Updated: 7/12/2021

Hallux Valgus

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  • summary
    • Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear.
    • Diagnosis is made clinically with presence of a hallux that rests in a valgus and pronated position. Radiographs of the foot are obtained to identify the severity of the disease and for surgical planning.
    • Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear.  
  • Epidemiology
    • Demographics
      • more common in women
    • Risk factors
      • intrinsic
        • genetic predisposition
          • 70% of pts with hallux valgus have family history
        • increased distal metaphyseal articular angle (DMAA)
        • ligamentous laxity (1st tarso-metatarsal joint instability)
        • convex metatarsal head
        • 2nd toe deformity/amputation
        • pes planus
        • rheumatoid arthritis
        • cerebral palsy
      • extrinsic
        • shoes with high heel and narrow toe box
  • Etiology
    • Two forms exist
      • adult hallux valgus
      • adolescent & juvenile hallux valgus
    • Pathoanatamy
      • valgus deviation of phalanx promotes varus position of metatarsal
      • the metatarsal head displaces medially, leaving the sesamoid complex laterally translated relative to the metatarsal head
      • sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached to the base of the proximal phalanx via the sesamoido-phalangeal ligament
      • this lateral displacement can lead to transfer metatarsalgia due to shift in weight bearing
      • medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
      • adductor tendon becomes deforming force
        • inserts on fibular sesamoid and lateral aspect of proximal phalanx
      • lateral deviation of EHL further contributes to deformity
      • plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx
      • windlass mechanism becomes less effective
        • leads to transfer metatarsalgia
    • Associated conditions
      • hammer toe deformity
      • callosities
    • Juvenile and Adolescent Hallux valgus
      • factors that differentiate juvenile / adolescent hallux valgus from adults
        • often bilateral and familial
        • pain usually not primary complaint
        • varus of first MT with widened IMA usually present
        • DMAA usually increased
        • often associated with flexible flatfoot
      • complications
        • recurrence is most common complication (>50%), also overcorrection and hallux varus
  • Anatomy
    • Pathoanatomy cascade 
  • Presentation
    • Symptoms
      • presents with difficulty with shoe wear due to medial eminence
      • pain over prominence at MTP joint
      • compression of digital nerve may cause symptoms
    • Physical exam
      • Hallux rests in valgus and pronated due to deforming forces illustrated above
      • examine entire first ray for
        • 1st MTP ROM
        • 1st tarsometatarsal mobility
        • callous formation
        • sesamoid pain/arthritis
      • evaluate associated deformities
        • pes planus
        • lesser toe deformities
        • midfoot and hindfoot conditions
  • Imaging
    • Radiographs
      • views
        • standard series should include weight bearing AP, Lat, and oblique views
        • sesamoid view can be useful
      • findings
        • lateral displacement of sesamoids
        • joint congruency and degenerative changes can be evaluated
        • radiographic parameters (see below) guide treatment
      • Radiographic Measurements in Hallux Valgus
        Hallux valgus (HVA)
        Long axis of 1st MT and prox. phalanx
        Identifies MTP deformity
        Normal < 15°
        Intermetatarsal angle (IMA)
        Between long axis of 1st and 2nd MT
        Normal < 9 °
        Distal metatarsal articular (DMAA)
        Between 1st MT axis and line through base of distal articular cap
        Identifies MTP joint incongruity
        Normal < 10°
        Hallux valgus interphalangeus (HVI)
        Between long. axis of distal phalanx and proximal phalanx
        Normal < 10°
  • Treatment - Adult Hallux Valgus
    • Nonoperative
      • shoe modification/ pads/ spacers/orthoses
        • indications
          • first line treatment
        • orthoses more helpful in patients with pes planus or metatarsalgia
    • Operative
      • surgical correction
        • indications
          • when symptoms present despite shoe modification
          • do not perform for cosmetic reasons alone
        • technique
          • soft tissue procedure
            • indicated in very mild disease in young female (almost never)
          • distal osteotomy
            • indicated in mild disease (IMA < 13)
          • proximal or combined osteotomy
            • indicated in more moderate disease (IMA > 13)
          • 1st TMT arthrodesis
            • arthritis at TMT joint or instability
          • fusion procedures
            • indicated in severe deformity/spasticity/arthritis
          • MTP resection arthroplasty
            • only indicated in elderly patients with low functional demands
  • Treatment - Juvenile and Adolescent Hallux valgus
    • Nonoperative
      • shoe modification
        • indications
          • pursue nonoperative management until physis closes
    • Operative
      • surgical correction
        • indications
          • best to wait until skeletal maturity to operate
            • can not perform proximal metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
          • surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
          • consider double MT osteotomy in adolescent patients with increased DMAA
        • technique
          • soft tissue procedure alone not successful
          • similar to adults if physis is closed (except in severe deformity)
  • Techniques
    • Soft Tissue Procedures
      • modified McBride
        • indications
          • goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage of MT head). Usually done in patients with
            • a HVA less than 25 degrees
            • IMA deformity less than 15 degrees
            • usually in patient 30-50 years of age
          • rarely appropriate in isolation
            • usually performed in conjunction with
              • medial eminence resection
              • MT osteotomy
              • 1st TMT arthrodesis (Lapidus procedure)
        • technique
          • includes
            • release of adductor from lateral sesamoid/proximal phalanx
            • lateral capsulotomy
            • medial capsular imbrication
            • (original McBride included lateral sesamoidectomy)
    • Metatarsal Osteotomies
      • distal metatarsal osteotomy
        • indications
          • mild disease (HVA ≤ 40, IMA < 13)
        • distal metatarsal osteotomies include
          • biplanar Chevron (corrects DMAA)
          • Mitchell
          • may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy)
      • proximal metatarsal osteotomy
        • indications
          • moderate disease (HVA >40°, IMA >13°)
        • proximal metatarsal osteotomies include
          • crescentic osteotomy
          • Broomstick osteotomy
          • Ludloff
          • Scarf
      • double (proximal and distal) osteotomy
        • indications
          • severe disease (HVA 41-50°, IMA 16-20°)
      • first cuneiform osteotomy
        • indications
          • severe deformity in young patient with open physis
    • Proximal phalanx osteotomies
      • Akin osteotomy
        • indications
          • hallux valgus interphalangeus
          • congruent joint with DMAA <10°
          • as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) did not provide sufficient correction due to a large DMAA or HVI
          • some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in HVI
    • Fusion procedures
      • Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride)
        • indications
          • severe deformity (very large IMA)
          • arthritis at 1st TMT
          • metatarsus primus varus
          • hypermobile 1st TMT joint
          • concomitant pes planus
      • MTP Arthrodesis
        • indications are hallux valgus in
          • cerebral palsy
          • Down's syndrome
          • Rheumatoid arthritis
          • Gout
          • Severe DJD
          • Ehler-Danlos
    • Resection arthroplasty
      • proximal phalanx (Keller) resection arthroplasty
        • indications
          • largely abandoned
          • rarely indicated in some elderly patient with reduced function demands
    • Surgical Indications for Specific Conditions
      Juvenile/Adolescent with open physis
      First cuneiform osteotomy
      Hypermobile 1st MT
      Lapidus procedure
      DJD
      MTP arthrodesis
      Skin breakdown
      Simple bunionectomy with medial eminence removal
      Gout
      MTP arthrodesis
      Recurrence with pain in 1st TMT joint
      Lapidus procedure
      Rheumatoid arthritis
      MTP arthrodesis
      Down's syndrome, CP, Ehler-Danlos
      MTP arthrodesis
    • Surgical Indications for Various Techniques to treat Hallux Valgus
      HVA
      IMA
      Modifier 
      Procedure
      Mild
      < 25°
      < 13°
      Distal MT osteotomy
      • Chevron osteotomy 
      • Biplanar if DMAA > 10° with mod McBride
      Moderate
      26-40°
      13-15°
      Proximal MT +/- distal MT osteotomy
      • Chevron/mod McBride + Akin
      • Proximal MT osteotomy and mod McBride
      Severe
      41-50°
      16-20°
      Double osteotomy, DMAA > 15°
      • Proximal MT osteotomy plus biplanar chevron, mod McBride
      • Lapidus procedure plus Akin
      41-50°
      16-20°
      Elderly/very low demand patient
      • Keller resection arthroplasty
      41-50°
      16-20°
      Juvenile/Adolescent with DMAA > 20
      • Double osteotomy of first ray
    • Various Hallux valgus procedures
      Procedure
      Technique
      Indications
      Complications
      Modified McBride
      • Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication
      • HVA 15-25°
      • IMA < 13°
      • HVI < 15°
      • Recurrence
      • Hallux varus
      Original McBride
      • Includes lateral sesamoidectomy and has been abandoned
      Not indicated
      • Hallux Varus
      Chevron
      • Distal 1st MT osteotomy (intra-articular).
      • Can perform in two planes (Biplanar distal Chevron)
      • Reserved for mild to moderate deformities in adults and children
       • Biplanar chevron--> corrects increased DMAA
      • AVN of MT head
      • Recurrence
      • Dorsal malunion with transfer metatarsalgia
       
      Mitchell
      • Distal 1st MT osteotomy (extra-articular).
      • More proximal than Chevron
      Same as Chevron (rarely utilized)
      • Recurrence
      • Malunion
      • Transfer metatarsalgia

       
      Akin 
      • Proximal phalanx medial closing wedge osteotomy
      • Combined with Chevron in moderate to severe deformities
      • Hallux valgus interphalangeus

       
      Scarf / Ludloff / Mau
      • Metatarsal shaft osteotomies.
      • IMA 14-18°
      • DMAA is normal or increased
      • Dorsal malunion with transfer metatarsalgia
      • Recurrence 
      Proximal Crescentic or Broomstick 
      • Proximal metatarsal osteotomy plus modified McBride
      • Severe deformity
      • IMA > 20°
      • HVA > 50°
      Hallux varus
      • Dorsal malunion with transfer metatarsalgia
      • Recurrence
       
      Keller resection arthroplasty
      • Includes medial eminence removal and resection of base of proximal phalanx

      • Largely abandoned due to complications
      • Indicated only in older patients with reduced functional demands
      • Cock-up toe deformity
      • Poor potential for correction of deformity
       
      MTP arthrodesis
      • Indicated in moderate to severe hallux valgus
      • DJD of 1st MTP
      • Painful callosities beneath lesser MT heads
      Lapidus procedure
      • First TMT joint arthrodesis with distal soft tissue procedures (medial eminence removal, first web space release of AdH, lateral capsule release)
      • Moderate or severe deformity
      • Hypermobility of first ray
      • Nonunion (may or may not be symptomatic)
      • Dorsiflexion of the first metatarsal with transfer metatarsalgia
      First Cuneiform Osteotomy
      • Opening wedge osteotomy (often requires autograft)
      • Children with ligamentous laxity, flatfoot, and hypermobile first ray
      • Adolescent with an open physis
      • Nonunion (may or may not be symptomatic)
  • Complications
    • Recurrence
      • most common cause of failure is insufficient preoperative assessment and failure to follow indications
        • e.g., failure to recognize DMAA > 10°
        • inadequate correction of IMA
        • e.g., failure to do adequate distal soft tissue realignment
      • more common in juvenile/adolescent population
      • noncompliant patient that bears weight
      • rounded shape to the first metatarsal head
      • residual tibial sesamoid lateral displacement
      • increased preoperative IMA and HVA
      • failure to perform a lateral release of the adductor hallucis tendon
    • Avascular necrosis
      • medial capsulotomy is primary insult to blood flow to metatarsal head
      • distal metatarsal oseotomy and lateral soft tissue release inconjunction do not increase risk for AVN (Chevron plus lateral release thought to increase risk in the past)
    • Dorsal malunion with transfer metatarsalgia
      • due to overload of lesser metatarsal heads
      • risk associated with shortening of hallux MT
        • Lapidus
        • proximal crescentric osteotomies
    • Hallux Varus
      • caused by
        • overcorrection of 1st IMA
        • excessive lateral capsular release with overtightening of medial capsule
        • overresection of medial first metatarsal head
        • lateral sesamoidectomy
    • Cock up toe deformity
      • due to injury of FHL
      • most severe complication with Keller resection
      • due to injury of FHL
      • most severe complication with Keller resection
    • 2nd MT transfer metatarsalgia
      • often seen concomitant with hallux valgus
      • shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
    • Neuropraxia
      • Painful incisional neuromas after bunion surgery frequently involve the medial dorsal cutaneous nerve (a terminal branch of the superficial peroneal nerve).
        • It is most commonly injured during the medial approach for capsular imbrication or metatarsal osteotomy.
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(SBQ18FA.37) Figure A is the preoperative radiographs of a 55-year-old female that underwent hallux valgus correction one year ago. She presents to the office today and notes that her toe has become progressively “too straight.” Performing which of the intraoperative techniques will result in increased risk for iatrogenic hallux varus?

QID: 211506
FIGURES:
1

Complete medial sesamoidectomy

26%

(425/1662)

2

Complete release of abductor hallucis

15%

(246/1662)

3

Post-operative inter metatarsal angle (IMA) of 15 degrees

2%

(31/1662)

4

Complete excision of medial eminence

35%

(585/1662)

5

Excessive lateral capsulorrhaphy

22%

(363/1662)

L 5 A

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(SBQ18FA.24) A 53-year-old woman has had progressive hallux valgus deformity of her right great toe for the last 12 years. She has failed nonoperative management including shoe modifications and padded inserts. Her surgeon recommends a Lapidus procedure (1st metatarsal cuneiform arthrodesis). Which of the following is an indication for this procedure?

QID: 211363
1

Intermetatarsal angle: 12°

4%

(75/1747)

2

Hallux valgus angle: 40°

11%

(200/1747)

3

Age > 50-years-old

1%

(10/1747)

4

Flexible cavovarus deformity

3%

(59/1747)

5

1st tarsometatarsal arthritis

80%

(1395/1747)

L 2 A

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(SBQ18FA.35) A 65-year-old female presents with persistent pain in the left great toe. She is interested in surgery as she has been seeing a podiatrist for many years who had prescribed wider shoewear and an unknown kind of orthotic. Her exam shows pes planus which reconstitutes with heel raise, calluses under the first MTP. The 1st TMT joint shows excessive passive plantar and dorsiflexion. While examining the rest of the lower extremity, both knees are able to hyperextend to about 15 degrees but show no other malalignment. Additionally, she shows she is able to reproduce the finding shown in Figure A. Her current radiographs are shown in Figure B. What is the best surgical option to address her deformity?

QID: 211484
FIGURES:
1

Double metatarsal osteotomy with sesamoidectomy

2%

(37/1944)

2

Double metatarsal osteotomy with modified McBride

18%

(357/1944)

3

Metatarsophalangeal joint arthrodesis with modified McBride

15%

(292/1944)

4

Modified McBride with Akin osteotomy

8%

(148/1944)

5

Tarsometatarsal joint arthrodesis with modified McBride

56%

(1083/1944)

L 4 A

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(OBQ16.216) Which of the following pre-operative measurements would call for a surgical plan involving both a proximal 1st metatarsal osteotomy and a distal-medial closing wedge osteotomy?

QID: 8978
1

HVA 30, IMA 10, HVI 8, congruent MTP

3%

(58/1834)

2

HVA 30, IMA 16, HVI 14, incongruent MTP

10%

(185/1834)

3

HVA 45, IMA 12, HVI 8, DMAA 8

8%

(155/1834)

4

HVA 30, IMA 16, HVI 8, DMAA 16

44%

(809/1834)

5

HVA 45, IMA 16, HVI 14, incongruent MTP

33%

(603/1834)

L 4 B

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(OBQ13.264) A 56-year-old male laborer presents with the deformity shown in Figure A and B. He complains of long standing pain and swelling over the medial aspect of his right forefoot only. There is minimal tenderness with full flexion and extension of the first metatarsophalangeal joint and no tarsometatarsal joint laxity bilaterally. What treatment is most appropriate for this patient?

QID: 4899
FIGURES:
1

Bilateral first metatarsalphalangeal arthrodesis

2%

(80/3989)

2

Bilateral first metatarsal osteotomy with distal bunionectomy

15%

(612/3989)

3

Distal biplanar Chevron osteotomy of right foot only

10%

(382/3989)

4

Proximal first metatarsal osteotomy combined with Akin osteotomy of right foot only

62%

(2463/3989)

5

Bilateral Lapidus procedure combined with bilateral biplanar chevron osteotomy

10%

(416/3989)

L 4 B

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(OBQ13.106) A 45-year-old woman undergoes surgical treatment for hallux valgus. One year later she presents with the painless foot deformity shown in Figure A. All of the following variables can lead to the development of this deformity EXCEPT:

QID: 4741
FIGURES:
1

Resection of the fibular sesamoid

20%

(615/3117)

2

Resection of the tibial sesamoid

63%

(1952/3117)

3

Avascular necrosis (AVN) of the first metatarsal head secondary to a distal osteotomy

5%

(148/3117)

4

Excessive postoperative bandaging

9%

(295/3117)

5

Excessive medial capsular reefing

3%

(82/3117)

L 4 B

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(SBQ12FA.30) The procedure shown in Figure A would be most appropriate for which of the following scenarios?

QID: 3837
FIGURES:
1

HVA = 10, IMA = 6, DMAA= 7, congruent joint

4%

(99/2335)

2

HVA = 40, IMA = 20, DMAA = 8, advanced MTP arthritic changes

8%

(195/2335)

3

HVA = 20, IMA = 10, DMAA = 20, congruent joint

46%

(1081/2335)

4

HVA = 16, IMA = 12, DMAA = 14, congruent joint, TMT hyper-mobility

5%

(121/2335)

5

HVA = 18, IMA = 12, DMAA = 9, congruent joint

34%

(799/2335)

L 4 B

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(SBQ12FA.11) A 47-year-old female presents with persistent left great toe pain. Two years prior, she underwent hallux valgus corrective surgery with a Chevron osteotomy. Figure A exhibits her most recent radiograph. What is the most likely diagnosis and appropriate treatment?

QID: 3818
FIGURES:
1

Post-traumatic arthritis of the metatarsal head and MTP arthrodesis

15%

(400/2699)

2

Osteonecrosis of the metatarsal head and intraarticular osteotomy

4%

(117/2699)

3

Osteonecrosis of the metatarsal head and MTP arthrodesis

79%

(2123/2699)

4

Hallux varus and lateral capsular imbrication

1%

(19/2699)

5

Hallux valgus recurrence and conservative management

0%

(11/2699)

L 2 C

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(OBQ11.240) A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work. Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st metatarsalphalangeal (MTP)joint deformity that passively corrects. A clinical image is shown in Figure A and a radiograph is shown in Figure B. The hallux valgus angle (HVA) is measured at 23 degrees and the intermetatarsal angle (IMA) is measured at 12 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities?

QID: 3663
FIGURES:
1

Distal metatarsal osteotomy (Chevron)

70%

(1711/2450)

2

Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride)

21%

(504/2450)

3

Resection of medial eminence (Silver bunionectomy)

3%

(63/2450)

4

Proximal metatarsal osteotomy and first MTP arthrodesis

4%

(104/2450)

5

Metatarsal cuneiform fusion (Lapidus)

2%

(48/2450)

L 3 B

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(OBQ11.260) A 38-year-old woman has a 2-year history of left greater than right foot pain. Physical examination demonstrates full 1st metatarsalphalangeal (MTP)joint dorsiflexion and plantarflexion with a deformity that passively corrects. A clinical image is shown in Figure A and a radiograph is shown in Figure B. The hallux valgus angle (HVA) is measured at 31 degrees and the intermetarsal angle(IMA) is measured at 16 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities?

QID: 3683
FIGURES:
1

Keller resection arthroplasty

0%

(14/3120)

2

Distal first metatarsal osteotomy (Chevron) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride)

28%

(874/3120)

3

Proximal first metatarsal osteotomy (Scarf) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride)

66%

(2061/3120)

4

Metatarsal cuneiform fusion (Lapidus) with lateral metatarsophalangeal joint soft-tissue release (modified Mcbride)

4%

(112/3120)

5

Lateral metatarsophalangeal joint soft-tissue release (modified Mcbride)

1%

(37/3120)

L 3 B

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(OBQ10.138) A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT:

QID: 3189
FIGURES:
1

Multiple screw fixation across the metatarsocuneiform arthrodesis

11%

(320/2823)

2

Augmentation of the metatarsocuneiform arthrodesis with bone grafting

15%

(431/2823)

3

Dorsiflexion unloading of the first metatarsal

56%

(1577/2823)

4

Correction of the first intermetatarsal angle

3%

(83/2823)

5

Failure of conservative treatments prior to surgery

14%

(389/2823)

L 3 B

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(OBQ09.211) A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. All of the following contribute to the risk of recurrence after surgery EXCEPT:

QID: 3024
FIGURES:
1

Resection of the lateral sesamoid

68%

(1907/2804)

2

Lack of lateral capsular release

8%

(218/2804)

3

Lack of medial metatarsophalangeal joint capsule closure

8%

(216/2804)

4

Use of an Akin procedure alone for a moderate to severe deformity

10%

(275/2804)

5

Undercorrection of the widened 1-2 intermetatarsal (IMA) angle

6%

(179/2804)

L 2 C

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(OBQ08.166) A 55-year-old female attorney complains of progressive pain and deformity of the great toe. The pain is localized to a prominence of the medial metatarsal head. A clinical image is provided in figure A. Which of the following best describes the hallux deformity?

QID: 552
FIGURES:
1

Valgus and supination

11%

(318/2973)

2

Valgus and pronation

85%

(2519/2973)

3

Valgus and hyperextension

3%

(85/2973)

4

Varus and supination

0%

(10/2973)

5

Varus and pronation

1%

(30/2973)

L 1 C

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(OBQ08.211) A 57-year-old female underwent surgery for severe hallux rigidus. Postoperative radiographs are shown in Figure A. One year later she complains of pain at the 2nd metatarsal head and her exam shows a plantar callosity under the 2nd metatarsal head. What procedure could have been combined with her initial operation to prevent this outcome?

QID: 597
FIGURES:
1

Second metatarsalphalangeal joint arthrodesis

2%

(66/2791)

2

Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release

76%

(2129/2791)

3

Flexor to extensor tendon transfer (Girdlestone-Taylor)

5%

(153/2791)

4

Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release

8%

(230/2791)

5

Second metatarsal head resection with extensor tendon and dorsal capsular release

7%

(186/2791)

L 2 B

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(SAE07PE.51) A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?

QID: 6111
FIGURES:
1

Distal soft-tissue realignment

1%

(7/725)

2

Distal first metatarsal osteotomy with distal soft-tissue realignment

14%

(98/725)

3

Proximal first metatarsal osteotomy with distal soft-tissue realignment

23%

(167/725)

4

Proximal and distal first metatarsal osteotomy

61%

(443/725)

5

Osteotomy of the proximal phalanx

1%

(4/725)

L 3 E

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(OBQ07.237) Which of the following clinical scenarios regarding hallux valgus could be appropriatley treated with a modified McBride procedure?

QID: 898
1

35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint

62%

(1412/2266)

2

40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint

25%

(563/2266)

3

70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray

6%

(129/2266)

4

65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus

3%

(69/2266)

5

85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA

3%

(71/2266)

L 3 D

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(OBQ06.267) A 34-year-old woman presents with right foot pain and a callus over the 1st metatarsalphalangeal joint. A clinical image is shown in Figure A. Accommodative shoewear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures B and C. This distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity?

QID: 278
FIGURES:
1

Closing wedge osteotomy of the proximal phalanx (Akin)

13%

(328/2443)

2

Distal soft-tissue release

2%

(40/2443)

3

MTP arthrodesis

21%

(520/2443)

4

Medial eminence resection and exostectomy (Silver)

2%

(46/2443)

5

Scarf osteotomy

61%

(1494/2443)

L 3 B

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(SBQ04PE.75) A 14-year-old female presents for evaluation of painful hallux valgus deformity of her left great toe. She has attempted modifying her footwear and wearing orthotic inserts, however her pain has progressed and she is now having difficulty with ambulation. Current radiographs demonstrate a hallux valgus angle of 36º, an intermetatarsal angle of 16º, and a distal metatarsal articular angle of 21º with closed first metatarsal physis. Which of the following is the best next step in treatment?

QID: 2260
1

Double first metatarsal osteotomy

56%

(853/1533)

2

Proximal Ludloff osteotomy with distal soft tissue procedure

23%

(350/1533)

3

First cuneiform osteotomy

3%

(48/1533)

4

Metatarsophalangeal arthrodesis

2%

(38/1533)

5

Distal biplanar chevron osteotomy

15%

(236/1533)

L 4 D

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