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Forefoot MCQs

Practice Set 8 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 141

Topic: Forefoot

A 65-year-old male presents with severe pain and stiffness in his right great toe. Clinical examination reveals palpable dorsal osteophytes and pain throughout the arc of first MTP joint motion. Radiographs show complete joint space obliteration and dorsal osteophytosis. What is the most reliable definitive surgical treatment?

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

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

The patient has end-stage (Grade 3 or 4) hallux rigidus with diffuse pain and joint space obliteration. Arthrodesis is the gold standard and most reliable procedure for pain relief and functional restoration in severe hallux rigidus.

Question 142

Topic: Forefoot

A 45-year-old female complains of sharp, burning pain radiating to her 3rd and 4th toes, worsening with tight-fitting shoes. A positive Mulder's click is elicited. If the offending lesion is surgically excised, what is the classic histologic finding on pathology?

. Proliferation of atypical Schwann cells
. Epithelioid cells with prominent nucleoli
. Perineural fibrosis and nerve degeneration
. Granulomatous inflammation with giant cells
. Demyelination with extensive lymphocytic infiltration

Correct Answer & Explanation

. Perineural fibrosis and nerve degeneration

Explanation

Morton's neuroma is not a true neoplasm but rather a compressive neuropathy. Histology classically demonstrates perineural fibrosis, endoneurial edema, and nerve fiber degeneration secondary to repetitive microtrauma and compression.

Question 143

Topic: Forefoot

A 50-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and plantar gapping at the 1st tarsometatarsal (TMT) joint consistent with hypermobility. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

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

Question 144

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Radiographs reveal a hallux valgus angle of 42 degrees, an intermetatarsal angle of 18 degrees, and obvious hypermobility of the first tarsometatarsal joint on clinical exam. What is the most appropriate surgical treatment?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal joint arthrodesis with distal soft tissue release
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis with distal soft tissue release

Explanation

The Lapidus procedure (first tarsometatarsal joint arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) accompanied by first ray hypermobility. It stabilizes the medial column and prevents recurrence.

Question 145

Topic: Forefoot

A 22-year-old woman has a painful bunion. Radiographs reveal a hallux valgus angle of 35 degrees, an intermetatarsal angle of 12 degrees, and a distal metatarsal articular angle (DMAA) of 20 degrees. The first MTP joint is congruous. Which of the following procedures is most appropriate?

. Lapidus procedure
. Distal chevron osteotomy with medial closing wedge
. Proximal opening wedge osteotomy
. First MTP joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy with medial closing wedge

Explanation

An abnormally high DMAA (>15 degrees) indicates that the distal articular surface is laterally deviated. A biplanar distal chevron osteotomy (incorporating a medial closing wedge) corrects both the intermetatarsal angle and the articular orientation.

Question 146

Topic: Forefoot

A patient undergoes a bunionectomy with a distal chevron osteotomy. Intraoperatively, the intermetatarsal and hallux valgus angles are completely corrected, but the great toe remains deviated laterally at the interphalangeal joint. What is the most appropriate next step?

. Lateral capsular release
. Medial closing wedge osteotomy of the proximal phalanx
. Adductor hallucis tenotomy
. Revision of the metatarsal osteotomy
. First MTP joint arthrodesis

Correct Answer & Explanation

. Medial closing wedge osteotomy of the proximal phalanx

Explanation

Residual valgus deformity of the hallux at the interphalangeal joint, despite a corrected MTP joint, is termed hallux interphalangeus. It is effectively treated with a medial closing wedge osteotomy of the proximal phalanx (Akin procedure).

Question 147

Topic: Forefoot

A 60-year-old woman with advanced rheumatoid arthritis presents with severe bilateral bunions, lesser toe deformities, and subluxation of the first MTP joints. Radiographs of the first MTP joint show complete loss of cartilage and erosion. What is the gold standard surgical treatment for her first ray?

. Proximal crescentic osteotomy
. Distal soft tissue reconstruction
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Silicone replacement arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the procedure of choice for severe, arthritic hallux valgus in rheumatoid patients. It provides definitive, long-lasting relief and creates a stable medial column to assist in lesser toe reconstruction.

Question 148

Topic: Forefoot

A 48-year-old woman has a severe hallux valgus deformity with a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 20 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. What is the surgical procedure of choice?

. 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

For severe hallux valgus (IMA >15 degrees) associated with first TMT joint hypermobility, a Lapidus procedure (first TMT arthrodesis) provides reliable correction and stabilizes the medial column to prevent recurrence.

Question 149

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 40 degrees and an intermetatarsal angle (IMA) of 17 degrees. There is no evidence of first tarsometatarsal (TMT) joint hypermobility or degenerative changes at the first metatarsophalangeal (MTP) joint. Which of the following is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft-tissue procedure
. First MTP joint arthrodesis
. Lapidus procedure
. Akin osteotomy

Correct Answer & Explanation

. Proximal metatarsal osteotomy with a distal soft-tissue procedure

Explanation

An IMA greater than 13-15 degrees with a large HVA requires a proximal metatarsal osteotomy or Lapidus procedure to achieve adequate correction. Since there is no TMT hypermobility, a proximal osteotomy with distal soft-tissue realignment is appropriate.

Question 150

Topic: Forefoot

A 48-year-old woman presents with a painful bunion. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. Radiographs show an intermetatarsal angle (IMA) of 18 degrees and a hallux valgus angle (HVA) of 42 degrees. What is the most appropriate definitive procedure?

. Distal chevron osteotomy
. Ludloff osteotomy
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Scarf osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is specifically indicated for patients with moderate to severe hallux valgus accompanied by first TMT joint hypermobility.

Question 151

Topic: Forefoot

A 45-year-old woman presents with pain and medial deviation of her great toe 6 months after undergoing a distal chevron osteotomy and lateral soft tissue release for hallux valgus. Standing radiographs reveal an intermetatarsal angle (IMA) of 6 degrees and a hallux valgus angle (HVA) of -15 degrees. What intraoperative technical error is the most likely cause of this complication?

. Failure to release the adductor hallucis
. Over-resection of the medial eminence (staking the metatarsal head)
. Under-correction of the intermetatarsal angle
. Dorsiflexion malunion of the capital fragment
. Failure to perform an Akin osteotomy

Correct Answer & Explanation

. Over-resection of the medial eminence (staking the metatarsal head)

Explanation

Hallux varus is a known complication of bunion surgery. It is most commonly caused by over-resection of the medial eminence (staking the head), over-tightening of the medial capsule, over-release of the lateral structures, or excision of the fibular sesamoid.

Question 152

Topic: Forefoot

A 35-year-old woman presents with a painful bunion. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint, with dorsal elevation of the first ray on weight-bearing. Standing radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 18 degrees. Which of the following is the most appropriate surgical procedure?

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

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility or TMT joint arthritis. It definitively addresses the apex of the deformity and stabilizes the medial column.

Question 153

Topic: Forefoot

A patient undergoes a proximal crescentic osteotomy and distal soft tissue release for severe hallux valgus. Postoperative radiographs show the intermetatarsal angle is corrected to 7 degrees, but the great toe still deviates laterally at the interphalangeal joint with a Hallux Valgus Interphalangeus (HVI) angle of 18 degrees. What is the best next step to achieve full clinical correction?

. Revision of the proximal metatarsal osteotomy
. Medial closing wedge osteotomy of the proximal phalanx (Akin osteotomy)
. Repeat lateral soft tissue release
. Extensor hallucis longus lengthening
. First metatarsophalangeal arthrodesis

Correct Answer & Explanation

. Medial closing wedge osteotomy of the proximal phalanx (Akin osteotomy)

Explanation

An Akin osteotomy (medial closing wedge of the proximal phalanx) is indicated to correct hallux valgus interphalangeus. It does not correct the intermetatarsal angle but straightens the toe when the primary MTP deformity has been addressed.

Question 154

Topic: Forefoot

A 40-year-old woman has a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. The first TMT joint is stable with no evidence of hypermobility or arthritis. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal first metatarsal osteotomy with distal soft-tissue release
. First TMT arthrodesis (Lapidus)
. First MTP arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. Proximal first metatarsal osteotomy with distal soft-tissue release

Explanation

For a severe hallux valgus deformity (IMA >15 degrees, HVA >40 degrees) without first TMT hypermobility or midfoot arthritis, a proximal osteotomy with distal soft-tissue release provides the necessary powerful correction.

Question 155

Topic: Forefoot

A 45-year-old woman complains of a painful bunion. Radiographs reveal an HVA of 38 degrees and an IMA of 16 degrees. Clinical examination reveals significant sagittal plane hypermobility of the first tarsometatarsal (TMT) joint. What is the best surgical option?

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

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is specifically indicated for moderate to severe hallux valgus when associated with clinical first TMT hypermobility to prevent recurrence.

Question 156

Topic: Forefoot

A 45-year-old woman presents with a symptomatic bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is clinical hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy
. Modified McBride procedure
. First TMT joint arthrodesis (Lapidus)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

Severe hallux valgus (HVA >40, IMA >15) with first TMT joint hypermobility is best treated with a first TMT joint arthrodesis (Lapidus procedure). This provides powerful correction of the intermetatarsal angle and stabilizes the incompetent medial column.

Question 157

Topic: Forefoot

A professional football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. If left untreated, what is the most likely long-term complication?

. Hallux varus
. Hallux rigidus
. Cock-up deformity of the hallux
. Hammer toe deformity
. Transfer metatarsalgia

Correct Answer & Explanation

. Hallux rigidus

Explanation

A complete plantar plate tear (Grade 3 turf toe) causes severe instability and altered kinematics of the first MTP joint. Without surgical repair to restore the anatomical alignment, progressive joint degeneration inevitably leads to hallux rigidus.

Question 158

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. 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. Which of the following surgical procedures is most appropriate?

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

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A severe hallux valgus deformity (HVA > 40°, IMA > 15°) associated with first TMT joint hypermobility is best treated with a first TMT arthrodesis (Lapidus procedure). This provides stable long-term correction and directly addresses the hypermobile segment.

Question 159

Topic: Forefoot

A 50-year-old woman presents with severe bunion deformity. Examination reveals a hypermobile first tarsometatarsal (TMT) joint. Radiographs show 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 with distal soft tissue release
. First TMT arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA >15 degrees) accompanied by first ray hypermobility. It effectively stabilizes the medial column and reliably corrects large intermetatarsal angles.

Question 160

Topic: Forefoot

A 55-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal closing wedge osteotomy
. First TMT arthrodesis (Lapidus procedure)
. Metatarsophalangeal (MTP) joint arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) especially in the presence of first ray hypermobility. It provides powerful correction and stabilizes the medial column.

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