150 B 3/8 ( & A 3/7 Day) Daily Mastery Plan

Front 1

A load-elongation curve for a tendon is shown in Figure A. Which of the following statements accurately describes the region labeled "X"?
1. The failure region which has crimped tendon fibers
2. The linear region which has parallel oriented tendon fibers
3. The linear region which has crimped tendon fibers
4. The toe region which has parallel oriented tendon fibers
5. The toe region which has crimped tendon fibers

Back 1

Region "X" in the illustration is the toe region of the load-elongation curve. This region represents the initial elongation during which a small amount of tension causes crimped, randomly arranged fibrils to become aligned parallel along the direction of loading. Magnusson et al looked at the properties of tendon in relation to muscular activity and training. Collagen composition of tendon is organized in a very hierarchical manner along parallel bundles. Tendon collagen bundles have a more parallel orientation along the long axis than ligaments, making their toe region smaller. Illustration A shows all the regions of the load-elongation curve.Ans5

Front 2

All of the following are independent risk factors for dislocation after total hip arthroplasty EXCEPT?
1. Female gender
2. Osteonecrosis
3. Inflammatory arthritis
4. Post traumatic osteoarthritis
5. Age >70

Back 2

The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. showed that patients at highest risk are female patients (relative risk 2.1),
those with a diagnosis of AVN of the femoral head (relative risk 1.9),
an acute fracture or nonunion proximal femur treated with THA (relative risk 1.8),
history of inflammatory arthritis (relative risk 1.5),
-age greater than 70 (relative risk 1.3).
The relative risk of dislocation for patients with posttraumatic arthritis of the hip was not significantly different from that for patients with osteoarthritis (relative risk, 1.3; 95% confidence interval, 0.6 to 2.8) (p = 0.59). Purely post traumatic arthritis should not have an increased risk of dislocation. However, if the post traumatic arthritis occurred after acetabular fixation or proximal femur fractures(mal unions/non unions), then the risk of dislocation is higher than primary OA. Ans4

Front 3

A 60-year-old male had a total hip replacement 8 years ago. Radiographs are shown in Figure A. When discussing the treatment options of acetabular revision versus isolated polyethylene exchange with the patient, what is the most common complication of polyethylene exchange that should be disclosed?
1. Sciatic nerve injury
2. Intraoperative acetabular fracture
3. Postoperative hip instability
4. Infection
5. Catastrophic implant failure

Back 3

The radiographs show retroacetabular osteolysis with a well fixed acetabular component. Treatment options include isolated polyethylene exchange versus acetabular revision. patients who had an isolated polyethylene liner exchange for wear or osteolysis and found six patients (25%) dislocated and another 4 patients complained of instability.
isolated polyethylene exchange versus acetabular revision and found a 10% failure rate when retaining the acetabular component. Their cohort had no dislocations, which they attribute to their direct lateral approach.

Therefore, although both implant failure and instability are known complications of isolated polyethylene exchange, it is currently believed that hip instability and dislocation are the most common. ANs3

Front 4

Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion?
1. Tibiotalar dorsiflexion
2. Tibiotalar plantarflexion
3. Subtalar eversion
4. Subtalar inversion
5. Internal rotation

Back 4

Varus alignment at the talar neck results in a decrease in subtalar eversion before impingement occurs. Varus talar neck alignment can cause a fixed internal rotation position of the midfoot as the navicular follows the talar head. This can lead to a more rigid hindfoot which is specifically manifested as a decreased eversion range of motion.Ans3

Front 5

A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?
1. Combined varus and plantar malunion
2. Isolated varus malunion
3. Isolated valgus malunion
4. Isolated dorsal malunion
5. Isolated plantar malunion

Back 5

Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.

Level 4 evidence from Canale and Kelly found that varus malunion occurred most frequently in Hawkins type 2 fractures that had been treated in a closed manner.Ans4

Front 6

A 30-year-old male undergoes successful surgical fixation of a displaced talar neck fracture. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved?
1. Tibiotalar and/or subtalar arthritis
2. Loss of forefoot supination
3. Osteonecrosis
4. Nonunion
5. Infection

Back 6

It is important to counsel patients regarding these devastating injuries and their poor prognosis, as osteonecrosis, subtalar and tibiotalar joint degeneration, and talar collapse are not infrequent.

In a series by Lindvall et al, subtalar joint arthritis was reported as more common than osteonecrosis of the talus at 4 year follow-up after fixation. Osteonecrosis of the talus was the next most common complication following surgery.Ans1

Front 7

A 14 year-old girl has chronic foot pain which has failed to respond to previous surgical coalition resection and soft tissue interposition. A radiograph of her foot is shown in Figure A. A CT scan demonstrates a talocalcaneal coalition with almost complete involvement of the subtalar joint. What is the treatment of choice?
1. revision coalition resection and extensor digitorum brevis interposition
2. revision coalition resection and fat interposition
3. tibiotalocalcaneal arthrodesis
4. talonavicular arthrodesis
5. triple arthrodesis

Back 7

For symptomatic coalition before degenerative changes have occurred, resection is the usual treatment; however, this is not indicated if the patient has failed previous coalition resection surgery, and has greater than 50% involvement of the subtalar joint. Triple arthrodesis involves fusion of the subtalar, calcaneocuboid, and talonavicular joints and is the most effective procedure for fixed hindfoot and forefoot deformities. Subtalar fusion can be performed in select cases with no significant hindfoot deformity. This procedure is contraindicated in young children (10-12 years) because of the limitation it puts on foot growth. Wilde et al found fair or poor results in all ten feet with preoperative CT scans showing an area of relative coalition to be >50% and heel valgus > 16 degrees. Scranton reported consistently successful resections of talocalcaneal coalitions if the coalition was less than one-half of the surface area of the talocalcaneal joint and there was no degenerative arthritic changes in the talonavicular joint.
Ans5

Front 8

A 24-year-old female who is training for her first marathon presents with six weeks of increasing foot pain. An AP radiograph and representative axial cut of her CT scan of her injury are seen in figures A and B. Management should consist of which of the following?
1. Weight bearing as tolerated in a hard soled shoe
2. Non weight bearing cast immobilization
3. Fragment excision and posterior tibial tendon advancement
4. Percutaneous screw fixation
5. Open reduction with autologous bone graft

Back 8

The patient presents with symptoms and imaging studies consistent with a navicular stress fracture. Initial mangement of these injuries consists of non weight bearing cast immobilization.

Khan et al found that patients managed with a minimum of 6 weeks of non weight bearing (NWB) had significantly improved rates of return to sport (86%) compared with patients that were allowed to weight bear as tolerated (26%). After failure of weight bearing management, 6/7 patients who were then NWB in a cast were able to return to sports. Ans2

Front 9

a 21-year-old male has 6 months of increasing knee pain and has recently noticed a mass at his knee. Radiographs are shown in Figures A and B. A biopsy specimen of the proximal tibia mass is shown in Figure C. What is the most appropriate first step in management?
1. Neoadjuvant chemotherapy
2. Wide surgical excision
3. Intralesional curettage and bone grafting
4. Radiation therapy
5. Hip disarticulation

Back 9

This patient's presentation, radiographs, and biopsy are consistent with telangiectatic osteosarcoma. Treatment is similar to classic osteosarcoma and initially includes multi-agent neoadjuvant chemotherapy (ex. adriamycin, cis-platinum, methotrexate, and ifosfamide) for 8-12 weeks followed by surgical resection (limb-salvage or amputation), followed by additional adjuvant chemotherapy for 6-12 months.

Capanna et al emphasizes that aneurysmal bone cyst's (ABC) occur in the same locations as telangiectatic osteosarcomas, and their radiographic appearances can be confused with each other. The treatment of ABC's are much different and includes intralesional curettage and bone grafting.Ans1

Front 10

what of the 5 common total hip complications

Back 10

1. nerve palsy
2. Limb length discrepancy
3. Iliopsoas impingement
4. Heterotopic ossification
5. Blood transfusion

Front 11

1. what of the 6th risk factors are put a patient at risk for total hip arthroplasty nerve palsy complication
2. what percent of patients report full strength recovery after sciatic nerve palsy

Back 11

1. DDH of the hip
2. Female gender
3. Limb lengthening
4. Revision surgery
5. Posttraumatic arthritis
6. Surgeon self-referred procedures difficulty
7. onlyapproximately >1/3

Front 12

1. patient presents with complaints of numbness paresthesia or weakness was most likely postoperative complication in hip
2. what the next best diagnostic study to confirm the diagnosis
3. with the differential diagnosis of nerve compression in the hip
4. With the treatment 3-in recovery
5. In the hospital
6. In the office

Back 12

1. sciatic nerve palsy
2. CT scan – rule out hematoma, EMG – guide patient regarding discussion
3. differential diagnoses – hematoma, retraction, type bandages, direct,, deep from PMMA, unknown 40%
4. Initially placed hip in extension and flex the knee – decrease his tension along sciatic nerve
5. Return to operating room for removal of postop hematoma
6. AFO orthoses

Front 13

was most, is revision for litigation following total hip arthroplasty

Back 13

leg length discrepancy

Front 14

most common reason for patient to feel like there is a limp limb length discrepancy

Back 14

sensation of feeling long because the abductors are weak using takes 3–6 months to a resolve postop

Front 15

patient presents postop with a feeling of limb length discrepancy

1. What the diagnosis
2. what next study to confirm the diagnosis
3. With the treatment

Back 15

1. limb length discrepancy
2. X-ray measurement – increasing WILL increase leg length, increasing femoral offset will not increase
3. > 6 months shoe-lift

Front 16

patient presents to the office after total hip replacement complaining of groin pain

1. what the diagnosis
2. what is the differential diagnosis
3. What the next best diagnostic study to confirm the diagnosis
4. With the treatment

Back 16

1. iliopsoas impingement
2. Diagnostic CORTISONE injection into the iliopsoas sheath
3. retained cement, malposition of the acetabular component- return to OR, limb length discrepancy, excessive length of screws
4. Iliopsoas tenotomy the postop x-rays are normal
5. Excessive anterior Overhang require revision acetabular component

Front 17

complication can limit the function after total hip replacement

Back 17

heterotopic ossification

Front 18

male patient presents to the office after difficult total hip replacement complains of limited function, history of clubbing of the digits, ossifying periostitis and arthritis of the other joints

1. what the diagnosis
2. With risk factors for this complication
3. What the treatment and prophylaxis

Back 18

1. heterotopic ossification
2. Prolonged surgical time, excessive soft tissue handling, hypertrophic arthritis, male gender
3. >6 months= excision for severe loss of motion
4. Prophylaxis oral INDOMETHACIN and radiation therapy – 600-800 GRAY within the 1st 24-48 hours after the procedure

Front 19

1. what is the best predictor for the knee of blood transfusion postoperatively after total hip replacement
2. what is normal
3. Comment presentation of anemia

Back 19

1. a low preoperative hemoglobin, Less than 10
2. normal is 1316 for man 12-16.1
3. restless leg syndrome, shortness of breath, pale skin

Front 20

A 45-year-old man has had the gait disturbance shown in Video A ever since a total hip replacement two years ago. Since then he has undergone physical therapy and nerve exploration without any clinical improvement. Extensive AFO bracing was attempted but was not tolerated by the patient. A recent ankle radiograph is shown in Figure A. The Silfverskiold test reveals dorsiflexion of 20 degrees with knee flexion, and 10 degrees with full knee extension. The results of muscle testing using a Cybex dynamometer are shown in Figure B. What is the most appropriate next step in in treatment

1. Ankle arthrodesis in 30 degrees of dorsiflexion

2. Posterior tibial tendon transfer to the lateral cuneiform through the interosseous membrane

3. Split anterior tibial tendon transfer to the cuboid

4. Peroneus longus transfer to the navicular and gastrocnemius recession

5. Flexor hallucis transfer to the navicular and tendo Achilles lengthening (TAL)

Back 20

The posterior tibial tendon is the most commonly used donor muscle.

Rodriguez et al. retrospectively reviewed the results of the Bridle procedure 10 patients (11 feet) with a foot drop. The Bridle procedure consists of a posterior tibial tendon transfer through the interosseous membrane to the dorsum of the foot with a dual anastomosis to the tendon of the anterior tibial and a rerouted peroneus longus in front of the lateral malleolus. In their study all 11 feet were brace-free at final followup at 6.68 years.

Incorrect Answers:
Answer 1: There is no arthrosis of the ankle joint and several tendons possess sufficient strength to make a tendon transfer feasible. Tendon transfer should be attempted first.
Answer 3: The anterior tibial tendon attaches to the plantar-medial aspect of the medial cuneiform and 1st metatarsal base. This muscle is weak (0/5 power) and transfer of its tendon muscle will not correct footdrop.
Answer 4: The peroneus longus attaches to the medial cuneiform and 1st metatarsal (plantar-posterolateral aspect). This muscle is weak (2/5 power) and transfer of this tendon will not correct footdrop. Gastrocnemius recession will not increase the effectiveness of this transfer as there is no gastrocnemius contracture.
Answer 5: The flexor hallucis longus is a secondary plantar flexor of the ankle. Its power is not mentioned in the question stem. But it is a less desirable tendon transfer compared with the posterior tibialis tendon. TAL will not increase its effectiveness. TAL is not necessary as there is dorsiflexion to 10degrees past neutral with the knee extended.
ans2

Front 21

A 62-year-old female has persistent activity related anterior groin pain 10 months after total hip arthroplasty (THA). Infection workup is negative. New radiographs are unchanged compared to the intial films provided in Figures A and B. Pain is temporarily relieved following an injection of lidocaine and cortisone into the iliopsoas tendon sheath. What is the next appropriate treatment option?

1. Indefinite activity modification

2. Iliopsoas tendon release

3. Femoral component revision

4. Acetabular component revision

5. Femoral and acetabular component revision

Back 21

After diagnosis of iliopsoas impingement, iliopsoas muscle tenotomy or resection is the treatment of choice if radiographs are within normal limits. In contrast, if imaging shows anterior acetabular overhang (as shown in Illustration A), then acetabular revision would be the next appropriate step in management.

Front 22

A 66-year-old female underwent a surgical procedure 6 weeks ago, and video A demonstrates her gait during ambulation. Based on her gait pattern, which reconstructive procedure did the patient most likely have? (in video the patient is seen from behind and she walked away from the camera and the RIGHT hemipelvis drops)

1. Right total hip arthroplasty through Smith-Petersen approach

2. Left total hip arthroplasty through Smith-Petersen approach

3. Left total hip arthroplasty through modified Hardinge approach

4. Right total hip arthroplasty through modified Hardinge approach

5. Left L2-L3 decompression foraminotomy

Back 22

The video demonstrates a left sided Trendelenberg gait resulting from left sided gluteus medius weakness. Left-sided abductor muscle weakness is most likely found in the setting of a left total hip arthroplasty performed through a lateral approach, of the options listed.

Front 23

Risk factors for a motor nerve palsy following primary total hip arthroplasty include all of the following EXCEPT?

1. Developmental dysplasia of the hip

2. Limb lengthening

3. Posttraumatic arthritis

4. Obesity

5. Posterior approach

Back 23

Certain pre-operative risk factors may place patients at increased risk for the development of nerve injury during primary total hip arthroplasty (THA). These include a history of developmental dysplasia of the hip (DDH), limb lengthening, posttraumatic arthritis, cementless femoral fixation, and the posterior approach. ans4

Front 24

1. what is the #1 most common cause of revision total hip surgery
2. what is the #2 most common cause of revision total hip surgery

Back 24

1. infection
2. Dislocation

Front 25

1. what is the mechanism of dislocation anteriorly
2. With mechanism of dislocation posteriorly
3. what direction his wrist dislocation

Back 25

1. anterior – extension and external rotation
2. Posterior – flexion and internal rotation
3. posterior

Front 26

1. what activities get the patient due to provoke a hip dislocation
2. examples of activity of daily living up with the hip at risk for dislocation

Back 26

1. hip – flex, abduction, internal rotation
2. time shoe, sitting a low toilet seat

Front 27

patient comes to the office with hip pain unable to ambulate after total hip prosthesis, patient states he was tying his shoe

1. what is the diagnosis
2. next best test to confirm the diagnosis
3. With the treatment

Back 27

1. hip no dislocation – most likely posterior limb flexed and internally rotated
2. x-ray looking for eccentricpositioning of the femoral head as indication of polyethylene wear
3. Closed reduction – two thirds of dislocations
4. Revision total hip arthroplasty if 2 or more dislocations with evidence of polyethylene wear malalignment – vertical acetabular component, acetabular retroversion, hardware failure

Front 28

the patient had a total hip and it needs replacing because of soft tissue deficiency or dysfunction will type surgery is done

Back 28

hemiarthroplasty with a large head

Front 29

when a psychiatric patient has multiple hip dislocations for secondary gain what is the treatment or there is significant bone loss and soft tissue deficiency

Back 29

resection arthroplasty

Front 30

technique used to increase the tension for the abductor complex

Back 30

trochanteric osteotomy and advancement

Front 31

technique you with recurrent instability and a well-positioned acetabular component due to soft tissue deficiency or dysfunction

Back 31

constrained acetabular component

Front 32

All of the following are independent risk factors for dislocation after total hip arthroplasty EXCEPT?

1. Female gender

2. Osteonecrosis

3. Inflammatory arthritis

4. Post traumatic osteoarthritis

5. Age >70

Back 32

Dislocation continues to be a problem for patients undergoing total hip arthroplasty. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. ans4

Front 33

what of the 3 sources of blood supply to the talus

Back 33

1. posterior tib artery –which is dominant major supply to the body of the talus
2. Anterior tibial artery – supply of head and neck
3. Perforating peroneal artery via the artery of the tarsal sinus also supplied the head and neck

Front 34

was the purpose of the Canale view when shooting the foot

Back 34

optimal view of the talar neck

Front 35

1. with the diagnosisand with the classification
2. with the best diagnostic studies to confirm the diagnosis
3. Was a risk of AVN
4. With the treatment

Back 35

1. Neck Fracture, HAWKINS 2 fracture of the talar neck with subtalar dislocation
2. CT scan
3. 2 = 50% risk of AVN
4. Urgent closed reduction in the ER opened up the internal fixation

Front 36

1. what is the diagnosis and classification
2. With the best diagnostic study confirmed diagnosis
3. With the risk of AVN
4. With the treatment

Back 36

1. patella neck fracture and on 3 = subtalar and tibiotalar dislocation
2. CT scan
3. 100% AVN rate
4. Open reduction urgently internal fixation

Front 37

1. with the diagnosis and classification
2. What the risk of AVN
3. What the treatment

Back 37

1. talar neck fracture and classification = subtalar tibiotalar talonavicular dislocation
2. 100%
3. Urgent open reduction internal fixation

Front 38

1. what is the sign
2. when is it seen on x-ray
3. What is the meaning of this sign

Back 38

1. HAWKINS sign
2. 6-8 weeks = subchondral lucency seen on the mortise x-ray
3. good sign = intact vascularity with resorption of subchondral bone

Front 39

what is the most common complication with talar neck fracture

Back 39

posttraumatic arthritis – subtalar arthritis 50%, tibiotalar arthritis 33%

Front 40

1. what is the most common complication to decreased subtalar eversion
2. What is the treatment
3. Was a effect on gait

Back 40

1. varus malunion
2. Medial opening wedge osteotomy of the talar neck
3. Weightbearing the lateral aspect of the foot

Front 41

there are two approaches talus anterior medial and anterior lateral which approach is the most important to preserve the deep deltoid ligament

Back 41

anterior medial approach

Front 42

A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms?

1. Combined varus and plantar malunion

2. Isolated varus malunion

3. Isolated valgus malunion

4. Isolated dorsal malunion

5. Isolated plantar malunion

Back 42

Figure A displays a Hawkins Type 2 talar neck fracture. (Hawkins classification shown in Illustration A). Malunion after inaccurate reduction of talar neck fractures has a reported incidence as high as 32%, with varus malunion occurring most frequently. Dorsal malunion can occur when the body is not properly derotated during reduction and the head fragment remains dorsal to the body. Dorsal malunion can lead to symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. Canale found that 3 of the 4 patients with dorsal malunion improved following dorsal beak resection of the talar neck. Patients with varus malunion have decreased subtalar range of motion(especially eversion), walk with the foot internally rotated, and often complain of excessive weight bearing on the lateral border of the foot.ans4

Front 43

1. what the most common cause of peroneal spastic foot
2. what age group is affected

Back 43

1. tarsal coalition = calcaneal navicular
2. 8–12 years old

Front 44

name to other associated conditions withmultiple tarsal coalition

Back 44

1. fibular deficiency
2. Apert syndrome

Front 45

with the normal biomechanical function of the subtalar joint

Back 45

with the foot into internal rotation and varus in late stent

Front 46

patient presents with limited subtalar motion hindfoot valgus and recurrent ankle sprains

1. with the diagnosis
2. what image confirmed the diagnosis
3. What is the treatment

Back 46

1. calcaneal navicular coalition
2. 45° oblique view and CT scan looking for an either side
3. Resection of coalition , excised the bar, with interposition of fat graft for extensor digitorum brevis

Front 47

patient presents with paronychia of spasticity, forefoot abduction and inability to reconstitute the arch when standing on the toes

1. with the diagnosis
2. What image confirms the diagnosis
3. Was a treatment

Back 47

1. talocalcaneal coalition
2. CT scan to rule out additional coalitions
3. MRI to visualize fibrillations or cartilaginous coalitions
4. Casting initially with symptomatic cases, those that they'll surgical resection of coalition with interposition of back graft or extensor digitorum brevis

Front 48

A 14 year-old girl has chronic foot pain which has failed to respond to previous surgical coalition resection and soft tissue interposition. A radiograph of her foot is shown in Figure A. A CT scan demonstrates a talocalcaneal coalition with almost complete involvement of the subtalar joint. What is the treatment of choice?

1. revision coalition resection and extensor digitorum brevis interposition

2. revision coalition resection and fat interposition

3. tibiotalocalcaneal arthrodesis

4. talonavicular arthrodesis

5. triple arthrodesis

Back 48

For symptomatic coalition before degenerative changes have occurred, resection is the usual treatment; however, this is not indicated if the patient has failed previous coalition resection surgery, and has greater than 50% involvement of the posterior facet of the subtalar joint. Triple arthrodesis involves fusion of the subtalar, calcaneocuboid, and talonavicular joints and is the most effective procedure for fixed hindfoot and forefoot deformities. Subtalar fusion can be performed in select cases with no significant hindfoot deformity. This procedure is contraindicated in young children (10-12 years) because of the limitation it puts on foot growth. Wilde et al found fair or poor results in all ten feet with preoperative CT scans showing an area of relative coalition to be >50% and heel valgus > 16 degrees. Scranton reported consistently successful resections of talocalcaneal coalitions if the coalition was less than one-half of the surface area of the talocalcaneal joint and there was no degenerative arthritic changes in the talonavicular joint. ans5

Front 49

A 10-year-old male presents with 6 months of bilateral foot pain at the tarsal sinus. Clinical images of standing examination and heel rise are shown in Figures A and B, respectively. Radiographs of the left foot are shown in Figure C and D. Which of the following findings most likely is associated with this patient's condition?

1. Dynamic supination during swing phase of gait

2. Limited push-off power, limited forefoot contact, and excessive heel contact during stance phase of gait

3. Recurrent ankle sprains

4. Posterior tibial tendon insufficiency

5. Weak tibialis anterior relative to the peroneus longus resulting in first ray plantar flexion

Back 49

Recurrent ankle sprains may be associated with tarsal coalition between the talus, the calcaneus, and/or the navicular. Calcaneonavicular coalitions are most common in children aged 8 to 12 years and talocalcaneal coalitions are most common in the 12 to 15 year age group. 10% to 20% of patients with tarsal coalitions have two coalitions and 50% are bilateral. Tarsal coalitions are often asymptomatic, and can present in late childhood or adolescence due to stresses transferred from the rigid hindfoot. Patients with tarsal coalition often exhibit a rigid flatfoot as shown in Figures A and B.
ans3