar distraction bone block arthrodesis

3) Tibiotalocalcaneal arthrodesis

2) C orrective osteotomy

5) C ustom orthotics with lateral heel posting

4) C ustom Arizona ankle brace with heel lift

Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge-shaped structural bone graft.

■Correct Answer: Subtalar distraction bone block arthrodesis

1316. (3471) Q3-4408:

Incisions made through blood-filled fracture blisters have:

1) A lower risk of wound healing problems than clear fluid-filled fracture blisters

3) The same ability to heal as clear fluid-filled fracture blisters

2) No increased risk of wound healing problems than through normal skin

5) Should be left open to heal by secondary intention

4) A higher risk of wound healing problems than clear fluid-filled fracture blisters

Biopsies of the edge of fracture blisters following ankle fracture show that blood-filled blisters represent a deeper injury than clear fluid-filled blisters. The dermis of clear blisters still showed some epithelial cells remaining, while the dermis of blood blisters showed no epithelial cells. Therefore, blood-filled blisters are more difficult to heal.

■Correct Answer: A higher risk of wound healing problems than clear fluid-filled fracture blisters

1317. (3472) Q3-4409:

Following triple arthrodesis, ankle range of motion is:

1) Unaffected

3) Decreased

2) Increased

5) Increases initially, but then returns to preoperative levels

4) Improves over time

This clinical study following triple arthrodesis patients for 10 years showed a 27% loss of ankle plantarflexion but no loss of dorsiflexion.

■Correct Answer: Decreased

1318. (3473) Q3-4410:

A Moberg procedure for hallux rigidus is:

1) An oblique first metatarsal shortening osteotomy

3) A medial closing wedge osteotomy of the proximal phalanx

2) An ostectomy of the medial eminence of the metatarsal

5) A lateral closing wedge osteotomy of the proximal phalanx

4) A dorsal closing wedge osteotomy of the proximal phalanx

The Moberg procedure involves a dorsal closing wedge osteotomy of the proximal phalanx. This sets the hallux higher off the floor, allowing for easier toe-off with less dorsal impingement during gait.

■Correct Answer: A dorsal closing wedge osteotomy of the proximal phalanx

1319. (3475) Q3-4413:

The distinguishing factor in a Hawkins type 4 talar neck fracture is:

1) The presence of an incongruent ankle joint

3) The presence of an incongruent subtalar joint

2) The presence of a talonavicular dislocation

5) The presence of an associated talar body fracture

4) The presence of an associated talar body fracture

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.

■Correct Answer: The presence of a talonavicular dislocation

1320. (3476) Q3-4414:

First metatarsophalangeal prosthetic joint replacements:

1) Significantly increase joint range of motion

3) Provide less pain relief than first metatarsophalangeal arthrodesis

2) Have less complications than first metatarsophalangeal arthrodesis

5) Provide greater pain relief than first metatarsophalangeal arthrodesis

4) Have not been found to undergo osteolysis or loosening

First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.

■Correct Answer: Provide less pain relief than first metatarsophalangeal arthrodesis

1321. (3479) Q3-4418:

The optimal position for ankle arthrodesis is:

1) 5° plantarflexion, 5° valgus, 5° external rotation

3) Neutral flexion, 0° varus/valgus, 5° external rotation

2) Neutral flexion, 5° valgus, 5° external rotation

5) 5° dorsiflexion, 5° valgus, 5° external rotation

4) Neutral flexion, 5° valgus, 5° internal rotation

The optimal position for ankle arthrodesis is neutral flexion, 5° valgus, and 5° external rotation. Historically, surgeons thought that women should be fused in some amount of equinus to better allow them to wear heeled shoes. However, this can increase the development of neighboring joint arthritis and also create a knee recurvatum deformity when ambulating barefoot. C urrently it is recommended that all patients are fused in neutral dorsi-/plantarflexion.

■Correct Answer: Neutral flexion, 5° valgus, 5° external rotation

1322. (3480) Q3-4420: Isolated talonavicular fusion:

1) Decreases subtalar motion by 25%

3) Locks subtalar motion

2) Decreases subtalar motion by 50%

5) Decreases subtalar motion by 10%

4) Has no effect on subtalar motion

This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talo- navicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.

■Correct Answer: Locks subtalar motion

1323. (3481) Q3-4421:

The distinction between a Lauge-Hansen supination-external rotation III injury and a Lauge-Hansen supination-external rotation

IV injury is:

1) A spiral oblique fracture of the lateral malleolus

3) Posteroinferior tibiofibular ligament (PITFL) disruption or posterior malleolus fracture

2) Anteroinferior tibiofibular ligament (AITFL) disruption

5) Anterior talo-fibular ligament disruption

4) Deltoid ligament disruption or medial malleolus fracture

The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.

■Correct Answer: Deltoid ligament disruption or medial malleolus fracture

1324. (3482) Q3-4422: Isolated subtalar fusion:

1) Is not associated with development of ankle or transverse tarsal joint arthritis

3) Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared

2) Is associated only with development of transverse joint arthritis, but the ankle joint is spared

5) Is associated with knee joint degenerative arthritis

4) Is associated with the development of both ankle and transverse tarsal joint arthritis

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.

■Correct Answer: Is associated with the development of both ankle and transverse tarsal joint arthritis

1325. (3488) Q3-4428:

The optimal position for hallux interphalangeal joint arthrodesis is:

1) 5° to 10° of plantarflexion

3) Neutral flexion

2) 5° to 10° of dorsiflexion

5) 10° of valgus

4) Slight supination of the toe

The optimal position for hallux interphalangeal joint arthrodesis is 5° to 10° of plantarflexion, neutral varus-valgus, and neutral rotation. The plantarflexion helps the toe pad to contact the ground during gait.

■Correct Answer: 5° to 10° of plantarflexion

1326. (3501) Q3-4451:

Following anatomic open reduction and internal fixation of a Lisfranc fracture-dislocation:

1) Development of tarsometatarsal arthritis will not occur.

3) If tarsometatarsal arthritis develops, then subsequent arthrodesis is required.

2) Tarsometatarsal arthritis may still arise in approximately 25% of patients.

5) The screws should be routinely removed at 6 weeks.

4) The screws should be routinely removed at 12 weeks.

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.

■Correct Answer: Tarsometatarsal arthritis may still arise in approximately 25% of patients.

1327. (3504) Q3-4455:

The maximal joint reactive force in the ankle is approximately:

1) Two times body weight

3) Five times body weight

2) Three times body weight

5) Eight times body weight

4) Seven times body weight

Stauffer and colleagues quantified ankle joint reactive force to be approximately 5 times body weight. This is a significant concern for prosthetic ankle arthroplasty because the implant surface area is relatively small over which these forces must be spread out.

■Correct Answer: Five times body weight

1328. (3510) Q3-4462:

Hallux rigidus is associated with:

1) Metatarsus primus elevatus

3) Long first metatarsal

2) First ray hypermobility

5) Bipartate sesamoid

4) Flat- or chevron-shaped metatarsal head

In a large series of patients with hallux rigidus, risk factors were evaluated. The only factor that had a positive correlation with having hallux rigidus was the radiographic shape of the 1st metatarsal head. Metatarsus primus elevatus, first ray hypermobility, or long first metatarsal head were not significantly associated with hallux rigidus.

■Correct Answer: Flat- or chevron-shaped metatarsal head

1329. (3742) Q3-7522:

Which nerve is NOT one of the terminal branches of Baxterâs nerve, also known as the first branch of the lateral plantar nerve:

1) Nerve to the medial calcaneal periosteum (sensory)

3) Nerve to the flexor digitorum brevis muscle (motor)

2) Lateral dorsal cutaneous nerve (sensory)

5) None of the above

4) Nerve to the abductor digiti minimi muscle (motor)

The three terminal branches of Baxterâs nerve are the nerve to the medial calcaneal periosteum, the nerve to the flexor digitorum brevis, and the nerve to the abductor digiti minimi. The lateral dorsal cutaneous nerve is a branch of the sural nerve.

■Correct Answer: Lateral dorsal cutaneous nerve (sensory)

1330. (3814) Q3-7597:

A regimen of ankle bracing and supervised physical therapy:

1) Has no beneficial effect on stage II posterior tibial tendon dysfunction

3) C an significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction

2) Is helpful in relieving the pain symptoms associated with stage II posterior tibial tendon dysfunction but does not increase strength

5) Prevents patients from requiring surgery in only 11% of cases

4) Is only useful for postoperative rehabilitation after flexor digitorum longus tendon transfer and medial slide calcaneal osteotomy

In a study performed by Alvarez and colleagues, 47 patients with stage I or II posterior tibial tendon dysfunction were treated nonoperatively with either a hinged ankle-foot orthosis or foot orthosis and a supervised physical therapy program. After 10 therapy visits, 83% of patients had successful subjective and functional outcomes. Eighty-nine percent of patients were satisfied with the outcome of nonoperative treatment. This included significant improvement in visual analog scale scores and increased strength, concentrically and eccentrically. In this study, 11% of patients failed conservative treatment and required surgery.

■Correct Answer: C an significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction

1331. (3815) Q3-7598:

The use of hyperbaric oxygen (HBO) in the treatment of problematic diabetic foot wounds has been shown to do all of the following except:

1) To increase the healing rate

3) To be potentially cost-effective when the costs of long-term care of a nonhealing wound and limb amputation are considered

2) To decrease the amputation rate

5) To increase the juxta-wound pO2

4) To be ineffective in changing the outcome of diabetic foot wounds

A meta-analysis of 12 studies showed that healing rates increased from 48% to 76%, and amputation rates decreased from 45% to 19% with the use of hyperbaric oxygen (HBO) and local wound care. In randomized controlled trials, wound area decreased significantly and days to healing decreased significantly in patients treated with HBO. The juxta-wound pO2 was also significantly increased in the HBO-treatment group.

■Correct Answer: To be ineffective in changing the outcome of diabetic foot wounds

1332. (3816) Q3-7599:

The greatest insult to the vascular supply of the first metatarsal head during chevron bunionectomy with lateral release according to intraoperative laser Doppler blood flow measurements was:

1) During the lateral release

3) During the metatarsal osteotomy

2) During the adductor tenotomy

5) During skin incision

4) During the medial capsular release

Twenty patients were prospectively monitored with laser Doppler measurements of metatarsal head blood flow during chevron bunionectomy with lateral release. The greatest loss of blood flow occurred with the medial capsulotomy (45% decrease). The lateral release combined with the adductor tenotomy decreased the blood flow to the metatarsal head by 13%, and the metatarsal osteotomy decreased blood flow by an additional 13%. Total decrease in blood flow to the head was 71%. No patients developed avascular necrosis.

■Correct Answer: During the medial capsular release

1333. (3817) Q3-7600:

In a randomized controlled trial comparing first metatarsophalangeal arthrodesis versus total joint replacement arthroplasty for end-stage hallux rigidus, all of the following statements are true except:

1) There was a significant improvement in functional outcome in the arthrodesis group compared to the arthroplasty group.

3) Following arthroplasty, patients tend to bear weight on the lateral border of the foot.

2) Following arthroplasty, there was a significant increase in dorsiflexion compared to preoperative status.

5) Fusion had a lower complication rate than arthroplasty.

4) The cost ratio was 2:1 in favor of arthrodesis.

In the study by Gibson and Thomson, 38 fusions and 39 arthroplasties were prospectively compared at 2-year follow-up. There was an 82% improvement in the arthrodesis group and only a 45% improvement in the arthroplasty group. Fusion also had lower complication rates and lower cost. There was not a significant increase in first metatarsophalangeal joint dorsiflexion between preoperative and postoperative levels following total joint replacement.

■Correct Answer: Following arthroplasty, there was a significant increase in dorsiflexion compared to preoperative status.

1334. (3818) Q3-7601:

The nonunion rate for the Lapidus procedure (first tarsometatarsal arthrodesis) for the treatment of moderate to severe hallux valgus is:

1) 2%

3) 15%

2) 7%

5) 25%

4) 20%

In a prospective cohort study following 105 Lapidus bunionectomies for 3.7 years, the nonunion rate was found to be 6.7%. The American Orthopaedic Foot & Ankle Society scores improved significantly, and loss of correction over 3.7 years was less than 1° for intermetatarsal and hallux valgus angles.

■Correct Answer: 7%

1335. (3819) Q3-7602:

When using external fixation in the treatment of tibial pilon fractures, distal transfixation wires:

1) Should always traverse the distal tibia-fibula joint for optimal fixation

3) Are not at risk for causing joint infection

2) Should remain more than 12.2 mm above the subchondral plate of the distal tibia

5) Should remain at least 5 mm above the subchondral plate of the distal tibia

4) Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle

In a cadaveric and in vivo study of the reflections of the ankle joint capsule, the distal tibia-fibula joint was found to communicate with the ankle joint capsule, thus representing a risk for ankle sepsis if it is penetrated by a transfixion wire. The anterolateral capsule displayed the most proximal reflection in all specimens.

■Correct Answer: Should remain more than 12.2 mm above the subchondral plate of the distal tibia

1336. (3820) Q3-7603:

The best clinical outcome following a primarily ligamentous Lisfranc injury is with:

1) Protected weight-bearing and early range of motion in a removable boot

3) Open reduction and internal fixation of the Lisfranc injury

2) Non-weight bearing in a fiberglass cast

5) Primary repair of the ligaments

4) Primary arthrodesis of the Lisfranc injury

Forty-one patients were prospectively randomized into traditional open reduction internal fixation (ORIF) versus primary arthrodesis. The American Orthopaedic Foot & Ankle Society scores at 2-year follow-up were significantly better in the fusion group versus the ORIF group. Of the patients in the ORIF group, 25% later developed arthritis and were converted to fusions.

■Correct Answer: Primary arthrodesis of the Lisfranc injury

1337. (3821) Q3-7604:

The clinical variable found to be associated with a higher risk of complications following open reduction and internal fixation of unstable ankle fractures in diabetic patients was:

1) Presence of a severe fracture pattern

3) Insulin-dependent diabetes mellitus

2) Presence of an open fracture

5) Presence of nephropathy

4) Peripheral neuropathy or vasculopathy

A retrospective Level IV study followed 84 patients with diabetes who underwent open reduction internal fixation of unstable ankle fractures. After analyzing multiple patient factors including sex, fracture pattern, open or closed injury, nephropathy, hypertension, vasculopathy, peripheral neuropathy, and diabetic control (insulin-dependent compared with non-insulin- dependent), the only factors that predicted a higher rate of complications were vasculopathy and peripheral neuropathy. There was a 12% rate of postoperative infection and an overall 14% rate of complications.

■Correct Answer: Peripheral neuropathy or vasculopathy

1338. (3822) Q3-7605:

Which modality for the treatment of chronic insertional Achilles tendinopathy was shown to have the best clinical outcome:

1) C oncentric Achilles tendon stretching

3) Short-term immobilization of the ankle in equinus

2) Eccentric Achilles tendon stretching

5) Topical anesthetic

4) Low-energy shockwave therapy

A randomized controlled trial compared recalcitrant insertional Achilles tendinopathy treated with eccentric heel cord stretching versus low-energy shockwave therapy. At 4 months, 28% of the stretching group and 64% of the shockwave therapy group reported complete relief of symptoms or greatly improved symptoms. All outcome measures showed favorable results with shockwave therapy.

■Correct Answer: Low-energy shockwave therapy

1339. (3823) Q3-7606:

Urgent closed reduction of ankle fracture-dislocations using intraarticular lidocaine injection:

1) Provides a similar degree of analgesia compared to conscious sedation

3) Results in inferior reduction of ankle deformity compared to conscious sedation

2) Requires more time to perform the reduction and splint the leg than with conscious sedation

5) Is painful due to distension of the joint capsule

4) Requires frequent repeat reduction procedures due to persistent fracture malalignment

A prospective randomized study compared intraarticular lidocaine injection to conscious sedation for analgesia during reduction of ankle fracture-dislocations. There was no difference in the amount of analgesia provided by the two methods. Time for reduction and splinting was less in the local anesthetic group. Quality of reduction was similar in both groups.

■Correct Answer: Provides a similar degree of analgesia compared to conscious sedation

1340. (3865) Q3-7648:

A tailorâs bunion is an abnormal prominence of the lateral aspect of the 5th metatarsal head. Similar to hallux valgus deformities, tailorâs bunions can be due to a widened intermetatarsal angle between the 4th and 5th metatarsal shafts. The normal 4-5 intermetatarsal angle is:

1) Less than 8°-9°

3) Less than 15°

2) Less than 12°

5) Less than 25°

4) Less than 20°

4-5 intermetarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.

■Correct Answer: Less than 8°-9°

1341. (3866) Q3-7649:

A 54-year-old woman with a 10-year history of type II diabetes mellitus develops a Wagner grade 2 ulceration under the first metatarsal head, which has not healed for 3 months. There is no gross cellulitis or drainage. A tagged white blood cell scan shows no signs of osteomyelitis, and noninvasive vascular studies reveal normal hemodynamics. She has failed wet-to-dry normal saline dressings and bacitracin ointment local wound care. The next step in treating this patientâs chronic ulcer is:

1) Application of hydro-colloid gel dressings

3) Application of a total contact cast by a qualified physician or cast technician

2) Use of a custom-made pressure off-loading plastizote insole

5) Amoxicillin/clavulanate  potassium 875 mg twice daily

4) Regular debridment of the ulcer

The description of the ulcer indicates that it is not grossly infected and that there is no underlying bony involvement. According to evidence based medicine, the only treatments that are likely to be effective in the healing of diabetic foot ulcerations are topical growth factors, total contact casting, and for severely infected ulcers hyperbaric oxygen.

■Correct Answer: Application of a total contact cast by a qualified physician or cast technician

1342. (3916) Q3-7796:

Which is the best match in surface topography when performing an osteochondral autograft transplantation procedure from the distal femur to the talar dome for an osteochondral lesion of the talus:

1) From the superior-medial femoral condyle to the antero-medial talar dome

3) From the superior-lateral femoral condyle to any position on the medial talar dome

2) From the inferior-medial femoral condyle to the postero-medial talar dome

5) From the inferior-lateral femoral condyle to the antero-medial talar dome

4) From the inferior-medial femoral condyle to the centro-medial talar dome

In a magnetic resonance imaging topography study looking for the best corresponding shape of the articular surface between the non-weightbearing femoral condyle and the medial talar dome, plugs from the supero-lateral femoral condyle had the best fit with osteochondral lesions of the medial talus in the anterior, central, and posterior zones.

■Correct Answer: From the superior-lateral femoral condyle to any position on the medial talar dome

1343. (3918) Q3-7852:

The most frequent location for osteochondral lesions of the talar dome is:

1) Anterolateral talar dome (Raikin zone 3)

3) Lateral talar dome, mid-body (Raikin zone 6)

2) Posteromedial talar dome (Raikin zone 7)

5) Anteromedial talar dome (Raikin zone 1)

4) Medial talar dome, mid-body (Raikin zone 4)

A survey of 428 osteochondral lesions of the talus was undertaken using a nine zone anatomical grid system to determine the most frequent location in which these lesions occur. Results showed that 62% of lesions occurred in the medial talar dome and

34% over the lateral talar dome. The most frequent location along the medial dome was the mid-body of the talus. Medial lesions were larger in surface area as well as deeper than lateral lesions.

■Correct Answer: Medial talar dome, mid-body (Raikin zone 4)

1344. (3919) Q3-7853:

Which gait parameters are significantly improved following first metatarsophalangeal arthrodesis for symptomatic hallux rigidus:

1) Maximal ankle push off power

3) Walking velocity

2) Stride length

5) Foot progression angle

4) C adence

A prospective gait study was performed measuring various gait parameters 1 week prior to and 1 year following first metatarsophalangeal joint arthrodesis. The three significant changes in gait were increased maximal ankle push off power, increased single limb support time on the affected limb, and decreased step width. Stride length, walking velocity, and cadence were not significantly different after fusion.

■Correct Answer: Maximal ankle push off power

1345. (3920) Q3-7855:

Which clinical or radiographic finding is not commonly associated with moderate or severe hallux valgus deformity in adults:

1) Positive family history

3) Oval or curved metatarsophalangeal joint on radiographs

2) Presence of bilateral bunion deformity

5) Achilles tendon contracture

4) Longer 1st metatarsal than 2nd metatarsal

A clinical series of 122 bunions was evaluated for demographic, etiologic, and radiographic findings associated with moderate to severe hallux valgus deformity. The following findings were reported:

83% of patients had a positive family history of bunions

84% of patients had bilateral bunion deformities

71% of patients had curved or oval-shaped metatarsophalangeal joints

71% of patients had a longer 1st metatarsal compared to the 2nd metatarsal by an average of 2.4 mm

11% of bunions were associated with an Achilles tendon contracture

■Correct Answer: Achilles tendon contracture

1346. (3921) Q3-7856:

A 58-year-old runner has symptoms of chronic noninsertional Achilles tendinopathy for 8 months. Rest, ice, anti-inflammatory medications, and heel wedges have not helped. Which of the following treatments may help alleviate this patientâs symptoms:

1) C oncentric Achilles tendon stretching

3) Intratendinous cortisone injection

2) Topical lidocaine patches

5) Oral fluorquinolone therapy

4) Topical glyceryl trinitrate

Noninsertional Achilles tendinosis is a noninflammatory degenerative condition that is common in middle-aged athletes. In a 3- year follow-up study examining the use of topical glyceryl trinitrate for Achilles tendinosis, patients were noted to have significantly less tendon tenderness and improved clinical scores compared to the placebo group. At 3 years, 88% of treated patients were asymptomatic. Novel nonoperative measures include sclerosing injections into the Achilles tendon with polidocanol and shock-wave therapy to the Achilles tendon.

■Correct Answer: Topical glyceryl trinitrate

1347. (3922) Q3-7858:

When comparing complication rates following operative and nonoperative management of ankle fractures in the elderly (age 65-

99):

1) Operatively managed patients have a higher mortality rate and a higher rehospitalization rate than conservatively managed patients.

3) Operatively managed patients have a lower mortality rate and a lower rehospitalization rate than conservatively managed patients.

2) Operatively managed patients have a higher mortality rate but a lower rehospitalization rate than conservatively managed patients.

5) Operatively managed patients have a high rate of revision of internal fixation, conversion to arthroplasty or arthrodesis, or amputation.

4) Operatively managed patients have a lower mortality rate but a higher rehospitalization rate than conservatively managed patients.

A study using the National Medicare C laims History System was performed looking at outcomes following ankle fracture in 33,704 elderly patients, specifically looking at mortality, rehospitalization, and the need for additional surgery. Researchers found that conservatively managed patients had a higher mortality rate up to 2 years following injury compared to patients who underwent open reduction internal fixation. Operatively treated patients had a higher rate of rehospitalization following their injury. Less than

1% of patients required revision of internal fixation, arthroplasty, arthrodesis, or amputation.

■Correct Answer: Operatively managed patients have a lower mortality rate but a higher rehospitalization rate than conservatively managed patients.

1348. (3923) Q3-7861:

Exposure of tendons to ciprofloxacin in vitro causes all of the following except:

1) A decrease in fibroblast proliferation

3) A decrease in proteoglycan synthesis

2) An increase in proteoglycan synthesis

5) A decrease in collagen synthesis

4) An increase in matrix degrading proteolytic activity

C iprofloxacin was shown to cause a decrease in fibroblast proliferation, proteoglycan synthesis, and collagen synthesis. Matrix degrading proteolytic activity was increased.

■Correct Answer: An increase in proteoglycan synthesis

1349. (3924) Q3-7863:

Following first metatarsophalangeal joint cheilectomy for hallux rigidus, which patient parameter is NOT altered compared to preoperative values:

1) Shifting of plantar forefoot pressures medially toward the hallux

3) Increased first metatarsophalangeal joint dorsiflexion during gait

2) Increased active dorsiflexion of the first metatarsophalangeal joint

5) Increased hallux abduction

4) Decreased first metatarsophalangeal joint plantarflexion at rest

The resting position of the hallux in normal patients is 20° of dorsiflexion relative to the first metatarsal shaft. In patients with hallux rigidus, the resting position is decreased to 10° of dorsiflexion relative to the metatarsal shaft. This relatively plantarflexed position was not improved to a more normal value following cheilectomy.

■Correct Answer: Decreased first metatarsophalangeal joint plantarflexion at rest

1350. (3925) Q3-7865:

The Brostrom lateral ligament reconstruction is a reliable technique for primary stabilization of ankle instability. The Gould modification of this technique uses which structure to reinforce the repair:

1) One half of the peroneus brevis

3) The calcaneofibular ligament

2) One half of the peroneus longus

5) The posterior inferior tibiofibular ligament

4) The inferior extensor retinaculum

The initial description of the Gould modification of the Brostrom procedure recommended âsuturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculumâ.

■Correct Answer: The inferior extensor retinaculum