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Forefoot MCQs

Practice Set 3 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 41

Topic: Forefoot

A 52-year-old avid runner presents with severe dorsal forefoot pain. Examination shows a rigid 1st metatarsophalangeal (MTP) joint with less than 10 degrees of dorsiflexion. Radiographs reveal diffuse joint space narrowing, a flat metatarsal head, and large dorsal osteophytes (Coughlin and Shurnas Grade 3 Hallux Rigidus). Which surgical intervention provides the most reliable long-term pain relief and functional restoration?

. Dorsal cheilectomy alone
. First MTP joint arthrodesis
. Moberg osteotomy
. Keller resection arthroplasty
. First MTP joint silicone arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4) with diffuse joint space loss and significant motion restriction, a 1st MTP joint arthrodesis is the gold standard for reliable pain relief and durability. Cheilectomy is primarily indicated for Grade 1 and 2 disease with preserved joint space.

Question 42

Topic: Forefoot

A 62-year-old female presents with significant pain over the first metatarsophalangeal (MTP) joint. Radiographs show Coughlin and Shurnas Grade 3 hallux rigidus with less than 10 degrees of dorsiflexion. She has failed conservative management. Which of the following surgical interventions provides the most reliable long-term pain relief and functional improvement for this patient?

. First MTP joint cheilectomy
. First MTP joint arthrodesis
. Synthetic hemiarthroplasty of the first metatarsal head
. Keller resection arthroplasty
. Dorsal closing wedge osteotomy of the proximal phalanx (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 and 4) hallux rigidus, providing reliable, long-lasting pain relief and functional improvement. Cheilectomy is primarily indicated for Grade 1 and 2 disease characterized by predominantly dorsal osteophytes and impingement.

Question 43

Topic: Forefoot

A 45-year-old female presents with a painful bunion. 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. Which surgical procedure is most appropriate?

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

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for patients with moderate to severe hallux valgus (IMA > 15 degrees) accompanied by first TMT joint hypermobility. A distal chevron osteotomy is inadequate for this degree of deformity and does not address the TMT instability.

Question 44

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Radiographs demonstrate a hallux valgus angle (HVA) of 26 degrees and an intermetatarsal angle (IMA) of 11 degrees. The first tarsometatarsal joint is stable without hypermobility. Which of the following is the most appropriate surgical option?

. First metatarsophalangeal arthrodesis
. Distal metatarsal osteotomy (Chevron)
. Proximal metatarsal crescentic osteotomy
. Lapidus procedure (First tarsometatarsal arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal metatarsal osteotomy (Chevron)

Explanation

A distal metatarsal osteotomy (e.g., Chevron) is indicated for mild-to-moderate hallux valgus deformities (HVA <30 degrees, IMA <13 degrees) in the absence of hypermobility. Severe deformity or hypermobility typically necessitates proximal osteotomies or a Lapidus procedure.

Question 45

Topic: Forefoot

What is the optimal position for a first metatarsophalangeal (MTP) joint arthrodesis to ensure normal gait and function in a patient with severe hallux rigidus?

. 0 degrees of dorsiflexion, 0 degrees of valgus, and neutral rotation
. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation
. 30 degrees of dorsiflexion relative to the floor, 5 degrees of valgus, and neutral rotation
. 15 degrees of plantarflexion, 15 degrees of valgus, and neutral rotation
. 5 degrees of dorsiflexion relative to the floor, 20 degrees of valgus, and neutral rotation

Correct Answer & Explanation

. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation

Explanation

The optimal position for 1st MTP arthrodesis is 10-15 degrees of dorsiflexion relative to the floor, 10-15 degrees of valgus, and neutral rotation. This position allows for adequate toe clearance during the swing phase and normal toe-off during gait.

Question 46

Topic: Forefoot

A 58-year-old female presents with severe pain in her left great toe. Examination reveals pain specifically during the mid-range of passive dorsiflexion and plantarflexion of the 1st MTP joint. Radiographs demonstrate severe joint space narrowing and large dorsal, medial, and lateral osteophytes. According to the Coughlin and Shurnas classification, what is the most appropriate surgical treatment?

. Dorsal cheilectomy
. Moberg osteotomy
. First MTP arthrodesis
. First MTP joint arthroscopy
. Resection arthroplasty (Keller procedure)

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

The patient has Grade 4 hallux rigidus, characterized by pain in the mid-range of motion and extensive degenerative changes. First MTP arthrodesis is the gold standard surgical treatment to predictably relieve pain for Grade 4 disease.

Question 47

Topic: Forefoot

A patient undergoes a dorsal cheilectomy for Grade 2 hallux rigidus. Postoperatively, she complains of numbness along the dorsomedial aspect of her hallux. Which nerve was most likely injured during the surgical approach?

. Deep peroneal nerve
. Sural nerve
. Dorsomedial cutaneous nerve
. Proper plantar digital nerve
. Saphenous nerve

Correct Answer & Explanation

. Dorsomedial cutaneous nerve

Explanation

The dorsomedial cutaneous nerve (a branch of the superficial peroneal nerve) crosses the 1st MTP joint dorsomedially. It is at high risk of iatrogenic injury during dorsal surgical approaches for a cheilectomy.

Question 48

Topic: Forefoot

A 70-year-old sedentary female undergoes a Keller resection arthroplasty for severe hallux rigidus. Postoperatively, she develops a "cock-up" deformity of the great toe and transfer metatarsalgia. The compromise of which structure during the index procedure most likely caused this complication?

. Extensor hallucis longus
. Flexor hallucis brevis
. Flexor hallucis longus
. Adductor hallucis
. Abductor hallucis

Correct Answer & Explanation

. Flexor hallucis brevis

Explanation

The Keller arthroplasty involves resecting the base of the proximal phalanx, which risks detaching the insertion of the flexor hallucis brevis. This loss of plantar intrinsic stability allows the extensor hallucis longus to overpower the digit, causing a cock-up deformity.

Question 49

Topic: Forefoot

For the 65-year-old lady with an intermetatarsal angle of 15°, a hallux valgus angle of 35°, and minimal passive correction of the hallux on her right foot, assuming a normal first tarsometatarsal joint, what is the most appropriate surgical plan?

. A. Chevron osteotomy with a lateral release.
. B. Mitchell osteotomy with a medial capsular plication.
. C. Scarf osteotomy, lateral release, and potentially an Akin osteotomy.
. D. First metatarsophalangeal joint arthrodesis.
. E. Keller resection arthroplasty.

Correct Answer & Explanation

. C. Scarf osteotomy, lateral release, and potentially an Akin osteotomy.

Explanation

Correct Answer: CThe case explicitly states that for an intermetatarsal angle of 15° and a hallux valgus angle of 35° with minimal passive correction, the candidate would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary. This combination addresses the severe intermetatarsal angle, the significant hallux valgus angle, and the lack of passive correction. The Scarf osteotomy is chosen for its versatility and ability to achieve substantial correction without significant shortening, which is crucial for severe deformities.Option A (Chevron osteotomy)is typically reserved for mild to moderate deformities (IM angle < 13-15°, HV angle < 30-35°) and would likely be inadequate for the described severe deformity.Option B (Mitchell osteotomy)is also a distal osteotomy and, as mentioned in the case, produces shortening of the first metatarsal, which could lead to transfer metatarsalgia, making it less desirable for severe corrections.Option D (First metatarsophalangeal joint arthrodesis)is a salvage procedure or indicated for severe arthritis, recurrent deformity, or in specific cases like the patient's left foot with a missing second toe, but not as a primary procedure for a correctable deformity with a normal TMT joint.Option E (Keller resection arthroplasty)is generally reserved for elderly, low-demand patients with significant MTP joint arthritis and is associated with complications like hallux cock-up deformity and loss of push-off strength, making it less suitable for this active patient with a correctable deformity.

Question 50

Topic: Forefoot

A few months post-Scarf osteotomy, the patient develops a flexible hallux varus deformity. Which of the following is the most appropriate initial management strategy for this complication, as discussed in the case?

. A. Immediate revision surgery with MTP joint arthrodesis.
. B. Transfer of a slip of the Extensor Hallucis Longus (EHL) tendon.
. C. Abductor hallucis and medial capsular release.
. D. Attempting improvement with normal footwear and observation.
. E. Resection of the medial eminence and lateral capsular plication.

Correct Answer & Explanation

. D. Attempting improvement with normal footwear and observation.

Explanation

Correct Answer: DThe case states, 'A subtle varus may improve as the patient returns to normal foot wear.' This indicates that for a flexible or subtle varus, initial non-operative management with observation and appropriate footwear is the first step. The case then describes soft tissue procedures (EHL slip transfer, abductor hallucis and medial capsular release) forflexibledeformity, and arthrodesis forsignificant stiffness or arthrosis. Since the question specifies a 'flexible' deformity, the initial approach would be the least invasive.Option A (Immediate revision surgery with MTP joint arthrodesis)is incorrect. Arthrodesis is reserved for significant stiffness or arthrosis, not for a flexible deformity, especially as an initial step.Option B (Transfer of a slip of the Extensor Hallucis Longus (EHL) tendon)andOption C (Abductor hallucis and medial capsular release)are soft tissue procedures described forflexibledeformity, but they would typically follow initial conservative measures if the varus does not resolve with footwear changes.Option E (Resection of the medial eminence and lateral capsular plication)is a procedure for hallux valgus, not hallux varus. Hallux varus involves the hallux deviating medially, so a lateral capsular plication would worsen it, and medial eminence resection is for the bunion deformity.

Question 51

Topic: Forefoot

The candidate emphasizes obtaining a detailed history, including questioning about relevant conditions. Which of the following conditions is NOT specifically mentioned in the case as a relevant condition to inquire about during the history for a patient presenting with hallux valgus?

. A. Diabetes.
. B. Inflammatory arthritis.
. C. Vascular disease.
. D. Gout.
. E. Neuropathy.

Correct Answer & Explanation

. D. Gout.

Explanation

Correct Answer: DThe candidate states: 'I would complete the history, including questioning about relevant conditions such as diabetes, inflammatory arthritis, vascular disease and neuropathy...'Options A, B, C, and Eare all explicitly mentioned in the case as relevant conditions to inquire about during the history.Option D (Gout)is a common condition that can affect the MTP joint and mimic or exacerbate hallux valgus symptoms, and would typically be part of a comprehensive history. However, it is not explicitly listed in the specific conditions mentioned by the candidate in this teaching case, making it the correct answer to the question 'NOT specifically mentioned'.

Question 52

Topic: Forefoot

A 45-year-old female presents with severe hallux valgus, an intermetatarsal angle of 18 degrees, and obvious hypermobility of the first tarsometatarsal (TMT) joint. Which of the following is the most appropriate surgical intervention?

. Proximal crescentic osteotomy
. Scarf osteotomy
. Distal chevron osteotomy
. First TMT joint arthrodesis (Lapidus)
. First MTP joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility or symptomatic TMT arthritis. It provides powerful deformity correction and stabilizes the medial column.

Question 53

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees, an Intermetatarsal Angle (IMA) of 19 degrees, and clinical evidence of first tarsometatarsal (TMT) joint hypermobility. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15-20 degrees) especially in the presence of first ray hypermobility. Distal osteotomies cannot adequately correct an IMA of this magnitude.

Question 54

Topic: Forefoot

A patient presents for bunion correction. Radiographs demonstrate an HVA of 20 degrees, an IMA of 8 degrees, and a Hallux Valgus Interphalangeus (HVI) angle of 18 degrees.

Which of the following procedures is most appropriate to address the interphalangeal deformity?

. Proximal crescentic osteotomy
. Akin osteotomy
. Scarf osteotomy
. Chevron osteotomy
. Lapidus arthrodesis

Correct Answer & Explanation

. Akin osteotomy

Explanation

An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx. It is specifically indicated for correcting Hallux Valgus Interphalangeus or as an adjunct procedure when the great toe remains in valgus despite correcting the first MTP joint.

Question 55

Topic: Forefoot

A 60-year-old female with profound rheumatoid arthritis presents with a severe hallux valgus deformity, complete destruction of the first MTP joint cartilage, and multiple lesser toe deformities. What is the surgical treatment of choice for her first ray?

. First MTP joint silicone arthroplasty
. Keller resection arthroplasty
. First MTP joint arthrodesis
. Ludloff osteotomy
. Distal chevron osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard for severe hallux valgus in the setting of inflammatory arthritis (like RA) with joint destruction. It provides reliable pain relief, permanent deformity correction, and restores medial column weight-bearing.

Question 56

Topic: Forefoot

Which of the following is an absolute contraindication to performing a Keller resection arthroplasty for hallux valgus?

. Patient age greater than 75 years
. Severe first MTP joint osteoarthritis
. Active, high-demand lifestyle in a young patient
. Previous failed chevron osteotomy
. Presence of a lesser toe hammer toe deformity

Correct Answer & Explanation

. Active, high-demand lifestyle in a young patient

Explanation

A Keller arthroplasty involves excising the base of the proximal phalanx, which destabilizes the first MTP joint and weakens push-off strength. It is contraindicated in young, active, high-demand patients due to the resultant loss of toe purchase and push-off power.

Question 57

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Radiographs show a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus)
. First MTP arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA >15-20 degrees) combined with first ray hypermobility. Distal osteotomies are insufficient for large IMAs, and MTP fusion is usually reserved for arthritis or severe deformity in older, low-demand patients.

Question 58

Topic: Forefoot

A 55-year-old female presents with a progressively painful, medially deviated great toe 1 year after a modified McBride bunionectomy and distal chevron osteotomy. Clinical exam reveals a flexible first MTP joint. Which of the following is the most appropriate treatment?

. First MTP arthrodesis
. Extensor hallucis brevis tenodesis
. Extensor hallucis longus transfer (Jones procedure)
. Keller arthroplasty
. Closing wedge osteotomy of the proximal phalanx

Correct Answer & Explanation

. Extensor hallucis brevis tenodesis

Explanation

Iatrogenic hallux varus with a flexible MTP joint can be treated with soft tissue reconstruction, such as EHB tenodesis or EHL transfer, often combined with medial capsule release. If the joint were rigid or arthritic, an MTP arthrodesis would be indicated.

Question 59

Topic: Forefoot

During a hallux valgus correction, a surgeon successfully reduces the IMA to 8 degrees and the MTP joint is congruent. However, the patient's great toe remains deviated laterally into valgus due to an interphalangeal angle of 20 degrees. Which of the following is the most appropriate next step?

. Lapidus procedure
. Proximal Akin osteotomy
. Distal chevron osteotomy
. Extensor hallucis longus lengthening
. First MTP arthrodesis

Correct Answer & Explanation

. Proximal Akin osteotomy

Explanation

An Akin osteotomy (medial closing wedge of the proximal phalanx) is indicated for hallux valgus interphalangeus. It is also used when residual clinical valgus remains despite a congruent MTP joint and corrected IMA.

Question 60

Topic: Forefoot

A patient presents with a recurrent hallux valgus deformity 2 years after a distal chevron osteotomy. The IMA is now 18 degrees and the first MTP joint is subluxated. The medial eminence is flush. What is the most appropriate revision strategy?

. Repeat distal chevron osteotomy
. First MTP arthrodesis
. Proximal opening wedge osteotomy
. Lapidus procedure
. Akin osteotomy

Correct Answer & Explanation

. Lapidus procedure

Explanation

Recurrent hallux valgus with a large IMA (18 degrees) and subluxation typically requires a more proximal correction. The Lapidus procedure provides powerful IMA correction and addresses first ray hypermobility, making it an excellent choice for revisions without MTP arthritis.

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