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Forefoot MCQs

Practice Set 11 of 17

This practice set contains high-yield board review questions covering key concepts in Forefoot. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 201

Topic: Forefoot

A 45-year-old woman complains of progressive pain and deformity of her left great toe that limits her ability to wear closed-toe shoes. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint with dorsal elevation of the first ray. There is no evidence of metatarsophalangeal (MTP) joint arthritis. Which of the following surgical procedures is most appropriate to provide a durable correction?

. Distal chevron osteotomy
. First metatarsophalangeal (MTP) arthrodesis
. Proximal crescentic osteotomy without TMT arthrodesis
. First tarsometatarsal (Lapidus) arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 15 degrees) combined with clinical hypermobility of the first tarsometatarsal (TMT) joint. A Lapidus procedure (first TMT arthrodesis) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and definitively addresses the underlying instability at the TMT joint, preventing recurrence. Distal osteotomies are insufficient for this degree of deformity, and proximal osteotomies without fusion do not address the TMT hypermobility. MTP arthrodesis is typically reserved for severe deformity with concomitant MTP arthritis.

Question 202

Topic: Forefoot

A 50-year-old male presents with chronic dorsal pain in his first metatarsophalangeal (MTP) joint, exacerbated by walking. He has failed conservative management including a stiff-soled shoe with a Morton extension. X-rays reveal dorsal osteophytes and mild to moderate joint space narrowing primarily in the dorsal aspect of the joint, while the plantar joint space is preserved (Coughlin and Shurnas Grade 2). He desires to maintain motion. What is the most appropriate surgical intervention?

. First MTP joint arthrodesis
. Cheilectomy of the first MTP joint
. Keller resection arthroplasty
. Silicone implant arthroplasty
. First metatarsal corrective osteotomy (Scarf procedure)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Coughlin and Shurnas Grade 2 hallux rigidus presents with moderate osteophyte formation, dorsal joint space narrowing, and preserved plantar joint cartilage. Cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is the treatment of choice for Grade 1 and 2 hallux rigidus to relieve dorsal impingement and preserve motion. Arthrodesis is typically reserved for Grade 3 or 4 hallux rigidus (diffuse joint space loss). Keller arthroplasty is largely historical or reserved for elderly, low-demand patients due to the risk of transfer metatarsalgia and cock-up deformity.

Question 203

Topic: Forefoot

A 45-year-old woman presents with persistent forefoot pain and a prominent bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and notable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to address her pathology?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy with distal soft tissue realignment
. First tarsometatarsal joint arthrodesis (Lapidus procedure) with distal soft tissue realignment
. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) accompanied by first TMT joint hypermobility. A first TMT arthrodesis (Lapidus procedure) is the procedure of choice in this scenario, as it allows for large corrections of the IMA while simultaneously addressing the apex of the deformity and stabilizing the hypermobile medial column. Distal osteotomies are insufficient for IMA correction of this magnitude.

Question 204

Topic: Forefoot

A 42-year-old woman presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination reveals profound hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Modified McBride procedure
. First metatarsophalangeal (MTP) joint arthrodesis
. Proximal metatarsal osteotomy or Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient has severe hallux valgus (HVA >40 degrees, IMA >15 degrees) combined with first TMT hypermobility. A distal osteotomy (Chevron) cannot adequately correct a large IMA of 18 degrees. The Lapidus procedure (first TMT arthrodesis) is highly effective for large IMA corrections and uniquely addresses the TMT hypermobility. A proximal osteotomy is also an option for severe deformities without hypermobility, but Lapidus is the classic choice when hypermobility is present.

Question 205

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle (IMA) of 17 degrees. Clinical examination of the first tarsometatarsal (TMT) joint demonstrates significant hypermobility in the sagittal plane. What is the most appropriate surgical intervention?

. Distal soft tissue reconstruction with proximal phalanx osteotomy (Akin)
. Distal metatarsal chevron osteotomy
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis
. Diaphyseal scarf osteotomy

Correct Answer & Explanation

. Distal soft tissue reconstruction with proximal phalanx osteotomy (Akin)

Explanation

Hallux valgus associated with first tarsometatarsal (TMT) joint hypermobility and a significant intermetatarsal angle (IMA > 15 degrees) is best treated with a first TMT arthrodesis, also known as the Lapidus procedure. This provides powerful correction of the IMA and stabilizes the medial column, addressing the primary deforming force and reducing the risk of recurrence. Distal osteotomies are indicated for mild deformities without hypermobility.

Question 206

Topic: Forefoot

A 65-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 16 degrees. There is evidence of hypermobility at the first tarsometatarsal (TMT) joint, but no degenerative changes are noted at the first metatarsophalangeal (MTP) joint. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue reconstruction
. First tarsometatarsal joint arthrodesis (Lapidus procedure) with distal soft tissue reconstruction
. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient presents with a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13 degrees) combined with first tarsometatarsal (TMT) joint hypermobility. A first TMT joint arthrodesis (Lapidus procedure) provides correction of the severe deformity and stabilizes the hypermobile medial column, preventing recurrence. Distal osteotomies (like a chevron osteotomy) are inadequate for severe deformities and do not address TMT hypermobility. First MTP arthrodesis is typically reserved for severe hallux valgus associated with MTP joint degenerative changes.

Question 207

Topic: Forefoot

A 55-year-old man presents with dorsal midfoot pain and limited dorsiflexion of the great toe. Radiographs show a dorsal osteophyte on the first metatarsal head and joint space narrowing involving less than 50% of the joint. What is the preferred surgical treatment if conservative measures fail?

. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty
. Cheilectomy with or without Moberg osteotomy
. Total joint arthroplasty of the first MTP
. Lapidus procedure

Correct Answer & Explanation

. Cheilectomy with or without Moberg osteotomy

Explanation

For mild-to-moderate hallux rigidus (Grade 1 or 2) with dorsal impingement and preserved plantar joint space, a cheilectomy is the preferred surgical option. First MTP arthrodesis is generally reserved for advanced, end-stage disease.

Question 208

Topic: Forefoot

A 55-year-old woman presents with severe hallux valgus (HVA 45 degrees, IMA 18 degrees) and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical interventions is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) accompanied by first TMT hypermobility, as it permanently stabilizes the medial column.

Question 209

Topic: Forefoot

A 42-year-old man presents with chronic pain at the first MTP joint. Examination reveals dorsal osteophytes and pain limited to maximum forced dorsiflexion. Radiographs confirm Grade 2 Hallux Rigidus. Initial conservative management has failed. What is the most appropriate surgical treatment?

. Cheilectomy
. First MTP arthrodesis
. Keller arthroplasty
. Total joint arthroplasty
. First TMT arthrodesis

Correct Answer & Explanation

. Cheilectomy

Explanation

Cheilectomy, which involves excision of dorsal osteophytes and the dorsal one-third of the metatarsal head, is the treatment of choice for symptomatic mild-to-moderate hallux rigidus that fails nonoperative care.

Question 210

Topic: Forefoot

A 22-year-old collegiate football player sustains a grade 3 turf toe injury. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

. Taping, stiff-soled shoe, and immediate return to play
. Immobilization in a walking boot for 6 weeks
. Primary surgical repair of the plantar plate
. Surgical excision of the tibial sesamoid only
. Arthrodesis of the first metatarsophalangeal joint

Correct Answer & Explanation

. Primary surgical repair of the plantar plate

Explanation

Grade 3 turf toe injuries involving a complete tear of the plantar plate and sesamoid retraction generally require primary surgical repair to restore push-off strength and prevent chronic instability or hallux rigidus.

Question 211

Topic: Forefoot

A 60-year-old female presents with severe hallux valgus (HVA 45 degrees, IMA 18 degrees) and hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?

. First TMT arthrodesis (Lapidus procedure).
. Proximal crescentic osteotomy.
. Distal chevron osteotomy.
. First MTP arthrodesis.
. Akin osteotomy.

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure).

Explanation

A Lapidus procedure (first TMT arthrodesis) is specifically indicated for severe hallux valgus with an increased intermetatarsal angle and first ray hypermobility. It provides triplanar correction and restores medial column stability.

Question 212

Topic: Forefoot

A 45-year-old male runner presents with dorsal midfoot pain and limited MTP dorsiflexion. Radiographs reveal dorsal osteophytes at the 1st MTP joint with preserved plantar joint space (Coughlin/Shurnas Grade 2). He failed nonoperative management. What is the best surgical option?

. 1st MTP arthrodesis.
. Cheilectomy.
. Keller arthroplasty.
. Silicone joint replacement.
. Lapidus procedure.

Correct Answer & Explanation

. Cheilectomy.

Explanation

Cheilectomy (removal of dorsal osteophytes and the dorsal one-third of the metatarsal head) is highly effective for Grade 1 and 2 hallux rigidus. It relieves impingement pain while preserving joint motion required for running.

Question 213

Topic: Forefoot

A 48-year-old female presents for surgical management of a painful hallux valgus deformity. Clinical examination reveals profound hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. Weight-bearing radiographs show a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Which of the following procedures is most strongly indicated?

. Distal chevron osteotomy with a modified McBride procedure
. Scarf (midshaft) osteotomy of the first metatarsal
. Proximal opening wedge osteotomy of the first metatarsal
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (HVA >40 degrees, IMA >15 degrees) combined with first TMT joint hypermobility. The Lapidus procedure (first TMT arthrodesis) is the procedure of choice in the setting of first ray hypermobility or significant midfoot instability, as it corrects the primary site of instability and allows for excellent correction of a large IMA. Distal or diaphyseal osteotomies would likely fail or recur due to the unaddressed hypermobility at the TMT joint.

Question 214

Topic: Forefoot

A 45-year-old female presents with a progressive medial deviation of her great toe 1 year after a distal chevron osteotomy with a lateral soft tissue release for hallux valgus. She complains of pain and difficulty with shoe wear. Examination reveals a flexible hallux varus deformity. Radiographs show a congruent first metatarsophalangeal (MTP) joint with a negative intermetatarsal angle and no evidence of MTP joint arthritis. What is the most appropriate surgical management?

. First MTP joint arthrodesis
. Extensor hallucis longus (EHL) transfer beneath the transverse metatarsal ligament
. Medial capsulorrhaphy with adductor hallucis advancement
. First tarsometatarsal (TMT) joint arthrodesis
. Closing wedge osteotomy of the proximal phalanx

Correct Answer & Explanation

. Extensor hallucis longus (EHL) transfer beneath the transverse metatarsal ligament

Explanation

This patient has an iatrogenic flexible hallux varus deformity following an overcorrected bunion surgery. For a flexible deformity without degenerative changes, soft tissue reconstruction is indicated. The classic and most reliable procedure is the transfer of the extensor hallucis longus (EHL) (either split or whole) beneath the transverse intermetatarsal ligament into the base of the proximal phalanx, often combined with an MTP joint release. First MTP arthrodesis is reserved for a stiff, arthritic hallux varus or failed soft tissue reconstructions.

Question 215

Topic: Forefoot

A 45-year-old female presents with a progressive and painful bunion deformity. Clinical examination demonstrates notable hypermobility in the sagittal plane at the first tarsometatarsal (TMT) joint. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Based on these findings, which surgical procedure is most appropriate to address her deformity and prevent recurrence?

. Distal chevron osteotomy
. First TMT arthrodesis (Lapidus procedure)
. Akin osteotomy alone
. Keller resection arthroplasty
. Proximal opening wedge osteotomy without TMT addressing

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) associated with first TMT joint hypermobility. A first TMT arthrodesis (the Lapidus procedure) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and inherently addresses the hypermobility at the TMT joint, which, if left untreated, is a common cause of hallux valgus recurrence. Distal osteotomies (like the Chevron) are typically reserved for mild to moderate deformities (IMA < 13 degrees) without hypermobility. A Keller arthroplasty is generally reserved for elderly, low-demand patients with severe deformity and arthritis.

Question 216

Topic: Forefoot

A 55-year-old female presents with severe pain and stiffness in her first metatarsophalangeal (MTP) joint. Radiographs demonstrate marked dorsal osteophytes, total loss of joint space, and subchondral sclerosis consistent with Coughlin and Shurnas Grade 3 hallux rigidus. Conservative measures have failed. Which of the following surgical procedures is considered the gold standard for long-term pain relief and functional improvement?

. Cheilectomy
. First MTP joint arthrodesis
. First MTP joint total arthroplasty
. Keller resection arthroplasty
. Proximal phalanx osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4), arthrodesis of the first MTP joint remains the gold standard. It provides excellent long-term pain relief, functional stability, and high patient satisfaction rates. Cheilectomy is generally reserved for Grades 1 and 2 where the joint space is relatively preserved.

Question 217

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most biomechanically appropriate to correct her deformity?

. Distal chevron osteotomy
. Scarf osteotomy
. Proximal crescentic osteotomy with distal soft tissue realignment
. First TMT joint arthrodesis (Lapidus procedure) with distal soft tissue realignment
. First metatarsophalangeal (MTP) joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure) with distal soft tissue realignment

Explanation

A severe hallux valgus deformity (IMA >15 degrees, HVA >40 degrees) in the presence of first TMT joint hypermobility is classically treated with a Lapidus procedure (first TMT arthrodesis). This provides powerful correction of the intermetatarsal angle and stabilizes the medial column, preventing recurrence that is common if hypermobility is ignored.

Question 218

Topic: Forefoot

A 22-year-old running back sustains an acute hyperextension injury to his great toe. MRI demonstrates a complete tear of the plantar plate with proximal retraction of the sesamoids. Which of the following is an absolute indication for operative repair in this type of injury?

. Associated dorsal capsular sprain
. Diastasis of a bipartite sesamoid of 1 mm
. Proximal migration of the sesamoids with a frankly unstable first MTP joint
. Inability to push off at 2 days post-injury
. Extension block of 5 degrees compared to the contralateral side

Correct Answer & Explanation

. Proximal migration of the sesamoids with a frankly unstable first MTP joint

Explanation

Turf toe is a sprain/tear of the first MTP plantar plate complex. Operative indications for turf toe include: a large intra-articular sesamoid fracture, retraction of the sesamoids >3 mm, traumatic bunion deformity, a purely unstable joint (gross instability), or failure of conservative management. Proximal migration of the sesamoids with gross first MTP instability indicates a complete (Grade 3) rupture requiring surgical repair.

Question 219

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 16 degrees. Which of the following surgical options is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First tarsometatarsal (TMT) joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis
. Isolated medial eminence excision (Silver procedure)

Correct Answer & Explanation

. First tarsometatarsal (TMT) joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for patients with moderate to severe hallux valgus (IMA > 13 degrees) who have concurrent hypermobility of the first ray. It provides excellent correction of the intermetatarsal angle and stabilizes the medial column, preventing recurrence that is often seen if only a distal or proximal osteotomy is utilized in the presence of TMT hypermobility.

Question 220

Topic: Forefoot

A 45-year-old female presents with symptomatic hallux valgus that has failed nonoperative management. Weight-bearing radiographs demonstrate an intermetatarsal angle (IMA) of 18 degrees and a hallux valgus angle (HVA) of 42 degrees. There is no evidence of first tarsometatarsal hypermobility or osteoarthritis. Which of the following surgical options is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue procedure
. Akin osteotomy alone
. Keller resection arthroplasty
. First metatarsophalangeal arthrodesis

Correct Answer & Explanation

. Proximal crescentic osteotomy with distal soft tissue procedure

Explanation

A severe hallux valgus deformity (IMA > 13-15 degrees, HVA > 40 degrees) requires a proximal metatarsal osteotomy (e.g., proximal crescentic or Ludloff) or a Lapidus procedure, combined with a distal soft tissue release to achieve adequate correction. A distal chevron osteotomy cannot provide sufficient translation for large IMA corrections. First MTP arthrodesis is typically reserved for severe deformity with concomitant arthritis or rheumatoid arthritis.

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