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8. Foot and Ankle MCQs

Practice Set 142 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2821

Topic: 8. Foot and Ankle

A 60-year-old man with diabetes mellitus is referred for evaluation of nonhealing ulcers of his left foot. Nonsurgical management has failed to provide relief, and a below-the-knee amputation is being considered. Which of the following studies best predicts successful amputation wound healing?

. Hemoglobin A1c of 8.2
. Serum albumin of 2.5 g/dL
. Hemoglobin of 10 g/dL
. Ankle-brachial index of 1.0
. Transcutaneous partial pressure of O2 (TcPO2) of 50 mm Hg

Correct Answer & Explanation

. Transcutaneous partial pressure of O2 (TcPO2) of 50 mm Hg

Explanation

The TcPO2 measures the O2 delivering capacity of the local vasculature. Values above 40 mm Hg have been shown to correlate with positive healing potential. The hemoglobin A1c is a good indicator of long-term glucose levels; however, it has no direct correlation with wound healing potential. Serum albumin is an indirect measure of nutritional status, and deficiencies in nutrition must be addressed before any surgery. Adequate hemoglobin levels are also necessary to promote adequate oxygenation to the amputation site. The ankle-brachial index may be falsely elevated as a result of calcified vessels in patients with diabetes mellitus. Wyss CR, Harrington RM, Burgess EM, et al: Transcutaneous oxygen tension as a predictor of success after amputation. J Bone Joint Surg Am 1988;70:203-207.

Question 2822

Topic: 8. Foot and Ankle

Examination of a 7-year-old girl with myelomeningocele reveals calcaneal deformities of both feet. She ambulates on both extremities wearing ankle-foot orthoses and has no upper extremity aids. She has grade 5/5 motor strength to the tibialis anterior muscles and absent motor strength to the triceps surae. There is no varus or valgus deformity of the hindfoot, and the skin over the heels is intact; however, mild callosities are present. Management should consist of

. bilateral calcaneal osteotomies.
. modification of the ankle-foot orthoses.
. extra-articular subtalar arthrodesis.
. transfer of the anterior tibial tendon to the calcaneus.
. Achilles tendon tenodesis to the fibula.

Correct Answer & Explanation

. transfer of the anterior tibial tendon to the calcaneus.

Explanation

A calcaneal deformity of the foot may occur in children who have low lumbar myelomeningocele. Strong dorsiflexors overcome a weak or absent gastrocnemius-soleus complex, leading to downward growth of the calcaneal apophysis. The deformity is usually progressive and does not respond to nonsurgical management. Most authorities recommend transfer of the tibialis anterior muscle through the interosseous membrane to the posterior aspect of the calcaneus. This procedure has been reported to be effective in limiting progression of the deformity. An extra-articular subtalar arthodesis, a treatment option for valgus deformity of the hindfoot, is not indicated. Similarly, Achilles tendon tenodesis to the fibula, an option for managing valgus of the ankle, is not indicated. Calcaneal osteotomy may be used in older children with severe calcaneal deformity. Stott NS, Zionts LE, Gronley JK, Perry J: Tibialis anterior transfer for calcaneal deformity: A postoperative gait analysis. J Pediatr Orthop 1996;16:792-798.

Question 2823

Topic: 8. Foot and Ankle

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 23

. Bone scan
. Curettage and bone grafting of the cyst
. Cast immobilization
. Observation with reduced activity
. Skeletal survey

Correct Answer & Explanation

. Observation with reduced activity

Explanation

The most likely diagnosis is Sever's disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus. Ogden JA, Ganey TM, Hill JD, et al: Sever's injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.

Question 2824

Topic: 8. Foot and Ankle

A 12-year-old girl who has a history of frequent tripping and falling also has bilateral symmetric hand weakness, high arched feet, absent patellar and Achilles tendon reflexes, and excessive wear on the lateral border of her shoes. She reports that she has multiple paternal family members with similar deformities. She most likely has a defect of what protein?

. Peripheral myelin protein-22
. Dystrophin
. Type I collagen
. Alpha-L-iduronidase
. Cartilage oligomeric matrix protein

Correct Answer & Explanation

. Peripheral myelin protein-22

Explanation

The girl shows clinical features of hereditary motor sensory neuropathy type 1, Charcot-Marie-Tooth disease. The most common type of this autosomal-dominant disease is due to an underlying defect in the gene coding for peripheral myelin protein-22 on chromosome 17. Many other less common mutations have been identified in this family of neuropathies. Dystrophin is a protein that is abnormal in Duchenne's muscular dystrophy, which affects males and is diagnosed earlier. Type I collagen is defective in osteogenesis imperfecta. Alpha-L-iduronidase is defective in mucopolysaccharidosis type I, Hurler's syndrome. Defective cartilage oligomeric matrix protein is associated with some forms of multiple epiphyseal dysplasia. Patel PI, Roa BB, Welcher AA, et al: The gene for the peripheral myelin protein PMP-22 is a candidate for Charcot-Marie-Tooth disease type 1A. Nat Genet 1992;1:159-165.

Question 2825

Topic: Ankle Trauma & Sports

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 29

. Level of the fibular fracture
. Lauge-Hansen fracture class
. Intraoperative stress testing
. Widening of the medial clear space
. Talar dislocation

Correct Answer & Explanation

. Intraoperative stress testing

Explanation

The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.

Question 2826

Topic: 8. Foot and Ankle

A 29-year-old woman reports dysesthesias and burning after undergoing bunion surgery that consisted of a proximal crescentic first metatarsal osteotomy 6 months ago. Examination reveals a positive Tinel's sign at the proximal aspect of the healed incision. What injured nerve is responsible for her continued symptoms?

. Recurrent branch of the deep peroneal
. Recurrent branch of the sural
. Terminal cutaneous branch of the saphenous
. Dorsomedial cutaneous branch of the superficial peroneal
. Medial plantar

Correct Answer & Explanation

. Dorsomedial cutaneous branch of the superficial peroneal

Explanation

Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly. Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.

Question 2827

Topic: 8. Foot and Ankle

A patient with a below-the-knee amputation is being evaluated for a new prosthesis. He wants to improve his ability to walk on uneven surfaces. What modification to the prosthesis can be made to accommodate this request?

. Shorten the keel
. Lengthen the keel
. Change the keel to a split keel
. Change to a solid ankle, cushioned heel (SACH)
. Change to carbon fiber

Correct Answer & Explanation

. Change the keel to a split keel

Explanation

Changing from a solid keel to a keel with a sagittal split allows an amputee to navigate uneven terrain more easily. Changing the length of the keel affects the responsiveness of the prosthesis but does not address the surface conditions for ambulation. The SACH is not used as frequently anymore, because overload problems to the nonamputated foot have been observed. Koval K (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 31-45.

Question 2828

Topic: Midfoot & Hindfoot

A 62-year-old man has a severe pes planus and pain in the hindfoot. Radiographs show advanced degenerative changes at the talonavicular and subtalar joints with good preservation of the ankle joint. What is the most appropriate surgical procedure to alleviate his pain?

. Flexor digitorum longus transfer with calcaneal osteotomy
. Lateral column lengthening with tendon transfer
. Subtalar arthrodesis
. Triple arthrodesis
. Isolated talonavicular fusion

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Once degenerative changes have occurred, soft-tissue procedures are not indicated. Triple arthrodesis is the treatment of choice for adult-acquired flatfoot. Isolated fusion of the subtalar or talonavicular joint will not be sufficient to correct the problem. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 269-282.

Question 2829

Topic: 8. Foot and Ankle

A 38-year-old marathon runner has had Achilles tendon pain for the past 2 months. Examination reveals that the tendon is thickened and tender proximal to the calcaneal insertion. The tendon sheath is not thickened or tender. The pathophysiology of the tendon is best described as

. acute inflammation.
. chronic inflammation.
. partial tendon rupture.
. anaerobic degeneration.
. impaired collagen cross-linking.

Correct Answer & Explanation

. anaerobic degeneration.

Explanation

Atraumatic Achilles tendon disease can be differentiated into Achilles tendinosis and peritendinitis. Thickening and tenderness of the Achilles tendon are present in both, but thickening and tenderness of the tendon sheath indicates peritendinitis. Histologic examination of Achilles tendinosis reveals an absence of acute and chronic inflammatory cells. Radiologists often diagnose partial tendon rupture by MRI and there may be microscopic longitudinal tears present, but there is no mechanical compromise as would be implied by a partial rupture. The thickening typically occurs in the portion of the tendon with the poorest blood supply, and biochemical analysis detects high levels of lactate and other products of anaerobic glycolysis. Astrom M, Rausing A: Chronic Achilles tendinopathy: A survey of surgical and histopathologic findings. Clin Orthop 1995;316:151-164. Ohberg L, Lorentzon R, Alfredson H: Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: An ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 2001;9:233-238.

Question 2830

Topic: 8. Foot and Ankle

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 13

. Anterior tibialis tendon transfer to the dorsolateral midfoot
. Posterior tibialis tendon transfer to the dorsolateral midfoot
. Peroneus longus tendon transfer to the dorsolateral midfoot
. Peroneus brevis tendon transfer to the dorsolateral midfoot
. Flexor hallucis longus tendon transfer to the peroneus brevis

Correct Answer & Explanation

. Peroneus longus tendon transfer to the dorsolateral midfoot

Explanation

Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque. Hansen ST: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott, Williams & Wilkins, 2000, pp 433-435.

Question 2831

Topic: 8. Foot and Ankle

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

. Ankle ligament repair
. Resection of the accessory navicular
. Resection of the talocalcaneal coalition
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Resection of the accessory navicular

Explanation

The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present. McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.

Question 2832

Topic: 8. Foot and Ankle

A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is the most likely diagnosis?

. Posterior tibial tendinitis
. Tarsal tunnel syndrome
. Os trigonum impingement syndrome
. Insertional tendinitis of the Achilles tendon
. Osteochondritis dissecans of the talus

Correct Answer & Explanation

. Os trigonum impingement syndrome

Explanation

Posterior ankle impingement or os trigonum syndrome is well described in dancers, and it is often associated with flexor hallucis longus tendinitis. High-quality MRI imaging will reveal the inflammation about the os trigonum and flexor hallucis longus tendinitis. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont IL, American Academy of Orthopaedic Surgeons, 1998, pp 315-332.

Question 2833

Topic: Midfoot & Hindfoot

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

. Quicker return to activities
. Quicker return to work
. Increased subtalar joint range of motion
. Decreased risk of nonunion
. Decreased risk of posttraumatic arthritis

Correct Answer & Explanation

. Decreased risk of posttraumatic arthritis

Explanation

The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 2834

Topic: 8. Foot and Ankle

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 26

. Open treatment of the metatarsal malunion
. Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis
. Cast application and an external bone stimulator
. Hallux valgus correction
. Hallux metatarsophalangeal arthrodesis

Correct Answer & Explanation

. Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis

Explanation

The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint. Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214. McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.

Question 2835

Topic: 8. Foot and Ankle

Figures 33a and 33b show the radiographs of a 10-year-old girl who reports a 4-month history of medial foot pain after she was kicked while playing soccer. The pain is worse with activity and partially relieved by rest. Examination reveals tenderness directly over a prominent navicular tuberosity. Management should consist of

. calcaneal lengthening osteotomy with reefing of the tibialis posterior tendon.
. excision of the ossicle in the navicular and tibialis posterior tendon advancement.
. talonavicular joint arthrodesis.
. open reduction and internal fixation of the navicular.
. activity and shoe modification and non-narcotic analgesics.

Correct Answer & Explanation

. activity and shoe modification and non-narcotic analgesics.

Explanation

An accessory tarsal navicular is located at the medial tuberosity of the navicular bone. Nearly all children and adolescents who have a symptomatic accessory tarsal navicular bone become asymptomatic when they reach skeletal maturity. Initial management should include activity restrictions, shoe modification to avoid pressure over the prominent navicular, and non-narcotic analgesics. Although anecdotal, the use of arch supports may be helpful. When pain is refractory to these methods, a short period of cast immobilization may be useful. Surgery should be reserved for patients who have disabling symptoms despite a prolonged period of nonsurgical management. When surgery is indicated, simple excision of the accessory navicular is recommended. Sella EJ, Lawson JP, Ogden JA: The accessory navicular synchondrosis. Clin Orthop 1986;209:280-285.

Question 2836

Topic: 8. Foot and Ankle

Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing total contact casts. The deformity does not correct passively. Dorsalis pedis and posterior tibial pulses are palpable. The patient is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. The ulcer is currently healed. What is the best option to prevent recurrent ulceration and infection?

. Therapeutic footwear/depth-inlay shoes and a custom accommodative foot orthosis
. Charcot restraint orthotic walker (CROW)
. Percutaneous Achilles tendon lengthening, a total contact cast, and a CROW walker
. Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear
. Ankle disarticulation (Syme) amputation

Correct Answer & Explanation

. Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear

Explanation

This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear. Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573. Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.

Question 2837

Topic: 8. Foot and Ankle

The parents of a 3-year-old girl who has had pain and swelling in the right ankle for the past 3 months now report that she has a limp and that the right knee and both ankles are painful and swollen. The limp and difficulty walking are most severe in the morning when the child first gets out of bed and are also more severe after extended walking. The parents deny fever, chills, weight loss, or night pain. Examination shows mild swelling and slightly restricted motion of the right knee and both ankles but is otherwise normal. In addition to initiation of treatment, the child should be referred to which of the following specialists?

. Neurosurgeon
. Ophthalmologist
. Oncologist
. Otolaryngologist
. Urologist

Correct Answer & Explanation

. Ophthalmologist

Explanation

Pauciarticular juvenile rheumatoid arthritis (JRA) is the most common subgroup of JRA. It typically presents between the ages of 2 to 4 years with a mild swelling of one to four joints. Girls are affected four times more often than boys. The ankle and knee are commonly involved, and limping is typically worse in the morning and after extended activity. The diagnosis of pauciarticular JRA is typically one of exclusion because laboratory studies, including erythrocyte sedimentation rate and rheumatoid factor, are usually within normal limits. Pauciarticular JRA has the highest incidence of chronic uveitis, and in the subgroup with elevated antinuclear antibody (ANA) titers, the incidence is 75%. In JRA, uveitis usually occurs after the onset of synovitis but may precede the joint symptoms. At the early stage of uveitis, the patient is asymptomatic. If the eye condition is not detected and treated, progressive loss of vision may occur. Orthopaedic surgeons may be instrumental in making the diagnosis of pauciarticular JRA. Pauciarticular JRA is not associated with conditions that require input from the other specialists. Carey TP: Inflammatory arthritides: Juvenile rheumatoid arthritis, seronegative spondyloarthropathies, transient synovitis, hemophilic arthropathy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1315-1321.

Question 2838

Topic: Midfoot & Hindfoot

A 54-year-old male with long-standing diabetes presents with a swollen, warm, and erythematous left foot. Radiographs reveal fragmentation and periarticular debris at the tarsometatarsal joints. Which classification system is commonly used to stage the anatomical location of this disease process?

. Eichenholtz classification
. Brodsky classification
. Sanders classification
. Tscherne classification
. Hardinge classification

Correct Answer & Explanation

. Brodsky classification

Explanation

The Brodsky classification describes the anatomic location of Charcot arthropathy. Type 1 is the tarsometatarsal (Lisfranc) joint, which is the most common. Type 2 involves the Chopart/subtalar joints. Type 3A involves the ankle (tibiotalar), and Type 3B involves the calcaneal tuberosity. The Eichenholtz classification describes the clinical and radiographic progression (development, coalescence, consolidation).

Question 2839

Topic: 8. Foot and Ankle

A 38-year-old male sustains an acute Achilles tendon rupture while playing basketball. He opts for non-operative management with a functional rehabilitation protocol. Based on recent Level I evidence, compared to operative repair, non-operative management utilizing early functional bracing is associated with which of the following?

. Lower rate of deep vein thrombosis
. Higher rate of wound complications
. Equivalent re-rupture rate
. Significantly higher re-rupture rate
. Increased sural nerve injury rate

Correct Answer & Explanation

. Equivalent re-rupture rate

Explanation

Recent high-quality level I evidence (such as the Willits study) has demonstrated that when an early functional rehabilitation protocol (early weight-bearing in a functional brace) is utilized, the re-rupture rate of non-operative management is equivalent to that of operative repair, while completely avoiding surgical risks such as wound breakdown and sural nerve injury.

Question 2840

Topic: Forefoot

A 45-year-old female presents with severe pain over the medial eminence of her first metatarsophalangeal (MTP) joint. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. Clinical examination reveals hypermobility at the first tarsometatarsal (TMT) joint. The distal metatarsal articular angle (DMAA) is normal. Which of the following surgical procedures is the most mechanically appropriate to permanently correct this deformity?

. 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

This patient has a severe hallux valgus deformity (IMA > 15 degrees) combined with first ray hypermobility. A distal osteotomy (like a Chevron) cannot achieve sufficient translation to correct an IMA of 16 degrees. A Lapidus procedure (arthrodesis of the first TMT joint) provides powerful multiplanar correction of a large IMA and definitively addresses the underlying first ray hypermobility, preventing recurrence.

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