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Forefoot MCQs

Practice Set 7 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 121

Topic: Forefoot

A 40-year-old female presents with a symptomatic hallux valgus deformity that has failed conservative shoe wear modification. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 35 degrees and a 1-2 intermetatarsal angle (IMA) of 16 degrees. Clinical exam shows a stable first tarsometatarsal (TMT) joint without hypermobility. Which of the following surgical procedures is most biomechanically appropriate?

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

Correct Answer & Explanation

. Proximal metatarsal osteotomy combined with distal soft tissue reconstruction

Explanation

An intermetatarsal angle (IMA) greater than 13-15 degrees represents a moderate-to-severe deformity. A proximal osteotomy (e.g., Ludloff, crescentic, or proximal chevron) combined with a distal soft tissue release provides superior corrective power for larger IMAs. Distal osteotomies are reserved for mild deformities (IMA < 13 degrees). A Lapidus is indicated if first ray hypermobility is present.

Question 122

Topic: Forefoot

A 60-year-old male presents with dorsal midfoot pain and limited dorsiflexion of the great toe. Radiographs demonstrate dorsal osteophytes and joint space narrowing at the first metatarsophalangeal (MTP) joint, consistent with Coughlin and Shurnas Grade 3 hallux rigidus. Conservative management has failed. What is the most reliable surgical treatment for long-term pain relief?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Synthetic hemiarthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with severe pain and functional limitation, arthrodesis of the first MTP joint is the gold standard and most reliable surgical procedure for definitive pain relief. Cheilectomy is indicated for earlier grades (Grade 1 and 2) with primarily dorsal impingement pain.

Question 123

Topic: Forefoot

A 60-year-old female presents with dorsal midfoot pain and stiffness in the first metatarsophalangeal (MTP) joint. Radiographs show advanced joint space narrowing, a large dorsal osteophyte, and flattening of the metatarsal head (Coughlin and Shurnas Grade 3 hallux rigidus). She has failed nonoperative management. What is the gold standard surgical treatment?

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

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with diffuse joint involvement and severe pain, the gold standard surgical treatment is a first MTP joint arthrodesis. It provides reliable and durable pain relief and restores walking ability. Dorsal cheilectomy is indicated for early stages (Grades 1 and 2) where the plantar joint space is preserved.

Question 124

Topic: Forefoot

A 55-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 17 degrees. Clinical examination reveals no first tarsometatarsal (TMT) hypermobility and no evidence of midfoot arthritis. Which of the following procedures is most appropriate for correcting this deformity?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft tissue release
. Lapidus procedure (first TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy with a distal soft tissue release

Explanation

The patient has a severe hallux valgus deformity (HVA >30, IMA >13). A distal chevron osteotomy cannot provide sufficient translation to correct an IMA of 17 degrees. A proximal osteotomy (e.g., Ludloff, crescentic, or proximal chevron) combined with a distal soft tissue procedure is required for this magnitude of deformity. A Lapidus procedure is also an option but is strictly indicated when TMT hypermobility or arthritis is present.

Question 125

Topic: Forefoot

A 45-year-old female presents with painful hallux valgus. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. The first tarsometatarsal (TMT) joint shows no hypermobility and no signs of arthritis. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal first metatarsal osteotomy (e.g., crescentic or Ludloff) with distal soft tissue procedure
. Akin osteotomy alone
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal first metatarsal osteotomy (e.g., crescentic or Ludloff) with distal soft tissue procedure

Explanation

An IMA greater than 15 degrees signifies a severe deformity that generally cannot be fully corrected with a distal osteotomy alone (like a Chevron). A proximal osteotomy (crescentic, Ludloff, or Scarf) is indicated for larger IM angles. A Lapidus (TMT fusion) is typically indicated when there is concurrent first TMT hypermobility or osteoarthritis, which is absent in this patient.

Question 126

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Weight-bearing radiographs show a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. Clinical examination reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy of the proximal phalanx
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. Scarf osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (arthrodesis of the first TMT joint) is the treatment of choice for moderate to severe hallux valgus (IMA > 13 degrees) complicated by hypermobility of the first TMT joint. It corrects the deformity at the apex of the instability.

Question 127

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 35 degrees, an Intermetatarsal Angle (IMA) of 16 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 22 degrees. To achieve a congruent joint and prevent early recurrence, the surgical plan MUST incorporate which of the following?

. A simple proximal crescentic osteotomy
. An isolated modified McBride soft tissue release
. An arthrodesis of the first tarsometatarsal joint (Lapidus) only
. A biplanar osteotomy (e.g., a distally based closing wedge) to specifically correct the articular orientation
. A resection arthroplasty of the first metatarsophalangeal joint (Keller procedure)

Correct Answer & Explanation

. A biplanar osteotomy (e.g., a distally based closing wedge) to specifically correct the articular orientation

Explanation

A normal Distal Metatarsal Articular Angle (DMAA) is less than 10 degrees. An abnormally high DMAA (22 degrees in this case) indicates significant lateral deviation of the distal metatarsal articular surface. Procedures that correct only the IMA (like a standard proximal osteotomy or Lapidus) without addressing the DMAA will leave the MTP joint incongruent, leading to stiffness, pain, and high recurrence risk. A biplanar or double osteotomy (often including a distal medial closing wedge like a Reverdin) is necessary to reorient the articular surface.

Question 128

Topic: Forefoot

A 45-year-old woman presents with severe bunion pain. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 20 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to address her pathology?

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

Correct Answer & Explanation

. Lapidus procedure (1st TMT arthrodesis)

Explanation

The Lapidus procedure (first tarsometatarsal joint arthrodesis) is indicated for severe hallux valgus deformities (HVA > 40 degrees, IMA > 15-20 degrees), particularly when there is associated hypermobility of the first TMT joint. Distal or diaphyseal osteotomies (Chevron, Scarf) are insufficient for severe deformities with TMT hypermobility.

Question 129

Topic: Forefoot

A 58-year-old male presents with painful, restricted dorsiflexion of his first metatarsophalangeal (MTP) joint. Radiographs show large dorsal osteophytes and complete joint space obliteration consistent with Grade 3 hallux rigidus. He has failed shoe modifications and NSAIDs. Which surgical procedure is considered the gold standard for durable pain relief in this patient?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4) with significant pain and loss of motion, first MTP joint arthrodesis is the gold standard surgical treatment, providing the most predictable, powerful, and durable pain relief. Cheilectomy is indicated for earlier stages (Grades 1 and 2) where the joint cartilage space is still relatively preserved.

Question 130

Topic: Forefoot

A distal chevron osteotomy is generally considered the most appropriate surgical intervention for a patient with symptomatic hallux valgus possessing which of the following radiographic profiles?

. Intermetatarsal (IM) angle > 20 degrees
. Hallux valgus angle (HVA) > 40 degrees with a hypermobile first tarsometatarsal joint
. Intermetatarsal (IM) angle < 13 degrees and Hallux valgus angle (HVA) < 30 degrees
. First metatarsophalangeal joint severe osteoarthritis
. Metatarsus adductus with an IM angle > 15 degrees

Correct Answer & Explanation

. Intermetatarsal (IM) angle < 13 degrees and Hallux valgus angle (HVA) < 30 degrees

Explanation

The distal chevron osteotomy is indicated for mild to moderate hallux valgus deformities. This corresponds to an Intermetatarsal (IM) angle of less than 13 to 15 degrees and a Hallux Valgus Angle (HVA) of less than 30 to 35 degrees. Severe deformities (IM > 15) or hypermobility typically require a proximal osteotomy or Lapidus procedure, and advanced MTP arthritis is a contraindication.

Question 131

Topic: Forefoot

A 45-year-old female presents with symptomatic hallux valgus that has failed non-operative management. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Based on these parameters, which of the following is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy
. Akin osteotomy alone
. Keller resection arthroplasty
. Silver procedure (simple bunionectomy)

Correct Answer & Explanation

. Proximal metatarsal osteotomy

Explanation

An Intermetatarsal Angle (IMA) > 15 degrees and a Hallux Valgus Angle (HVA) > 40 degrees constitute a severe hallux valgus deformity. A distal osteotomy (like a chevron) is insufficient to translate the metatarsal head enough to correct this large IMA. A proximal metatarsal osteotomy (or a Lapidus procedure) is required to achieve adequate correction.

Question 132

Topic: Forefoot

A 61-year-old woman has increasing pain in her left great toe. She states that she has had discomfort for years but now has pain with all shoe wear. A radiograph is shown in Figure 35. To provide the most predictable pain-free result, treatment should consist of

Orthopedic Surgery Board Review 2026 | High-Yield MCQs - Set 1 - Figure 58

. distal chevron bunionectomy.
. proximal first metatarsal osteotomy with distal soft-tissue realignment.
. dorsal cheilectomy of the first metatarsophalangeal joint.
. arthrodesis of the first metatarsophalangeal joint.
. silicone arthroplasty.

Correct Answer & Explanation

. arthrodesis of the first metatarsophalangeal joint.

Explanation

Because the patient has a hallux valgus with increased intermetatarsal and hallux valgus angles and advanced degenerative arthritis of the joint, arthrodesis of the first metatarsophalangeal joint will provide the most predictable pain-free result. An attempt to correct the bunion with a bunionectomy or osteotomy would most likely fail. The hallux valgus and advanced degenerative changes put the foot beyond the indications for a cheilectomy. Long-term results with silicone arthroplasty have been disappointing. Mann RA: Disorders of the first metatarsophalangeal joint. J Am Acad Orthop Surg 1995;3:34-43.

Question 133

Topic: Forefoot

A 35-year-old woman presents with a symptomatic hallux valgus deformity. Examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 40 degrees and an intermetatarsal angle of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. First metatarsophalangeal (MTP) arthrodesis
. First tarsometatarsal (TMT) arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. Akin osteotomy only

Correct Answer & Explanation

. First tarsometatarsal (TMT) arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus deformities, especially in the setting of first ray hypermobility, as it addresses the instability at the apex of the deformity.

Question 134

Topic: Forefoot

A 68-year-old woman with a history of generalized osteoarthritis presents with significant pain and stiffness in her big toe. Radiographs show absent joint space, marked osteophytosis, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. She has failed shoe modifications and NSAIDs. What is the gold standard surgical treatment?

. Cheilectomy
. First MTP joint arthrodesis
. First MTP joint arthroplasty with a silastic implant
. Moberg osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

The patient has end-stage (Grade 3/4) hallux rigidus. The gold standard surgical treatment providing the most reliable long-term pain relief and functional outcome is a first MTP joint arthrodesis.

Question 135

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 38 degrees, an intermetatarsal angle (IMA) of 16 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical option?

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

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

For a moderate-to-severe hallux valgus deformity combined with hypermobility of the first TMT joint, the Lapidus procedure provides excellent correction and stability to the medial column.

Question 136

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the 1st tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Scarf osteotomy
. 1st TMT joint arthrodesis (Lapidus procedure)
. 1st MTP joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. 1st TMT joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus (IMA >15 degrees) combined with 1st TMT hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 137

Topic: Forefoot

A patient undergoes excision of a symptomatic mass in the 3rd intermetatarsal space after failing shoe modifications and injections. A Mulder's click was present preoperatively. What histopathologic finding is expected in the excised specimen?

. Malignant peripheral nerve sheath cells
. Perineural fibrosis and axonal degeneration
. Multinucleated giant cells and hemosiderin deposition
. Proliferation of disorganized nerve fascicles (true neuroma)
. Synovial cell hyperplasia

Correct Answer & Explanation

. Perineural fibrosis and axonal degeneration

Explanation

Morton's neuroma is not a true neoplastic neuroma but rather a compressive neuropathy. Histology classically shows perineural fibrosis, endoneurial edema, and axonal degeneration of the common digital nerve.

Question 138

Topic: Forefoot

A 58-year-old male presents with dorsal foot pain and inability to wear dress shoes. Examination shows less than 10 degrees of 1st MTP dorsiflexion and pain throughout the midrange of motion. Radiographs show severe joint space narrowing and large dorsal osteophytes (Grade 3 hallux rigidus). What is the most reliable definitive treatment?

. Cheilectomy
. 1st MTP joint arthrodesis
. Moberg osteotomy
. Resection arthroplasty (Keller procedure)
. Silicone joint replacement

Correct Answer & Explanation

. 1st MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with pain in the midrange of motion and diffuse joint space loss, 1st MTP arthrodesis provides the most reliable pain relief and functional improvement. Cheilectomy is reserved for earlier stages with pain only at terminal dorsiflexion.

Question 139

Topic: Forefoot

A 42-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and obvious widening and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following is the most appropriate surgical treatment?

. Distal soft-tissue reconstruction with medial eminence resection
. Distal metatarsal chevron osteotomy
. Proximal metatarsal opening wedge osteotomy
. First TMT arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

First tarsometatarsal (TMT) arthrodesis, or the Lapidus procedure, is indicated for severe hallux valgus with an intermetatarsal angle >15 degrees and associated first TMT hypermobility.

Question 140

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 17 degrees. The first tarsometatarsal joint is hypermobile. Which of the following is the most appropriate surgical management?

. Distal chevron osteotomy
. Modified McBride procedure
. Keller resection arthroplasty
. First tarsometatarsal (Lapidus) arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First tarsometatarsal (Lapidus) arthrodesis

Explanation

For severe hallux valgus (IMA > 15 degrees) especially with first ray hypermobility, a proximal procedure like a Lapidus (first TMT arthrodesis) is required. Distal osteotomies cannot adequately correct an IMA of this magnitude.

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