Foot surgery decisions start with a precise account of the problem: where the pain or instability lies, whether a deformity is flexible, what imaging shows under load, and whether infection or impaired perfusion changes the plan. This guide builds from those observations to surgical principles, foot-specific techniques, perioperative choices, complications and general medical conditions that affect care. Each concept pairs a decision rule with a case that has enough findings to support a conclusion. Pay particular attention to distinctions that change treatment, such as a reducible joint versus a fixed deformity, sterile inflammation versus infection, and a stable injury versus one that separates under load. The aim is to make the reasoning behind a choice clear enough to apply to a new patient.
Diagnostic Studies/Medical Imaging
1. Read a weight-bearing forefoot study
Read standing anteroposterior and lateral views with the foot bearing weight. On the anteroposterior view, compare the long axes of the first and second metatarsals, then compare the first metatarsal axis with the proximal phalanx of the hallux. Medial deviation of the first metatarsal and lateral deviation of the hallux describe different parts of hallux valgus. Next inspect the first metatarsophalangeal joint: do its opposing surfaces remain aligned, or is the proximal phalanx displaced relative to the metatarsal head? Check rotation, joint degeneration and the location of any additional deformity before attributing everything to one angle. Loading can reveal divergence or instability concealed on unloaded films. The ABFAS Foot Surgery content outline includes imaging interpretation; the useful habit is to describe each observed relationship before considering correction.
Worked example: A standing study shows the first metatarsal angled medially relative to the second, the hallux angled laterally, and the proximal phalanx displaced across the metatarsal head. This is a combined first-metatarsal alignment and joint-congruity problem. The same patient's unloaded film looks less divergent, so using that view alone would understate the deformity. Joint-surface condition and first-ray stability still need assessment before selecting treatment.
Watch the distinction: Calling every prominent medial eminence an isolated bunion misses the first metatarsal's position and joint congruity. A procedure aimed only at the prominence may leave the principal deformity intact.
Reference: [1]
2. Separate hallux rigidus from isolated pain
First metatarsophalangeal pain becomes more informative when you locate it within the arc of motion. A dorsal osteophyte can strike the proximal phalanx near the end of dorsiflexion, producing focal impingement while the central cartilage still carries load. Compare that pattern with pain through the middle of motion, reduced motion in both directions, crepitus and widespread radiographic joint-space loss. Those findings suggest broader cartilage failure. Inspect standing radiographs for dorsal spurring, joint-space preservation, subchondral change and the position of the hallux. Examination matters because a spur can appear on a film without explaining the patient's main pain. This distinction shapes procedure selection: removing an obstructing spur can address a mechanical block, whereas extensive joint degeneration may require a treatment that does not depend on preserved cartilage. Record both symptoms and structural findings.
Worked example: A patient feels sharp dorsal pain only at the last part of hallux dorsiflexion. The film shows a dorsal osteophyte and preserved central joint space; midrange motion is comfortable. Dorsal impingement is the leading mechanism. If the same joint instead hurt throughout motion and showed diffuse space loss, isolated spur removal would be less likely to address the full problem.
Watch the distinction: A painful first metatarsophalangeal joint is not automatically advanced arthritis. The location of pain during motion and the remaining joint space separate focal impingement from diffuse degeneration.
Reference: [1]
3. Locate lesser metatarsophalangeal instability
A plantar plate helps restrain dorsal translation of the proximal phalanx at a lesser metatarsophalangeal joint. When it fails, the toe may rise, drift sideways or begin to cross its neighbor. Examine the toe's resting position, the precise site of tenderness and the response to a controlled drawer test that translates the proximal phalanx relative to its metatarsal head. Pain and excessive translation at the joint favor instability. A primary interdigital nerve lesion more often produces web-space symptoms, burning or tingling into adjacent toes, sometimes provoked by compression of the interspace. Focused ultrasound or MRI can help when examination leaves uncertainty, but imaging findings must agree with the clinical pattern. Also assess metatarsal length and loading, since persistent overload can contribute to plantar plate failure and affect treatment planning.
Worked example: A second toe has begun drifting medially. Its metatarsophalangeal joint is tender, drawer testing reproduces that pain and permits abnormal dorsal translation, and MRI describes a plantar plate tear. The findings localize the problem to joint restraint. A neuroma might cause forefoot pain, but it would not readily explain this combination of toe drift and joint laxity.
Watch the distinction: Treating all pain between the metatarsal heads as a neuroma overlooks joint instability. Locate tenderness and test the joint before relying on a symptom label.
Reference: [1]
4. Detect subtle Lisfranc disruption
The Lisfranc complex maintains alignment between the medial cuneiform and second metatarsal base while the tarsometatarsal joints carry load. A twisting or axial-load injury can disrupt its stabilizing structures without producing an obvious abnormality on unloaded radiographs. Plantar bruising, focal midfoot tenderness and pain with stress raise suspicion. Compare the alignment of the metatarsal bases with their corresponding cuneiforms, inspect for a small avulsion fragment and obtain appropriate loaded comparison views when the patient can tolerate them. Separation or malalignment that appears under load indicates loss of stability. CT clarifies small fractures and joint geometry; MRI can show ligament injury, but neither replaces interpretation of alignment under physiologic loading. The related ABFAS certification guide provides pathway context; this diagnostic decision rests on the clinical and imaging findings.
Worked example: After twisting the foot, a patient has plantar midfoot bruising and focal tenderness. Unloaded films look nearly aligned, but tolerable standing comparison views show separation between the first and second metatarsal bases on the injured side. The new separation under load supports an unstable Lisfranc injury. Protect the foot and obtain timely foot-trauma evaluation, with additional imaging if needed to define its components.
Watch the distinction: A nearly normal unloaded radiograph does not establish Lisfranc stability. Persistent characteristic findings warrant loaded alignment assessment or further imaging when loading is unsafe.
Reference: [1]
5. Judge evidence for bone infection
Suspected osteomyelitis requires evidence that an infection reaches bone, not simply evidence that a wound contains bacteria. Determine whether an ulcer tracks to exposed or palpable bone and whether there is a plausible continuous route from wound to cortex. Radiographs may show erosion, destruction or periosteal response, although early infection can precede visible bony change. MRI can define marrow abnormality and associated soft-tissue infection, but trauma, surgery and other inflammatory processes may also alter marrow signal. Interpret each finding alongside wound duration, examination and the patient's systemic state. When identifying an organism will guide treatment, a properly obtained bone specimen has a clearer relationship to bone infection than a superficial swab colonized by skin or wound flora. Evaluate perfusion and the extent of nonviable tissue because both affect healing and source-control decisions.
Worked example: A chronic plantar ulcer extends to exposed metatarsal bone. Radiographs describe adjacent cortical erosion, and MRI shows matching marrow abnormality along with a tract from the ulcer. Together, these findings strongly support contiguous osteomyelitis. A swab taken from the wound surface may identify colonizers; a carefully obtained bone specimen is more informative when microbiologic confirmation is needed.
Watch the distinction: A positive surface swab does not prove that the same organism infects bone. Specimen depth and sampling technique determine how well a culture answers the bone-infection question.
Reference: [1]
6. Map deep soft-tissue infection
Cellulitis involves spreading inflammation through soft tissue, whereas an abscess is a localized collection that often needs physical drainage. Begin with vital signs and the pace of illness, then look for disproportionate pain, tense compartments, fluctuance, tissue discoloration, crepitus or loss of function. Imaging can map a deep collection when its boundaries are not apparent on examination and can show spread along plantar spaces or near joints and tendons. A report of fluid should be interpreted with its location, rim characteristics and clinical setting; sterile postoperative fluid and infected collections are not identical. Fever and rapidly worsening pain alongside a defined deep collection increase concern for infection requiring source control. Evaluate systemic illness at the same time, since controlling the local focus and treating the patient's broader response are linked decisions.
Worked example: A patient has fever, escalating plantar pain and tense swelling. Cross-sectional imaging describes a defined fluid collection tracking through a plantar compartment rather than diffuse tissue edema alone. This supports a deep abscess, with possible spread beyond the visible skin redness. Arrange urgent surgical assessment for drainage and tissue evaluation while systemic infection is assessed and treated.
Watch the distinction: Labeling a deep collection as uncomplicated cellulitis delays source control. Antibiotics reach tissue, but they cannot reliably empty a loculated abscess or remove dead tissue.
Reference: [1]
7. Interpret perfusion and venous clues
Ulcer location and surrounding tissue offer clues, but they do not replace vascular and neurologic examination. Arterial insufficiency often produces a painful distal wound with cool skin, weak pulses or poor tissue viability. Venous hypertension more often produces dependent edema, skin discoloration and a shallow wound near the ankle, where persistent pressure and inflammation damage skin. Neuropathy reduces protective sensation, allowing repeated pressure at a plantar prominence to cause an ulcer that may be surprisingly painless. These mechanisms can coexist: a neuropathic ulcer can also have inadequate arterial supply, and edema can obscure pulse assessment. Compare limb temperature, capillary refill, pulses, swelling, sensation and wound distribution. When incision or reconstruction is contemplated, determine whether the tissue is likely to heal and whether further perfusion assessment is warranted.
Worked example: One patient has a painful toe-tip ulcer, cool forefoot and weak pedal pulses. Another has leg edema, brown gaiter-area discoloration and a shallow medial ankle wound. The first pattern raises concern for arterial insufficiency; the second favors venous disease. Neither pattern alone proves the full vascular status, so examination and appropriate vascular studies guide wound and incision planning.
Watch the distinction: A wound's location is a clue, not a definitive vascular diagnosis. Neuropathy, arterial disease and venous disease may overlap and change the healing outlook.
Reference: [1]
8. Assess an indeterminate foot mass
A foot mass should be assessed by behavior as well as appearance. Document its growth, depth, fixation to surrounding structures, pain, skin change and any neurologic effect. Radiographs can reveal bone involvement or mineralization; MRI can define size, tissue character and the relationship to muscle, tendon, neurovascular bundles and normal tissue planes. A slowly changing superficial lesion with characteristic benign features differs from a deep enlarging mass with heterogeneous signal or invasion across planes. Imaging alone may not establish histology, so tissue sampling must be planned with definitive treatment in mind. A poorly placed biopsy or casual excision can contaminate additional planes and complicate later surgery. When findings are concerning or indeterminate, obtain specialist input before opening the lesion, while maintaining a useful differential that includes benign, malignant and inflammatory causes.
Worked example: A plantar mass enlarges over several months and feels deep rather than confined to the skin. MRI describes heterogeneous tissue extending across normal planes near intrinsic muscles. Those features do not identify a specific tumor, but they make simple office excision inappropriate. Refer for coordinated imaging review and a planned biopsy route that can be incorporated into any definitive treatment.
Watch the distinction: Small visible size does not establish that a mass is harmless. Depth, growth and invasion of tissue planes may matter more than its surface outline.
Reference: [1]
9. Identify pediatric structural deformity
Flat appearance alone does not define a pediatric foot disorder. Assess symptoms, onset and whether the arch reappears when the child sits, stands on tiptoe or the heel is placed through motion. A flexible flatfoot changes shape and retains subtalar movement; a rigid foot resists correction and may reflect coalition, congenital structure or arthritis. Pain, recurrent sprains and restricted subtalar motion warrant closer investigation. Standing radiographs show overall alignment, while focused cross-sectional imaging can characterize a suspected bony or fibrous bridge when indicated. Interpret pediatric images with developmental anatomy in mind, since incomplete ossification can change what appears on plain films. A coalition may mechanically limit hindfoot motion and produce compensatory stress elsewhere. The practical sequence is to establish flexibility first, localize pain second, then select imaging that answers the remaining structural question.
Worked example: An adolescent has painful flatfoot, repeated activity-related discomfort and markedly restricted subtalar motion. The arch does not re-form during attempted heel rise. Imaging describes a calcaneonavicular bridge. The rigid examination and bridge support tarsal coalition as the structural explanation. An asymptomatic flexible flatfoot would show correction with movement and would not be explained by that bridge.
Watch the distinction: Treating every low arch as the same deformity misses the distinction between flexible alignment and restricted joints. Symptoms and motion determine which structural findings need investigation.
Reference: [1]
10. Distinguish crystal arthritis from sepsis
Crystal arthritis and septic arthritis can both cause a hot, painful first metatarsophalangeal joint. Aspiration provides several kinds of evidence: appearance, cell findings, crystal identification, Gram stain and culture. Urate or calcium pyrophosphate crystals support a crystal-driven inflammatory process, but their presence cannot exclude simultaneous infection. Fever, a nearby draining wound, bacteremia risk, marked illness or a rapidly destructive course heighten concern for sepsis. Serum inflammatory markers can support concern but do not identify the organism or settle the diagnosis alone. Obtain joint fluid and relevant cultures using sound sampling technique, then judge the whole clinical picture. Delay is consequential when a joint is infected because cartilage and adjacent tissue can deteriorate. The reasoning is additive: a credible crystal explanation must still be tested against independent evidence of infection.
Worked example: A patient has an acutely swollen first metatarsophalangeal joint. Aspirated fluid contains urate crystals, yet the patient is febrile and has a nearby draining wound. The crystals explain one possible cause of inflammation, but they do not account safely for all the infection clues. Send appropriate fluid studies and cultures and arrange urgent assessment for possible septic arthritis.
Watch the distinction: Finding crystals does not close the diagnostic case. A joint can contain crystals and bacteria at the same time, especially when separate infection clues are present.
Reference: [1]
Surgical Principles
11. Trace forefoot load transfer
During stance, the first ray helps accept load beneath the medial forefoot. If it is elevated, shortened or unable to function against the ground, force shifts toward the lesser metatarsal heads. The second ray often becomes symptomatic because it takes a greater share of that transferred pressure. Look for a new plantar callus, localized tenderness and a change in the metatarsal head's position on standing examination or imaging. A painful lesser metatarsal may also have its own pathology, so compare timing and structure before assigning cause. Treatment reasoning starts with the load path: identify why the first ray no longer bears its expected share, then judge whether offloading alone is enough or the underlying alignment requires correction. ABFAS Foot Didactic practice questions can help rehearse this kind of applied interpretation.
Worked example: Before surgery, a patient had no second-metatarsal pain. After a first-ray procedure healed with the first metatarsal elevated, a new plantar callus and focal pain appeared beneath the second head. The chronology, pressure location and alignment support transfer metatarsalgia. Trimming the callus may relieve its surface symptoms, but it does not restore the first ray's share of loading.
Watch the distinction: A new second-metatarsal callus after first-ray surgery need not be an isolated second-ray disorder. Check the position and function of the first ray.
Reference: [1]
12. Test deformity flexibility
Passive correction shows how much of a digital deformity arises from flexible imbalance and how much is fixed in joint or bone. Examine the toe both standing and unloaded, then gently straighten each involved joint separately. A claw pattern can involve metatarsophalangeal hyperextension with flexion at the interphalangeal joints; one segment may correct while another remains contracted. Check whether metatarsophalangeal position changes when the ankle or adjacent joints move, and inspect skin pressure points. If the toe fully corrects, a plan focused on restoring tendon balance or restraint may be feasible. A joint that remains rigid after soft-tissue relaxation calls for a procedure that addresses fixed contracture or joint damage. Imaging adds information about arthritis, dislocation and bony shape. The decision depends on which structure prevents correction, not merely the toe's resting silhouette.
Worked example: Two patients have similar claw-shaped second toes while standing. In the first, the metatarsophalangeal and interphalangeal joints straighten fully with gentle manipulation, indicating substantial flexible imbalance. In the second, the proximal interphalangeal joint stays bent despite relaxation and manipulation. Its persistent block indicates fixed contracture that soft-tissue balancing alone is unlikely to correct.
Watch the distinction: Identical toe shapes can have different operative requirements. A resting photograph does not show whether the joint surfaces and contracted tissues will permit correction.
Reference: [1]
13. Sequence combined deformity correction
Complex forefoot deformity should be traced from its mechanical driver to its visible consequences. First assess first-ray alignment, stability and ground contact; then inspect lesser-metatarsal loading, plantar plate restraint and digital position. A drifting second toe may be a local instability, a response to persistent overload, or both. Correcting the toe without addressing the load that damaged its restraint can invite recurrence. Conversely, restoring first-ray support may not reverse an established plantar plate tear or fixed digital contracture. Plan the correction in a sequence that establishes a stable weight-bearing foundation and then addresses residual joint instability or fixed deformity. Patient symptoms, tissue quality and joint condition limit how much correction is useful. Explain each proposed component by the abnormal force or structure it changes, so the plan remains coherent across multiple levels.
Worked example: A patient has a painful plantar callus beneath the second metatarsal, a medially drifting second toe and an elevated first ray. The first-ray position explains increased second-ray loading, while the drifting toe suggests additional joint restraint failure. A plan limited to straightening the second toe would leave the overload. Assess and address first-ray support and the lesser-joint instability together.
Watch the distinction: The most visible toe deviation is not always the primary problem. Follow the load path and test local restraint before choosing the order of correction.
Reference: [1]
14. Apply surgical infection control
Surgical infection control has two distinct parts. Prevention limits new contamination through preparation, clean handling, appropriate antibiotic use and protection of viable tissue. Source control removes infection already established in the wound: open and drain collections, break up loculations, remove nonviable tissue and identify any involved joint, bone or foreign material. Antibiotics circulate through living tissue but penetrate dead tissue and a sealed pus cavity poorly; they cannot remove a mechanical reservoir of infection. Collect meaningful specimens from the involved site when microbiology will guide treatment, ideally without substituting a superficial surface sample for deep tissue. After debridement, reassess viability, perfusion and whether further staged work may be needed. Closure should not trap residual purulence. The operative endpoint is a drained, viable field that can respond to systemic therapy and heal.
Worked example: During exploration of a plantar abscess, antibiotics have already been started. The surgeon finds two connected purulent pockets and a patch of dead fascia. Draining only the first pocket would leave an infected reservoir. Both spaces need drainage, nonviable fascia needs removal, and deep material should be sampled as appropriate before the wound is managed for healing.
Watch the distinction: Administering antibiotics does not mean the operation has controlled infection. Residual pus and dead tissue can sustain infection despite an otherwise appropriate drug.
Reference: [1]
15. Protect perfusion during closure
Skin survives closure through intact microvascular supply and manageable tension. Incision placement should preserve broad, viable tissue bridges and avoid unnecessary injury to vessels supplying already compromised skin. Edema increases pressure within tissue and makes closure tighter than it first appears; excessive suture tension can further restrict perfusion and cause edge necrosis. Evaluate the color, bleeding and thickness of wound edges after debridement, and consider the effect of postoperative swelling and weight-bearing forces. When direct approximation threatens viability, staged closure, a different incision plan or coverage that brings healthy tissue may be safer. Also assess underlying arterial disease because a technically neat closure cannot overcome inadequate blood delivery. The goal is durable viable coverage, with enough tissue to tolerate healing stresses, rather than immediate edge contact at any cost.
Worked example: Two nearby incisions leave a narrow skin bridge after forefoot surgery. The bridge appears dusky and the surrounding tissue is swollen; bringing both wound edges together makes it blanch further. Those findings suggest threatened perfusion. Reassess the incision and coverage plan to avoid closing under tension across the bridge, and examine overall limb perfusion before committing to closure.
Watch the distinction: An incision that can be pulled shut is not necessarily safe to close that way. Blanching, edema and a narrow skin bridge predict tissue failure.
Reference: [1]
16. Explain fracture and fusion healing
Fracture and arthrodesis healing require viable bone, blood supply and an appropriate mechanical environment. At a fusion, prepared bone surfaces must remain sufficiently apposed and stable for new bone to cross the interface. Repeated motion can preserve a gap and fatigue fixation; poor perfusion, infection or adverse host factors can limit biological repair even with good hardware. Serial images are more informative than a single early film: look for progressive bridging, maintained alignment and any widening gap or hardware change. Clinical pain, focal tenderness and motion also matter because radiographic appearance can lag behind healing. When revision is considered, separate mechanical questions from biological ones. Restoring compression or stability without addressing infected or poorly viable surfaces may fail, as may adding graft while leaving persistent movement. The related RRA didactic guide covers its distinct procedural scope.
Worked example: A first tarsometatarsal fusion remains painful months after surgery. Examination finds focal motion, films show an unbridged gap, and the patient reports ongoing smoking exposure. Persistent movement points to insufficient mechanical stability; smoking raises concern about healing biology. Revision planning must assess both, along with infection and perfusion, rather than assuming one new fixation device solves every cause.
Watch the distinction: A visible gap and painful motion are not explained fully by hardware choice alone. Bone viability, blood supply, infection and host factors can also prevent union.
Reference: [1]
17. Choose a fixation strategy
Fixation should match the fracture's geometry and the healing environment it can sustain. A simple fracture with broad opposing surfaces may accept direct compression, increasing contact and limiting movement at the line. A neutralization construct protects a compressed fracture against bending or rotational forces that would otherwise undo the reduction. In a comminuted segment, the small fragments may have no reliable surfaces for compression; a bridging construct spans the zone and preserves overall length, rotation and alignment while healing occurs through a different mechanical environment. Assess soft-tissue injury and blood supply before exposing fragments merely to obtain perfect contact. Reduction quality still matters: maintaining a stable but shortened or dorsally displaced metatarsal can create later weight-bearing problems. Select fixation by the forces it must resist and the fragments it can safely hold.
Worked example: One metatarsal fracture has two broad, clean surfaces that meet anatomically. Compression across that line can increase contact, with additional protection if bending forces threaten it. A second fracture has a fragmented middle segment with no continuous surface to compress. Bridging fixation should hold its length, rotation and plantar alignment while avoiding unnecessary disruption of the small fragments.
Watch the distinction: Trying to compress every fragment in a comminuted zone can damage blood supply and shorten the bone. Bridging targets overall alignment when direct contact is unavailable.
Reference: [1]
18. Match graft function to a defect
Bone graft serves mechanical and biological purposes that must be distinguished. A structural graft or support maintains length and resists collapse across a segmental void. Biological augmentation may contribute living cells, a scaffold or signals that favor new bone formation, depending on the material used. Loose cancellous material can fill small contained spaces but cannot by itself hold open a defect subjected to load. Start by measuring the defect's shape, checking whether healthy host bone contacts the graft and determining what loads the reconstruction must tolerate. Remove nonviable tissue and investigate infection before placing a graft into a compromised bed. Then choose fixation that protects the graft and keeps corrected alignment while union develops. In revision surgery, the useful question is what is missing: structural continuity, healing potential, stable contact or some combination.
Worked example: After removal of failed fusion tissue, a segmental gap remains and the first ray shortens when gentle compression is applied. Packing loose graft into that space would add healing material but would not preserve length. A structural solution must support the corrected span, while viable host surfaces, suitable biological material and fixation provide conditions for incorporation and healing.
Watch the distinction: Calling a graft “bone” does not mean it can carry load. Match its structural strength and biological role to the actual defect.
Reference: [1]
19. Select viable wound coverage
Coverage succeeds when the wound bed supplies blood to the covering tissue and the result withstands local forces. Direct closure is suitable only when viable edges meet without damaging tension. A skin graft requires a vascularized bed for take; bare tendon without an adequate vascularized surface, exposed hardware or poorly perfused bone may not provide one. A flap brings its own blood supply and can cover selected exposed structures, though its design depends on defect size, location and available donor tissue. Plantar wounds add pressure and shear, so a thin cover that survives initially may still break down during walking. Before choosing coverage, complete debridement, assess infection and perfusion, and map which structures remain exposed. Plan postoperative offloading around the reconstructed tissue. The decision is based on bed viability and durable function, not simply the area of missing skin.
Worked example: Debridement leaves a plantar defect with bare tendon exposed and no vascularized tissue covering it. A simple skin graft placed directly onto that surface is unlikely to take reliably or endure walking shear. The reconstruction needs a suitable vascularized bed or tissue coverage, followed by protection from pressure while the repair establishes itself.
Watch the distinction: A skin graft cannot rescue every open wound. Its success depends on blood supply from the recipient bed and, on the sole, resistance to repeated shear.
Reference: [1]
20. Recognize limb-threatening trauma
Crush trauma can cause swelling and bleeding inside foot compartments bounded by relatively unyielding fascia and bone. Rising compartment pressure reduces small-vessel flow before major arterial pulses necessarily disappear. The concerning pattern is progressive, disproportionate pain, especially pain provoked by passive toe movement, together with tense swelling or evolving sensory change. Examine repeatedly because findings can change after an initially reassuring assessment. Also assess arterial injury through skin temperature, color, perfusion and pulse comparison; a vascular problem and compartment syndrome can coexist. Remove external constriction and obtain urgent specialist assessment when the clinical picture is concerning. Pressure measurement may help when examination is unreliable or equivocal, but it must not replace recognition of a rapidly deteriorating limb. Time matters because prolonged tissue ischemia can cause irreversible muscle and nerve damage.
Worked example: Several hours after a foot crush injury, pain rises despite immobilization. The foot is tense, passive toe stretch causes marked pain, and pedal pulses remain detectable. Preserved pulses show that large-vessel flow persists, but they do not exclude impaired flow within the compartments. The progression warrants immediate reassessment for compartment syndrome and associated vascular injury.
Watch the distinction: Waiting for pulses to vanish before considering compartment syndrome is unsafe. Small-vessel tissue perfusion can fail while palpable arterial pulses remain.
Reference: [1]
21. Plan biopsy before excision
A destructive bone lesion or enlarging deep mass needs a diagnosis that preserves options for definitive treatment. Begin with examination and imaging that define the lesion, its cortical extent, soft tissue component, and relation to nerves and vessels. The ABFAS Foot Surgery Didactic subject outline includes foot neoplasms within surgical decision making. If malignancy is plausible, involve the appropriate tumor specialist before choosing a biopsy route. The incision and tissue tract may need removal with the tumor later, so they should lie within a feasible future resection field and avoid crossing uninvolved compartments. A planned core biopsy can provide tissue while limiting disruption; an unplanned excision may leave disease behind and spread tumor cells along several planes. Match specimen handling to the suspected diagnosis, since infection and some tumor types require different analyses.
Worked example: A patient has progressive metatarsal pain and a firm dorsal mass. Radiographs show cortical destruction; MRI shows tissue extending beyond bone into one adjacent compartment. These findings make a routine small excision inappropriate. Review the full imaging with a tumor specialist, choose a biopsy tract that can be removed during definitive surgery, and obtain tissue for the planned pathology studies.
Watch the distinction: A small lesion is not automatically safe to excise. Aggressive imaging features and deep extension matter more than surface size, because an unplanned incision can complicate definitive resection.
Reference: [1]
22. Localize neurologic symptoms
Localize altered sensation before naming a nerve disorder. Map the painful and numb areas, compare both feet, and test whether pressure at one site reproduces the familiar symptoms. Focal interdigital irritation often causes burning or tingling in adjacent sides of two toes and may worsen in narrow shoes. A discrete provocative site supports a local process, although metatarsophalangeal instability can produce nearby pain. Symmetric sensory loss beginning in the toes and extending proximally suggests a length dependent neuropathy; check protective sensation, vibration, reflexes, and relevant systemic history. Symptoms spanning a larger named nerve territory may point to compression farther proximally. The distinction changes treatment: removing a suspected web space lesion cannot restore sensation lost through a diffuse neuropathic process, and systemic disease may affect wound protection.
Worked example: One patient has burning between the third and fourth toes that tight shoes provoke; pressure in that web space reproduces it, and sensation elsewhere is intact. Focal interdigital pathology is plausible. Another has bilateral numbness across all toes, reduced vibration, and no discrete trigger. That pattern favors generalized neuropathy, so investigate its cause before proposing focal nerve surgery.
Watch the distinction: Burning forefoot pain does not identify a neuroma by itself. Joint instability, stress injury, and generalized neuropathy can overlap in location; distribution and a reproducible focal examination refine the diagnosis.
Reference: [1]
Surgical Procedures/Techniques
23. Orient a first-metatarsal osteotomy
A distal first metatarsal osteotomy changes the relationship between the shaft and capital fragment while retaining a useful joint surface. First identify where the deformity lies and whether the first metatarsophalangeal joint can be realigned. For a suitable distal deformity, shifting the capital fragment toward the second metatarsal narrows the intermetatarsal relationship. Cut geometry must permit that translation without sacrificing bone contact or destabilizing the head. Check the correction in more than one plane: a straight frontal image can conceal elevation, shortening, or residual pronation. Fixation should resist the loads and rotation expected during healing while maintaining the intended position. Soft tissue balance and sesamoid alignment also matter; a correctly placed bone cut alone does not guarantee a congruent joint. The required correction and available bone contact limit how much translation is sensible.
Worked example: Standing films show a distal first metatarsal contribution to hallux valgus, a preserved joint, and no major proximal instability. After a distal cut, the surgeon shifts the capital fragment laterally while maintaining broad contact. Alignment is checked for joint congruity and unintended elevation before fixation. A larger shift that leaves minimal contact would trade correction for instability.
Watch the distinction: Lateral translation is not an unlimited correction. Excess movement can reduce bone contact or elevate the head, creating healing problems or transfer pain despite a narrower intermetatarsal appearance.
Reference: [1]
24. Prepare the first tarsometatarsal fusion
First tarsometatarsal arthrodesis can correct a deformity driven near the base of the first ray while stabilizing that joint. The operative sequence starts by exposing the joint and removing cartilage and other tissue that would separate the fusion surfaces. Preserve enough bone to correct position without unnecessary shortening. Bring the metatarsal into the desired transverse, sagittal, and rotational alignment; pronation may leave the sesamoids poorly related to the head even when a single radiographic angle improves. Broad contact and compression reduce motion at the prepared interface. Fixation must hold the correction while bone bridges across it. Assess adjacent joint position and first ray ground contact before accepting the construct. A solid fusion in an elevated or malrotated position can heal yet continue to cause shoe conflict or lesser metatarsal overload.
Worked example: A painful hallux valgus deformity accompanies first tarsometatarsal instability and metatarsal pronation, while the first metatarsophalangeal cartilage is preserved. Joint preparation creates viable opposing surfaces. The surgeon corrects rotation and first ray position, compresses the surfaces, and secures them. Removing the medial eminence alone would leave the unstable proximal driver in place.
Watch the distinction: Compression cannot compensate for a malpositioned fusion. Check rotation, length, and sagittal position before fixation, because reliable union preserves whatever alignment the construct holds.
Reference: [1]
25. Preserve motion in dorsal impingement
Cheilectomy targets mechanical collision at the dorsal first metatarsophalangeal joint. A dorsal osteophyte and opposing phalangeal prominence can block dorsiflexion during propulsion, producing pain chiefly near the end of motion. When substantial central cartilage remains and midrange motion is relatively comfortable, removing the impinging bone may improve functional clearance while preserving the joint. Inspect the joint surface and test motion after resection so that residual contact is recognized. The resection must be controlled: removing too much dorsal metatarsal head sacrifices articular surface and can impair joint stability. Diffuse cartilage loss, substantial pain throughout the arc, or marked deformity changes the decision because clearing the dorsal lip does not remove pain generated by the entire degenerated joint. Postoperative expectations should reflect that remaining arthritis may still progress.
Worked example: A patient feels sharp dorsal pain when the hallux reaches dorsiflexion, but midrange motion is comfortable. Imaging shows a dorsal osteophyte with preserved central joint space. Cheilectomy addresses the observed impingement; after limited resection, dorsiflexion is reassessed. If the same patient instead had diffuse joint loss and pain throughout motion, joint preservation would be less persuasive.
Watch the distinction: More bone removal does not mean more useful motion. An aggressive resection can damage the joint surface, while persistent diffuse arthritis remains a separate source of pain.
Reference: [1]
26. Correct hallux varus imbalance
Hallux varus is medial deviation of the great toe relative to the first metatarsal. After hallux valgus surgery, possible drivers include excessive medial soft tissue tension, loss of lateral restraint, overcorrection of the metatarsal, or a combination. Examine whether the toe can be brought into neutral alignment, whether the metatarsophalangeal joint is congruent, and whether cartilage is preserved. Review standing imaging for first metatarsal position and sesamoid relationship. A flexible joint with reasonably positioned bone may respond to restoring balanced soft tissue restraint. A malpositioned metatarsal requires correction of that bony driver; fixed arthritic deformity may require a different reconstruction. The operative goal is a stable, plantigrade, shoe compatible toe, not simply a toe that looks straight while held in place.
Worked example: After bunion correction, a patient's hallux drifts medially and rubs against the shoe. It can be reduced to neutral, the joint space is maintained, and the first metatarsal is not excessively shifted. Those facts favor a soft tissue imbalance. Rebalancing medial and lateral restraint addresses the mechanism more directly than treating the joint as fixed arthritis.
Watch the distinction: Hallux varus is not always a soft tissue problem. If the first metatarsal was overcorrected, soft tissue repair alone may leave the structural force pulling the toe medially.
Reference: [1]
27. Align a rigid hammertoe
A rigid hammertoe has a fixed component that persists after passive manipulation and soft tissue release. At the proximal interphalangeal joint, preparation for fusion removes the surfaces preventing correction and creates opposing bone that can unite. Before fixation, align the toe in the sagittal plane and correct any rotation that would leave a nail or side of the toe rubbing in footwear. Check the metatarsophalangeal joint as well; persistent dorsal subluxation there may keep loading the corrected toe abnormally. The fixation method must maintain contact and orientation through healing while protecting nearby structures. Excess shortening can leave a weak or poorly positioned toe, while incomplete correction leaves the original shoe conflict. The desired result is stable alignment during stance and shoe wear, rather than a straight appearance on one intraoperative view.
Worked example: A second toe remains bent at its proximal interphalangeal joint after tendon balancing. The surgeon prepares opposing joint surfaces, rotates the toe so its nail faces upward, and holds the corrected position for fusion. Before closing, the metatarsophalangeal joint is checked for persistent dorsal drift. Fusing the toe while it remains rotated would preserve painful lateral shoe contact.
Watch the distinction: A straight toe in a side view may still be malrotated. Inspect nail orientation and the metatarsophalangeal joint before accepting fixation.
Reference: [1]
28. Repair lesser-joint instability
The plantar plate restrains dorsal translation at a lesser metatarsophalangeal joint and helps maintain a centered toe during loading. A tear can allow the proximal phalanx to drift dorsally or across an adjacent toe. Examine reducibility, drawer instability, toe position, and plantar tenderness; imaging can clarify the tear and associated joint condition. Repair aims to reattach viable restraint to its functional insertion and restore joint alignment. Evaluate metatarsal length and plantar pressure at the same time. If an overloaded, relatively long metatarsal continues to drive pressure through the joint, soft tissue repair alone may be stressed repeatedly. Conversely, shortening without restoring a deficient plantar plate can leave instability. Confirm that the toe is reduced without excessive tension and that the chosen fixation or soft tissue repair protects adjacent structures.
Worked example: A second toe crosses toward the hallux, reduces manually, and shows a painful positive drawer examination. Operative inspection finds a torn plantar plate; standing assessment also shows excessive second ray loading. Restoring plantar restraint addresses the dorsal drift, while correcting the loading contribution reduces recurrent stress. An isolated toe release would make the toe temporarily straighter without replacing its missing restraint.
Watch the distinction: A drifting toe is not necessarily caused by tight dorsal tissue alone. Releasing tissue without assessing the plantar plate can increase mobility while leaving the unstable joint unrestrained.
Reference: [1]
29. Correct a bunionette
A bunionette is a symptomatic lateral prominence at the fifth metatarsal head, but the source of that prominence varies. Standing imaging can show an enlarged head, a distal shaft bow, or a more proximal increase in separation between the fourth and fifth metatarsals. Match the correction level to the deformity: a head level problem may allow distal correction, while shaft or proximal geometry may require a cut that acts farther from the joint. The intended movement reduces the lateral prominence without elevating the head or creating excessive shortening. Preserve enough contact for stability and assess the fifth toe's alignment after correction. Soft tissue pressure from footwear helps explain symptoms, but removal of a small lateral bump alone may fail when the metatarsal axis continues to project the head outward.
Worked example: A patient has persistent lateral forefoot shoe pain. Weight bearing films show a fifth metatarsal head prominence with outward bowing of the distal shaft. A plan limited to shaving the head would leave much of the shaft driven prominence. A corrective osteotomy chosen at the relevant deformity level can shift the head inward while preserving length, plantar position, and stable bone contact.
Watch the distinction: The visible bump is not always the full deformity. Determine whether head shape, shaft bowing, or intermetatarsal alignment produces it before selecting the cut.
Reference: [1]
30. Handle a duplicated digit
Duplicated digits differ in how completely their bones, tendons, joints, nails, vessels, and nerves are separate. Examination and age appropriate imaging should establish what each toe contributes to the border and whether either shares a metatarsal head or joint surface. Select the ray that offers the best stable, sensate, well aligned foot, rather than assuming the smaller digit should be removed. During correction, preserve blood supply to the retained digit, rebalance tendon attachments, and reconstruct collateral support where shared structures are divided. The width and shape of the foot matter for shoe wear, but function takes priority over a narrow cosmetic outline. Growth can reveal angular drift after surgery, so the plan should account for future alignment and follow-up. Complex shared anatomy can make reconstruction more important than the excision itself.
Worked example: A child has two lateral toes sharing part of one metatarsal head. Both have tendon attachments, and the larger toe angles outward. Imaging shows that simply removing the smaller toe would leave the retained toe without balanced joint support. The operative plan identifies a viable digit, preserves its neurovascular supply, reconstructs shared restraints, and checks the border's alignment.
Watch the distinction: Removing the smaller duplicate is not an automatic rule. Shared joint and tendon anatomy can leave the remaining toe unstable unless those structures are mapped and reconstructed.
Reference: [1]
31. Correct metatarsus adductus at its source
Metatarsus adductus describes inward deviation of the metatarsals relative to the midfoot. Locate the deformity with standing views and examine how much of the forefoot can be passively corrected. Flexible, mild deformity and rigid bony adduction require different plans. When the metatarsal alignment turns near the tarsometatarsal region, straightening only the toes leaves their supporting rays pointed inward. Bone correction must address the relevant level while maintaining metatarsal length, plantar position, and a usable lateral column. Closing space on one side of the forefoot can crowd the outer rays, while opening another side can create a defect requiring support. Consider associated hallux valgus or lesser toe crowding as effects of the underlying geometry. Judge success by a balanced forefoot under load, not by isolated toe appearance.
Worked example: An adult has a rigid adducted forefoot, crowded lesser toes, and standing films that locate the bend near the metatarsal bases. Passive manipulation cannot straighten the rays. Digital releases alone would leave the metatarsals adducted. A bony correction planned at the deformity level must also preserve lateral ray spacing and the plantar weight bearing arc.
Watch the distinction: Toe crowding does not prove the toes are the primary problem. Check the metatarsal axes and rigidity before choosing digital correction, or the structural adduction will remain.
Reference: [1]
32. Restore Lisfranc alignment
The Lisfranc complex stabilizes the tarsometatarsal joints, with the second metatarsal base seated between the cuneiforms. Operative correction of an unstable injury starts with identifying every displaced or interposed structure. Restore the second metatarsal to its normal relationship with the middle cuneiform, then assess the neighboring columns and joint surfaces. Remove tissue that blocks reduction, but preserve viable structures when possible. Fixation must hold the achieved alignment until the chosen joints or ligaments heal; a rigid construct placed across a malreduced joint simply fixes the error. Check reduction under appropriate imaging and loading assessment, including sagittal displacement that may be missed on one view. For further case based practice, the Foot NEW CBPS study guide addresses this injury through a different examination format.
Worked example: Following a twisting injury, standing views show the second metatarsal base shifted laterally, and operative inspection confirms an unstable first to second ray relationship. The surgeon clears an interposed fragment, reduces the second base into its cuneiform position, checks adjacent joint alignment in multiple views, and then fixes the reduction. Fixing before reduction would preserve the displacement.
Watch the distinction: A stable construct is not proof of anatomic reduction. Verify the second metatarsal base and adjacent columns before fixation, because persistent displacement concentrates load across the midfoot.
Reference: [1]
33. Control a displaced metatarsal fracture
Central metatarsals share load across the forefoot, so fracture alignment affects pressure under neighboring heads. Assess length, rotation, sagittal angulation, comminution, and the position of adjacent rays on suitable views. A shortened metatarsal may transfer load elsewhere; a dorsally displaced head may lose ground contact, while a plantar displaced head can become a focal pressure point. Reduction should restore the metatarsal head to the functional plantar arc and correct rotation before fixation is finalized. The fracture pattern determines whether direct compression is possible or whether alignment must be held across fragmented bone. Preserve soft tissue attachments and blood supply where feasible. A radiograph showing connected fragments does not establish a good result if the head remains elevated or the toe points in the wrong direction.
Worked example: A displaced third metatarsal fracture heals poorly positioned on provisional imaging: the distal fragment is shortened and dorsally angled. The head would sit above the neighboring weight bearing arc, increasing pressure beneath the second and fourth rays. Reduction restores length, sagittal position, and toe rotation before fixation. Fragment contact alone would not correct the loading problem.
Watch the distinction: Fracture union is only one goal. A healed but elevated or shortened metatarsal can produce persistent transfer pain, so assess the head's final position under load.
Reference: [1]
34. Protect nerves during neuroma surgery
Interdigital nerve surgery requires a well localized symptomatic lesion and careful knowledge of structures sharing the web space. Correlate the patient's sensory distribution, provocative examination, and any imaging with the intended nerve. During dissection, identify the common digital nerve and follow it sufficiently to treat the involved segment while avoiding blind removal of surrounding tissue. The adjacent digital vessels supply the toes; injury can create a problem unrelated to the original nerve pain. Protect neighboring tendons and joint restraints as well. Explain that treatment may exchange painful irritation for an area of numbness, and persistent pain can arise if another source was responsible or a painful nerve stump develops. A broad excision is no substitute for confirming which structure reproduces the symptoms.
Worked example: A patient has years of focal burning in one web space despite shoe changes and other conservative care. Examination reproduces the pain locally, and imaging describes an enlarged interdigital nerve. At surgery, dissection follows that nerve and protects nearby digital vessels. The surgeon treats the symptomatic segment while limiting injury to unaffected tissue; indiscriminate removal would add risk without improving localization.
Watch the distinction: A larger excision does not guarantee relief. Confirm the symptomatic nerve and protect adjacent vessels, since pain may persist when joint pathology or another nerve source was overlooked.
Reference: [1]
35. Debride an infected forefoot joint
Purulence within a metatarsophalangeal joint indicates an infected space requiring source control. Establish the joint's extent and whether infection has tracked into tendon sheaths, plantar spaces, or bone. Obtain meaningful deep specimens before extensive irrigation when feasible, then drain accessible pockets and remove necrotic capsule or other nonviable tissue. Preserve viable cartilage, bone, tendons, and blood supply when infection control allows, but do not leave dead tissue merely to maintain anatomy. Irrigation reduces contamination after debridement; it cannot replace opening an undrained compartment. Closure and any drain choice depend on remaining tissue viability and the risk of trapping fluid. Systemic treatment should be guided by the patient's condition and microbiology, with reassessment if pain, drainage, or inflammatory signs persist.
Worked example: A patient with a puncture wound has a swollen second metatarsophalangeal joint. Exploration finds pus inside the joint and necrotic capsule extending plantarly. Deep samples are obtained, the joint and connected pocket are drained, and nonviable tissue is removed while healthy structures are protected. Closing after washing only the dorsal opening would leave a plantar reservoir of infection.
Watch the distinction: Antibiotics and irrigation cannot reliably sterilize a closed pocket of pus. Find connected spaces and remove dead tissue, then use cultures and clinical response to guide further care.
Reference: [1]
Procedural Perioperative Management
36. Select a hallux valgus procedure
Choose hallux valgus surgery by locating the deformity and testing the joints that must support the correction. Standing imaging shows the metatarsal and hallux relationship, joint congruity, and associated first ray position. Examination adds first tarsometatarsal stability, first metatarsophalangeal motion, reducibility, and symptoms from lesser ray overload. A distal osteotomy may suit a deformity centered distally when adequate correction and stable fixation are possible. A proximal stabilizing procedure addresses a substantial first tarsometatarsal driver. A severely degenerated first metatarsophalangeal joint changes the role of joint preserving procedures. Patient activity, footwear demands, bone quality, and recovery constraints matter because they affect the acceptable tradeoffs. Do not let one angular measurement dictate the operation while overlooking rotation, instability, or arthritis. The decision should correct the source of pain and deformity while preserving a functional first ray.
Worked example: A patient has painful hallux valgus, transfer pain under the second metatarsal, a mobile first tarsometatarsal joint, and preserved first metatarsophalangeal cartilage. A proximal stabilizing correction addresses the first ray driver and may improve load sharing. An isolated medial eminence removal would reduce the visible bump but leave the unstable alignment that contributes to pain.
Watch the distinction: A prominent bunion does not identify the required procedure. Locate the deformity, assess proximal stability and joint cartilage, and then choose the correction that addresses those findings.
Reference: [1]
37. Choose surgery for hallux rigidus
Pain timing helps separate dorsal impingement from diffuse first metatarsophalangeal arthritis. End range dorsal pain with a palpable spur, relatively comfortable midrange motion, and preserved central joint space supports a motion preserving approach such as cheilectomy. Pain throughout the motion arc, extensive joint space loss, and deformity indicate that the articular surfaces themselves are a major pain source. Fusion can provide a stable lever for push off when the joint is too degenerated to preserve comfortably, but it sacrifices first metatarsophalangeal motion and requires careful position for shoe wear and gait. Consider activity demands and adjacent joint condition when discussing options. Examine the entire foot because transfer pain or a concomitant deformity may influence the plan. The ABFAS Foot Didactic practice questions can help rehearse this distinction through clinical findings.
Worked example: Patient A has painful dorsal contact only at maximum dorsiflexion, with preserved midrange motion and central cartilage. Joint preserving spur removal targets that mechanism. Patient B has pain from the start of movement, crepitus, and diffuse joint space loss. Removing a dorsal spur would leave the main arthritic pain source; fusion offers a more coherent definitive option.
Watch the distinction: A dorsal osteophyte does not make every stiff hallux a cheilectomy candidate. Determine whether pain comes chiefly from impingement or from widespread cartilage loss.
Reference: [1]
38. Plan treatment for a drifting lesser toe
A drifting lesser toe can reflect plantar plate failure, excess metatarsal loading, and secondary soft tissue contracture in different proportions. Start with standing toe position, plantar callus, joint tenderness, drawer instability, and whether the toe reduces without force. Imaging helps assess metatarsal length and joint congruity; focused soft tissue imaging may define a suspected plate tear. A reducible joint with torn plantar restraint can be rebalanced if the repair also withstands the pressure environment. When a relatively long or plantar prominent metatarsal contributes to overload, correcting that driver may protect the repair. A fixed dislocation or arthritic joint needs a different discussion because soft tissue repair alone may not restore congruity. Check for first ray insufficiency, since persistent lateral transfer can undermine a well performed lesser ray procedure.
Worked example: A second toe crosses toward the hallux but reduces easily. It has plantar joint pain, a positive drawer test, and imaging suggests a plate tear; the second metatarsal is relatively long with a callus beneath its head. Repairing restraint addresses instability, while correcting excess loading reduces recurrence risk. An isolated toe release addresses neither driver.
Watch the distinction: Reducibility does not mean the joint is structurally sound. A toe can be pushed straight while its plantar plate remains torn and its metatarsal head remains overloaded.
Reference: [1]
39. Time congenital digit correction
Timing pediatric digit correction requires a functional assessment as well as an anatomic one. Document skin connection, separate or shared bones, joints, tendons, and nail units using examination and suitable imaging. Note shoe problems, recurrent skin injury, pain, progressive angular change, and whether the child uses the foot normally. Growth may magnify imbalance or reveal a shared structure that complicates separation. Family preferences matter, but a painless, stable syndactyly does not become urgent solely because the toes look unusual. If correction is chosen, plan for durable coverage, preserved sensation and perfusion, and a balanced retained digit. Discuss scars, graft or flap needs when relevant, and the possibility of later alignment changes. Follow-up should track function and growth rather than treating the initial appearance as the only outcome.
Worked example: A child with joined second and third toes runs comfortably, has no skin breakdown, and shows no progressive angulation. Imaging shows separate bones beneath a soft tissue connection. There is no functional reason for urgent separation. The surgeon documents growth and shoe tolerance, then discusses elective correction with the family, including the need for reliable skin coverage between the toes.
Watch the distinction: Visible syndactyly alone does not establish surgical urgency. Function, progressive deformity, shared anatomy, and the demands of reconstruction determine whether and when correction offers benefit.
Reference: [1]
40. Choose a lengthening strategy
Brachymetatarsia correction must restore useful metatarsal length without exceeding the tolerance of skin, vessels, nerves, tendons, and joints. Establish the needed change from standing foot shape, toe position, pressure pattern, and patient symptoms rather than a cosmetic number alone. A modest gap may be addressed in one stage if bone contact or graft support and soft tissue closure remain sound. Greater lengthening stretches all attached tissues at once, raising concern for joint stiffness, toe subluxation, vascular tension, and wound problems. Gradual distraction spreads that adaptation over time and can achieve more length, but it brings prolonged device care, monitoring, and risk of regenerate or alignment problems. Whatever method is chosen, maintain the metatarsal's plantar position and toe alignment so the restored length improves loading rather than creating a new pressure point.
Worked example: A short fourth metatarsal leaves the fourth toe elevated and causes pressure beneath neighboring heads. Planned restoration is substantial, while examination shows little soft tissue slack around the toe. Abrupt one-stage lengthening would place the skin, nerve, and joint under marked tension. Gradual lengthening better accommodates adaptation, provided follow-up monitors alignment, joint position, and new bone formation.
Watch the distinction: Achieving the target length does not prove success. A lengthened ray that heals elevated or leaves the toe subluxed may continue to transfer pressure and cause shoe problems.
Reference: [1]
41. Decide whether Lisfranc injury is stable
A Lisfranc injury can look aligned when the foot is unloaded because the disrupted ligament is no longer being stressed. Examine the mechanism, plantar bruising, focal tarsometatarsal tenderness and ability to bear weight, then compare the first and second tarsometatarsal relationships on appropriate standing views. Look for widening, a small avulsion fragment, or loss of alignment between the second metatarsal base and middle cuneiform. If pain prevents reliable loading, further imaging and specialist assessment may be needed; an apparently normal unloaded film does not settle stability. Maintained alignment under load supports protected observation with reassessment, whereas separation or joint incongruity suggests a mechanically unstable injury that may need operative evaluation. The ABFAS Foot Surgery subject outline includes Lisfranc trauma within Foot topics.
Worked example: Two patients have midfoot pain after twisting injuries. The first can bear weight; comparison standing views show preserved second metatarsal to middle cuneiform alignment and no widening. Protection and close follow-up are reasonable while symptoms are reassessed. The second has plantar bruising, focal tenderness and separation visible only on loaded views. That load-dependent displacement indicates instability and calls for operative assessment.
Watch the distinction: Treating a nearly normal unloaded radiograph as proof of stability misses ligament injury that becomes visible under load. Clinical findings and reliable weight-bearing alignment must agree.
42. Choose surgery for foot infection
The operative question in foot infection is whether infected material or dead tissue must be physically removed. Cellulitis spreads through viable soft tissue and, without a drainable focus or necrosis, may respond to systemic treatment, local wound care and close reassessment. An abscess contains a bounded collection where drug delivery and drainage are limited; opening and draining it provides source control. Devitalized tissue likewise cannot recover simply because an antimicrobial reaches nearby living tissue. Examine for fluctuance, rapidly advancing changes, crepitus, systemic illness and pain out of proportion, and use imaging when it clarifies a deep collection or the extent of involved tissue. If bone or a joint is involved, obtain meaningful specimens when feasible and plan treatment around viable tissue, stability and coverage. The urgency rises when infection threatens the limb or the patient.
Worked example: One patient has diffuse forefoot redness, warmth and swelling but no collection on examination or imaging, no necrosis and stable systemic findings. Medical treatment with reassessment addresses the apparent cellulitis. Another has fever, a deep plantar fluid collection and nonviable tissue. Drainage, debridement and systemic treatment are needed because medication alone leaves the infected focus in place.
Watch the distinction: Assuming every red foot needs an incision leads to unnecessary surgery. Assuming antibiotics drain an abscess leaves a source of infection untreated. Identify the tissue problem first.
Reference: [1]
43. Assess rearfoot deformity before referral or surgery
A standing flatfoot describes shape, not the source or flexibility of the deformity. Assess hindfoot position, arch restoration on heel rise, passive subtalar motion, tendon function, pain location and weight-bearing alignment. A flexible acquired deformity may correct when the heel rises or the foot is manipulated; a rigid foot with limited subtalar motion suggests coalition or established joint disease. Cavus has a different loading pattern, typically a high arch and lateral overload, so it should not be grouped with every painful rearfoot shape change. Imaging can show coalition, arthrosis or the level of bony malalignment, and helps determine whether joint-preserving treatment is plausible. This remains relevant to Foot perioperative decisions, while the RRA didactic guide addresses the related reconstructive rearfoot and ankle scope. Avoid selecting a procedure from appearance alone.
Worked example: Both patients appear flat while standing. The first has medial pain, a mobile subtalar joint and an arch that returns on heel rise, supporting a flexible deformity. The second cannot restore the arch, has restricted subtalar motion and imaging describes a calcaneonavicular coalition. The rigid structural cause changes referral and treatment planning; the same operation should not be assumed for both.
Watch the distinction: Calling every low arch flexible because it looks similar in stance ignores motion and imaging. A coalition or arthritic joint changes which corrections can work.
44. Protect a healing fusion
A first tarsometatarsal fusion must maintain corrected alignment while bone bridges the prepared joint surfaces. Fixation limits motion, but an intact construct is not itself evidence of union. Postoperative loading places force across the fusion, so protection is matched to the construct, local bone quality, soft-tissue condition and observed healing. At review, compare pain and focal tenderness with serial weight-bearing status and imaging: look for progressive bridging, persistent lucency, migration, loss of correction or hardware fatigue. Early images often show stable position before bridging can be confidently identified. Continue the planned protection when evidence of union is incomplete, then adjust activity as clinical and imaging findings support it. Check wound condition and host factors that can impair healing. ABFAS Foot Didactic practice questions can help rehearse this distinction between maintained alignment and demonstrated union.
Worked example: At an early review after first tarsometatarsal fusion, the patient has mild expected soreness. Films show unchanged correction and intact fixation, but the joint line remains visible without convincing bridging. The construct has maintained position; it has not yet demonstrated union. Continue the planned loading protection and reassess symptoms and serial images before advancing activity.
Watch the distinction: Equating intact hardware with healed bone advances loading on an unproven fusion. Fixation can hold alignment temporarily while the fusion interface still needs time and surveillance.
Reference: [1]
Complications
45. Work up a painful nonunion
A painful fusion is not automatically a nonunion. Determine whether symptoms and images show progression over time: diminishing lucency and increasing bridging favor slow healing, while persistent focal pain, motion, a gap or fixation failure raise concern for symptomatic nonunion. CT can clarify an uncertain fusion interface, but interpret it alongside the examination and serial films. Then ask why healing failed. Mechanical causes include poor contact, malalignment and inadequate stability; biological causes include compromised vascularity, host illness and nicotine exposure. Infection may be subtle and requires attention to wound history, inflammatory findings and appropriately obtained specimens when revision is considered. A revision plan must correct the cause, restore viable apposed surfaces and stable alignment, and address infection or host factors. Replacing hardware without diagnosing the failed environment is incomplete.
Worked example: Several months after a foot fusion, a patient still has focal pain and palpable motion. Serial films show an unchanged gap and a broken screw, without progressive bridging. This supports symptomatic nonunion more strongly than delayed but advancing healing. Assess for infection and impaired host biology, then plan revision to restore contact and stability while treating any identified infection.
Watch the distinction: A single visible joint line cannot establish nonunion without timing, symptoms and comparison. Conversely, broken fixation with pain and persistent motion should not be dismissed as routine slow healing.
Reference: [1]
46. Recognize transfer metatarsalgia
The first ray normally accepts a substantial share of forefoot load during stance and push-off. If surgery leaves it shortened, elevated or unable to bear weight effectively, pressure shifts toward the lesser metatarsal heads. New plantar pain and a callus beneath the second ray after first-ray correction therefore invite a mechanical review, not only a search for disease within the second ray. Compare preoperative and current symptoms, examine first-ray ground contact and mobility, and review standing images for elevation, shortening or recurrent deformity. Also consider a long or plantarflexed lesser metatarsal and plantar plate instability, since more than one driver can coexist. Treatment begins by identifying where load is being transferred; footwear and offloading may help, while persistent structural causes can require a correction that restores a balanced forefoot.
Worked example: Before hallux valgus correction, the patient had no pain beneath the second metatarsal. After healing, a new callus and focal plantar pain develop there. Standing films show the first metatarsal healed elevated, and examination finds reduced first-ray ground contact. The chronology and mechanics support transfer metatarsalgia; treating the callus alone would leave the load shift unchanged.
Watch the distinction: Labeling every postoperative second-ray pain as a new isolated neuroma overlooks first-ray position. Check where the forefoot contacts the ground before choosing a local procedure.
Reference: [1]
47. Classify a postoperative wound problem
A postoperative wound should be classified by depth and behavior, not by the mere presence of an open edge. A small dry separation with viable tissue and no advancing inflammation may be a superficial healing problem. Purulence, increasing pain, spreading erythema, deep probing, exposed fixation or systemic illness raises concern for deeper infection. Examine the entire incision, surrounding perfusion and any tracking wound; document drainage quality and compare symptoms over time. Imaging may help assess a collection, hardware position or bone involvement, while suitable deep specimens can guide antimicrobial treatment if debridement is needed. Closure over persistent infected material risks trapping the source. The management sequence is to assess severity, identify depth and source, protect viable coverage, and coordinate drainage or debridement when a deep focus is present.
Worked example: At follow-up, one incision has a small dry edge gap with pink viable tissue, little tenderness and no spreading redness. Local protection and reassessment fit a superficial separation. A second patient has increasing pain and pus draining from a tract over fixation. That pattern requires prompt evaluation for deep infection, hardware involvement and a collection needing source control.
Watch the distinction: Calling any wound gap an infection can misdirect care. Calling purulent drainage a simple dehiscence misses a possible deep focus, especially when pain is increasing over fixation.
Reference: [1]
48. Respond to postoperative vascular change
A new pale, cool or numb toe after foot surgery is a change in perfusion or nerve function until promptly reassessed. Compare color, temperature, capillary refill, sensation and movement with other toes and with the immediate postoperative examination. Inspect for a tight dressing, splint, swelling, hematoma or toe position that may compress vessels. Releasing an external constriction is an immediate reversible step, followed by repeat examination; persistent abnormal findings require urgent evaluation for vascular injury, thrombosis or excessive tension on the repaired tissues. Palpable proximal pulses do not guarantee adequate flow to an individual digit. Document the time course and response to each action. Pain out of proportion or a progressing neurologic deficit also broadens concern beyond a simple dressing problem. The key is a repeated examination, not passive observation of a changing limb.
Worked example: After forefoot correction, a toe that was previously warm becomes pale and cool, with slower refill and new tingling beneath a tight dressing. The dressing is promptly loosened and the toe is reexamined. If warmth and refill return, continue close surveillance; if they do not, urgent vascular and surgical assessment is needed to identify an ongoing flow problem.
Watch the distinction: A palpable foot pulse does not rule out digital ischemia. Waiting for the next routine round can allow a reversible compression problem or vascular injury to progress.
Reference: [1]
49. Distinguish CRPS from focal nerve injury
Postoperative burning pain may come from a focal nerve lesion, a broader regional pain syndrome or another surgical complication. Map the sensory findings before naming the disorder. Numbness or tingling restricted to a particular digital nerve territory, especially with local provocation, favors focal injury or entrapment. Complex regional pain syndrome is considered when pain is disproportionate and accompanied by regional changes such as allodynia, swelling, altered color or temperature, sweating changes and reduced movement. Its pattern extends beyond one named peripheral nerve; no single symptom proves it. Review wound, perfusion, fixation and infection findings as competing explanations, and compare both sides on examination. Early recognition permits coordinated pain control and functional rehabilitation while the diagnosis is evaluated. A normal-looking incision does not exclude either neurologic problem.
Worked example: A patient reports burning throughout the operated foot, with swelling, color fluctuation and severe pain from light touch across several nerve territories. That regional pattern warrants assessment for complex regional pain syndrome after other causes are checked. In another patient, persistent numbness is limited to the adjacent sides of two toes and is provoked at one web space, favoring a focal digital nerve problem.
Watch the distinction: Using the word neuropathy for all postoperative burning obscures distribution. Regional vasomotor and swelling changes differ from a reproducible deficit in one named nerve territory.
Reference: [1]
50. Analyze recurrent or overcorrected bunion deformity
Postoperative hallux alignment must be judged against the direction of deformity and the condition of the first metatarsophalangeal joint. Recurrent hallux valgus means renewed lateral deviation, often from an uncorrected first-ray driver, loss of correction or imbalance. Hallux varus means medial deviation and may follow excessive bony correction, excessive medial soft-tissue tightening or loss of lateral restraint. Examine whether the toe can be passively returned to neutral, whether the joint is congruent and whether arthritis is present. Standing images show metatarsal position and joint alignment under load. A flexible hallux varus with preserved cartilage may call for restoring soft-tissue balance; a fixed or arthritic deformity changes the options. Revision should address the actual direction and mechanism rather than repeat the original bunion maneuver by habit.
Worked example: After bunion correction, a patient's hallux points medially and rubs in shoes. The first metatarsophalangeal joint remains mobile, and standing films show medial toe deviation without diffuse joint destruction. This is flexible hallux varus, an overcorrection pattern. Further medial pull would worsen alignment; assess the bony correction and lateral soft-tissue restraint before selecting revision.
Watch the distinction: Calling any deformity after bunion surgery a recurrence reverses the decision. Recurrent valgus and hallux varus point in opposite directions and have different mechanical causes.
Reference: [1]
51. Interpret fixation failure
Hardware breaks when repeated force exceeds what the implant can sustain, but the implant may have been carrying that force because bone never became a stable load-sharing bridge. In a painful fusion with persistent lucency, a broken screw is therefore often a consequence and marker of motion, not the whole diagnosis. Compare sequential images for loss of alignment, widening, backing out and healing progress. Examine for focal motion and pain, and assess infection, bone quality, contact at the fusion surface and loading history. A well-united site can also have symptomatic prominent hardware, so imaging and symptoms must be interpreted together. If the site is unhealed, revision must restore the biological and mechanical conditions for union. Simply replacing an implant in the same unstable gap exposes the new device to the same cyclic forces.
Worked example: A screw across a first tarsometatarsal fusion fractures. The patient has focal pain, a persistent joint gap and no progressive bridging on serial films. Repeated loading through an unhealed interface explains the fatigue failure. Revision assessment should address why the fusion did not unite and how to restore contact and stability, rather than treating the broken screw as an isolated defect.
Watch the distinction: Assuming the screw failed first and caused every nonunion ignores chronology and bone healing. A persistent gap can overload otherwise correctly placed fixation until it fractures.
Reference: [1]
52. Recognize post-traumatic joint collapse
Union of a fracture and health of its joint surface are separate outcomes. An intra-articular injury can heal while residual step-off, cartilage damage or altered loading drives post-traumatic arthritis. Injury to the blood supply of a bone segment may instead produce avascular necrosis, with delayed subchondral collapse and loss of the supporting contour. When pain returns or intensifies after apparent fracture union, compare serial images for joint-space change, surface irregularity, sclerosis, fragmentation and collapse. CT can define bony shape and congruity; MRI may help assess marrow viability when the diagnosis remains unclear. Relate the image changes to the original injury and current motion and loading. Management depends on the involved joint, severity, symptoms and remaining viable surface, not merely whether the original fracture line has disappeared.
Worked example: A patient initially improves after an intra-articular foot fracture, then develops renewed pain and stiffness. Later images show an irregular joint surface and collapse beneath the cartilage, although the fracture line appears united. Fracture healing has occurred, but the articular segment has failed. Reassess for post-traumatic arthritis or loss of bone viability before attributing the pain to routine recovery.
Watch the distinction: Declaring treatment complete because a fracture line has united overlooks delayed cartilage failure or avascular collapse. Follow the joint surface and symptoms as well as bony union.
Reference: [1]
General Medicine
53. Interpret perioperative glucose problems
Perioperative glucose reflects both usual diabetes control and the stress of the current illness. Infection, surgical stress, reduced intake and changes to home medication can push values in different directions over hours or days. Repeated high readings during infection matter because hyperglycemia can impair immune function and wound healing, while an isolated earlier normal value says little about the current trend. Interpret the sequence with meal intake, medication timing, hydration, renal function and evidence of acute metabolic illness. Coordinate treatment with the medical and anesthesia teams, especially when the patient is fasting or unable to follow a usual regimen. Recheck after interventions rather than assuming one adjusted dose solves the problem. A long-term marker can describe baseline control, but it cannot replace real-time assessment of a patient whose condition is changing.
Worked example: A patient usually reports steady home readings but develops a deep foot infection. During admission, glucose values repeatedly rise as fever and poor intake develop, despite one normal reading before illness. The current pattern calls for coordinated assessment of hydration, medication and infection treatment, with repeat measurements. The earlier value does not establish that perioperative glucose is controlled.
Watch the distinction: Using one normal reading to clear a patient with repeated later elevations ignores acute stress and treatment changes. Follow the trend and clinical context, including poor intake.
Reference: [1]
54. Balance anticoagulation and bleeding
An anticoagulant plan balances the reason for treatment against bleeding from the proposed procedure and anesthesia technique. Establish the indication, timing of the thromboembolic event or other high-risk condition, drug, kidney function and expected surgical bleeding. Interruption can expose a patient to clotting risk; continuation may cause bleeding into a confined operative site or interfere with regional anesthesia choices. Those risks vary, so there is no universal instruction to stop every anticoagulant before a foot incision. Coordinate the plan with the prescribing clinician and anesthesia team, including when treatment can safely resume and whether an elective operation should be deferred. Distinguish anticoagulants from antiplatelet medicines because their effects and reasons for use differ. Record the agreed plan clearly so preoperative and postoperative teams act on the same decision.
Worked example: A patient is scheduled for elective forefoot surgery shortly after treatment for a thromboembolic event. The operation has manageable but real bleeding risk, while interrupting therapy so soon may carry substantial clotting risk. Review the event, medicine and planned anesthesia with the treating teams. Deferring the elective procedure or tailoring treatment is more defensible than an automatic preoperative stop.
Watch the distinction: Stopping anticoagulation simply because surgery is planned ignores why it was prescribed. Continuing it without considering operative bleeding and anesthesia is equally incomplete.
Reference: [1]
55. Identify unstable cardiopulmonary disease
New chest pressure, reduced exercise tolerance or worsening breathlessness before elective foot surgery can signal an active cardiopulmonary problem. Ask when symptoms began, what provokes them, whether they occur at rest, and whether there is fainting, swelling, fever or known heart or lung disease. Examine vital signs and oxygenation and seek appropriate medical evaluation when symptoms suggest instability. The perioperative concern is that anesthesia, fluid shifts and surgical stress can worsen an active condition; a previously tolerated operation does not establish present safety. Separate longstanding stable limitations from a recent change, because the trajectory often matters more than a diagnosis written in an old chart. An elective procedure can wait while a potentially serious new condition is identified and treated. Emergently required source control presents a different timing decision and requires coordinated risk management.
Worked example: Before elective first-ray surgery, a patient reports chest pressure with minimal walking and breathlessness that has worsened over several days. These are new symptoms, not a stable historical limitation. Postpone the elective operation and arrange prompt medical assessment of the possible cardiac or pulmonary cause. A normal foot examination would not change the systemic priority.
Watch the distinction: Treating a familiar cardiac diagnosis as reassuring overlooks new symptoms. The change in function and chest pressure determine urgency more than the old problem list.
Reference: [1]
56. Account for kidney disease
Kidney function affects drug clearance, electrolyte balance and the ability to handle fluid changes around surgery. A rising creatinine after illness suggests deterioration from the patient's baseline, even when chronic kidney disease is already known. Review recent trends, intake and losses, blood pressure, possible obstruction and medicines that may reduce renal perfusion or accumulate when clearance falls. Elevated potassium raises concern for a cardiac effect and requires timely medical assessment in context. Analgesics, antibiotics, anticoagulants and other perioperative drugs may need reassessment because dosing based on old renal results can become inappropriate. Fluid decisions also require care: both dehydration and excess fluid may cause harm. The key sequence is to recognize change, investigate the cause, review medication exposure and coordinate correction before an elective procedure proceeds.
Worked example: A patient with chronic kidney disease becomes dehydrated during an acute illness. New tests show creatinine rising from the patient's usual level and potassium also increasing. The paired trend suggests worsened renal handling, not a stable baseline. Reassess fluid status, the cause of deterioration and renally cleared or kidney-stressing medicines; arrange timely evaluation of the potassium finding.
Watch the distinction: Calling every abnormal creatinine value the patient's normal chronic disease misses an acute rise. Compare with baseline and examine potassium and medication exposure before routine dosing continues.
Reference: [1]
57. Interpret systemic inflammatory disease
A painful foot in systemic inflammatory disease can have both a local mechanical problem and active disease elsewhere. Morning stiffness, multiple involved joints and fluctuating swelling suggest inflammatory activity; focal shoe pressure, a fixed deformity or a localized callus suggests a structural component. Review disease control, functional goals and current immune-modifying medicines before planning an operation. Such treatment can affect infection risk and perioperative coordination, while uncontrolled inflammation can complicate recovery or leave pain after a technically successful local correction. Examine skin, vascular status and joint condition, and distinguish infection from a flare when a joint becomes acutely hot and painful. The surgical target should be a clearly defined deformity or damaged joint whose correction meets the patient's functional need. Local surgery does not replace systemic management of rheumatoid or other inflammatory disease.
Worked example: A patient with rheumatoid arthritis takes immune-modifying treatment and has a painful rigid lesser toe. Morning stiffness and swelling in several hand and foot joints have also recently increased. The toe may need structural correction, but the broader symptoms suggest active systemic disease. Assess disease control and infection risk with the treating team before assuming the toe operation will resolve all pain.
Watch the distinction: Attributing every painful joint to mechanical deformity can miss an inflammatory flare or infection. Conversely, systemic arthritis does not erase a specific fixed toe problem.
Reference: [1]
58. Recognize local-anesthetic toxicity
Local-anesthetic systemic toxicity occurs when enough anesthetic reaches the circulation to affect the central nervous and cardiovascular systems. It may follow unintended intravascular injection or absorption from a tissue site. Early clues can include tinnitus, altered taste, dizziness, agitation or confusion; progression may bring seizure, conduction disturbance, arrhythmia or cardiovascular collapse. The sequence and timing after injection are important, although symptoms can vary and sedation may hide early neurologic signs. Stop anesthetic administration immediately, summon the anesthesia emergency team, support airway and circulation, and follow the team's established toxicity treatment protocol, which may include lipid emulsion therapy. Communicate the drug, concentration, amount, site and injection time accurately. Do not wait for every classic symptom before responding to a rapidly evolving multisystem pattern.
Worked example: Minutes after a regional injection, a patient reports ringing in the ears, becomes confused and develops an arrhythmia. The close timing and progression from neurologic to cardiovascular findings make systemic anesthetic toxicity a leading concern. Stop further injection, activate the anesthesia emergency response and support the patient while the team initiates its toxicity treatment protocol.
Watch the distinction: Explaining confusion alone as anxiety misses the subsequent arrhythmia and injection timing. Toxicity can evolve quickly, so an incomplete early symptom pattern still warrants action.
Reference: [1]
59. Assess venous thromboembolism symptoms
Expected postoperative discomfort is usually related to the operated limb and changes gradually. Sudden unexplained breathlessness, pleuritic chest pain, rapid pulse, faintness or reduced oxygenation suggests a systemic event, including pulmonary embolism. Recent surgery and reduced mobility contribute to risk, but neither confirms the diagnosis; pneumonia, cardiac disease and other causes also require assessment. Evaluate vital signs and cardiopulmonary status promptly, arrange emergency medical care, and communicate the operation, mobility, anticoagulant history and symptom onset. Leg swelling or calf pain may coexist, yet their absence does not exclude an embolus. Diagnostic testing and treatment decisions depend on the patient's stability and medical evaluation. The foot surgeon's key decision is to recognize that this symptom combination is outside routine wound recovery and needs immediate systemic assessment.
Worked example: A patient recovering from foot surgery develops abrupt breathlessness, sharp pain on inspiration and a rapid pulse after having felt well earlier. There is no new wound complaint. The abrupt cardiopulmonary pattern requires urgent evaluation for pulmonary embolism and other serious causes. Routine postoperative analgesia and a later clinic review would not address the immediate risk.
Watch the distinction: Attributing sudden chest symptoms to ordinary postoperative pain delays assessment of a possible embolus. A normal-looking foot or absence of calf pain does not rule it out.
Reference: [1]
60. Recognize systemic sepsis
Sepsis is a dangerous systemic response to infection associated with new organ dysfunction. A possible foot source may be visible, but confusion, low blood pressure and increasing respiratory rate show that the problem extends beyond local tissue. Assess airway, breathing, circulation, mental state, perfusion and available laboratory evidence while activating emergency medical care. Resuscitation and prompt antimicrobial assessment proceed alongside a search for the source; a deep collection or dead tissue may also need urgent drainage or debridement. Do not wait for a positive culture before responding to a deteriorating patient, and do not assume that every abnormal vital sign has a single explanation. Repeated assessment matters because organ function and hemodynamics can change quickly. Source control and systemic treatment are complementary parts of managing a severe infection.
Worked example: A patient with a draining foot wound becomes newly confused. Blood pressure is falling, breathing grows faster and the patient appears poorly perfused. The wound may be the source, but the new mental and circulatory changes raise concern for sepsis with organ dysfunction. Activate emergency care, begin coordinated resuscitation and infection treatment, and assess for a focus requiring source control.
Watch the distinction: Treating the foot wound alone while overlooking new confusion and hypotension misses systemic deterioration. Waiting for culture confirmation before escalating care can lose critical time.
Reference: [1]
Official references and further reading
- Part I Board Qualification Exam Content | ABFAS
- How to Navigate the Didactic Exam | ABFAS
- New Certification Process, Effective September 2020 | ABFAS