Forefoot / Midfoot · Reconstructive · Medicine & Peri-op · Advanced
Third Attempt
Podiatric surgery residency interview case. Work through it the way you would at an interview: take the history, ask for the exam and imaging, then commit to a diagnosis and plan.
Chief complaint
"My big toe joint still hurts and moves when I walk. The fusion never healed."
51-year-old male seen in clinic, 9 months after a revision first-metatarsophalangeal joint fusion.
History of present illness
Originally presented with end-stage hallux rigidus of the left foot and underwent a primary 1st MTPJ arthrodesis with a gastrocnemius recession. The fusion did not heal, giving a painful, symptomatic nonunion.
- Revision #1: nonunion resection, structural graft to restore length, biplanar plate-and-screw fixation, bone marrow aspirate concentrate and allograft; vitamin D, calcium and zinc supplementation started
- 9 months after the revision he again has pain, localized swelling and a sense of motion at the joint when pushing off
- Pain worse with weight-bearing and shoe wear; no fever, drainage or wound problems
- Outside CT confirmed a persistent failure at the graft-host interface
Questions a strong candidate asks at this step
- Onset, duration, character and location of pain; pain at rest vs. with push-off
- Perceived motion, clicking or swelling at the fusion site
- Number and type of prior procedures: fixation, graft, biologics, time in a cast and non-weight-bearing
- Post-operative compliance: weight-bearing status, boot use, return to activity
- Signs of infection: fever, chills, drainage, wound dehiscence, prior antibiotics
- Tobacco/nicotine, NSAID use and glycemic control (nonunion risk factors)
Present the rest of the case
Past history, exam, imaging, assessment, plan and discussion questions, with model answers, are in the interactive trainer. The diagnosis is kept there on purpose so you can practice committing to one.