• Flatfoot deformity• Flexible hindfoot• Normal forefoot
• (-) single-leg heel raise• Mild sinus tarsi pain
• Flatfoot deformity• Rigid forefoot abduction• Rigid hindfoot valgus
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A 65-year-old female returns to the office with continued medial and lateral hindfoot pain. She has attempted bracing, physical therapy and non-steroidal anti-inflammatories with limited relief. The patient is unable to perform a single-leg heel rise. The position of her right hindfoot and talonavicular joint are not passively correctable. She has pain with attempted inversion against resistance. Figures A-C are weight-bearing foot radiographs. Which of the following is the most appropriate treatment option?
Charcot resistant orthotic walker
Medializing calcaneal osteotomy, posterior tibial tendon debridement
Medializing calcaneal osteotomy, posterior tibial tendon debridement with flexor digitorum longus transfer
Medializing calcaneal osteotomy, lateral column lengthening, posterior tibial tendon debridement with flexor digitorum longus transfer
Talonavicular and subtalar arthrodesis
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A 58-year-old female with a history of acquired flatfoot deformity is taken to the operating room for surgical intervention. Representative radiographs are shown in Figures A and B. The position of the forefoot after the subtalar joint is aligned is shown in Figure C. What maneuver is indicated to prevent the development of weight-bearing based lateral border foot pain in this patient?
Dorsiflexion osteotomy of the medial cuneiform
Isolated talonavicular fusion
No further maneuvers are indicated
Derotation of the forefoot through the transverse tarsal joints
Derotation of the forefoot through the calcaneocuboid alone
A 48-year-old woman complains of progressive medial sided foot pain and sinus tarsi pain for 2 years. She has achieved minimal relief with an Arizona brace and physical therapy. Examination reveals forefoot abduction with "too many toes" sign, passively correctable hindfoot valgus, passive correctable forefoot abduction, and inability to perform a single-leg toe raise. Standing radiographs are shown in Figures A and B. Percutaneous Achilles tendon lengthening is performed in the operating room. What is the best next step in treatment?
Plantigrade casting for 6-8 weeks
Posterior tibial tendon debridement
Flexor digitorum longus tendon transfer and medial slide osteotomy
Flexor digitorum longus tendon transfer, medial slide osteotomy and lateral column lengthening
A 59-year-old woman presents for initial evaluation of medial-sided right foot pain that has been present for 18 months and has not responded to extensive physical therapy and ankle foot orthosis treatment. On exam, she is unable to perform a single leg heel raise. She has pes planus with a 'too many toes' sign but her hindfoot is supple. With her talonavicular joint held in a reduced position she can be passively dorsiflexed to negative 10 degrees. This does not correct when her knee is flexed. Her radiographs show arch collapse, with 50% uncoverage of the talus but no subtalar or tibiotalar arthritis. What is the most appropriate stage and treatment for her condition?
Stage I: debridement of the posterior tibial tendon
Stage IIA: transfer of flexor digitorum longus (FDL) to the medial navicular with medializing calcaneal osteotomy (MCO)
Stage IIB: transfer of FDL to the medial navicular with MCO, lateral column lengthening and tendo-Achilles lengthening (TAL)
Stage III: triple arthrodesis and TAL
Stage IV: tibiotalocalcaneal arthrodesis
A 57-year-old male undergoes the procedure exhibited in Figure A. He reports a long history of painful, flat feet which failed conservative measures. Which stage of posterior tibial tendon insufficiency is likely for this patient?
A 54-year-old female has a painful flatfoot that has not improved with over 8 months of conservative management with orthotics. Preoperatively, she was unable to perform a single-heel rise and her hindfoot was passively correctable. Figures A and B are radiographs of the affected left foot. She undergoes FDL tendon transfer to the navicular, medial slide calcaneal osteotomy, and tendoachilles lengthening procedures. Following these procedures, the appearance of the foot is demonstrated in Figure C. What is the next most appropriate intraoperative procedure to be performed during her foot reconstruction?
Dorsiflexion closing wedge medial cuneiform osteotomy
In-situ 1st-3rd tarsometatarsal joint arthrodesis
Plantarflexion opening wedge medial cuneiform osteotomy
Lateral column closing wedge shortening osteotomy
A 44-year-old female has a Stage 2B acquired flat foot deformity that does not improve over 6 months of conservative management. She undergoes FDL tendon transfer to the navicular, calcaneal osteotomy, and tendoachilles lengthening. After this correction, it is thought that she would benefit from a opening wedge first cuneiform (Cotton) osteotomy. Which of the following best describes the Cotton osteotomy?
Plantarflexion osteotomy to correct residual forefoot varus
Medial opening wedge osteotomy to correct residual forefoot abduction
Plantarflexion osteotomy to correct residual forefoot valgus
Medial opening wedge osteotomy to correct residual hindfoot abduction
Plantarflexion osteotomy to correct residual hindfoot valgus
A 53-year-old female has a 20 month history of left hindfoot pain that has failed to respond to AFO bracing and physical therapy. She has a unilateral planovalgus deformity, shown in Figure A, which is flexible. She is unable to do a single leg-heel rise. Which of the following surgical options is most appropriate?
Isolated FDL transfer to the navicular
Dorsiflexion osteotomy of the 1st ray with peroneus longus-to-brevis transfer
Lateralizing calcaneal osteotomy with FDL to navicular transfer
Lateral column lengthening, medializing calcaneal osteotomy, and FDL transfer to the navicular
A 56-year-old woman comes to your office with foot pain after a 9 month trial of orthotics. Your examination reveals the hindfoot is in valgus, the arch is depressed, and the forefoot is abducted when the foot is viewed posteriorly. She is unable to perform a single heel rise on the affected side. The hindfoot is flexible and there is an equinus contracture. What combination of surgical interventions is most appropriate
Tenosynovectomy followed by UCBL orthotic use
Dwyer closing wedge calcaneal osteotomy, 1st metatarsal closing wedge osteotomy, and plantar fasica release
Medial calcaneal displacement osteotomy, lateral column lengthening, FDL tendon transfer, and tendoachilles lengthening
Arthrodesis of the subtalar, talonavicular, and calcaneocuboid
Lateral calcaneal displacement osteotomy, FDL tendon transfer, and tendoachilles lengthening
The lower limb orthosis shown in Figure A is the most effective method for nonsurgical management in which of the following conditions?
Diabetic foot neuropathy
Acquired flexible flatfoot deformity
A 70-year-old female complains of progressive pain of the medial ankle and foot over the past 10 years. Orthotics no longer provide relief of her pain. The hindfoot deformity is unable to be passively corrected on physical exam. Figure A is a posterior view of the patient's foot upon standing and a current radiograph is provided in Figure B. Which of the following is the best treatment option?
Posterior tibialis tendon debridement
FDL transfer to navicular and calcaneal slide osteotomy
FDL transfer to navicular, calcaneal slide osteotomy, and lateral column lengthening through the cuboid
A 54-year-old laborer presents with 4 months of progressive left foot pain. Figures A and B are clinical photographs of the patient in single and double leg stance. Figure C is a clinical photograph of the patients fixed forefoot deformity with the supple hindfoot passively corrected to neutral by the examiner. What is the most appropriate next step in treatment?
First tarsometatarsal joint arthrodesis (Lapidus), lateral column lengthening, and spring ligament repair
Medial heel lift, longitudinal arch support, and medial forefoot posting
Short period of immobilization in walker boot with lateral heel wedge
Flexor digitorum longus tendon transfer and medial calcaneal displacement osteotomy
A 46-year-old obese female presents with foot pain and the radiographs shown in Figures A and B. Which of the following physical findings will most likely be present?
Achilles tendon contracture
Clawing of the toes
What is the preferred surgical treatment for painful acquired flatfoot deformity with stage III posterior tibial tendon insufficiency?
FDL transfer to the navicular, medial displacement calcaneal osteotomy, and tendoachilles lengthening
FDL transfer to the navicular with lateral column lengthening through the anterior calcaneus
Posterior tibial tendon debridement and tenodesis to FDL
Arthrodesis of calcaneocuboid, talonavicular, and subtalar joints
An obese 65-year-old woman has a chronic painful flatfoot with a rigid valgus hindfoot deformity. Radiographs reveal subtalar joint degenerative changes but no signs of ankle joint degenerative changes or abnormal talar tilt. She is unable to single-leg heel raise and has a "too many toes" sign. What stage of posterior tibial tendon dysfunction is she best classified as?
A healthy 42-year-old male has a 2-year history of worsening hindfoot pain that is refractory to therapy and orthotics. Physical exam reveals a flexible planovalgus foot with an equinus contracture. He is unable to perform a single limb heel rise on the affected side. In addition to a flexor digitorum longus tendon transfer to the navicular, which of the following operative procedures is indicated?
Gastrocnemius lengthening only
Triple arthrodesis and gastrocnemius lengthening
Subtalar arthrodesis and gastrocnemius lengthening
Lateralizing calcaneal osteotomy, medial column lengthening, and gastrocnemius lengthening
Medializing calcaneal osteotomy, lateral column lengthening, and gastrocnemius lengthening
A 55-year-old woman presents with a planovalgus deformity of her foot. She is unable to perform a single-limb heel rise and has tenderness and swelling behind the medial malleolus. Her hindfoot valgus is passively correctable and she has failed a trial of orthotics. What is the most appropriate treatment?
posterior tibial tendon debridement
medial displacement calcaneal osteotomy and posterior tibial augmentation with flexor digitorum longus tendon transfer
A 40-year-old male with a progressive planovalgus foot deformity secondary to posterior tibial tendon insufficiency (PTTI) has failed nonoperative treatment. What feature must be evaluated for that is commonly seen in patients with advanced PTTI and should be addressed at time of surgery?
When harvesting flexor digitorum longus (FDL) for a tendon transfer for stage II posterior tibialis tendon dysfunction, what anatomic structure crosses immediately deep (dorsal) to it in the midfoot region?
flexor hallucis brevis (FHB)
flexor hallucis longus (FHL)