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Andrea Nicolas and Simon Chambers
Table 10.1 Hawkins Classification
Type Description
Hawkins I Undisplaced
Hawkins II Subtalar dislocation
Hawkins III Subtalar and tibiotalar dislocation
HawkinsIVSubtalar, tibiotalar and talonavicular
dislocation
Figure 10.5 Hawkins classification of talar neck fractures
This classification was further expanded 8 years
later by Canale and Kelly (1978) who added the
type IV category).
The rate of AVN of the talus as reported in
subsequent studies has been 0–24% after
Hawkins Type I, 0–50% after Hawkins Type II
and 33–100% after Hawkins Type III and IV
fractures (Metzger et al. 1999).
Patients with talus fractures of Hawkins Type
I and II had considerably better outcomes (with
95% being excellent or good) compared with
individuals suffering dislocated fractures with
involvement of the articulating surface which
had 70% good results in Hawkins Type III and
10% good results in Hawkins Type IV fractures
(Alton et al. 2015).
Alton T, Patton DJ, Gee AO. Classifications in
brief: the Hawkins classification for talus fractures. Clin Orthop Relat Res. 2015;473:3046–3049.
Canale ST, Kelly FB Jr. Fractures of the neck
of the talus: long-term evaluation of seventy-one
cases. J Bone Joint Surg Am. 1978;60:143–156.
Hawkins LG. Fractures of the neck of the
talus. J Bone Joint Surg Am. 1970;52:991–1002.
Metzger MJ, Levin JS, Clancy JT. Talar neck
fractures and rates of avascular necrosis. J Foot
Ankle Surg. 1999;38:154–162.
13. Answer E. Weight bearing X-rays
Low energy Lisfranc injuries are challenging to
diagnose. Most units will do non-weight bearing radiographs and subtle Lisfranc injuries
can be missed. Patients may present wit h pain
and swelling without any obvious deformity
andinsomecasesareabletoweightbear.
Clinicians should have a high index of suspicion if patients present with plantar equimosis, alte red sensation in the first web spac e
secondary to post-traumatic neuropathy of
the medial terminal branch of the deep peroneal nerve and hypermobility of a metatarsal
head (‘ piano key sign’). In those cases, further
investigation with weight bearing radiographs
is needed.
Weight bearing radiographs are superior to
the radiographs performed under stress manoeuvres, in which the applied force is limited
compared with that of the entire weight of the
body.
A computed tomography (CT) scan allows a
more accurate assessment of the Lisfranc joint. It
allows the diagnosis of more subtle fractures and
subluxations that are not observed in simple
radiographs. The CT scan is generally used for
surgical planning.
Magnetic resonance imaging (MRI) is very
useful for detecting soft-tissue injuries and ligamentous injuries. It presents a sensitivity and
predictive value of up to 94% in determining
instability of the Lisfranc joint and can therefore
be useful for the diagnosis of the subtle Lisfranc
injury.
A CT or more preferably an MRI scan would
be indicated if weight bearing radiographs are
negative but there is still a high index of suspicion for a Lisfranc injury.
Moracia-Ochagavía I, Rodríguez-Merchán
EC. Lisfranc fracture-dislocations: current man-
agement. EFORT Open Rev. 2019 ;4:430–444.
214
Foot and Ankle II Structured SBA
Ankle
14. Answer C. Calcaneofibular ligament
The lateral ligamentous complex is formed by the
anterior talar fibularligament (ATFL), the calcaneofibular ligament (CFL) and the posterior talar fibular ligament. Damage to the lateral ligamentous
complex often occurs because of ankle inversion
injuries. The ATFL is the most common injured
structure of the complex followed by a combined
injury to ATFL and CFL. The ATFL is more vulnerable when the ankle is in a plantarflexed position
and undergoes supination and adduction forces. It
originates at the anterior aspect of the lateral malleolus and inserts on the anterolateral aspect of the
talus, therefore with the ankle in plantar flexion it is
vertically orientated and becomes taut. The CFL
originates from the anterior-inferior aspect of the
lateral malleolus inferior to the origin of the ATFL.
It runs postero-inferiorly and inserts on the lateral
calcaneus. Isolated injuriestotheCFLarerarebut
can occur with inversion injuries with the ankle in
dorsiflexion where the CFL is taut and the ATFL is
lax.
The load to failure of the CFL is approxi-
mately 2–3.5 times greater than the load to failure of the ATFL. The CFL is the primary
constraint to talar inversion when the ankle is
dorsiflexed, and in plantarflexion, it resists inversion in conjunction with the ATFL.
Hur ES, Bohl DD, Lee S. Lateral ligament
instability: review of pathology and diagnosis.
Curr Rev Musculoskelet Med. 2020;13:494–500.
15. Answer D. Referral to foot and ankle surgeon
for surgical repair
This patient has a chronic Achilles tendon rupture. The diagnosis of chronic Achilles tendon
ruptures can be challenging. There may not be a
palpable gap due to fibrous tissue and the
Simmonds (squeeze calf ) test may be inconclusive. Active plantar flexion of the foot can be
preserved because of the action of tibialis posterior, the toe flexor and the peroneal tendons. MRI
or USS can aid with the diagnosis but clinical
examination remains the gold standard.
Maffulli N, Via AG, Oliva F. Chronic
Achilles tendon rupture. Open Orthop J.
2017;11:660–669.
16. Answer D. Reconstruction with ipsilateral ham-
string autograft
There are multiple surgical options for the management of chronic Achilles tendon rupture. For those
patients with a gap <2cm, primary repair can be
attempted. With gaps of 2–5cm V-Y advancement
is recommended. For gaps of>5cm tendon transfer
with FHL or peroneus previs with or without V-Y
advancement is recommended. For larger gaps
>6cm despite maximal plantarflexion of ankle, ipsilateral hamstring tendon graft is indicated.
Arshad Z, Lau EJS, Leow SH, Bhatia M.
Management of chronic Achilles ruptures: a
scoping review. Int Orthop. 2021;45:2543–2559.
Maffulli N, Via AG, Oliva F. Chronic
Achilles tendon rupture. Open Orthop J.
2017;11:660–669.
17. Answer D. Fixed bearing total ankle
arthroplasty
The anteroposterior (AP) radiograph demonstrates end stage OA of the ankle. A recent
randomised controlled trial published in 2022
of 281 patients demonstrated that both total
ankle arthroplasty (TAR) and ankle fusion
(AF) have similar post-operative scores and
complication rates. TAR had higher nerve
damage and healing complications, while AF
patients had higher thromboembolic events
and a non-union rate of 7%.
TAR surgeons in the UK involved in the trail
used both a 2-component, fixed-bearing and a 3component, mobile-bearing implant.
When a fixed bearing TAR was looked at
separately, this showed a significant improvement
in clinical scores and quality of life over AF.
A post hoc analysis suggested superiority of
fixed-bearing total ankle arthroplasty over ankle
arthrodesis.
The SBA is assuming that the patient is suit-
able for either TAR or ankle fusion considering
patient characteristics such as deformity, sources
of pain, adjacent joints, stability, bone quality,
soft tissue envelope and neurovascular status.
Goldberg AJ et al. Total ankle replacement
versus arthrodesis for end-stage ankle osteoarthritis: a randomized controlled trial. Ann Intern
Med. 2022;175:1648–1657.
18.
Answer B. Osteochondral lesion of the lateral
talus
Osteochondral lesions of the talus are common
injuries that affect a wide variety of active
215
Andrea Nicolas and Simon Chambers
patients. Many of these lesions are associated
with ankle sprains and fractures.
Most patients are 20– 40 years old, with men
being more commonly affected than women
(1.6:1). Typically, patients will present with
non-specific ankle pain that may or may not
correspond to the location of the lesion.
Additionally, they will often complain of swelling
and occasional joint instability.
Most osteochondral lesions occur in the centromedial and centrolateral area of the talus. In a
large study of 500 patients, it was identified that
98% of the lateral lesions were associated with
injuries (most commonly ankle sprains). The
mechanism of injury of lateral osteochondral
lesions is a shearing force on the talar dome when
the ankle is in a dorsiflexed and inverted position.
On the other hand, the medial lesions are associated with an axial load while the ankle is forced
into a plantarflexed and inverted position.
Elias I et al. Osteochondral lesions of the
talus: change in MRI findings over time in talar
lesions without operative intervention and implications for staging systems. Foot Ankle Int.
2006;27:157–166.
Looze CA et al. Evaluation and management
of osteochondral lesions of the talus. Cartilage
2017;8:19–30.
19. Answer B. Careful dissection must be taken to
avoid damage of the superficial peronea l nerve
at the distal end of the incision
During the anterior approach to the ankle, a
longitudinal incision is made immediately lateral
to the anterior tibial tendon extending distally to
the level of the talonavicular joint. Special care is
taken at the distal end of the incision to avoid
damage to the superficial peroneal nerve. Deep
dissection can be taken either through the tibialis
anterior sheath or through the extensor hallucis
longus but one must be aware that the neurovascular bundle lies just behind the EHL tendon at
the level of the ankle joint.
Dekker RG 2nd, Kadakia AR. Anterior
approach for ankle arthrodesis. JBJS Essent Surg
Tech. 2017;7:e10.
Hindfoot and Forefoot
20. Answer B. Coleman block test
The patient suffers from Charcot-Marie-Tooth
disease and cavovarus foot. Patients with CMT
216
disease develop hindfoot varus, pes cavus,
clawing of the toes and hands and plantarflexionofthefirstray.Asymmetricalcavovarus
deformities are more typical of spinal
dysraphism.
Although nerve conductive studies are necessary for the diagnosis of CMT this cannot be
performed in clinic.
Silfverskiöld test will give an indication of a
tight gastrocnemius and although this is often
present in cavovarus disease it is not specific for
this pathology. It is important to assess for
Achilles shortening when planning any hindfoot
deformity correction as Achilles tendon
lengthening may be required.
Coleman block test evaluates the flexibility of
the hindfoot (flexible or fixed) and pronation.
The test is based on premise that the first metatarsal is plantarfle xed. The test is performed by
placing the patient’s weight bearing foot on a
block, with the heel and lateral border of foot
on the block and the first metatarsal off the
block. It eliminates contribution of the plantarflexed first ray and forefoot pronation to the
hindfoot deformity.
Single heel raise is performed to assess tibialis
posterior power.
Anterior drawer test is performed to test
ankle stability and the anterior tibio-fibular
ligament.
Coleman SS, Chesnut WJ. A simple test for
hindfoot flexibility in the cavovarus foot. Clin
Orthop Relat Res. 1977;123:60–62.
Kovaleski JE, Norrell PM, Heitman RJ,
Hollis JM, Pearsall AW. Knee and ankle pos-
ition, anterior drawer laxity, and stiffness of the
ankle complex. J Athl Train. 2008;43:242–248.
21. Answer C. Stage IIB
The original classification described by Johnson
and Strom in 1989 describes three stages of tibialis posterior tendon dysfunction (Johnson &
Strom 1989). In 1997, this was revised by
Myerson to include a fourth stage.
Stage I – Tenosynovitis of tibialis posterior
tendon without arch collapse.
Stage II is subdivided.
○ Stage IIa – Arch collapse with valgus
hindfoot deformity but normal midfoot
alignment.
Foot and Ankle II Structured SBA
Table 10.2 Staging of the adult acquired flatfoot deformity as proposed by Johnson and Strom, later modified by Myerson
Stage I Stage II Stage III Stage IV
Posterior
tibial tendon
Deformity Absent Flexible, reducible pes
Pain Medial Medial, lateral or both Medial, lateral or
Single limb
heel rise
Too many
toes sign
Valgus
deformity and
ankle arthritis
Tenosynovitis,
degeneration or
both
Mild weakness,
hindfoot inverts
normally
Negative Positive Positive Positive
No No No Yes
Elongation and degeneration Elongation and
degeneration
Fixed, irreducible pes
planovalgus deformity with
hindfoot held in equines
Marked weakness, no or weak
inversion of hindfoot
planovalgus
deformity
both
Unable to perform
test, no inversion of
hindfoot
Elongation and
degeneration
Fixed, irreducible
pes planovalgus
deformity
Medial, lateral or
both
Unable to perform
test, no inversion of
hindfoot
○ Stage IIb – Arch collapse with valgus
hindfoot deformity and midfoot
abduction.
Stage III – Fixed valgus deformity and
midfoot abduction.
Stage IV – Fixed valgus deformity and
midfoot abduction and associated valgus
ankle deformity secondary to deltoid
ligament insufficiency.
○ Stage IVA – Flexible ankle valgus
deformity.
○ Stage IVB – Fixed ankle valgus deformity.
Abousayed MM, Tartaglione JP,
Rosenbaum AJ, Dipreta JA. Classifications in
brief: Johnson and Strom classification of adultacquired flatfoot deformity. Clin Orthop Relat
Res. 2016;474:588–593.
Johnson KA, Strom DE. Tibialis posterior
tendon dysfunction. Clin Orthop Relat Res.
1989;239:196–206.
Myerson MS. Adult acquired flatfoot
deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect.
1997;46:393–405.
22. Answer B. Hallux rigidus
Although conservative treatment does not prevent progression of hallux rigidus it has a role in
symptom control for patients with early disease.
Insoles with a first ray extension (Morton’s
extension) have been used for the conservative
management of hallux rigidus. These are semirigid insoles with a first toe extension made of
carbon graphite or spring stele. It works by minimising the movement of the metatarsophalangeal joint and therefore reducing pain as well as
decreasing the forces across the midfoot and
forefoot.
Colò G et al. The efficacy of shoe modifications a nd foot orthose s in treating
patients w ith hallux rigidus: a comprehensive
review of literature. Acta Biomed. 2020;91(14S):e2020016.
Sánchez-Gómez R et al. Morton’s extension
on hallux rigidus pathology. Prosthesis
2023;5:251–263.
23. Answer D. Lesser toe deformity characterised
by MTP hyperextension with PIP and DIP
flexion
Hammer toe is defined as a primary flexion
deformity of the PIPJ, with or without
217
Andrea Nicolas and Simon Chambers
hyperextension at the MTPJ, but with a neutral
or hyperextended DIPJ.
A mallet toe deformity is a DIPJ flexion
deformity. This may occur due to direct pressure
from a shoe and eventually the FDL tightens
resulting in a fixed deformity. This may gradually cause callosities at the tip of the toe and
pressure on the nail.
A claw toe initially presents with hyperextension atthe MTPJ. When theMTPJ becomes chronically hyperextended, the intrinsics shorten, the
flexors are pulled taut and flex the IPJs. Initially
this clawing may be flexible and dynamic but gradually as the plantar plate ruptures, the MTPJ subluxes and the deformity becomes rigid. This is
commonly seen in neuromuscular disorders.
24. Answer B. Metatarsal bar
Morton’s neuroma is a thickening of the digital
nerve commonly caused by pressure or repetitive
trauma. The most commonly affected loc ation is
the third intermetatarsal space. Conservative
management is the first line of treatment. Wide
toe shoes and metatarsal bar. The metatarsal bar
is an insole that relieves the pressure of the metatarsal head and therefore relieves pressure on the
neuroma, improving symptoms. If simple orthotics fail, the next step will be a corticosteroid
injection. Surgical excision (more commonly
done through a dorsal approach) can be considered if conservative measures fail.
Table 10.3 Common toe conditions
MTP PIP DIP
Claw toe Hyperextension Flexion Flexion
Hammer toe Slight extension Flexion Extension
Mallet toe Normal Normal Flexion
Bhatia M, Thomson L. Morton’s neuroma –
current concepts review. J Clin Orthop Trauma.
2020;11:406–409.
25. Answer D. 10–15° of valgus, 15° of dorsiflexion
and neutral rotation
The first MTP joint is positioned in a way that
allows the pulp of the great toe to rest 5–10 mm
above the flat surface with weight bearing.
Positioning of the hallux is of paramount
importance to obtain proper foot function and
optimal shoe fit. Malunion can occur in one or
more of the sagittal, frontal and transverse planes.
Sagittal plane malposition, especially excessive dorsiflexion is poorly tolerated by the patient
due to increased plantar pressure at the first
MTP joint and concomitant abutment of the
hallux against the shoe wear, whereas excessive
plantarflexion significantly increases pressure on
the big toe during heel off. Malrotation may also
represent a problem as it causes painful callosities as well as painful nail deformities. Finally,
malunion in the transverse plane, namely varus
malposition, usually causes painful abutment
of the medial aspect of the hallux against the
shoe. Excessive valgus alignment of the hallux
will result in abutment with the second toe and
the potential for the crossover second toe
deformity.
Wagner E, Wagner P, Ortiz C. Arthrodesis
of the hallux metatarsophalangeal joint. JBJS
Essent Surg Tech. 2015;5:e20.
26. Answer D. Scarf osteotomy +/ Akin
osteotomy
The intermetatarsal angle (IMA) rather than the
hallux valgus angle is the more important angle
that determines the type of surgery required
(Table 10.4).
Table 10.4 Radiographic angular measurements in hallux valgus
Deformity Hallux valgus
angle (HVA)
Normal <15° <9° None
Mild <20° 9–11° Distal osteotomy +/ soft tissue procedures
Moderate 20–40° 11–16° Proximal osteotomy +/ soft tissue procedure
Severe >40° >16° Proximal osteotomy or first tarsometatarsal arthrodesis
Intermetatarsal
angle (IMA)
Management
+/ soft tissue procedure
218
Foot and Ankle II Structured SBA
Coughlin MJ, Jones CP. Hallux valgus:
demographics, aetiology, and radiographic
assessment. Foot Ankle Int. 2007;28:759–777.
Ray JJ et al. Hallux valgus. Foot Ankle
Orthop. 2019;4:2473011419838500.
27. Answer B. The angle created between the lines
that longitudinally bisect the proximal phalanx
and the first metatarsal
The angle drawn between the first and second
metatarsal shaft on an axial view of the foot is the
Intermetatarsal Angle (IMA).
The angle drawn between the longitudinal
axis and the articular surface of the first metatarsophalangeal joint is Distal Metatarsal
Articular Angle (DMAA).
The angle drawn between the long axis of the
distal phalanx and proxim al phalanx is the
Hallux Valgus Interphalangeus Angle (HVIA).
Ray JJ et al. Hallux valgus. Foot Ankle
Orthop. 2019;4:2473011419838500.
Figure 10.6
Hallux valgus
radiology angles
Diabetes
28. Answer B. Close contact cast
This patient has a diabetic foot ulcer. His inflammatory markers are normal which suggest it is
not actively inf ected. He has neuropathy,
therefore debridement to remove the necrotic
tissue and promote granulation can be done in
clinic with an aseptic technique by a qualified
practitioner (podiatrist or orthopaedic surgeon).
Off-loading the ulcers is essential to allow it to
heal. Multiple studies have demonstrated that
increased plantar press ures significantly contribute to the development of plantar ulcers in diabetic patients. The most effective method for offloading is total contact cast.
Alexiadou K, Doupis J. Management of dia-
betic foot ulcers. Diabetes Ther. 2012;3:4.
Burns J, Begg L. Optimizing the offloading
properties of the total contact cast for plantar
foot ulceration. Diabet Med. 2011;28:179–185.
Veves A, Murray HJ, Young MJ, Boulton
AJ. The risk of foot ulceration in diabetic
patients with high foot pressure: a prospective
study. Diabetologia 1992;35:660–663.
29. Answer A. Stage 1 Fragmentation
The patient has a Charcot foot, the clue being
that they are diabetic as this is the most common
cause of Charcot arthropathy in developed countries. It can be challenging to diagnose, as its
earliest manifestations (e.g. swelling, inflammation and warmth) are similar to those seen with
deep venous thrombosis, osteomyelitis, cellulitis
and rheumatoid arthritis. The Eichenholtz classification is a temporal based system used to assist
clinicians in diagnosis, staging and selecting
appropriate treatment (Eichenholtz 1966).
Stage 1 presents with radiographic evidence of
osteopenia, periarticular debris and fragmentation,
and joint subluxation or dislocation. Clinical examination reveals swelling, erythema and/or ligamentous laxity (Rosenbaum & DiPreta 2015).
Stage 2 presents with absorption of periarticular debris, early sclerosis and bony co nsolidation of some of the larger fragments seen in Stage
1. New bone begins to form in this stage.
Clinically there is decreased warmth and swelling
of the involved joint are observed.
Stage 3 represents the progression of the joint
to a more stable structure. Although deformity
still may be evident on radiographs, new bone
formation continues and becomes a more prominent feature. Decreased sclerosis, rounding and
smoothing of bone fragments, joint space
narrowing with arthrosis, and fibrous and/or
219
Andrea Nicolas and Simon Chambers
Table 10.5 Classification of Charcot’s foot
Deformity Clinical
signs
Stage 1
Fragmentation
Stage 2
Coalescence
Stage 3
Reconstruction
Swelling,
erythema,
warmth
Decreased
swelling,
erythema,
warmth
Absence of
swelling,
erythema,
warmth,
stable joint
+/ fixed
deformity
Radiographic signs
Osseous
fragmentation with
joint dislocation
Coalescence of
fragments and
absorption of fine
bone debris
Consolidation and
remodelling of
fracture fragments
osseous ankylosis are seen. On clinical examination, swelling and erythema has dissipated, and
the joint will seem stable in the setting of a fixed
deformity.
Clinical signs (such as swelling, warmth and
erythema) regularly precede the radiographic
findings seen with Eichenholtz Stage 1 arthropathy. As such a fourth stage, Charcot foot Stage 0,
was added to the conventional Eichenholtz classification (Shibata et al. 1990). The addition of
this prodromal stage has important therapeutic
implications, because the immobilisation and
off-loading of feet with Stage 0 symptoms may
prevent progression of skeletal destruction and
deformity.
Eichenholtz SN. Charcot Joints. Springfield,
IL: Charles C. Thomas; 1966.
Rosenbaum AJ, DiPreta JA. Classifications
in brief: Eichenholtz classification of Charcot
arthropathy. Clin Orthop Relat Res.
2015;473:1168–1171.
Shibata T, Tada K, Hashizume C. The
results of arthrodesis of the ankle for leprotic
neuroarthropathy. J Bone Joint Surg Am.
1990;72:749–756.
30. Answer E. It consists of the ratio between the
systolic blood pressure of the lower extrem ity,
specifically the ankle, and the upper extremity.
Normal value is 0.9–1.4
The Ankle Brachial Index (ABI) is a non-invasive
tool to assess the vascular status of the lower
limb. The normal value is 0.9 – 1.4. A value of less
than 0.9 is suggestive of peripheral vascular disease and greater than 1.4 is indicative of vessel
stiffening.
Aboyans V et al. ESC Guidelines on the
Diagnosis and Treatment of Peripheral Arterial
Diseases, in collaboration with the European
Society for Vascular Surgery (ESVS); 2017.
Document covering atherosclerotic disease of
extracranial carotid and vertebral, mesenteric,
renal, upper and lower extremity arteries.
McClary KN, Massey P. Ankle Brachial Index.
Treasure Island (FL): StatPearls Publishing; 2023.
31. Answer D. Radical debridement
This patient is presenting with a foot attack, a
severe form of diabetic foot infection. Patients
require urgent admission, investigations and
resuscitation following the local sepsis pathway.
Early debridement is essential as this is a life- and
limb-threatening condition. Radical debridement
should follow the RAG (red-amber-gre en) model
described by Ahluwalia et al. (2019). Tissues
should be debrided down to healthy, unaffected
tissue (green zone), this is also applicable to bone
debridement.
Ahluwalia RS, Reichert ILH. Surgical management of the acute severely infected diabetic
foot – the ‘infected diabetic foot attack’ .An
instructional review. J Clin Orthop Trauma.
2021;18:114–120.
Ahluwalia R et al. Surgical diabetic foot
debridement: improving training and practice
utilizing the traffic light principle. Int J Low
Extrem Wounds 2019;18:279–286.
32. Answer A. Conservative management with
orthoses
The management of acquired flat foot deformi ty
is complex. It includes a combination of soft
tissue balancing with bony realignment.
Conservative management is always the first
option regardless of stage.
For stage I, the main line of treatment is
conservative management with physiotherapy
and orthoses. Physiotherapy is aimed at addressing weakness in specific muscle groups and
improving gait kinematics. A UCBL brace is the
220
Foot and Ankle II Structured SBA
orthotic of choice for a flexible flatfoot whilst a
rigid (accommodative) bracing is used for more
severe deformities in patients unfit for surgery.
In those rare cases that surgical management is
required this may include tibialis posterior
tendon debrideme nt/tendon repair/FDL transfer.
Stage II includes a combination of soft tissue
and bony corrections. The choice depends on
each individual case but includes medial calcaneal osteotomy, gastrocnemius recession, FDL
transfer and spring ligament reconstruction.
Stage III is a fixed deformity therefore
arthrodesis of the talonavicular, naviculocuneiform +/ calcaneocuboid is needed.
Stage IV includes deformity at the ankle level;
for stage IVA, the deformity is flexible so in
addition to the arthrodesis described above, the
ankle deformity can be addressed with deltoid
ligament reconstruction. For those cases with a
fixed ankle deformity (Stage IVB) ankle arthrodesis or ankle replacement is also required.
Ling SK, Lui TH. Posterior tibial tendon
dysfunction: an overview. Open Orthop J.
2017;11:714–723.
Vulcano E, Deland JT, Ellis SJ. Approach
and treatment of the adult acquired flatfoot
deformity. Curr Rev Musculoskelet Med.
2013;6:294–303.
221
Section 2
Chapter
11
Adult Elective Orthopaedics and Spine
Spine I Structured SBA
Paul Rushton and Niall Eames
SPINE I STRUCTURED SBA QUESTIONS
Basic Science
1. Regarding normal spinopelvic alignment, which
of the following statements is correct?
A. A change in pelvic incidence (PI) associated
with degenerative changes underlies sagittal
balance problems in adults
B. A vertical plumb line from the centre of the C7
vertebral body should pass just anterior to the
sacral end plate
C. Mathematically: Sacral slope (SS) = Pelvic inci-
dence (PI)+ Pelvic tilt (PT)
D. Patients’ lumbosacral lordosis is proportional
to their pelvic incidence (PI)
E. Sagittal balance problems in adults are usually
associated with an increased lumbar lordosis,
which can necessitate surgery
2. An implant company is encouraging a surgeon to
change to a new type of rod for their scoliosis
corrections. They propose changing from the
5.5mm diameter titanium alloy (Ti) rods the surgeon currently uses to their new 5.5mm diameter
cobalt-chrome (CoCr) rods.
Which of the following is true?
A. Bending rigidity is inversely proportional to
second moment area (SMA) of the rod
B. Changing from the Ti to the CoCr rod as sug-
gested will roughly double the bending rigidity
C. Changing to a 6mm diameter Ti rod would
have a greater increase in bending rigidity than
changing to the new 5.5mm diameter
D. CoCr rod woul d be more at risk of fractures
due to the surface damage intraoperatively
following rod contouring
E. Young’s modulus describes the plastic portion
of the material’s deformation on a stress –
strain graph
3. A surgeon is undertaking a scoliosis correction
with an all pedicle screw construct. They are keen
to increase the strength of the bone–screw
interface.
The surgeon is best to use a pedicle screw with
which of the following?
A. Cannulation
B. Larger core diameter
C. Larger pitch
D. Larger thread diameter
E. Larger thread depth
4. In the normal intervertebral disc, the tissue
derived from the primitive notochord is made
of which collagen type predominantly?
A. I
B. II
C. V
D. IX
E. X
5. As part of a lumbar central decompression you are
removing compressi ve soft tissue material from
the interlaminar region.
This tissue is made predominantly of which of
the following?
A. Elastin
B. Proteoglycans
C. Sharpey’s fibres
D. Type I collagen
E. Type II collagen
Paediatric Spine
Questions 6–7 Stem:
You see a 12-month-old boy presenting with a scoli-
osis. He is otherwise well. He has only just started to
walk. On examination he has a subtle thoracic scoliosis and grossly normal neurological examination. A
plain radiograph demonstrates a single thoracic fully
segmented hemivertebra.
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6. What is the most relevant next step in his
management?
A. CT scan with 3D reformats
B. Referral to orthotics for brace fitting
C. Renal ultrasound
D. Review by neurodevelopmental paediatrician
E. Whole spine MRI scan
7. The anticipated progression of his deformity
would likely be greater if it was which of the
following?
A. Incarcerated hemivertebra
B. Block vertebra
C. Single semi-segmented hemivertebra
D. Single unsegmented hemivertebra
E. Unilateral bar
8. A 9-month-old boy has been referred to you by a
paediatrician he saw about his plagiocephaly as
the physician noted a scoliosis. He is otherwise
well with normal milestones and no apparent
pain. Neurological examination is unremarkable.
A radiograph demonstrates normal segmentation and a left thoracic scoliosis with Cobb angle
of 15°. The rib head is in phase 1 and rib vertebral angle difference (RVAD) 16°.
The most appropriate management at this
stage would be which of the following?
A. Cast treatment
B. Insertion of growing rod construct
C. Instrumented correction and fusion
D. MRI of whole spine
E. Observation
9. You assess an 11-year-old boy referred from a
dermatologist with a rapidly progressive scoliosis. A whole spine radiograph is shown in
Figure 11.1.
The underlying diagnosis related to a mutation
in which gene?
A. COL1
B. COL2
C. Dystrophin
D. FBN1
E. NF1
10. You are seeing an otherwise well, pre-menarchal
12-year-old girl referred in with a thoracic scoliosis. Examination is unremarkable aside from
Spine I Structured SBA
Figure 11.1 PA whole spine standing radiograph
the left thoracic scoliosis with a small rib hump.
She has a normal neurological examination.
Whole spine X-rays confirm the scoliosis with
apex at T8 with Cobb angle of 20° and normal
segmentation.
The most appropriate next step in management
is which of the following?
A. Application of CTLSO brace
B. Application of TLSO brace
C. MRI scan of whole spine
D. Observation with repeat X-ray in 3–6 months
E. Posterior instrumented correction and fusion
Questions 11–13 Stem:
You are seeing a 16-year-old female with a scoliosis first
diagnosed 4 years previously. She is otherwise well and is
now 2 years post-menarchal. Examination demonstrates
a thoracic scoliosis, right-sided rib hump on Adam’s
forward bending and the right shoulder slightly higher
than the left. A whole spine MRI scan is normal, aside
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