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1
Q

A 21-year-old collegiate basketball player comes down with a rebound and rolls his ankle. He is able to finish the game, but complains of ankle pain and swelling afterwards. Physical exam is notable for moderate inversion laxity with the ankle held in dorsiflexion. With placement of the ankle in plantarflexion, no inversion laxity is appreciated. Which of the following ligaments has been attenuated?

QID:3185

1 Anterior talofibular ligament

2 Calcaneofibular ligament

3 Anterior tibiofibular ligament

4 Posterior tibiofibular ligament

5 Deltoid ligament

A

Anterior talofibular ligament

19%

(358/1928)

2

Calcaneofibular ligament

71%

(1374/1928)

3

Anterior tibiofibular ligament

5%

(100/1928)

4

Posterior tibiofibular ligament

4%

(68/1928)

5

Deltoid ligament

1%

(23/1928)

The primary static stabilizers of the lateral ankle are the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. The calcaneofibular ligament becomes most taut with the ankle dorsiflexed and inverted. Conversely, the anterior talofibular ligament is most tensioned with the ankle plantarflexed and inverted. The anterior and posterior tibiofibular ligaments contribute stability to the tibiofibular articulation and syndesmosis. The deltoid ligament is the primary stabilizer medially and is stressed with ankle eversion testing.

2
Q

A 51-year-old male postal worker presents complaining of ankle pain that makes completing his occupational duties difficult. He has taken nonsteroidal anti-inflammatory medications over the counter on his own, but this is his first time seeking professional consultation for his problem. His ankle has limited range of motion with pain throughout an arc of motion. There is no point tenderness and painless inversion/eversion of the hindfoot. No skin breakdown, swelling, or erythema is noted. Radiographs of his ankle are seen in Figures A and B. What is the next most appropriate intervention?

QID:5642

FIGURES:

A https://upload.orthobullets.com/question/5642/images/ankle_arthritis_ap.jpg

B https://upload.orthobullets.com/question/5642/images/ankle_arthritis_lateral.jpg

1 Opiate pain medications and limited weightbearing for 6 weeks

2 Cast immobilization and non-weight bearing 12 weeks

3 Intraarticular corticosteroid injection and a cushioned rocker-bottom shoe

4 Triple arthrodesis and a cushioned rocker-bottom shoe

5 Pan-talar arthrodesis and a cushioned rocker-bottom shoe

A

Opiate pain medications and limited weightbearing for 6 weeks

1%

(13/1426)

2

Cast immobilization and non-weight bearing 12 weeks

3%

(38/1426)

3

Intraarticular corticosteroid injection and a cushioned rocker-bottom shoe

66%

(940/1426)

4

Triple arthrodesis and a cushioned rocker-bottom shoe

12%

(173/1426)

5

Pan-talar arthrodesis and a cushioned rocker-bottom shoe

17%

(248/1426)

For this patient with tibiotalar arthritis the first step in treatment would be non-operative measures such as a corticosteroid injection and cushioned rocker-bottom shoe.

Tibiotalar arthritis in high demand patients can be painful and debilitating. The first step in treatment would be non-operative measures such as a corticosteroid injection to help decrease pain, and a cushioned rocker-bottom shoe to limit motion in the ankle during gait. A cane or other supportive device could also be considered. If these modalities fail then surgery can be considered. Young, active patients should be considered for a fusion while older low-demand patients may consider total ankle arthroplasty.

Labib et al. present a review of the treatment of ankle arthritis. They note that non-operative measures should be explored first, and only when those fail should surgical procedures such as arthrodesis or arthroplasty be considered. They note that if pain is present only at the end of dorsiflexion motion, then arthroscopic anterior spur debridement may be beneficial. If malalignment is present, a supramaleolar osteotomy may be needed.

Thomas et al. reviewed intermediate outcomes in 26 patients who underwent ankle arthrodesis for end stage tibiotalar arthritis. Pain relief and patient satisfaction were good, but gait analysis demonstrated significant differences in cadence and stride length, and hindfoot motion was limited. They recommend ankle arthrodesis for relief of pain and improvement of function, but counsel patients on alteration of gait.

Incorrect answers:
Answer 1: While activity modification is a possible non-operative treatment, a 6 week course of limited weight-bearing is unlikely to prevent the pain from his end-stage arthritis from recurring. Also, opiate pain medications should be avoided if possible.
Answer 2: Cast immobilization and non-weight bearing is unlikely to help his end-stage arthritis.
Answers 4 and 5: This patient has not yet tried any non-operative treatment aside from over the counter pain medications, so surgery would not be the next step in treatment. If surgery were pursued it would more likely be a tibiotalar arthrodesis with no indication to fuse additional joints.

3
Q

(OBQ15.222) A 52-year-old woman underwent the procedure in Figure A for posterior tibial tendon insufficiency. For what stage disease was this most likely performed? Review Topic

QID:5907

FIGURES:

A https://upload.orthobullets.com/question/5907/images/subtalar_flatfoot.jpg

1 Stage I

2 Stage IIA

3 Stage III

4 Stage IV with passively correctable ankle valgus

5 Stage IV with rigid ankle valgus

A

1 Stage I

2 Stage IIA

3 Stage III

4 Stage IV with passively correctable ankle valgus

5 Stage IV with rigid ankle valgus

The procedure shown in figure A is an isolated subtalar arthrodesis. This treatment is most appropriate in stage III posterior tibial tendon insufficiency (PTTI).

The treatment of PTTI depends on the stage of disease. In patients with stage II disease with subtalar arthritis and stage III disease, arthrodesis can be considered. While triple arthrodesis is the most common procedure, isolated subtalar and subtalar/talonavicular fusion can also be used depending on patient presentation (i.e. location of pain or presence of arthritis). While these procedures do not address the underlying flat foot, they do help improve pain.

Johnson et al. review the surgical management of stage III and IV PTTI. Arthrodesis options include isolated or a combination of subtalar, talonavicular, calcanecuboid and tibiotalar fusions. Depending on patient presentation, adjunctive procedures such as Achilles lengthening and calcaneal osteotomy may be indicated.

Kadakia et al. reviewed arthrodesis options in the hindfoot for PTTI. They state that for certain patients with most significant subtalar symptoms, isolated subtalar fusion may be appropriate.

Figure A is a lateral x-ray of a patient who underwent subtalar arthrodesis.

Incorrect Answers:
Answer 1: Stage I PTTI is typically treated with immobilization and in rare cases tenosynovectomy of the tendon.
Answer 2: Stage IIA PTTI can be surgically managed with flatfoot reconstruction (i.e. FDL transfer, calcaneal osteotomy, lateral column lengthening, spring ligament repair). Stage IIB is sometimes treated with arthrodesis in rare cases.
Answer 4: Stage IV disease with correctable ankle valgus is typically treated with triple arthrodesis and deltoid ligament reconstruction
Answer 5: Stage IV disease with rigid ankle valgus is typically treated with tibiotalocalcaneal arthrodesi

4
Q

(OBQ10.36) A 58-year-old golfer fell stepping into a sand trap and ruptured his Achilles tendon one year ago. He initially chose non-operative treatment, but became unsatisfied with a tender fullness behind his ankle and ankle weakness noticeable during his tee shots. At the time of surgery, a large disorganized fibrous mass is found at the site of rupture. Following extensive debridement there is a 5 cm gap between viable tissue ends. Which of the following surgical techniques provides the greatest likelihood of a successful clinical outcome? Review Topic

QID:3124

1- Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon

2- Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus

3- Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus

4- Reconstruction with hamstring autograft

5- Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program

A

QID:3124

1- Gastocnemius turndown repair augmented with transfer of the posterior tibial tendon

2- Gastocnemius turndown repair augmented with transfer of the extensor digitorum longus

3- Gastocnemius turndown repair augmented with transfer of the flexor hallucis longus

4- Reconstruction with hamstring autograft

5- Primary repair with the foot in maximal plantarflexion followed by a gradual stretching program

Tendon loss is a complication associated with secondary ruptures of a repaired Achilles tendon and chronic Achilles tendon ruptures. Gastrocnemius turndown utilizes a slip of the central third of the gastrocnemius tendon to bridge the gap. Flexor hallicus longus (FHL) is the preferred tendon transfer to augment tissue loss due to its proximity and vascularity. Answer choice 5 is not a prudent option given the risk of equinus contracture and recurrent rupture.

Wapner et al conducted a case review of 7 patients who underwent FHL augmentation for chronic Achilles tendon rupture. Results included no surgical complications, a small but functionally insignificant decrease in ankle and great toe range of motion, and clinical satisfaction of all 7 patients.

Chiodo et al summarize the AAOS clinical guidelines for evaluation and treatment of acute Achilles tendon ruptures predicated upon an extensive review of the literature.

Illustrations A-C depict the steps for a gastrocnemius turn-down flap consisting of a V-Y incision with the arms of the “V” measuring 6cm.

https://upload.orthobullets.com/question/3124/images/gastroc%20turndown%202b.jpg

5
Q

(OBQ14.80) A 50-year-old male presents with ongoing plantar medial heel pain for the past few months. It is associated with the first step in the morning and eases up after he takes a few additional steps. He has attempted physical therapy, including Achilles stretching, heel cups, and ice massage with no relief. On physical examination, there is pain over the plantar medial heel with a Tinel’s sign elicited just proximal to the abductor hallucis musculature. The pain radiates to the base of the 5th metatarsal. . A Tinel’s sign over the posterior tibial nerve is not found. Innervation to which anatomic structure is mostly like affected in this patient? Review Topic

QID:5490

1- Abductor hallucis

2- Abductor digiti minimi

3- FDL

4- FHL

5- Plantar fascia

A

1- Abductor hallucis

2- Abductor digiti minimi

3- FDL

4- FHL

5- Plantar fascia

Based on the clinical history and the findings on examination, the patient has entrapment of the first branch of the lateral plantar nerve (Baxter’s nerve). This will implicate nerve supply to the abductor digiti minimi

Compression of the first branch of the lateral plantar nerve (Baxter’s nerve) can be associated with plantar medial heel pain. This may be confused with plantar fasciitis. Patients with this nerve compression often have pain with compression at the origin of the abductor hallucis. The nerve travels dorsal to the fascia of abductor hallucis and plantar to the quadratus plantae. Tapping the nerve at the origin of the abductor hallucis may elicit pain that radiates towards the 5th metatarsal, as this nerve supplies the abductor digiti minimi.

https://upload.orthobullets.com/question/5490/images/trifurcation_of_ptn.jpg.jpg

6
Q

(OBQ15.268) Neurologic injury is the most common complication of ankle arthroscopy. The nerve most commonly injured is at risk during placement of which portal? Review Topic

QID:5953

1- Anterolateral

2- Anterocentral

3- Anteromedial

4- Posteromedial

5- Posterolateral

A

1- Anterolateral

2- Anterocentral

3- Anteromedial

4- Posteromedial

5- Posterolateral

The superficial peroneal nerve (SPN) is the most common nerve injured during ankle arthroscopy and is associated with anterolateral portal placement.

Ankle arthroscopy is an important therapeutic tool to manage a variety of pathologies including osteochondral defects and impingement syndrome. The average complication rate is 6-20% and the most common complication is neurologic injury. The SPN is most often injured, in part due to its variation in anatomic location. Identifying and marking important structures, as well as proper portal placement are vital to lessen the risk of neurovascular (NV) injury.

7
Q

OBQ15.54) A 70-year-old man is referred to your office for the neuropathic interphalangeal (IP) joint ulcer shown in Figure A. He had previously undergone 3 separate total contact castings (TCC) for the same complaint. There is generalized joint stiffness and hypomobility of the metatarsophalangeal and interphalangeal joints. A standing radiograph is shown in Figure B. What is the next best step? Review Topic

QID:5739

FIGURES:

A https://upload.orthobullets.com/question/5739/images/fig_a.jpg

B https://upload.orthobullets.com/question/5739/images/fig_b.jpg

1- Charcot restraint orthotic walker (CROW)

2- Resect the base of the distal phalanx

3- Resect the head of the proximal phalanx

4- Resect the base of the proximal phalanx

5- Resect the head of the metacarpal

A

1- Charcot restraint orthotic walker (CROW)

2- Resect the base of the distal phalanx

3- Resect the head of the proximal phalanx

4- Resect the base of the proximal phalanx

5- Resect the head of the metacarpal

https://upload.orthobullets.com/question/5739/images/illus_a.jpg

This patient has a plantar IP ulcer that is refractory to TCC, and rigid MTPJ. Keller resection arthroplasty (resection of the proximal phalanx base) is indicated.

Keller arthroplasty was originally developed to treat painful hallux valgus. It is also useful as a salvage procedure for plantar IP ulceration with a rigid forefoot. It is believed that decreased MTPJ motion, a known phenomenon in diabetes, leads to increased pressure over the IP joint of the great toe. The Keller procedure is motion-restoring at the MTPJ, and reduces pressure over the ulcer.

Pinzur et al. present AOFAS guidelines for diabetic foot care. They recommend a screening exam that includes includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Treatment is multimodal and combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care.

Lin et al. retrospectively compared TCC + Keller arthroplasty against TCC alone. Both groups showed ulcer healing in 3 weeks, without recurrence. They concluded that this method may be effective with diabetic neuropathic ulcers in the presence of hallux rigidus.

Figure A shows a plantar IP neuropathic ulcer. Illustration A shows the postoperative appearance after Keller resection arthroplasty maintain a plantigrade toe. A Kirschner wire is inserted to maintain a plantigrade toe, preserve a 5 mm gap at the MTP space, and to prevent cock-up toe deformity postop. Figure B shows severe joint space narrowing and sclerotic subchondral changes at the 1st MTPJ.

Incorrect Answers:
Answer 1: This patient has failed TCC. A TCC decreases high focal contact pressures by increasing the weight-bearing area of the plantar surface through a custom-molded cast. Because of closer customization, it is more effective in pressure distribution than a CROW. Patients transition from TCC (non-removable) to a CROW (removable). CROW is not indicated for failed TCC.
Answers 2, 3, 5: Keller resection arthroplasty involves motion restoration at the MTPJ through basal resection of the proximal phalanx.

8
Q

(SBQ12FA.38) A 38-year-old man presents to your clinic with long standing great toe pain. He has a positive grind test and a painful arc of motion of approximately 20 degrees. Figures A and B are his radiographs. He has failed conservative management with orthotics and anti-inflammatory medication. Which of the following surgical interventions do you recommend to give this patient the best long-term functional results and pain relief? Review Topic

QID:3845

FIGURES:

A https://upload.orthobullets.com/question/3845/images/ap.jpg

B https://upload.orthobullets.com/question/3845/images/lat.jpg

1- Dorsal synovectomy and joint debridement

2- Resection of dorsal osteophytes and ~25% of dorsal metatarsal head

3- Resurface proximal phalanx base with cobalt chrome implant

4- Joint resection and interposition of capsule and/or EHB tendon

5- Fusion in neutral rotation, 15 degrees of valgus, 10 degrees of dorsiflexion

A

1- Dorsal synovectomy and joint debridement

2- Resection of dorsal osteophytes and ~25% of dorsal metatarsal head

3- Resurface proximal phalanx base with cobalt chrome implant

4- Joint resection and interposition of capsule and/or EHB tendon

5- Fusion in neutral rotation, 15 degrees of valgus, 10 degrees of dorsiflexion

This patient has end stage hallux rigidus and would benefit most from first metatarsophalangeal joint (MTPJ) fusion in neutral rotation, 15 degrees of valgus and 10 degrees of dorsiflexion.

Hallux rigidus (HR), or degenerative joint disease of the first MTPJ, is the second most common pathology affecting the great toe after hallux valgus. Conservative management includes NSAIDs, activity modification and orthotics with a Morton’s extension to shield the first MTPJ. Mild disease (grades 1 and 2) may be treated with synovectomy, debridement and dorsal cheilectomy. The gold standard for advanced HR is first MTPJ arthrodesis.

Raikin et al performed a prospective study of 46 patients with HR who underwent either arthrodesis or metallic hemiarthroplasty. At at mean 6 years follow up, 24% of the hemiarthroplasties failed and required either revision or conversion to arthrodesis. All of the arthrodeses achieved successful fusion. The authors concluded that arthrodesis is a more predictable procedure for alleviating symptoms and restoring function.

Coughlin et al authored a retrospective review of 110 patients with HR who underwent either a dorsal cheilectomy or arthrodesis. Dorsal cheilectomy had predictable success in patients with grade 1 or 2 disease. The authors recommend arthrodesis for patients with grade 3 disease with < 50% of metatarsal head cartilage remaining and all grade 4 disease.

9
Q

(OBQ15.93) A 22-year-old football player lands on the forefoot with his great toe hyperextended during a football game. He presents with pain at the metatarsophalangeal (MTP) joint and difficulty with cutting drills. Examination demonstrates localized tenderness. Radiographs of both feet are shown in Figure A. Figures B and C are a lateral radiograph and sagittal MRI of the injured side, respectively. Non-operative measures have not been successful. What is the next best step? Review Topic

QID:5778

FIGURES:

A https://upload.orthobullets.com/question/5778/images/fig_a.jpg

B https://upload.orthobullets.com/question/5778/images/fig_b.jpg

C https://upload.orthobullets.com/question/5778/images/fig_c.jpg

1- Resection

2- Tendon repair

3- Tenotomy

4- Capsuloligamentous repair

5- Internal fixation of bone

A

1- Resection

2- Tendon repair

3- Tenotomy

4- Capsuloligamentous repair

5- Internal fixation of bone

https://upload.orthobullets.com/question/5778/images/illus_a.jpg

This patient has Grade III left turf toe with sesamoid retraction that has failed nonoperative measures. Capsuloligamentous repair is indicated.

Turf toe occurs after axial loading on the heel with the ankle plantarflexed and the hallux MTP hyperextended. The incidence is up to 45% in NFL players, with most occurring on artificial turf. Grade I injuries involve attenuation of plantar structures, localized swelling, and minimal ecchymosis. Grade II injuries involve partial tear of plantar structures, moderate swelling, and restricted motion as the result of pain. Grade III injuries involve complete disruption of plantar structures, significant swelling/ecchymosis, hallux flexion weakness, or frank instability of the MTP joint.

10
Q

(OBQ15.245) A 66-year-old man undergoes total ankle replacement (TAR). An unrecognized intraoperative complication occurred and he now returns for follow-up at 6 weeks. Radiographs are shown in Figure A. Which of the following is NOT a risk factor for this intraoperative complication? Review Topic

QID:5930

FIGURES:

A https://upload.orthobullets.com/question/5930/images/fig_a.jpg

1- saw blade excursion

2- tibial component size

3- tibial component position

4- joint distraction with an external fixator

5- medial malleolar pinning

A

1- saw blade excursion

2- tibial component size

3- tibial component position

4- joint distraction with an external fixator

5- medial malleolar pinning

https://upload.orthobullets.com/question/5930/images/ia.jpg

https://upload.orthobullets.com/question/5930/images/ib.jpg

Prophylactic intraoperative pinning of the medial malleolus helps to prevent intraoperative medial malleolar fractures, rather than cause them.

Periprosthetic fractures of the medial malleolus are more common than lateral fractures. Known causes include uncontrolled saw blade excursion, excessively medial or lateral placement of the tibia prosthesis, or oversized tibial prosthesis. The fibula lies behind the talus in a posterior position and may be cut if the direction of cut is not appropriate. Repeated pin placement for changes in template position also create stress risers and should also be avoided. Prophylactic K-wire (or screw) insertion through the medial malleolus prior to osteotomy may help prevent fracture.

11
Q

(OBQ10.138) A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT: Review Topic

QID:3189

FIGURES:

A https://upload.orthobullets.com/question/3189/images/hv2.jpg

B https://upload.orthobullets.com/question/3189/images/hv%201.jpg

1- Multiple screw fixation across the metatarsocuneiform arthrodesis

2- Augmentation of the metatarsocuneiform arthrodesis with bone grafting

3- Dorsiflexion unloading of the first metatarsal

4- Correction of the first intermetatarsal angle

5- Failure of conservative treatments prior to surgery

A

1- Multiple screw fixation across the metatarsocuneiform arthrodesis

2- Augmentation of the metatarsocuneiform arthrodesis with bone grafting

3- Dorsiflexion unloading of the first metatarsal

4- Correction of the first intermetatarsal angle

5- Failure of conservative treatments prior to surgery

The clinical photograph and radiograph demonstrate hallux valgus with a large first intermetatarsal angle. Metatarsus primus varus and hypermobility of the first ray are both indications for including metatarsocuneiform arthrodesis in the surgical correction of hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to prevent loading of the lesser metatarsals following surgery.

Myerson et al reports the results of 53 patients treated with metatarsocuneiform arthrodesis for hallux valgus and metatarsus primus varus. They found that 92% acheived clinical satisfaction despite numerous complications including 7 superficial pin tract infections, 3 dorsal bunions, 7 nonunions, 1 hallux varus, and 3 neuromas of the deep peroneal nerve. Only 1 of the complications needed secondary surgery.

Sangeorzan et al reports the results of metatarsocuneiform arthrodesis in 33 patients with hallux valgus and a hypermobile first ray and 7 patients with previous failed bunion surgery. Successful union occurred in 90%, and 75% were considered successful clinical results. Best results were achieved with bone grafting, multiple screw fixation, and accurate plantarflexion of the first metatarsal.

12
Q

(SBQ12FA.19) A 42-year-old patient complains of anterior and lateral ankle pain, as well as limited dorsiflexion, after non-surgical management of a displaced intra-articular calcaneus fracture. Imaging shows subtalar joint arthrosis, lateral wall exostosis and loss of calcaneus height. What would be the BEST management? Review Topic

QID:3826

1- Posterior tibial tendon transfer +/- vertical slide calcaneal osteotomy

2- Achilles tendon lengthening and lateral wall exostectomy

3- Superior peroneal retinaculum repair +/- sural nerve neurolysis

4- Subtalar bone block arthrodesis, lateral wall exostectomy +/- achilles tendon lengthening

5- Tibiotalocalcaneal nailing

A

1- Posterior tibial tendon transfer +/- vertical slide calcaneal osteotomy

2- Achilles tendon lengthening and lateral wall exostectomy

3- Superior peroneal retinaculum repair +/- sural nerve neurolysis

4- Subtalar bone block arthrodesis, lateral wall exostectomy +/- achilles tendon lengthening

5- Tibiotalocalcaneal nailing

Calcaneal malunion is a common problem with non-operative management. The classic indication for bone block arthrodesis is ANTERIOR ankle pain (and limited dorsiflexion) secondary to impingement of the horizontal talus on the tibia. Lateral ankle pain may be due to peroneal dislocation, subfibular impingement, or subtalar arthritis. In this scenario, lateral wall exostectomy would help to address the subfibular impingement.

The calcaneal malunion is evaluated with plain radiographs and CT scan and classified according to the Stephens-Sanders classification (see Illustration A). Type I malunions can be managed with a lateral wall exostectomy and a peroneal tenolysis. Type II malunions can be managed with a lateral wall exostectomy, peroneal tenolysis, and a subtalar bone block arthrodesis, using bone graft. Type III malunions can be managed with a lateral wall exostectomy, peroneal tenolysis, subtalar bone block arthrodesis, closing wedge calcaneal osteotomy to correct varus hindfoot malalignment, or triple arthrodesis.

Sanders et al. reviewed displaced calcaneal fractures. He states that peroneal tendinitis can occur with nonsurgical management of intra-articular calcaneal fractures. The expanded lateral wall often subluxates the peroneal tendons against the distal tip of the fibula causing impingement and pain.

13
Q

(OBQ10.184) A 57-year-old woman complains of pain and deformity of the second toe that is limiting ambulation. Shoe accomodations and NSAIDs have failed to provide relief. She has a fixed flexion deformity of 40 degrees at the PIP joint, but the MTP joint is not involved. The hallux is normal, but painless PIP flexion contractures are present in the other lesser toes. Which of the following is an indication for PIP resection arthroplasty as opposed to soft-tissue balancing and realignment? Review Topic

QID:3277

1- Fixed deformity

2- Pain with shoe wear

3- Presence of hammertoe deformity in all lesser toes

4- Absence of metatarsophalangeal joint deformity

5- Absence of a concomitant hallux valgus deformity

A

1- Fixed deformity

2- Pain with shoe wear

3- Presence of hammertoe deformity in all lesser toes

4- Absence of metatarsophalangeal joint deformity

5- Absence of a concomitant hallux valgus deformity

Hammertoe is defined as a flexion deformity of the proximal interphalangeal joint. A diagram of the deformity is provided in illustration A. There are many causes including neurogenic, degenerative, and metabolic processes. Hammertoe can also be secondary to another deformity in the foot such as hallux valgus or curly toe. Consequently, there are numerous surgical procedures available for treatment including soft tissue releases, tendon transfers, resection arthroplasty, and arthrodesis. The presence of fixed deformity precludes success with soft tissue procedures alone.

O’Kane et al review 100 cases of excisional arthroplasty for second digit hammertoe. High rates of clinical satisfaction were achieved with only 2 revision surgeries. Floating toe was the most frequent complication (7). However, floating toe did not adversely affect shoe wear in any patient experiencing this complication.

Coughlin et al review 63 cases of excisional arthroplasty for fixed hammertoe. The resection arthroplasty was stabilized with K-wire fixation that led to bony fusion in 81% and fibrous union in the remaining 19%. Only minor complications occurred and 84% of patients reported high clinical satisfaction.

14
Q

(OBQ15.260) A 35-year-old patient has had untreated Achilles tendon pain for 4 months. Physical examination reveals an intact Achilles tendon with normal plantar flexion power. MR imaging of the tendon reports areas with increased signal intensity. Color and power doppler ultrasound shows areas with increased blood flow in the tendon, as shown in Figure A. What would be the the next step in management of this patient? Review Topic

QID:5945

FIGURES:

A https://upload.orthobullets.com/question/5945/images/image11.jpg

1- Corticosteroid injection and close follow-up

2- CT chest, abdomen and pelvis

3- Eccentric closed-chain exercises

4- Plasma-rich protein injection with delayed arthroscopic tendon debridement

5- Achilles tendon resection, FHL tendon transfer and gastrocnemius-soleus fascia turndown graft

A

1- Corticosteroid injection and close follow-up

2- CT chest, abdomen and pelvis

3- Eccentric closed-chain exercises

4- Plasma-rich protein injection with delayed arthroscopic tendon debridement

5- Achilles tendon resection, FHL tendon transfer and gastrocnemius-soleus fascia turndown graft

**This patient’s presentation is consistent with Achilles tendinopathy. The next step in management should be focused physiotherapy with eccentric closed-chain exercises.

Conservative treatment of Achilles tendinopathy is recommended as the initial strategy by most orthopaedic surgeons. Generally, this consists of the combination of rest (complete or modified activity), medication (NSAIDs), orthotic treatment (heel lift, change of shoes, corrections of malalignments), stretching and strength training (eccentric closed-chain exercises). If conservative treatment fails, surgical treatment may be instituted.

Verall et al. assessed the efficacy of a modified 6-week eccentric heel-drop program in symptomatic athletes with Achilles tendinopathy. Pain, as assessed by Visual Analogue Scale (VAS), reduced from a mean of 7.2 at commencement of the regimen to 2.9 (p<0.01) after 6 weeks of stretching. Overall mean time to return to pre-morbid activity was 10 weeks. They concluded that results were best for mid-substance involvement rather than insertional tendinopathy.

Shalabi et al. evaluated the tendon response after acute eccentric strength training in chronic Achilles tendinosis using magnetic resonance imaging (MRI). They showed there was no significant difference in tendon volume or the intratendinous signal between the eccentrically heavily loaded symptomatic tendons and the concentrically loaded contralateral tendons**

15
Q

(OBQ11.95) A 35-year-old man injured his ankle while playing soccer two years ago. Ever since he has had persistent right ankle pain that has failed to improve with nonoperative modalities including physical therapy. A video of his right ankle is found below. Radiographs are shown in Figures A through C. What is the most appropriate next step in management? Review Topic

QID:3518

FIGURES:

V

https://video.orthobullets.com/thumbs/abc123-Peroneal-subluxation/frame_0000.jpg

A

B

C

1- Physical therapy directed at proprioception and strengthening

2- Fibular shortening osteotomy

3- Surgical repair of the anterior talofibular ligament (ATFL)

4- Surgical repair of the calcaneofibular ligament (CFL)

5- Fibular groove deepening and superior peroneal retinaculum repair

A

1- Physical therapy directed at proprioception and strengthening

2- Fibular shortening osteotomy

3- Surgical repair of the anterior talofibular ligament (ATFL)

4- Surgical repair of the calcaneofibular ligament (CFL)

5- Fibular groove deepening and superior peroneal retinaculum repair

The patient in this scenario has chronic peroneal subluxation. Radiographs are often normal in this condition. On physical exam, a consistent finding is subluxation of the tendons with resisted dorsiflexion and eversion of the ankle. This is most likely secondary to a disruption of the superior peroneal retinaculum (SPR). After a trial of non-operative management, surgical options include repair of the SPR, with or without fibular groove deepening.

Philbin et al reviewed peroneal tendon injuries. As 40% lead to chronic lateral ankle pain, they emphasized an accurate physical exam. They concluded that low-demand patients do well with a nonsurgical approach while high-demand patients may benefit from surgery.

Heckman et al reviewed operative techniques for peroneal disorders. They determined that operative repair consists of surgical repair of the (SPR) with or without fibular groove deepening for subluxation. Primary repair of the tendon is indicated for tears <50% while tenodesis is indicated for tears >50%.

16
Q

(OBQ15.211) A 42-year-old male presents with chronic plantar foot pain. The pain is worst when he wakes up, and remains persistent throughout his workday. Which of the following findings is an indication for gastrocnemius recession? Review Topic

QID:5896

1- A Silverskjold test demonstrates 10 degrees less than neutral with the knee in extension versus 10 degrees beyond neutral with the knee flexed

2- A Silverskjold test demonstrates 5 degrees of ankle dorsiflexion with the knee in extension, which does not change with the knee flexed.

3- Persistent pain despite three months of rigorous physical therapy

4- Flexible pes planovalgus

5- A positive “too many toes” sign

A

1- A Silverskjold test demonstrates 10 degrees less than neutral with the knee in extension versus 10 degrees beyond neutral with the knee flexed

2- A Silverskjold test demonstrates 5 degrees of ankle dorsiflexion with the knee in extension, which does not change with the knee flexed.

3- Persistent pain despite three months of rigorous physical therapy

4- Flexible pes planovalgus

5- A positive “too many toes” sign

Chronic plantar foot pain with a gastrocnemius contracture as evidenced by the results of the Silverskjold test is best treated with a gastrocnemius recession.

A gastrocnemius equinus contracture causes increased forefoot strike during gait, leading to increased tension on plantar structures including the plantar fascia. This has been implicated in progressive arch collapse, Achilles tendinopathy, plantar fasciitis, neuromas, and metatarsalgia. The Silverskjold test can differentiate an isolated gastrocnemius contracture from a tendoachilles contracture. Gastrocnemius contracture is diagnosed if the ankle dorsiflexion is <10 degrees with the knee in extension, but improves with knee flexion.

Maskill et. al. retrospectively reviewed 29 patients who underwent isolated gastroc recession for chronic foot pain in the setting of isolated gastrocnemius contracture with 6 month minimum follow up. At final follow up they noted 93% of patients were satisfied with their outcome and would recommend the procedure to a friend.

Anderson et. al. reviewed the impact of gastrocnemius contracture on midfoot arch collapse and as a cause of other painful foot and ankle conditions. They report that gastrocnemius recession can successfully treat patients with neuropathic plantar ulcers, isolated foot pain associated with arch collapse, and noninsertional Achilles tendinopathy.

17
Q

(OBQ14.251) Over the last two years, an active 47-year-old woman has noticed progressive collapse of her left foot arch. She has achieved minimal relief with orthotics and aggressive physical therapy. On examination she has first tarsometatarsal instability with a flexible, non-tender, hindfoot. The Silfverskiold test reveals ankle joint dorsiflexion = +5° with knee extended and +5° with knee flexed. Additional examination findings can be seen in Figures A and B. Standing radiograph of the foot is shown in Figure C and D. What is the best next step in treatment? Review Topic

QID:5661

FIGURES:

A https://upload.orthobullets.com/question/5661/images/ev.jpg

B https://upload.orthobullets.com/question/5661/images/images-5..jpg

C https://upload.orthobullets.com/question/5661/images/251a.jpg

D https://upload.orthobullets.com/question/5661/images/flatfoot.jpg

1- Triple arthrodesis and achilles tendon lengthening

2- Tibiotalocalcaneal arthrodesis and gastrocnemius recession

3- First tarsal-metatarsal joint arthrodesis, subtalar arthrodesis, posterior tibial tendon debridement +/- lateral column lengthening

4- Medial cuneiform dorsal opening wedge osteotomy, medializing calcaneal osteotomy, and flexor digitorum longus tendon transfer

5- First tarsal-metatarsal arthrodesis, medializing calcaneal osteotomy, flexor digitorum longus tendon transfer and lateral column lengthening

A

1- Triple arthrodesis and achilles tendon lengthening

2- Tibiotalocalcaneal arthrodesis and gastrocnemius recession

3- First tarsal-metatarsal joint arthrodesis, subtalar arthrodesis, posterior tibial tendon debridement +/- lateral column lengthening

4- Medial cuneiform dorsal opening wedge osteotomy, medializing calcaneal osteotomy, and flexor digitorum longus tendon transfer

5- First tarsal-metatarsal arthrodesis, medializing calcaneal osteotomy, flexor digitorum longus tendon transfer and lateral column lengthening

This patient presents with a progressive flatfoot deformity with posterior tibialis tendon dysfunction (PTTI), first TMT instability, forefoot abduction, and flexible hindfoot. The next best step would be first tarsal-metatarsal arthrodesis, medializing calcaneal osteotomy, and flexor digitorum longs (FDL) tendon transfer.

Treatment for PTTI is stage dependent. Surgery is indicated for stages II-IV. Stage II disease is substratified based on the degree of talonavicular uncoverage. Lateral column lengthening is added if there is >40% or >30 degrees uncovering of the talar head as FDL transfer and medial slide osteotomy will not correct severe forefoot abduction. LCL is performed either through the calcaneocuboid joint or the anterior calcaneus. First tarsal-metatarsal arthrodesis versus medial cuneiform dorsal opening wedge osteotomy depends on first TMT pathology. Significant arthritis or instability is the primary indication for arthrodesis.

18
Q

(SBQ12FA.33) A 55-year-old woman presents to the clinic with 6 months of worsening pain with prolonged standing, parasthesias, and burning in the lateral foot. On examination she is noted to have adult-acquired flatfoot and point tenderness on the plantar surface of the medial calcaneus. Which nerve is most likely involved in the patient’s worsening parasthesias? Review Topic

QID:3840

1- Tibial nerve

2- Saphenous nerve

3- Superficial peroneal nerve

4- Sural nerve

5- Deep peroneal nerve

A

1- Tibial nerve

2- Saphenous nerve

3- Superficial peroneal nerve

4- Sural nerve

5- Deep peroneal nerve

The patient presents with tarsal tunnel syndrome (TTS), impingement of the tibial nerve, often associated with adult-acquired flatfoot and plantar fasciitis.

TTS is a compression neuropathy of the tibial nerve as it enters and courses through the tarsal tunnel, composed of the talus and calcaneus deep to the structures, flexor retinaculum superficially, and abductor hallucis inferiorly. Tunnel contents include the posterior tibialis tendon, flexor digitorum longus, posterior tibial artery, tibial nerve, and flexor hallucis longus. Nerve impingment can be caused by multiple etiologies, but in the “heel pain triad” with flatfoot, plantar fasciitis, and tarsal tunnel syndrome, gradual loss of the stabilizers of the plantar arch can contribute to stretch and subsequent compression of the nerve as it courses through the tarsal tunnel, resulting in pain, parasthesias, a sharp burning sensation, a positive Tinel’s sign, and possible muscle wasting. Pain is often medial but can also present on the lateral side depending on severity and which branches of tibial nerve involved.

The tibial nerve branches as it passes through the tarsal tunnel into medial and lateral plantar nerves and the calcaneal nerve. In this patient, the lateral plantar nerve fibers seem to be primarily affected given lateral foot burning, but likely with some medial planter nerve involvement as well.

Labib et al. describe and coin the term “heel pain triad” after a review of of 286 patients with chronic heel pain. They identify 14 patients with the combination of posterior tibial tendon deficiency, plantar fasciitis, and tarsal tunnel syndrome. They hypothesize loss of dynamic and static stabilizers of the medial arch leads to traction neuropathy on the tibial nerve and found an 86% improvement rate after operative management.

Ahmad et al. present a literature review of tarsal tunnel syndrome describing presentation, anatomy, and workup. They emphasize that TTS is a clinical diagnosis which can be complemented by ultrasound and nerve conduction studies but caution against false negative results in symptomatic patients with negative conduction studies. They recommend early operative management to prevent fibrosis, with 44%-96% success rates reported. Particularly good results were found in patients with a positive Tinel’s sign pre-operatively.

19
Q

(OBQ15.62) A 21-year-old recreational runner sustained a right ankle twisting injury 10 days ago. A non-weightbearing splint was placed at the time of injury. Figures A and B show clinical and radiographic images of the ankle after the splint was removed. Examination reveals mild tenderness over the calcaneal fibular ligament, positive talar tilt and increased talar drawer test with the ankle in dorsiflexion. What would be the next best step in this patients management? Review Topic

QID:5747

FIGURES:

A https://upload.orthobullets.com/question/5747/images/lateral-ankle-sprain-physio.jpg

B https://upload.orthobullets.com/question/5747/images/a509797b07ed51_lat-hq.jpg

1- CT scan right ankle

2- MR imaging right ankle

3- Continue non-weightbearing casting for 2-4 weeks, followed by functional rehabilitation

4- Transition into a removable walking boot for 2-4 weeks, followed by functional rehabilitation

5- Early functional rehabilitation

A

1- CT scan right ankle

2- MR imaging right ankle

3- Continue non-weightbearing casting for 2-4 weeks, followed by functional rehabilitation

4- Transition into a removable walking boot for 2-4 weeks, followed by functional rehabilitation

5- Early functional rehabilitation

**This patient has sustained a low ankle sprain. The ideal treatment after 7-10 days of immobilization is to initiate functional rehabilitation.

Low ankle sprains often occur from inversion injuries that affect the anterior talo-fibular ligament (ATFL) and calcaneal fibular ligament (CFL). The initial treatment of these Injuries include rest, ice, elevation and compression, or short periods of immobilization (approx. 7-10 days). After swelling has subsided, neuromuscular and proprioceptive training has been shown to be an important step in the functional recovery of these injuries, as well as to decrease the risk of recurrence of ankle sprains.

Peterson et al. performed a systematic literature review of the evidence for the treatment and prevention of lateral ankle sprains. They showed that a short period of immobilization (max. 10 days) in a below knee cast is advantageous in grade III injuries. For non-surgical treatment, long-term immobilization should be avoided.**

20
Q

(SBQ13PE.76) A young child injured his foot after a fall at home. What is the most common location for fracture in this patient, as labeled in Figure A? Review Topic

QID:5211

FIGURES:

A https://upload.orthobullets.com/question/5211/images/new.jpg

1- Label 1

2- Label 2

3- Label 3

4- Label 4

5- Label 5

A

Figure A shows an AP foot x-ray of a 2.5 year old child. The first metatarsal (Label 1) is the most common site for metatarsal fractures in children less than 5 years old.

Metatarsal fractures are common in children. They are usually minimally displaced and rarely require operative treatment. The most common location for fracture is the first metatarsal in children less than 5 years old and the fifth metatarsal in children greater than 5 years old.

Singer et al. reviewed a consecutive series of 125 patients with metatarsal fractures. They found two groups of injuries. In children less than 5 years old the most common location of injury was home; the most common mechanism was a fall from a height; the most common bone involved was the first metatarsal. In children greater than 5 years old the most common location of injury was sports; the most common mechanism was a fall from standing; the most common bone involved was the base of 5th metatarsal.

Owen et al. retrospectively reviewed 62 metatarsal fractures. They showed that in children less than 5 years old, the first metatarsal accounted for 73% of metatarsal fractures. In children greater than 5 years old, first metatarsal fractures accounted for only 12%. In addition, 20% of first metatarsal fractures went unrecognized at the initial persentatio

21
Q

(SBQ12FA.26) A 45-year-old man presents to the orthopaedic clinic complaining of several weeks of increasing midfoot pain during and after his daily run that he recently resumed after a 2-week vacation. He is found on imaging to have a navicular stress fracture. What is the most appropriate initial immobilization and weight-bearing status for this patient? Review Topic

QID:3833

1- Hard-sole shoe and non-weight bearing

2- Hard-sole shoe and partial weight bearing

3- Walking boot and partial weight bearing

4- Short leg cast and non-weight bearing

5- Short leg cast and partial-weight bearing

A

1- Hard-sole shoe and non-weight bearing

2- Hard-sole shoe and partial weight bearing

3- Walking boot and partial weight bearing

4- Short leg cast and non-weight bearing

5- Short leg cast and partial-weight bearing

Navicular stress fractures are recommended to be treated with a period of non-weight bearing and immobilization with either short leg cast, or at times a walking boot.

Navicular stress fractures are often an overuse type injury in which there is no significant uni or bicortical fracture line on radiographs, but rather high signal intensity in the navicular bone on MRI indicating inflammation in the acute setting. Most important is a 6-8 week period of immobilization and no weight bearing, usually accomplished with a cast or walking boot and crutches.

Mann et al review the evaluation and management of navicular stress fractures, recommending that after a thorough history and physical examination, patients suspected to have midfoot pathology are to have radiographic imaging, followed by CT scan to evaluate any fracture lines, or if negative then MRI to evaluate for stress fracture. They note the often long and frustrating course for treatment of a navicular stress fracture.

Boden et al review several different high-risk stress fractures and describe the usual presentation as the insidious onset of pain associated with a new or increased high-repetition activity often in athletes or military recruits. Also described is the possible influence of hormonal factors, particularly in female patients.

22
Q

(OBQ10.206) For the treatment of new onset plantar fasciitis, which of the following modalities results in the highest patient satisfaction at 8 weeks of follow-up? Review Topic

QID:3299

1 - Achilles tendon–stretching program

2 - Corticosteroid injection

3 - Extracorporeal shock-wave therapy

4- Plantar fascia–specific stretching program

5- Distal tarsal tunnel decompression and partial plantar fascia release

A

1 - Achilles tendon–stretching program

2 - Corticosteroid injection

3 - Extracorporeal shock-wave therapy

4- Plantar fascia–specific stretching program

5- Distal tarsal tunnel decompression and partial plantar fascia release

A plantar fascia-specific stretching program has the highest patient satisfaction at the 8 week follow-up interval. Symptoms of plantar fasciitis include “start-up” inferior heel pain with patients often preferring to walk on their toes for the first few steps when getting out of bed. The pain lessens with ambulation and then increases again with increased activity. Illustration A depicts a patient performing plantar fascia-specific stretching. Illustration B displays a patient performing an achilles tendon–stretching program.

The review article by Neufeld and Cerrato details that stretching programs have been the primary treatment therapy modality for patients with plantar fasciitis. The purpose of plantar fascia–specific stretching is to recreate the windlass mechanism and achieve tissue tension through a controlled stretch of the plantar fascia.

23
Q

(OBQ15.46) A 63-year-old woman with history of rheumatoid arthritis underwent tibiotalocalcaneal fusion 3 years ago following failed total ankle arthroplasty. She is referred to your office because of persistent pain that is aggravated by weight bearing and relieved by rest. Radiographs are seen in Figures A and B. There are no signs of infection. What is the best next step? Review Topic

QID:5731

FIGURES:

A https://upload.orthobullets.com/question/5731/images/fig_a_new.jpg

B https://upload.orthobullets.com/question/5731/images/fig_b_new.jpg

1 - Conversion to total ankle arthroplasty

2 - Augmentation of fusion construct with supplemental screws

3 - Revision tibiotalocalcaneal arthrodesis

4 - Talar resection and tibiotalocalcaneal arthrodesis

5 - Total contact casting

A

1 - Conversion to total ankle arthroplasty

2 - Augmentation of fusion construct with supplemental screws

3 - Revision tibiotalocalcaneal arthrodesis

4 - Talar resection and tibiotalocalcaneal arthrodesis

5 - Total contact casting

This patient has a failed tibiotalocalcaneal (TTC) fusion with unstable ankle joint pseudoarthrosis. Revision TTC arthrodesis is indicated.

TTC fusion is indicated for global avascular necrosis of the talus, and combined ankle and subtalar arthrosis, Charcot neuroarthropathy, significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis, rheumatoid arthritis and flail ankle. Intramedullary nail TTC is useful in conditions of either distal tibial and talar bone loss or when conventional screw fixation is suboptimal.

Hammett et al. reviewed 52 TTC fusions using a retrograde locking intramedullary humeral nail for combined ankle and subtalar arthritis or complex hindfoot deformities. At 34 months, 82% were satisfied and had pain relief. They conclude that this is an effective technique.

24
Q

(SBQ12FA.5) A previously healthy, 70-year-old female underwent a reconstructive forefoot procedure approximately 8 years ago. She now presents with the progressive foot deformity shown in Figure A. On physical examination, the deformity cannot be manually corrected to a neutral position. Pain is worse during mid-range motion of the first metatarsophalangeal joint. What is the most appropriate management plan? Review Topic

QID:3812

FIGURES:

A https://upload.orthobullets.com/question/3812/images/63.jpg

1 - Cheilectomy and medial capsule release

2 - Hallux metatarsophalangeal joint fusion

3 - Metatarsal hemiarthroplasty

4 - Medial soft-tissue release and lateral capsule plication

5 - Metatarsal osteotomy, medial capsule release, and split extensor hallucis longus tendon transfer

A

1 - Cheilectomy and medial capsule release

2 - Hallux metatarsophalangeal joint fusion

3 - Metatarsal hemiarthroplasty

4 - Medial soft-tissue release and lateral capsule plication

5 - Metatarsal osteotomy, medial capsule release, and split extensor hallucis longus tendon transfer

This elderly patient presents with rigid hallux varus secondary to a failed bunion procedure. She has since developed symptomatic arthritis of the hallux metatarsophalangeal joint. The most appropriate treatment would be hallux metatarsophalangeal joint fusion.

The most common etiology of acquired hallux varus is surgical overcorrection of hallux valgus deformities. The main arms of treatment are joint sacrificing and joint preserving procedures. Joint sacrificing procedures (e.g. great toe arthrodesis) are predominately indicated in symptomatic patients with uncorrectable deformities or elderly patients. Passively correctable deformities are predominately considered for joint preserving procedures (e.g. tendon transfers with medial capsule release).

Johnson et al. reviewed extensor hallucis longus transfer for hallux varus deformities. They state that the steps to treatment include, (1) bony correction to create hallux metatarsophalangeal joint congruency (2) releasing the medial capsule and (3) transferring part of the extensor hallucis longus tendon into the proximal phalanx, under the intermetatarsal ligament laterally.

Hawkins et al. reviewed operative correction of FLEXIBLE hallux varus. He recommended two surgical techniques. (1) repositioning of aBDuctor hallucis to the remnant of aDDuctor hallucis or (2) suturing aBDuctor hallucis with a lengthening tendon graft back to the proximal phalanx and then repositioning the conjoined tendon to correct the varus deformity.

25
Q

(SBQ12FA.9) A 29-year-old male presents complaining of left foot pain after a twisting injury while on his motorcycle. His radiograph is shown in Figure A. In regards to his injury, how do the outcomes of arthrodesis and fixation compare? Review Topic

QID:3816

FIGURES:

A https://upload.orthobullets.com/question/3816/images/figure_a.jpg

1 - Equivalent outcome scores

2 - Fixation with better outcomes than arthrodesis

3 - Arthrodesis with better outcomes than fixation

4 - Fixation with higher hardware removal rate than arthrodesis

5 - Arthrodesis with higher hardware removal rate than fixation

A

1 - Equivalent outcome scores

2 - Fixation with better outcomes than arthrodesis

3 - Arthrodesis with better outcomes than fixation

4 - Fixation with higher hardware removal rate than arthrodesis

5 - Arthrodesis with higher hardware removal rate than fixation

When comparing fixation versus primary fusion in the treatment of Lisfranc injuries of the foot, fixation consistently has significantly higher removal of hardware rates than primary fusion.

Level 1 randomized trials have been conducted comparing open reduction and internal fixation (ORIF) versus primary fusion in the treatment of LIsfranc injuries. In regards to outcomes, results are mixed. A constant throughout the trials, however, is the significantly higher hardware removal rate following ORIF when compared to primary fusion.

Rammelt et al. conducted a cohort comparison between ORIF and delayed fusion (22 patients in each group) with a mean follow-up of 36 months. The authors here reported superior results for ORIF over fusion, improved outcome scores and satisfaction with earlier return to work, especially in the early follow-up period.

Smith et al in a recent systematic review and meta-analysis compared ORIF vs primary fusion, compiling results from 3 level 1 randomized trials. There was no significant difference between ORIF and primary fusion in regards to patient reported outcomes, but a significantly increased risk of subsequent hardware removal following ORIF was noted.

Ly et al. conducted a prospective randomized trial comparing ORIF vs primary fusion and reported significantly better patient reported outcomes for fusion in both the short-term and mid-term follow-up time points. ORIF also had a significantly higher rate of hardware removal.

Henning et al. conducted a prospective randomized trial comparing ORIF vs primary fusion, with planned removal of hardware for the ORIF group. Here, short term and midterm results were equivalent and with planned hardware removal in the fixation group, hardware removal rates were comparable to primary fusion patients.