Treat Part II preparation as a documentation audit of surgical reasoning. Work through five of your own rearfoot/ankle reconstruction cases, write a one-page rationale for each covering indication, staging, procedure selection, fixation, and outcome, and fix the records where a link in that chain is missing.
Why a case list is not a case rationale in this format
Because reviewers judge your documented cases without you present, preparation means making your decision-making traceable on paper. Build each case around a rationale chain: indication, findings, staging, procedure choice, fixation, and outcome.
The Case Review process, as the board describes it, involves a facility audit and an uploaded case documentation package built around a selected procedures list, with reviewers evaluating the material afterward. Candidates do not attend. Practical implication: everything you would normally explain verbally — why you staged the reconstruction this way, why this fixation — has to be recoverable from the record itself. Preparation therefore differs from didactic exam study; you are rehearsing written surgical reasoning, not question answering.
Define the rationale chain explicitly and apply it case by case. Link one: the documented indication, tied to history and exam. Link two: findings organized through a named staging or classification system where one exists. Link three: procedure selection, including alternatives you considered and why you rejected them. Link four: fixation and technique choices consistent with the deformity and tissue quality. Link five: postoperative management and outcome. A case missing any link leaves a reviewer to guess your logic, which is the failure mode this format invites.
Stage II flatfoot: connecting each exam finding to each osteotomy
Adult-acquired flatfoot reconstruction is studied best through the Johnson and Strom staging system as modified by Myerson. In flexible Stage II deformity, every corrective component should map to a specific finding you documented.
Worked scenario one: a Stage II posterior tibial tendon dysfunction case with too-many-toes sign, forefoot abduction, and forefoot varus on double-stance view. A plausible documentation mistake is recording 'FDL transfer with medializing calcaneal osteotomy performed' while noting forefoot varus in the exam without a corresponding corrective step or an explanation for omitting one. A better record states that the deformity was flexible, that subtalar motion was preserved, that a gastrocnemius recession addressed equinus, and — after Cotton test assessment of first-ray mobility — either adds a medial cuneiform plantarflexion osteotomy for fixed forefoot varus or documents why the first ray was supple enough to leave alone.
Why it matters: reviewers evaluating flatfoot cases are looking for reconstructive logic, and the Evans lateral column lengthening versus medializing calcaneal osteotomy decision, the choice to add a Cotton osteotomy, and spring ligament management are exactly the judgment points where an unexplained gap stands out. Study each Stage II component as a paired unit — finding plus procedure — and rehearse explaining the pairs in sequence. For Stage III rigid deformity, practice articulating why fusion-based correction replaces joint-sparing osteotomies, so the contrast between your flexible and rigid cases reads as deliberate staging rather than habit.
Ankle arthritis: choosing and defending arthrodesis, arthroplasty, or realignment
The three main operative directions for tibiotalar arthritis — fusion, replacement, and joint-sparing realignment — differ in indication profile, and your case record must show the selection reasoning, not just the implant or construct used.
Study the three options as decision profiles rather than technique lists. Arthrodesis suits severe arthritis, deformity, or prior infection history, trading tibiotalar motion for durable pain relief and predictable fusion biology. Total ankle arthroplasty preserves motion but demands stricter patient and deformity selection and carries distinct revision considerations. Supramalleolar osteotomy is the joint-sparing option for asymmetric arthritis or malunion with retained cartilage in the preserved compartment. When you present an ankle case, name the alternative you considered and the patient factor that decided the choice.
The table below is a self-check framework: for each of your own ankle cases, verify the record supports the best-fit profile and addresses the considerations column. Then extend the exercise to technique-level reasoning — arthroscopic versus open fusion, alignment targets, and graft choice in arthrodesis — keeping each claim tied to what the case actually documented.
| Option | Best-fit profile | Key considerations to document | What the case record should show |
|---|---|---|---|
| Tibiotalar arthrodesis | Severe arthritis, significant deformity, young or high-demand patients | Alignment goals, fusion preparation, salvage compatibility | Alternative considered (e.g., arthroplasty) and why rejected |
| Total ankle arthroplasty | Arthritis with preserved alignment, motion desired, lower-demand profile | Deformity and bone stock suitability, alignment correction | Selection criteria met and contraindications ruled out |
| Supramalleolar osteotomy | Asymmetric arthritis or malunion with retained cartilage | Correction planning, cartilage status of spared compartment | Why joint preservation was viable for this patient |
Syndesmotic injuries: proving reduction and stability, not just hardware
A syndesmotic case is defensible when the record shows how you assessed reduction and stability, not merely which fixation you placed. Rehearse the assessment methods as explicitly as the construct.
Worked scenario two: a rotational ankle fracture with an unstable syndesmosis requiring fixation. A plausible mistake is documenting screw position and count while omitting how reduction was confirmed and how stability was tested. A stronger record describes the reduction assessment — direct visualization or comparison imaging as performed — the intraoperative stress testing that established instability, assessment of deltoid competence, and a rationale for fixation choice and any planned removal. If a high fibular pattern forced a separate approach, the record should connect that anatomy to the construct.
Why it matters: syndesmotic malreduction and its sequelae are a central clinical concern in these injuries, so the reviewer's key question is whether your judgment process was sound and observable. Build a habit of documenting three elements in every syndesmotic case: the test that established instability, the method that confirmed anatomic reduction, and the reasoning behind the fixation plan and weight-bearing progression. Then audit your past cases for those three elements and note which ones you would need to supplement through the operative note narrative.
Cavus and ankle instability: treating the driver, not only the deformity
Cavovarus correction is studied as a sequence of drivers: peroneus longus overpull, first-ray plantarflexion, and hindfoot varus. Document the tests that identified each driver and the procedure that answered it.
Anchor your review in named concepts. The Coleman block test separates forefoot-driven from hindfoot-driven varus. Peroneus longus to peroneus brevis transfer addresses longus overpull; dorsiflexion first-ray or metatarsal osteotomy addresses a plantarflexed first ray; lateralizing calcaneal osteotomy corrects fixed hindfoot varus; and peroneal tendon pathology often coexists and deserves its own documentation. In varus ankle instability, connect ligament reconstruction — such as anatomic repair or augmentation — to the underlying alignment, and state whether osteotomy was needed to protect the ligament repair.
The characteristic documentation weakness in this topic is a procedure list without a driver map: 'Dwyer osteotomy, PL-to-PB transfer, Broström repair' with no record of which test justified which step. Rebuild each cavus case as an ordered narrative — alignment driver, soft-tbalance driver, instability driver — and practice explaining why an unbalanced correction, for instance ligament repair in an uncorrected varus hindfoot, invites recurrence. That reasoning is what distinguishes a reconstructed case log from a performed procedure list.
Tendon transfers and hindfoot fusion: explaining the trade-offs you accepted
Transfer and fusion cases carry inherent trade-offs — motion lost for correction, strength limits of the donor, tensioning decisions — and reviewers read your record for evidence that you weighed them deliberately.
For flexor transfers in flatfoot reconstruction, practice articulating donor considerations: the FDL versus FDB choice, anticipated strength relative to the deficient posterior tibial tendon, the accompanying gastrocsoleus recession, and how transfer tensioning was decided. For hindfoot fusion, contrast triple arthrodesis with selective fusions such as isolated subtalar or talonavicular procedures, and document the correction position you targeted — a plantigrade, neutral hindfoot — because fusion position is a judgment reviewers can verify against your own radiographs.
Make the trade-off explicit in your rationale one-pagers. In a rigid deformity case, state why the arthritic or malaligned joints made fusion preferable to osteotomy-based preservation; in a flexible case, state which joints you saved and what residual motion trade-off you accepted. Extend the same discipline to postoperative management: protected weight-bearing duration, orthotic plans, and outcome measures recorded at follow-up. When every trade-off has a documented reason, your fusion and transfer cases read as staged decisions rather than default selections.
A five-case audit exercise, preparation sequence, and readiness checks
Audit five of your own cases — one per major topic area — against a five-element rubric, then follow a phased sequence: map the log, complete the audit early, write rationale one-pagers, rehearse defenses, and finalize documentation.
Practical exercise: select five cases spanning flatfoot reconstruction, hindfoot fusion, ankle arthritis, fracture or syndesmotic management, and tendon transfer or cavus correction. For each, score five elements as present or absent: indication tied to exam findings; named staging or classification where applicable; procedure selection with an alternative considered; fixation or transfer reasoning; and outcome or postoperative plan. A useful milestone before you finalize documentation: every case scores five of five after revision, and you can narrate each rationale aloud in under three minutes without notes. Missed elements point directly at what to restudy.
Suggested sequence: first, map your case log against the RRA topic areas and note where documentation depth is uneven. Second, review the facility audit instructions as soon as the board issues them and confirm records, imaging, and operative notes are complete — administrative dates and rules are published at abfas.org, so verify current deadlines there rather than from memory. Third, write the rationale one-pagers from the exercise. Fourth, rehearse a colleague questioning your staging and fixation choices on your two most complex cases. Fifth, use the selected procedures list to prioritize which cases get finalized first.
- Readiness check one: every audited case scores five of five on the rubric, and each missing element has been repaired in the record.
- Readiness check two: you can state the alternative procedure considered for each case and the specific finding that rejected it.
- Readiness check three: your two most complex reconstructions survive a colleague's challenge on staging and fixation without hesitation.
- Readiness check four: facility audit materials and case documentation are complete well before the upload deadline.
References and further reading
Use these references to explore the concepts and check the latest information from the relevant organizations.