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Forefoot MCQs

Practice Set 12 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 221

Topic: Forefoot

A 45-year-old female presents with progressive foot pain and a bunion deformity. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and evidence of hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical interventions is most appropriate to minimize the risk of recurrence?

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

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15-20 degrees), especially when associated with first ray hypermobility. Distal osteotomies are suitable for mild to moderate deformities. Proximal osteotomies can correct larger deformities but do not address TMT hypermobility, leading to a high recurrence rate in these specific patients. A first MTP arthrodesis is an excellent option for severe deformity, but is typically reserved for cases with associated severe osteoarthritis.

Question 222

Topic: Forefoot

A 45-year-old female undergoes a proximal crescentic osteotomy and distal soft tissue realignment for severe hallux valgus. Six months postoperatively, she complains of medial forefoot pain and difficulty wearing shoes. Examination reveals the great toe is deviated medially, and weight-bearing radiographs show a negative hallux valgus angle. Which of the following intraoperative maneuvers most likely contributed to this complication?

. Excessive lateral translation of the capital fragment
. Inadequate release of the adductor hallucis
. Over-tightening of the medial capsule and excessive resection of the medial eminence
. Under-correction of the intermetatarsal angle
. Failure to perform an Akin osteotomy

Correct Answer & Explanation

. Over-tightening of the medial capsule and excessive resection of the medial eminence

Explanation

The complication described is iatrogenic hallux varus (medial deviation of the great toe following hallux valgus surgery). The most common intraoperative causes include excessive resection of the medial eminence ('staking the metatarsal head'), over-tightening of the medial joint capsule, and excessive release of the lateral structures (lateral collateral ligament and adductor hallucis) combined with over-correction of the intermetatarsal angle.

Question 223

Topic: Forefoot

A 60-year-old female presents with a painful bunion that restricts her shoe wear. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. Based on these findings, which of the following surgical procedures is most indicated to minimize the risk of recurrence?

. Distal soft tissue reconstruction (modified McBride procedure)
. Distal metatarsal chevron osteotomy
. Proximal metatarsal opening wedge osteotomy without TMT arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13 degrees) complicated by clinically demonstrable hypermobility of the first ray (first TMT joint). The Lapidus procedure (first TMT joint arthrodesis) is the most appropriate procedure as it provides powerful correction for large intermetatarsal angles and inherently addresses the hypermobility of the first ray, significantly lowering the risk of recurrence. Distal or proximal osteotomies alone do not stabilize the hypermobile first TMT joint.

Question 224

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals no hypermobility at the first tarsometatarsal joint. What is the most appropriate surgical management?

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

Correct Answer & Explanation

. Proximal metatarsal osteotomy with distal soft tissue reconstruction

Explanation

For a moderate to severe hallux valgus deformity (IMA 14-20 degrees, HVA < 40 degrees) without first tarsometatarsal (TMT) joint hypermobility or arthritis, a proximal metatarsal osteotomy (e.g., crescentic, Ludloff) combined with a distal soft-tissue procedure is indicated. A distal chevron osteotomy is reserved for mild deformities (IMA < 13 degrees). The Lapidus procedure is indicated if there is TMT hypermobility. MTP arthrodesis is preferred for severe deformity with arthritis or in patients with rheumatoid arthritis. A Keller arthroplasty is reserved for older, low-demand patients.

Question 225

Topic: Forefoot

A 62-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and obvious clinical hypermobility of the first tarsometatarsal (TMT) joint. No degenerative changes are noted at the metatarsophalangeal (MTP) joint. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The patient presents with a severe hallux valgus deformity accompanied by hypermobility of the first TMT joint. An isolated distal or proximal osteotomy is prone to failure and high recurrence rates in the setting of first ray hypermobility. A first TMT arthrodesis (Lapidus procedure) allows for powerful correction of the severe intermetatarsal angle and stabilizes the medial column, preventing recurrence.

Question 226

Topic: Forefoot

A 45-year-old woman presents with a severe, painful bunion deformity. She reports a long history of wearing narrow-toed shoes. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?

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

Correct Answer & Explanation

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

Explanation

The patient has severe hallux valgus (HVA > 40 degrees, IMA > 13 degrees) combined with first TMT joint hypermobility. A Lapidus procedure (first TMT arthrodesis) is the most appropriate choice to provide powerful correction of the high intermetatarsal angle and address the apex of the deformity (the hypermobile TMT joint). Distal chevron osteotomies are indicated for mild to moderate deformities. First MTP fusion is typically reserved for severe deformities with concurrent first MTP osteoarthritis or in cases of rheumatoid arthritis. The Keller procedure is historically used in low-demand, elderly patients.

Question 227

Topic: Forefoot

A 42-year-old woman presents with a painful bunion on her right foot. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is no hypermobility at the first tarsometatarsal (TMT) joint, and no evidence of osteoarthritis in the first metatarsophalangeal (MTP) joint. Which of the following surgical interventions is most appropriate?

. Proximal first metatarsal osteotomy or Lapidus procedure with distal soft tissue reconstruction
. Distal chevron osteotomy with modified McBride procedure
. First MTP joint arthrodesis
. First TMT joint arthrodesis only
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal first metatarsal osteotomy or Lapidus procedure with distal soft tissue reconstruction

Explanation

The patient has a severe hallux valgus deformity (HVA >40 degrees, IMA >13-15 degrees). For severe deformities without first MTP joint arthritis, a proximal first metatarsal osteotomy (e.g., proximal crescentic, Ludloff) or a first TMT fusion (Lapidus procedure) combined with a distal soft tissue reconstruction (modified McBride) is indicated to achieve adequate correction of the large IMA. A distal chevron osteotomy is indicated for mild to moderate deformities. First MTP arthrodesis is generally reserved for hallux valgus with severe first MTP osteoarthritis or rheumatoid arthritis.

Question 228

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 14 degrees. The first tarsometatarsal (TMT) joint shows no hypermobility or arthritic changes. The distal metatarsal articular angle (DMAA) is normal. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Proximal metatarsal osteotomy and distal soft-tissue reconstruction
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy and distal soft-tissue reconstruction

Explanation

The patient has a moderate to severe hallux valgus deformity (IMA between 13 and 20 degrees, HVA between 30 and 40 degrees). Distal chevron osteotomy is generally indicated for mild deformities (IMA < 13 degrees). For an IMA of 14 degrees, a proximal metatarsal osteotomy combined with distal soft-tissue reconstruction (or a diaphyseal osteotomy) is indicated to provide adequate translation and angular correction.

Question 229

Topic: Forefoot

A 55-year-old woman presents with progressive, painful deformity of her great toe. Clinical examination reveals severe hallux valgus with an overarching second toe and significant first ray hypermobility in the sagittal plane. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 20 degrees, and no signs of degenerative joint disease at the first metatarsophalangeal joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy
. First metatarsophalangeal joint arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. Proximal opening wedge osteotomy

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (Intermetatarsal Angle > 15°, Hallux Valgus Angle > 40°) accompanied by first ray hypermobility. The Lapidus procedure (first tarsometatarsal joint arthrodesis) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and addresses the underlying hypermobility by stabilizing the medial column. Distal chevron is indicated for mild-to-moderate deformity. First MTP arthrodesis is typically reserved for hallux valgus with concurrent severe degenerative changes (hallux rigidus) or in recurrent/salvage situations.

Question 230

Topic: Forefoot

A 55-year-old woman has a painful bunion. Radiographs reveal a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. There is clinically evident hypermobility at the first tarsometatarsal joint. Which procedure is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (First TMT arthrodesis)
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (First TMT arthrodesis)

Explanation

A Lapidus procedure is indicated for severe hallux valgus combined with first tarsometatarsal joint hypermobility. It corrects the deformity and provides stabilization of the medial column.

Question 231

Topic: Forefoot

A 40-year-old woman complains of burning pain in the plantar aspect of her forefoot, radiating into the third and fourth toes. Symptoms worsen with tight shoes. A Mulder's click is positive. The affected nerve is typically formed by branches from which two nerves?

. Deep peroneal and superficial peroneal nerves
. Medial plantar and lateral plantar nerves
. Medial plantar and saphenous nerves
. Lateral plantar and sural nerves
. Sural and deep peroneal nerves

Correct Answer & Explanation

. Medial plantar and lateral plantar nerves

Explanation

Morton's neuroma most commonly affects the third web space. The third common digital nerve is typically formed by communicating branches from both the medial and lateral plantar nerves.

Question 232

Topic: Forefoot

A 58-year-old man presents with pain and stiffness in his right great toe. Examination shows restricted dorsiflexion with a palpable dorsal exostosis. Radiographs show joint space narrowing primarily in the dorsal half and a large dorsal osteophyte (Grade 2). He wants to preserve joint motion. What is the most appropriate surgery?

. First MTP arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. Total first MTP joint replacement
. Lapidus procedure

Correct Answer & Explanation

. Cheilectomy

Explanation

A cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is indicated for mild to moderate hallux rigidus (Grades 1 and 2) in patients who wish to preserve motion.

Question 233

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical exam reveals severe hallux valgus and first ray hypermobility. Radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. What is the most appropriate surgical management?

. Chevron osteotomy
. Scarf osteotomy
. First tarsometatarsal (Lapidus) arthrodesis
. First metatarsophalangeal arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. First tarsometatarsal (Lapidus) arthrodesis

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus with first ray hypermobility. It provides powerful correction and stabilizes the medial column to prevent recurrence.

Question 234

Topic: Forefoot

A 60-year-old man presents with pain and stiffness in his right great toe, especially with push-off. Radiographs show dorsal osteophytes and joint space narrowing of the first metatarsophalangeal joint, but the plantar joint space is well preserved. He desires to maintain motion. What is the most appropriate surgical option?

. First MTP arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. Total joint arthroplasty
. Lapidus procedure

Correct Answer & Explanation

. Cheilectomy

Explanation

For mild to moderate hallux rigidus with preserved plantar joint space, a cheilectomy is highly effective. Removing the dorsal osteophytes and the dorsal one-third of the metatarsal head relieves impingement while preserving motion.

Question 235

Topic: Forefoot
A 55-year-old man presents with chronic pain and stiffness in his first metatarsophalangeal (MTP) joint. Examination reveals a palpable dorsal prominence and dorsiflexion limited to 10 degrees. Radiographs reveal advanced joint space narrowing (<50% remaining) and large dorsal osteophytes. What is the most reliable definitive treatment for this patient?
. Aggressive physical therapy and stretching
. First MTP joint cheilectomy
. First MTP joint arthrodesis
. Proximal phalanx osteotomy (Moberg)
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 3 hallux rigidus. While cheilectomy is highly effective for Grade 1 and 2, arthrodesis of the first MTP joint is the most reliable, definitive treatment for advanced (Grade 3 and 4) hallux rigidus, providing predictable pain relief.

Question 236

Topic: Forefoot

A 45-year-old woman with a painful bunion has an intermetatarsal angle of 18 degrees, a hallux valgus angle of 45 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to comprehensively address her pathology?

. Distal chevron osteotomy
. Akin osteotomy alone
. Keller resection arthroplasty
. First TMT joint arthrodesis (Lapidus procedure)
. First MTP joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

Severe hallux valgus (IMA >15 degrees, HVA >40 degrees) accompanied by hypermobility of the first TMT joint is best treated with a Lapidus procedure (first TMT arthrodesis) to provide medial column stability and robust correction of the deformity.

Question 237

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure is indicated for moderate to severe hallux valgus (IMA > 15 degrees) especially in the presence of first TMT joint hypermobility. Distal osteotomies cannot adequately correct an IMA of this magnitude.

Question 238

Topic: Forefoot

A 50-year-old woman presents with severe hallux valgus.

Her intermetatarsal angle (IMA) is 20 degrees and hallux valgus angle (HVA) is 45 degrees. There is clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Modified McBride procedure
. Akin osteotomy alone
. Lapidus procedure
. Keller arthroplasty

Correct Answer & Explanation

. Lapidus procedure

Explanation

A Lapidus procedure (first TMT joint arthrodesis) is indicated for severe hallux valgus, particularly when associated with a high IMA (>15 degrees) and hypermobility of the first TMT joint. It effectively addresses the deformity at its apex.

Question 239

Topic: Forefoot

A 55-year-old man presents with dorsal midfoot and great toe pain. Examination reveals a painful, restricted dorsiflexion of the first metatarsophalangeal (MTP) joint. Radiographs show a large dorsal osteophyte and preserved plantar joint space.

What is the most appropriate surgical treatment if nonoperative management fails?

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

Correct Answer & Explanation

. Cheilectomy

Explanation

Cheilectomy is the procedure of choice for early to moderate hallux rigidus (Coughlin and Shurnas Grade 1 and 2). It effectively relieves dorsal impingement while preserving the MTP joint.

Question 240

Topic: Forefoot

A 45-year-old woman complains of painful bunions. Examination reveals first tarsometatarsal (TMT) joint hypermobility. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (1st TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (1st TMT arthrodesis)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA >15 degrees) accompanied by first TMT joint hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

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