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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan Small Joint Surgery Coverag…
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    CurrentProvidence Health PlanPolicy 438

    Small Joint Surgery (Foot & Ankle) - Coverage Criteria

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    Medical policy governing coverage criteria for elective, non-emergent small joint surgeries of the foot and ankle for Providence Health Plan members (commercial and Medicaid/OHP products; Medicare only when directed by a separate Medicare policy).

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Policy Summary
    PayerProvidence Health Plan
    PolicySmall Joint Surgery (Foot & Ankle)
    Policy CodePolicy 438
    Change TypeNo material changes
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain prior authorization and submit documentation showing ≥3 months of supervised conservative management, imaging within 12 months, and evidence of adequate lower extremity perfusion.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    15+distinct procedures listed
    3 monthsconservative management
    Yesskeletally mature requirement
    Oftenradiographic confirmation
    12 moimaging timeframe
    >15ankle arthroplasty contraindications

    Coverage Criteria for Small Joint Foot & Ankle Procedures

    Ankle Arthrodesis (CPT 27870)

    Ankle arthrodesis may be considered medically necessary when ALL of the following are met

    Ankle arthrodesis primary criteria: A. Radiographic confirmation of advanced/end-stage arthritis of the tibiotalar joint; B. Significant pain and functional impairment due to ankle arthritis persist after at least 3 months of supervised conservative management (unless radiographs show Kellgren-Lawence grade 4); C. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months; Kellgren-Lawrence grade 4 exception

    Also allowed for revision of failed previous reconstructions if bone stock and soft tissue integrity are sufficient; not medically necessary if criteria not met.

    Total Ankle Arthroplasty (CPT 27702, 27703)

    Total ankle arthroplasty may be considered medically necessary when ALL of the following are met

    Primary TAA criteria: A. Radiographic confirmation of advanced/end-stage arthritis of the tibiotalar joint; B. Significant pain and functional impairment due to ankle arthritis persist after at least 3 months of supervised conservative management (unless radiographs show Kellgren-Lawrence grade 4); C. No contraindications exist for ankle arthroplasty (see Policy Guidelines); D. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months; Kellgren-Lawrence grade 4 exception

    Revision TAA has similar all-criteria plus confirmation of implant problem, absence of active infection (or resolution confirmed), and adequate perfusion.

    Bunionette Surgery (CPT 28110)

    Bunionette surgery may be considered medically necessary when ALL of the following are met

    Bunionette criteria: A. Skeletally mature patient (for bony procedures only); B. Significant pain and functional limitation of the fifth MTP and/or presence of a pre-ulcer (Wagner grade 0-1) persisting after at least 3 months of supervised conservative management OR nonhealing ulcer at the site; C. Radiographic confirmation of elevated intermetatarsal angle (>9 degrees) or lateral bony prominence when only exostectomy is planned; D. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months

    Not medically necessary if criteria not met.

    Hallux Valgus Surgery (CPTs 28292, 28295, 28296, 28297, 28299, 28315)

    Hallux valgus surgery may be considered medically necessary when ALL of the following are met

    Hallux valgus criteria: A. Skeletally mature patient (for bony procedures only); B. Significant pain and functional limitation of the first MTP and/or presence of a pre-ulcer (Wagner grade 0-1) persisting after at least 3 months of supervised conservative management OR nonhealing ulcer at the site of the bunion, the sole of the foot or the second toe; C. Radiographic confirmation of an elevated hallux valgus angle (HVA >15 degrees) or intermetatarsal angle (>9 degrees) OR presence of medial bony prominence when only exostectomy (CPT 28292) is planned; D. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months; HVA>15 or IMA>9

    Not medically necessary if criteria not met.

    Lesser Toe Deformity Surgery (CPT 28285)

    Lesser toe deformity surgery may be considered medically necessary when ALL of the following are met

    Lesser toe criteria: A. Significant pain and functional impairment persist after at least 3 months of supervised conservative management or non-healing ulcer attributed to the lesser toe deformity; B. Physical examination or imaging confirmation of a lesser toe deformity; C. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months

    Not medically necessary if criteria not met.

    Hallux Rigidus Surgery (CPT 28289, 28291, 28315)

    Surgery for hallux rigidus may be considered medically necessary when ALL of the following are met

    Hallux rigidus criteria: A. Mild/moderate hallux rigidus confirmed by radiography with either limited and/or painful range of motion of the first MTP joint or activity-limiting pain referable to the first MTP; B. Significant pain and functional impairment persist after at least 3 months of supervised conservative management; C. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months

    Not medically necessary if criteria not met.

    Sesamoidectomy (CPT 28315)

    Sesamoidectomy may be considered medically necessary when ALL of the following are met

    Sesamoidectomy criteria: A. Clinical diagnosis of sesamoiditis, confirmed by radiography; B. Significant pain and functional impairment persists after at least 3 months of supervised conservative management; C. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months

    Not medically necessary if criteria not met.

    First MTP Joint Arthrodesis (CPT 28750)

    First MTP arthrodesis may be considered medically necessary when ALL of the following are met

    First MTP arthrodesis criteria: A. Limited and/or painful range of motion of the first MTP joint; B. Significant pain and functional impairment of the first MTP joint; C. Presence of either severe hallux rigidus confirmed by radiography or failed prior hallux valgus/rigidus surgery; D. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).radiographic confirmation or prior failed surgery

    Not medically necessary if criteria not met.

    First MTP Joint Arthroplasty (CPT 28289, 28291)

    First MTP arthroplasty may be considered medically necessary when ALL of the following are met

    First MTP arthroplasty criteria: A. Use of specified implant types (double-stemmed silastic total prosthesis or metallic hemiarthroplasty); B. Limited and/or painful range of motion of the first MTP joint; C. Significant pain and functional impairment of the first MTP joint; D. Severe hallux rigidus confirmed by radiography or failed prior hallux rigidus surgery; E. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).implant type specified

    Not medically necessary if criteria not met.

    Metatarsal Osteotomy (CPT 28306, 28308)

    Metatarsal osteotomy may be considered medically necessary when ALL of the following are met

    Metatarsal osteotomy criteria: A. Significant pain and functional impairment and/or presence of a pre-ulcer (Wagner grade 0-1) that persists after at least 3 months of supervised conservative management OR non-healing ulcer attributed to the metatarsal deformity; B. Physical examination or imaging confirmation of an anatomical difference requiring osteotomy; C. Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses).3 months

    Not medically necessary if criteria not met.

    Evidence summaries (no explicit coverage rules in this section)

    Evidence summaries for procedures: Multiple systematic reviews and meta-analyses summarize outcomes for hallux rigidus (cheilectomy, arthroplasty, arthrodesis), hallux valgus (MIS vs open; various osteotomies), bunionette osteotomies, and total ankle replacement versus arthrodesis. No explicit coverage criteria provided in this section.

    See individual evidence summaries in chunks 41-55 for outcome rates and limitations

    This policy applies to elective, non-emergent small joint surgical procedures of the foot and ankle. It does not apply to acute fractures or other emergent conditions, which are outside the scope of this elective policy and may be denied if elective criteria are applied.

    Procedures described in this policy have explicit contraindications. For foot procedures these include active joint infection, active systemic bacteremia, active skin infection, inadequate bone stock for osteotomy or arthrodesis, and peripheral vascular disease. For ankle arthroplasty additional contraindications include (but are not limited to) Charcot neuroarthropathy, extensive talar avascular necrosis, malalignment greater than 15° not correctable, prior fusion of the ankle, absence of one or both malleoli, severe osteoporosis/osteopenia, insufficient ligamentous or muscular support, immunosuppressive therapy, neurologic impairment with dynamic imbalance, and psychiatric conditions that hinder perioperative cooperation.

    No additional explicit exclusions are listed in this portion of the policy beyond those noted for elective scope and the contraindications described elsewhere in the document.

    If an unlisted code is submitted for services that are not covered by this policy, the claim will be denied as not covered. Unlisted codes submitted for services that may be potentially covered are reviewed for medical necessity, correct coding, and pricing; prior authorization is recommended to avoid post-service denial.

    Each procedure listed in this policy (for example, ankle arthrodesis, total ankle arthroplasty, bunionette correction, hallux valgus procedures, lesser toe corrections, hallux rigidus surgery, sesamoidectomy, first MTP arthrodesis or arthroplasty, and metatarsal osteotomy) is considered not medically necessary when the specific criteria for that procedure are not met (for example, lack of radiographic confirmation, insufficient trial of supervised conservative management, absence of required skeletally mature status, or inadequate documentation of vascular perfusion).

    No explicit additional 'not medically necessary' statements are present in this section of the document beyond the procedure-specific statements that identify a procedure as not medically necessary when its listed criteria are not satisfied.

    General medical necessity

    Covered when ALL of the following are met

    General coverage: Surgical interventions for ankle and foot arthritis, deformities, and injuries are supported when conservative treatments have failed; procedure choice depends on deformity severity, joint integrity, patient function, alignment, comorbidities, and activity demands.

    Based on evidence summary and clinical practice guidelines (ACFAS, Rheumatology International).

    CPT and Code References

    Ankle ArthrodesisCPTCovered
    CPT 27870Ankle arthrodesis
    Ankle ArthroplastyCPTCovered
    CPT 27702Total ankle arthroplasty (component exchange)
    CPT 27703Total ankle arthroplasty (implant)
    Bunionette SurgeryCPTCovered
    CPT 28110Bunionette surgery
    Hallux ValgusCPTCovered
    CPT 28292Exostectomy (medial eminence) - Hallux valgus
    CPT 28295Correction, hallux valgus with bunionectomy; with resection of proximal phalanx base, when performed, any method
    CPT 28296Correction, hallux valgus with bunionectomy; with proximal metatarsal osteotomy, any method
    CPT 28297Correction, hallux valgus with bunionectomy; with distal metatarsal osteotomy, any method
    CPT 28299Correction, hallux valgus with bunionectomy; with double osteotomy, any method
    CPT 28315Sesamoidectomy, first toe (separate procedure)
    Lesser Toe DeformityCPTCovered
    CPT 28285Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)
    First MTP ArthroplastyCPTCovered
    CPT 28289First MTP joint arthroplasty (total prosthetic replacement with double-stemmed silastic implants)
    CPT 28291First MTP joint arthroplasty (metallic hemiarthroplasty)
    SesamoidectomyCPTCovered
    CPT 28315Sesamoidectomy
    First MTP ArthrodesisCPTCovered
    CPT 28750First metatarsophalangeal joint arthrodesis
    Metatarsal OsteotomyCPTCovered
    CPT 28306Osteotomy, metatarsal; first metatarsal
    CPT 28308Osteotomy, metatarsal; other than first metatarsal, each (with fixation)
    No CPT/ICD/HCPCS codes in this document sectionmixed
    No codes listed
    Covered/Referenced CPT CodesCPT
    27702Arthroplasty, ankle; with implant (total ankle)
    27703Arthroplasty, ankle; revision, total ankle
    27870Arthrodesis, ankle, open
    28110Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)
    28285Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)
    28295Correction, hallux valgus with bunionectomy; with resection of proximal phalanx base, when performed, any method
    28296Correction, hallux valgus with bunionectomy; with proximal metatarsal osteotomy, any method
    28297Correction, hallux valgus with bunionectomy; with distal metatarsal osteotomy, any method
    28299Correction, hallux valgus with bunionectomy; with double osteotomy, any method
    28306Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
    1–10 of 13
    1/2
    Conservative management duration — typical minimum before surgery
    Minimum duration>= 3 months of supervised conservative management before most listed foot/ankle surgeries
    ExceptionException when radiographs show end‑stage disease (Kellgren‑Lawrence grade 4) — conservative trial not required
    DocumentationClinical record must document extent and response to conservative care (e.g., PT, activity modification, medications, injections)
    Hallux valgus angle thresholds used for surgical indication

    Prior Authorization, Documentation, and Clinical Requirements

    Prior Authorization

    Prior authorization required for listed CPT codes

    Prior authorization is required for the elective small-joint foot and ankle procedures listed in this policy. The policy lists the following CPT codes as subject to prior authorization: CPT 27870; CPT 27702; CPT 27703; CPT 28110; CPT 28292; CPT 28295; CPT 28296; CPT 28297; CPT 28299; CPT 28315; CPT 28285; CPT 28289; CPT 28291; CPT 28750; CPT 28306; CPT 28308. Prior authorization is performed per Company processes and may be applied to Medicare members only when directed by a separate Medicare policy.

    Prior Authorization

    Submit all planned procedures in one PA request

    Include all planned procedures in a single prior authorization (PA) request for medical necessity review. Each requested procedure will be reviewed against applicable medical policy; if documentation does not support all requested services a partial approval may be issued and additional procedures performed without approval risk claim denial unless intraoperative findings supporting medical necessity are submitted.

    • Include indication, conservative care details, functional impairment, and imaging with the PA request.
    • If additional procedures are performed that were not fully approved, submit intraoperative documentation with the claim for reconsideration.

    Background and Scope

    This policy addresses elective small joint surgical procedures of the foot and ankle, including arthrodesis, arthroplasty, osteotomy, bunion and bunionette corrections, lesser toe procedures, sesamoidectomy, and related forefoot and ankle operations. For most listed conditions the policy requires radiographic confirmation where specified, documentation of skeletally mature status for bony procedures, documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses), and a trial of supervised conservative management for at least 3 months prior to surgery unless specific exceptions apply (for example, radiographs demonstrating end-stage disease).

    Key Definitions

    Skeletally mature — definition and age notes for policy application
    Definition (policy)Skeletally mature generally defined as age >= 15 years with documentation of closed growth plates under 18 years for ankle arthrodesis
    ApplicationTerm applied to bony procedures throughout policy (skeletally mature required for osteotomies, arthrodesis, arthroplasty where specified)
    DocumentationMedical record must document skeletally mature status (e.g., age and evidence of closed growth plates) when required
    Conservative Management — definition and required elements
    Core componentsFootwear modification and/or padding/accommodative devices (e.g., foot orthosis)
    Complementary strategiesAt least one of: activity modification; anti‑inflammatory medications/analgesics; corticosteroid injection(s); debridement of hyperkeratotic lesions
    Policy Summary
    PayerProvidence Health Plan
    PolicySmall Joint Surgery (Foot & Ankle)
    Policy CodePolicy 438
    Change TypeNo material changes
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain prior authorization and submit documentation showing ≥3 months of supervised conservative management, imaging within 12 months, and evidence of adequate lower extremity perfusion.
    SourceLink
    On This Page
    Coverage Criteria for Small Joint Foot & Ankle ProceduresCPT and Code ReferencesPrior Authorization, Documentation, and Clinical RequirementsBackground and ScopeKey Definitions
    HVA thresholdHallux valgus angle (HVA) > 15 degrees
    Intermetatarsal thresholdIntermetatarsal angle (IMA) > 9 degrees (alternative radiographic criterion)
    UseElevated HVA or IMA required as radiographic confirmation for hallux valgus surgery
    Intermetatarsal angle (bunionette) threshold
    Intermetatarsal angle threshold> 9 degrees (IMA >9°) required for radiographic confirmation for bunionette surgery
    ContextIMA >9° or lateral bony prominence supports indication for operative correction or osteotomy
    Guideline supportACFAS guidance recommends weightbearing radiographs to evaluate bunionette deformity prior to surgery
    Imaging recency requirement
    Required recencyImaging must be completed within the past 12 months to support medical necessity
    Advanced imagingIf CT/MRI/US/bone scan performed, a radiologist’s report is required; radiologist interpretation supersedes if discrepancies
    Surgeon interpretationDocumented interpretation of x‑rays may be performed and read by the operating surgeon
    Improvement in ROM (cheilectomy) — summary metrics from evidence
    ROM improvement (cheilectomy) — magnitudeMean improvement in range of motion ~51.15% after cheilectomy
    Pain reductionVisual analog scale (VAS) pain scores decreased by 72.61% in the pooled review
    Functional outcomeAOFAS scores improved (reported +33.99 points average); complication and revision rates noted (11% complications, 7.4% revisions)
    Prior Authorization

    PA recommended for unlisted or out-of-list CPT codes

    Some procedure CPT codes listed in the coding section are included for reference; unlisted or omitted codes should be submitted with prior authorization to avoid post-service denial. All unlisted codes will be reviewed for medical necessity, correct coding, and pricing at the claim level.

    • Prior authorization is recommended for unlisted codes for potentially covered services to avoid post-service denial.
    • If an unlisted code is submitted for non-covered services addressed in this policy it will be denied as not covered.
    Step Therapy

    Minimum 3 months of conservative management required

    Most surgical procedures in this policy require documentation of at least 3 months of supervised conservative management before surgical coverage will be considered; exceptions apply where radiographs show end‑stage disease (e.g., Kellgren‑Lawrence grade 4).

    • Conservative management duration: at least 3 months unless radiographic exception noted.
    • Exceptions when radiographs demonstrate end-stage disease (Kellgren‑Lawrence grade 4).
    Step Therapy

    Required conservative care elements

    Conservative care must include footwear modification and/or padding/orthosis plus at least one complementary strategy such as activity modification, anti-inflammatory medications/analgesics, corticosteroid injections, or debridement of hyperkeratotic lesions; if conservative management is not appropriate, the medical record must document why.

    • Footwear modification and/or padding/orthosis is required.
    • At least one complementary strategy: activity modification, NSAIDs/analgesics, corticosteroid injection(s), or debridement of corns/calluses.
    Step Therapy

    Orthotics/footwear changes recommended before hallux valgus surgery

    For hallux valgus, conservative measures such as orthotics and footwear changes are described as first-line therapy and should be attempted prior to surgical correction.

    • Document trial of orthotics and footwear modification in the record prior to surgical PA submission.
    Documentation Required

    Documentation must support radiography, maturity, and conservative care

    Clinical documentation submitted with PA or claims must substantiate radiographic confirmation when required, patient skeletally mature status where applicable, and details of at least 3 months of supervised conservative management (or documented reason why it was inappropriate).

    • Radiographic findings and imaging date (imaging within past 12 months preferred).
    • Evidence of skeletally mature status for bony procedures (e.g., age ≥15 with closed growth plates under 18).
    • Details of conservative care duration, modalities used, and outcomes.
    Documentation Required

    Required documentation for medical necessity review

    Submit indication for surgery and documentation of extent and response to conservative care (including outcomes of any prior procedures), medications, physical therapy notes, specific functional impairments, and imaging (performed within past 12 months; x-ray interpretation may be by the operating surgeon; radiologist report required for CT/MRI/US/bone scan).

    • Indication for requested surgery and functional impairment description.
    • Clinical notes documenting conservative care modalities and outcomes.
    • Imaging within 12 months; radiologist report for advanced imaging; radiologist supersedes if discrepancies arise.
    Documentation Required

    Diagnostic confirmation for hallux valgus requires X‑rays

    Diagnosis for hallux valgus is clinical and must be confirmed with X‑rays; include radiographic angles (e.g., HVA, IMA) when relevant to meet criteria.

    • Document clinical diagnosis and attach X‑ray confirming HVA >15° or IMA >9° when applicable.
    • Include radiology interpretation or operating surgeon's x‑ray read (advanced imaging requires radiologist report).
    Billing Rule

    Unlisted codes will be reviewed; PA recommended to avoid denials

    Unlisted CPT codes are reviewed at claim level for medical necessity, coding accuracy, and pricing; to avoid post‑service denial, prior authorization is recommended when an unlisted code is used for a potentially covered service. If an unlisted code is submitted for a non‑covered service addressed in this policy it will be denied as not covered.

    • All unlisted codes reviewed for medical necessity, correct coding, and pricing at claim level.
    • Prior authorization recommended for unlisted codes for potentially covered services; unlisted codes for non‑covered services will be denied.
    Denial Risk

    Elective‑only policy — emergent procedures excluded

    This policy applies only to elective, non‑emergent procedures; acute fractures and other emergent conditions are outside the scope of this elective policy and should not be processed under these elective criteria.

    • Emergent procedures (e.g., acute fractures) are not covered under this elective policy and may be reviewed separately.
    Denial Risk

    Omit risk by including multiple procedures in single PA — failure risks denial

    When multiple procedures are planned or may become necessary during surgery, include all relevant procedures in one PA request; failure to do so may result in partial approval and performing additional procedures not approved can lead to claim denial unless intraoperative documentation justifying the additional procedure is submitted.

    • All relevant procedures should be included in a single PA request.
    • If additional procedures are performed without prior approval, submit intraoperative findings with the claim to support medical necessity for reconsideration.
    Note

    No other explicit authorization/denial rules stated

    The policy notes no additional explicit authorization or denial rules in portions of the document beyond those described; follow the stated PA, documentation, and coding guidance above.

    Denial Risk

    Unlisted code submissions for non‑covered services will be denied

    If an unlisted code is submitted for a service that is non‑covered under this policy, it will be denied as not covered; verify coverage applicability or obtain PA for potentially covered unlisted services.

    • Unlisted codes for non‑covered services addressed in this policy will be denied as not covered.
    • Obtain PA for unlisted codes when the service may be covered to avoid post‑service denial.
    Note
    Note
    Documentation requirementIf conservative management is not appropriate, the medical record must clearly document why it is not reasonable
    Wagner's Classification — diabetic foot ulcer grading system (Grade 0-5)
    ScaleWagner's Classification grades diabetic foot ulcers from Grade 0 to Grade 5
    Grade 0Skin intact but 'foot at risk' due to bony deformities
    Grade 5Extensive gangrene
    Hallux rigidus — definition
    DefinitionHallux rigidus: arthritis of the big toe (first MTP) joint causing stiffness and pain due to cartilage degeneration
    Clinical featuresLimited and/or painful ROM or activity‑limiting pain referable to first MTP; severity guides surgical options (cheilectomy, osteotomy, arthroplasty, arthrodesis)
    Policy contextSurgery considered when mild/moderate disease confirmed by radiography and after >=3 months conservative care
    Hallux valgus — definition
    DefinitionHallux valgus: lateral deviation of the big toe toward the second toe, often forming a bunion at the base
    DiagnosisClinical diagnosis confirmed with weightbearing X‑rays; radiographic criteria include HVA >15° or IMA >9°
    Treatment spectrumConservative measures (orthotics, footwear changes) first‑line; surgical correction indicated for persistent pain/functional limitation with radiographic deformity
    Ankle arthrodesis vs arthroplasty — definition and comparative context
    DefinitionsAnkle arthrodesis = surgical fusion of the ankle joint; total ankle arthroplasty = replacement of the ankle joint
    Comparative contextArthrodesis is reliable for end‑stage ankle arthritis, particularly in younger/high‑demand patients; arthroplasty may be considered in older, lower‑demand patients with preserved alignment and bone stock
    Preoperative planningImaging (weightbearing radiographs, CT) and patient selection (alignment, bone stock, comorbidities) guide choice between fusion and replacement
    Conservative treatment — examples prior to surgery
    Examples of conservative treatmentsPadding and local protective measures (e.g., corn/callus debridement)
    Footwear modificationShoe modification and accommodative devices (orthotics) to reduce pressure and improve alignment
    Other examplesActivity modification, NSAIDs/analgesics, corticosteroid injections; attempt these prior to operative intervention unless not appropriate and documented