Available in Packages: PRESENT Podiatry Board Review w/ Boards By The Numbers
This final lecture of Dr. Schuberth's 3-part series focuses on reinforcing the skills necessary to be successful on the oral portion of the board examinations. He provides 3 more practice questions to aid in this process. Challenging cases are presented including bone tumors, and open fracture management with breakdown of the "points to pass". At the completion of this lecture the viewer will improve their line of questioning skills and their ability to interact with the examiner.
John Schuberth, DPM
Chief, Foot and Ankle Surgery
Kaiser Foundation Hospital
San Francisco, CA
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Jack Schuberth: We’re ready to start Part 3 or the second portion of the Practice Oral Examination. In the next three questions, the overlying theme should be “practice, practice, practice.” Hopefully, this will help you crystallize the process and hone one’s skills at taking questions. Although this material may or may not come easy to you, remember that the priority here is question mechanics, not rote memorization. Here we go. Question four. A 43-year-old female enters your office with a three-week history of pain on the second toe. She relays that she did a three-mile hike, and one to two days afterwards her symptom started. She is completely healthy and takes no medications. Discuss your evaluation, diagnosis, and treatment plan. Here is a clinical photograph of the patient as she presented to your office. Here we go again. The candidate should inquire about the patient history in order to make sure that nothing is overlooked. It seems rather elemental but remember that the purpose of these practice exams is really like conditioning, and conditioning enhances performance. On the other hand, we’ve mentioned several times that the examination is not designed to trick anyone. It’s designed to test your competency albeit in an artificial situation. Therefore, the candidate really should inquire about a history of trauma. Even though the stem of the question told you that the patient went hiking, the surgeon is obligated to elicit this history. In addition, some qualification about the nature, location, and duration of pain is required. The patient in this case has no history of trauma and the pain is located at the base of the second toe and made worse by weightbearing and relieved with rest. There is no radiation and it is described as a sharp localized pain. For the purpose of this question, we’re going to redirect you. The patient has a totally benign medical history, so please move on to examine this particular patient. Just to refresh your memory, here’s the clinical photograph again. How would you proceed? The candidate should palpate the base of the second toe. There is tenderness to palpation over this area. The second important maneuver should be the Lachman test. However, in this case, the patient jumps off the table as the examiner grasps the proximal phalangeal base. Next, some sort of assessment of the range of motion should be done. There is a smooth range of motion with pain at the end range of dorsiflexion. It appears that the range of motion is virtually full otherwise, but because of the tenderness it is difficult to assess accurately. The candidate should assess for first ray stability. In this particular case, the patient’s obvious hallux valgus is asymptomatic and the first ray is very stable. Lastly, the neuro examination really should be done. In this patient, there is loss of sharp, dull, and light touch discrimination to both sides of the plantar aspect of the digit. The rest of the examination proximal to the forefoot is completely normal. Now note that we have provided some direction for this examination. Essentially, we are telling you that the so-called money is in the forefoot. Some of you may worry that you did not follow this exact script when performing this examination. It really isn’t important that you follow every script exactly as it’s written. You can get any or all of these points in any order and you can certainly go back to all these specific information if something comes to mind in the actual testing process. Don’t worry about not migrating down this particular scripted pathway. The key is that you have enough sense to elicit the key issues of the patient examination. The examiner has just about told you to move on to something else, so you should now follow what you would do normally in your office. Most likely, you would order radiographs. Here they are. The two pictures on the left represent a close-up AP and oblique film, and the picture on the right is the right forefoot. Stop, pause the presentation, and interpret these radiographs. Now you have to recall the key issues raised in the first part of the series. Remember that the key is to utilize the systematic approach. For the purposes of this question, focus on the second toe and just describe the features that you see.
Articulate as many features as you can, but remember that they really should be pertinent. Don’t throw out terms just for the sake of providing guesses. These features include the fact that the lesion is well circumscribed and it’s located in the metaphyseal region of bone. The metaphyseal expansion has caused cortical thinning of the proximal phalanx. Also note that the matrix is not homogenous, meaning that the consistency is such that more than one histologic entity is likely to be present. As such, note that the matrix is calcified but it is not ossified. Lastly, one should have noted the cortical break plantarly on the proximal phalanx. Now that you’ve had a chance to examine the radiographs, can you come up with a tentative diagnosis? Remember that you should formulate your diagnosis on the basis of the information you have and shouldn’t just spew out possibilities based on whim and chance. Although you may be trying to figure out the exact tissue type here, answer this question in terms of what brought the patient in to see you. The most obvious and important diagnosis in this particular case is that the patient has a pathologic fracture of the base of the second toe. Remember the history of the three-mile hike, well the lesion has expanded the cortex so much that it succumbed to the repetitive load and the plantar cortex indeed failed. Now that you’re confronted with this lesion and broken toe, what are your plans for management? Pause and try and think of the entire package before you jump in to the obvious. The overall management plan should consist of both biopsy and fracture management. We’re going to get into the specifics in a bit but you really should have thought in these terms. Last we have alluded to, there is obviously some type of tumor present in the second toe. What do you really want to know about this lesion? Pause and think about those features that would be really important to ascertain before you embark on treatment. First of all, you should really decide whether this is benign, malignant, or metastatic. Although this seems rather obvious, the implications are significant. Secondly, you’d like to know the tissue type in this lesion. Let’s examine these two parameters in some depth. There’s nothing in this patient’s history to suggest that this is metastatic, as the stem of the question told you that the patient is entirely healthy. Now recall that in real life, patients may not be aware that they have a malignancy elsewhere and that the metastatic site could be the primary or initial presentation, yet the radiographic appearance of this lesion clearly mitigate against the metastatic lesion. First of all, metastases distal to the metatarsals are extremely uncommon, but the mere fact that the lesion is well circumscribed and there is no real lysis confirms that this is not metastatic. The same radiographic features are highly suggestive that this is a benign tumor of the digit. A well circumscribed lesion is usually benign. Now, let’s discuss the tissue type. We mentioned biopsy. How would you do this biopsy? What are the important features of the biopsy? Well, the biopsy in this case should be excisional. The reason for that is that you have a benign tumor and it would be best just to get rid of the problem, so to speak, in one single step. [Indecipherable] [08:51] stain at 40 and 100 magnification, so the tissue obtained at biopsy. Now, many candidates freak out when they see histo slides because this drudges up memories of the first year in school, peering through that microscope wondering what this has to do with anything relevant. However, it is part of the overall process in being a surgeon. Remember that it’s not the intent of this examination to make you pathologist, but you should at least be able to recognize some of the features of these specimens and tell us what the tissue type is. Pause the presentation and study the slide. Write down or memorialize any features that are descriptive in these two specimens. You should at least have determined that this was a cartilage tumor. These cells are uninucleated and no mitotic figures whatsoever are identified. Secondly, they appear to be chondrocytes embedded in a cartilaginous matrix. Lastly, although whether elemental, they are stained blue, again, suggestive of a basic or a non-acidic environment.
Now, you’re going to be asked to perform the biopsy and definitive management. What are the critical features of the biopsy in this case? Again, pause and write down all of the important things that you would do if this were your patient. This is not really hard if you take it slow and systematically. Analyze what would be observed if you were doing the case. Don’t forget to consider all of the information that you’ve already been given. The important features include complete excavation of the tumor, bone grafting the defect, and fracture stabilization. The next slide represents a photo of what you have left after the lesion is curetted. How would you handle the situation? Just to help along a little bit, note that there was an older defect at the base of the proximal phalanx. The fracture is now complete and that the diaphysis is completely detached from the proximal metaphysis. How would you stabilize this fracture after you put in some bone graft? Here are the most important thing to realize, that whatever fixation is utilized, it is contained within the phalanx so that one does not really violate other anatomic structures. In other words, the surgeon may be tempted to utilize transarticular K-wires, but this would be contraindicated because you might cede the second metatarsal. This leaves little choice but the small plates as seen in this example. Note that the plate is contained completely within the cubic content of the second proximal phalanx and that no adjacent structures had been violated by the hardware or the instrumentation used to deliver the fixation. Don’t worry, this question is about to conclude. Before it does, think about how you would follow up this patient. What is important in the context of this case? Really, there are three things that are important. First and foremost, the surgeon must be concerned with recurrence so serial radiographic follow-up is paramount. Secondly, one really wants to assess the degree of bone graft incorporation. This goes along with the assessment of fracture healing. Although rather elemental concepts, sometimes it’s difficult for candidates to jump from specific to more global issues. This is indeed an artificial environment and direct interaction with an examiner will make these transitions rather simple and seamless. Let’s discuss the points to pass in this question. The first, that the candidate ask the appropriate follow-up questions. The first is obvious regarding the history of trauma. The second is designed to encourage the candidate to elicit more information about the stem of the question. In an actual test, there is likely would be more latitude in this point to pass. The next point to pass is that the candidate does the appropriate examination maneuvers. These five components of the examination are really taken right from the question and it will be hard to argue that any of them should be excluded. These maneuvers include direct palpation, the Lachman test, range of motion of the second metatarsal phalangeal joint, first ray stability, and a neurological assessment. Remember that each of these components were alluded to in the stem of the question and it is incumbent upon the candidate to elicit further information to rule in or out specific diagnoses. The second point to pass is also rather obvious. We do give you some leeway and that we only ask for five of the seven good answers. We wanted you to identify the key radiographic features seen on the presenting radiographs. They include the fact that the lesion is well circumscribed. It is contained within the metaphyseal region, but there is metaphyseal expansion. There is cortical thinning, a nonhomogenous matrix, a calcified matrix. Lastly, a cortical bone break plantarly at the base of the toe. This next point to pass involves the diagnosis, but it is a two-edged sword because anyone can tell the examiner that a tumor is present. It’s so obvious that it doesn’t deserve credit, rather, recognition of the fact that the phalanx is fractured, represents the clinical acumen and assimilation of the important features of this question. You had to make the diagnosis that there was a pathologic fracture.
Remember the definition of a pathologic fracture is one that occurs through an area of so-called pathology, which in this case was a tumor of the second toe. The next point to pass involved the candidate’s ability to formulate an appropriate management plan. This plan must have included a biopsy and management of the pathologic fracture at the base of the second toe. To further refine the management plan, the candidate must have recognized that this is a benign process. Because it is benign, an excisional biopsy was the most appropriate way to definitively deal with this lesion. Now note that the two components of this point to pass are required in order to get it. You certainly don’t have to say these exact words, but the keys are benign and excisional. Any other deviations from this are not going to be accepted in this fundamental and important concept. The next point to pass deals with the candidate’s capacity to interpret the histologic specimen. We really wanted you to identify the fundamental histologic features of those specimens. These include the fact that this is a cartilaginous tumor. The cells are uninucleate without any mitotic figures. There are chondrocytes embedded in a cartilaginous matrix. Lastly, they are stained blue, indicative of a basic milieu. The next point to pass assesses the candidate’s ability to perform an appropriate surgical management of this bone tumor. These components include the fact that the candidate completely excavated the mass, and lastly, dealt with the pathologic fracture by stabilizing it. More specifically, this fracture stabilization included the fact that the candidate utilized self-contained fixation or rather did not use fixation that violated any other adjacent anatomic bony structures. To pass in this particular question is consistent with every single operation that we do and that is appropriate follow-up maneuvers. Pertinent to this question, serial radiographic follow-up, which assesses for bone graft incorporation and fracture healing is important. Now note that we told you that bone graft was delivered. However, that does not eliminate your responsibility to assess its long-term incorporation. Let’s move on to the next question. Alright, question five. You’re called to the emergency room to see a 50-year-old female who is involved in a motorcycle accident about an hour ago. Her left foot was impaled between the peg on the motorcycle and a car. She is in severe pain. The patient is otherwise healthy. Here are some clinical photographs of the left foot at the time of the presentation. Discuss your evaluation, diagnosis, and treatment plan. Here come the photos. Here is a dorsal, plantar, and medial view of the injured extremity. Please stop and study these for a little bit before we move on. Now that the brief history and some clinical photographs have been provided, again, the temptation is to jump right into the treatment but you would never do that in real life or at least hopefully not. Try and figure out your next course of action. What else do you really want to know, or for that matter, need to know? Before you proceed, pause and think. Here you need to ask the same set of qualifying questions as before so you don’t miss anything. They include, it says here you’re healthy, does that mean that you’re not taking any medications and you’re not being treated for anything by your regular MD? Do you have any allergies? Do you have any other injuries? The patient relates that she has no other injuries and has no allergies and that she has not taken any medications. In other words, she is completely healthy. How would you proceed from there? Obviously, this is a question involving some trauma. Yes, it is a different subject, and as such, there are different priorities when taking care of this patient. There’s a distinct dichotomy when placed in an artificial testing environment. Should you perform the usual sequence of events that you would for a patient with an obvious hallux valgus or do you tailor the line of questioning? The expected answers that you should stick with a standard sequence of questioning so you don’t miss anything and conform to the organized thought process. That is always the safest. Then the examiner will diverse you if that process is going to waste too much valuable time. That’s the case here. The examiner now asks you, what are your most important immediate concerns with this patient? Pause the presentation and itemize those things that may require particular detailed questioning or, in the case or real life, clinical attention.
Although there may be other concerns in your mind, there are some obvious and important issues with this injury. First and foremost, one must be concerned that this may be an open fracture. You really should expect this even before you get any radiographs. The secondary of concern is that of the circulation and pulses. In a sense, this is a corollary of the next one. Although it was not specifically pointed out, the stem of the question indicated that the foot was impaled between the peg on the motorcycle and a car. Therefore, the crashing type of mechanism adds another dimension to the complexity of this problem, and most likely, the question. Finally, although somewhat related to the fact that this is a crash injury, the candidate should mention that a compartment syndrome may be evolving. It is a common misconception that a compartment syndrome cannot develop when there is an open wound, but nothing could be further from the truth. What are your next steps? You should figure out what you’d do based on this presentation. Pause and think a bit. There are really only two things that need to be done. One is to check the pulses. In this case, the pulses are not palpable, but on the opposite side the pulses are full. Capillary refill time in the injured foot is about four seconds and instantaneous on the opposite foot. When you examine the wound, you note that the skin is loosely adhered to the dorsum of the foot. A gloved hand is inserted into the wound and the result looks like this. Note that in this photograph, the surgeon’s finger can traverse all the way over to the fifth metatarsal shaft and is palpating that during the examination. As you continue with the examination of this patient, you realize that the situation is worsening. What would be your next steps? Well, to deal with the nonpalpable pulses, the candidate must ascertain the integrity of the circulation. A Doppler examination should be done to figure out whether there is disruption to the dorsalis pedis and posterior tibial arteries. When you do that, you hear a biphasic signal for each of the three vessels including the peroneal artery. The next diagnostic test of course would be radiographs, and we’ll give you those in a bit. However, another important diagnostic maneuver would be measurement of the compartment pressures. In this particular case, the pressures measure 19 millimeters of mercury in the plantar central compartment. What significance would you place on this value? Pause and think a bit and see what you would do if you were encountered with this value. Naturally, this is a bit higher than normal but certainly below the threshold that would indicate the least of the compartments. Here are the X-rays that you ordered, please interpret these films. Again, don’t forget to pause the presentation and study them very, very carefully. Here, the radiographic diagnosis is not particularly difficult. Obviously, the most prevalent fracture is the first metatarsal, which happens to be displaced dorsally. The middle three metatarsals are also fractured in the diaphyseal region. Lastly, the fifth metatarsal has an oblique fracture of the distal metaphysis. It establishes the injury pattern. You’re likely to hear from the examiner, how would you manage this patient? What are your biggest priorities at this time? Stop and think before you act because we’re interested in the total management of this patient. First of all, the patient must be taken to the operating room for a debridement because of the open fracture situation. Remember that in this case, I&D stands for irrigation and debridement. Secondly, the candidate should express concern about the operative stabilization of the fractures. We’ll get to the specifics later, but the candidate should also worry about the compromised skin envelope. Lastly, the candidate should administer appropriate antibiotic coverage while in the emergency room. Now the candidate is asked, how would you classify this open fracture? You should recognize that this is at least a grade 2 injury based merely on the size of the wound and that it could be a grade 3A if one considers the degree of the injury. If you believe that this is a grade 1 injury, you really should review the Gustilo and Anderson open fracture classification scheme. Now, the candidate is asked, because this fracture is classified as a grade 2 injury, what is the appropriate antibiotic for this patient?
Although there is some controversy, the most commonly accepted answer is an early generation cephalosporin as the most likely infective organism would be Staph aureus. Some would consider adding an aminoglycoside, but because we told you that this is only a grade 2 injury, it is not appropriate to overmedicate in this situation. We ask to discuss the specific techniques for stabilization of these fractures. Please take everything into account that you know about this patient. How would you specifically deal with these bony injuries? We want you to be as detailed as possible. Since the first metatarsal is open and communicates with the environment, the only real option for the first metatarsal is a mini ex fix. This is necessary because of the introduction of internal fixation would be contraindicated. Certainly, one can make an argument that K-wire fixation would be appropriate for the first or even all four of the medial metatarsals. However, it’s impossible to probe this point adequately in an artificial situation such as this. In the real exam, it would likely delve into the compromise of the dorsal skin envelope. In other words, if the candidate did not express concern over the dorsal degloving, most likely he or she would have missed this particular point of the question. Further avenues for the central three metatarsal fixation can also include percutaneous fixation including ex fixes. The key is recognition of the degloving injury. While the patient was treated with closed intramedullary K-wires, and three months later, the following radiographs are noted. The pin from the fourth metatarsal has been removed. The wound has been closed by a secondary intention. How would you proceed from here? What can you tell us about the prognosis based on these radiographs? Pause the presentation before you proceed to the next slide. The surgeon should recognize immediately that there is an impending nonunion of the first metatarsal. There is also substantial osteopenia because of the long-term nonweightbearing. How would you deal with this situation? What would you be concerned about? The candidate should be concerned that the ability to use rigid fixation for the repair of the nonunion is going to be significantly compromised. Well, this question is a bit more obtuse than many candidates would prefer. The key is that it still examines your knowledge of open fractures, but in a more practical sense. Why is that? Remember that the oral examination should not be something that you can study for years for and still be able to pass, that is, if you don’t do the work. Think about it. Isn’t that the purpose of board certification, be able to practice and treat patients in a competent fashion? If you don’t think appropriately, then most likely you would not be able to take care of this patient in a satisfactory fashion. Now, this is my personal opinion but it would probably be yours too if it were your family member with this open fracture. Now, not to be completely negative, you may be surprised by the answers to the points to pass in this particular situation. The first point to pass is simply that the candidate prioritizes the concerns based merely on the initial presenting information. These include the potential for an open fracture, the possibility of a vascular compromise, the fact that this is a crush injury. Because of that crush injury, the potential for an evolving compartment syndrome. Note that we only want you to get three of these four possibilities, but they’re all critical in the management of this particular situation. Second point to pass, recognize the candidate’s ability to order appropriate additional diagnostic tests. Now, this seems rather simplistic, however, they include Doppler examination because of the nonpalpable pulses. Obviously, we’re going to order some radiographs. Lastly, checking the compartment pressures. Here, all three are required. Certainly, everyone will order radiographs, so in a sense, this is a given. You really needed to recognize that you had to do additional diagnostic testing to include Doppler and compartment pressures. This next point to pass, assess your capacity to identify all of the fractures. Now this seems somewhat simplistic because all we really wanted you to recognize was the fact that there is a midshaft fracture of the first metatarsal. Diaphyseal fractures of the second, third, and fourth metatarsals.
Lastly, an oblique distal metaphyseal fracture of the fifth metatarsal. Situation such as this typify the complexity at testing people over a computer, whether or not these qualifiers such as midshaft, diaphyseal, or oblique distal metaphyseal, really would be part of the point to pass is difficult to say. Nevertheless, recognition of all of the bony injuries was a critical component to dealing with this particular patient. This next point to pass deals with the candidate’s management of this patient. Here, we expect that the candidate to take the patient to the operating room for an immediate irrigation and debridement. We also wished the candidate to deal with the fractures, be concerned with the compromised skin envelope, and lastly, administer appropriate antibiotics. As we mentioned, in this situation, an early generation cephalosporin would be the drug of choice. This next point to pass is also rather obtuse. We really wanted you to understand the open fracture classification scheme of Gustilo and Anderson. You must have recognized that this fracture was classified as at least a grade 2. More importantly, that you could distinguish between a grade 2 and a grade 3 injury based on the information that you had. We realized that the soft tissue wound here was rather significant. All that’s important is that you appreciate that a grade 2 and a grade 3 are managed differently from an antibiotic perspective, at least from an academic standpoint. This next point to pass assesses your ability to recognize the complications on the three-month postoperative radiograph. The first includes recognition that there is an impending nonunion. We recognize that technically, you can’t call this a nonunion till at least six or nine months have expired. Nevertheless, the appearance of this fracture ends indicate that this is a distinct possibility. Secondly, you should have recognized the marked osteopenia from the longstanding nonweightbearing. This in turn would lead to a compromised fixation situation, should you be have called upon to revise the nonunion. Question six and thankfully the last question. A 33-year-old female enters your office complaining of a recurrent bunion. She had the original surgery about two years ago and noted that the deformity came back rather quickly. She is completely healthy and takes no medications. Discuss your evaluation, diagnosis, and treatment plan. Here is a clinical photograph of her foot at the time of presentation. In order not to be overbearing, we are going to direct you pass the past medical history. This patient is indeed healthy and has no medical problems. There are no allergies. The next component of the history and physical should be, pause and think about what you’d like to know. Of course, the most logical thing is the history of present illness. Most likely, you would like to know what operation was done in the postoperative course. The patient tells you that there was some sort of bone cutting and there was a long period of time before she could walk on the foot. You can now proceed with your examination at this point. Here, we’re just going to give you the pertinent findings for this patient. When something like this happens, you will most likely get this in a written format, but of course here, you won’t. Yet, this should serve as a stimulus to organize your thoughts as you gather and receive this information verbally. This patient has 50 degrees of dorsiflexion and 30 degrees of plantar flexion at the first metatarsal phalangeal joint in the unloaded position. However, it is track bound and you cannot reduce the deformity. The first metatarsal is splayed but is reducible. There is absolutely no significant dorsal hypermobility. Second metatarsal head area is painful to palpation but there is no plantar callus. The rest of the examination is normal, so there is no need to inquire about pulses, neurologic, and other issues. Let’s proceed. Here is an AP and a lateral radiograph of the foot at the time of presentation to you. Please pause the presentation, look at this carefully, and consider the important features of these films. The most important radiographic features of these films are, a short first metatarsal, an increased intermetatarsal angle, deviated sesamoids, an increased proximal articular set angle, and lastly, valgus rotation to the hallux.
Now, you might think that these features were relatively simple, and they are. Sometimes, the real question is really straightforward and represents everyday practice. Keep in mind that in a computer-based testing environment such as now, the published answers do not necessarily reflect other responses that you may have put forth in the actual examination. Remember that you’re given credit for what you say, but you’re not given credit for what you don’t say even though you may be thinking that you must articulate it to the examiner even if it seems oversimplified or redundant. Okay. Now, it’s time to fix this problem surgically. You really must formulate a surgical treatment plan based on the chief complaint, the elicited symptoms, and the radiographic findings. For this particular patient, an opening wedge osteotomy should be performed to compensate for the short first metatarsal. A Lapidus might be acceptable but the examination did relate to you that there was no dorsal hypermobility. It’s not the purpose at this point to debate the wisdom of a closing base wedge osteotomy versus a Lapidus, but in either case, you will need a bone graft. This must be part of the treatment plan. Next, a sesamoid release or even a removal must be performed. Again, it’s not the point of whether it should be removed or released, but nevertheless, dealt with. Lastly, I want you to consider the hallux. Because of the track bound position of the joint, something must be done to correct the position of the toe. You would all recognize that there is no way that that toe would be straight unless something was done to either the hallux itself or a head osteotomy. This is really difficult to pin down on any candidate, but as you might imagine, its dealer’s choice. Either answer is acceptable. The point is that you have dealt with the situation. Now the candidate is told, we want you to assume that you’re going to do an opening wedge osteotomy. What are the important features of the bone graft in this particular case? What would you want to consider or utilize in the execution of this opening wedge procedure? Please consider all of the components of the grafting procedure. No one would argue that the graft should be a cortical, cancellous graft. The cortex is necessary to maintain the correction and the cancellous component is necessary for a living substrate. Next one you should consider that a neutralization plate will be necessary for holding open the osteotomy. Again, a difficult concept to test artificially but I think you will all get the point. Now, the likely turn of the question would come if the examiner should ask you whether or not the graft should be autograft or allograft? We’re not going to do that here. Instead, we’re going to ask you what the most ideal properties of any bone graft should be, but not necessarily in this situation. Since you all know the answer to this question, the ideal graft is one that is structurally sound. Naturally, it can be just cancellous chips if you’re filling a stable void, but it may also need to be cortical if you’re using it for support or structure. The ideal graft should also be osteoconductive or it should serve as a scaffold for the cellular activity. In addition, the graft should be osteoinductive or have the capacity to set the bone production mechanism into action because of the nascent proteins. Lastly, the graft should have low immunogenic potential. As you recall, this can occur with both autograft or allograft, particularly with the modern techniques of preparation of allografts. Here’s Part 2 of the last question. This is a completely different patient but the overlying theme is the same. Here it is. A 48-year-old female enters your office complaining of an ingrown toenail on the medial aspect of the right hallux. She states that she had surgery to correct the painful big toe joint about nine months ago. Her preoperative pain went away, but now the pain is worse than the original problem. She is completely healthy and takes no medications. Discuss your evaluation, diagnosis, and treatment plan. Here are some clinical photographs of her foot at the time of presentation.
This is the same deal. There are no tricks with the past medical history. The most logical launch point and to this question is with the history of present illness. What questions would you want to know about this particular patient? Well, she relates that she had some arthritis in her big toe or at least that’s what the surgeon told her. She also relates that the surgeon said something about a fusion. Once she went back to complain about the painful ingrown toenail, the surgeon told her that the nail was normal. For the examination of this patient, you ascertain that there’s absolutely no motion at the first metatarsal phalangeal joint and there happens to be some decreased flexion at the interphalangeal joint. You note that the toe barely touches the ground even when after flexion at the IP joint. On the medial aspect of the hallux, there is minimal callus but it’s painful to palpation. The tibial border of the toenail is quite tender, but there is no drainage or erythema. Here are the radiographs that you have just taken in your office. By now, you know the drill. What do you see on these films? Pause the presentation if need be to carefully study them. Naturally, you observe the cross-screw fixation and the fact that there is a solid fusion of the first metatarsal phalangeal joint. What may or may not be so obvious is the accentuated plantar contour on the lateral side of the hallux. You are actually seeing more of the plantar contour than usual, which should lead you to the diagnosis. Doctor, do you have a diagnosis? It goes without saying that the first metatarsal phalangeal joint fusion is indeed malunited with the valgus and malrotation. The candidate is then asked for the optimal position of fusion of the first metatarsal phalangeal joint. The candidate either knows this or he or she doesn’t. There’s not much room for debate. We’ll get to the answer when we explore the points to pass, but let’s move on. In order to do that, we’d like you fix this problem surgically. Again, formulate your surgical treatment plan. It really should include a through and through derotational osteotomy directly through the fusion mass. Now, some candidates may elect to incorporate some plantar flexion correction into the design of the osteotomy. Again, this is optional as one could make a strong argument that the plantar position would improve once the access of the interphalangeal joint was right. We’re almost done. We’re going to talk about the points to pass for this last question. Remember that it was delivered in two parts. The first point to pass for question one dealt with the recognition of these obvious radiographic features in the preoperative situation. We wanted you to look at these five simple parameters. First of all, the first metatarsal was short. There was an increased intermetatarsal angle. The sesamoids were indeed deviated. There was an increased proximal articular set angle. There was valgus rotation to the hallux. All five of these should have been articulated to the examiner. Mostly likely, you would have found many more things that you would have related, but these are the five features that we are looking for, for this question. The second point to pass dealt with the candidate’s ability to formulate a logical surgical treatment plan that addressed the pathologic features. It included an open wedge osteotomy or Lapidus arthrodesis but the key feature was that a bone graft was included. The candidate must have done a sesamoid release or fibular sesamoidectomy. Lastly, did something to improve the position of the toe, whether that be a derotational Akin type osteotomy or a metatarsal head procedure to reduce the proximal articular set angle. Pass deals with the proper utilization of the bone graft. Now, remember that we told you that you were going to do an opening wedge osteotomy, so that the bone graft requirements in this case are slightly different and would be needed for a Lapidus arthrodesis. At any rate, the bone graft must have been a cortical cancellous type. The cortex must have been on the medial side to sustain the compression from the opening wedge procedure. Lastly, a neutralization plate should have been utilized to maintain the position of the graft and provide some stability for healing.
Point to pass is rather obtuse. Nevertheless, we wanted you to correctly identify the properties of an ideal bone graft that can be utilized in any situation. These include, the bone graft should be structurally sound for the job. Secondly, it should be osteoconductive, it should be osteoinductive, and lastly, have a low immunogenic potential regardless of its source. Okay, let’s get into the points to pass for the second component of that last question. Remember that this required some simplistic observations on the presenting radiographs. We wanted you to observe simply that there was cross-screw fixation, and that the first metatarsal phalangeal joint indeed had a solid fusion. Lastly, although rather subtle, we wanted you to recognize the prominent plantar contour of the proximal phalanx on the lateral aspect of the hallux itself. This next point to pass is that the candidate made the diagnosis of a valgus malunion or a valgus malrotated first metatarsal phalangeal joint fusion. Now, recall that we wanted you to describe the optimal position of first metatarsal phalangeal joint fusions in general. These components include hallux are disparallel to the second toe. Hallux are displaced in neutral rotation and contradistinction to the presenting point in this particular question. Lastly, that there was about 15 degrees of dorsiflexion at the first metatarsal phalangeal joint. It’s only fitting that we conclude this examination with a surgical procedure. The last point to pass is that we wanted you to fix the valgus malrotation with a surgical procedure. The necessary component was that it was a derotational osteotomy. The location of such osteotomy was through the center of the fusion mass. Naturally, there would be some debate as to the configuration and orientation of the bone cut. Again, this is described in rather generic terms and it would be up to the discretion of the examiner and appropriate interaction to decide whether or not your answer was appropriate or accomplished the goals that that patient needed in that question. Well, that concludes this rather extensive practice examination. What are your thoughts? Many of you have panicked long ago and may even have a sensation of despair. However, I can’t emphasize enough that you really should ignore your score if you indeed kept one. It doesn’t matter here. It’s more important to realize that this environment is entirely artificial and it doesn’t allow for that crucial interaction with the examiner. I also realized that some of these answers may not be in agreement with your thought process or training, and that’s okay. The point here is that the answers aren’t that aberrant and they should be in the realm of any competent foot surgeons. Even if you don’t like the choices, it should have provided you with an opportunity to organize your thoughts, the most critical requirement to perform well on the examination come this June. I thank every candidate for their dedication and commitment to becoming board certified. I’d also like to thank the PRESENT team for putting together an exceptional program for board preparation.