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First metatarsophalangeal joint arthrodesis
Clin Podiatr Med Surg 21 (2004) 65 – 96
First metatarsophalangeal joint arthrodesis Gerard V. Yu, DPM, FACFASa,*, Paul O. Gorby, DPMb a
23823 Lorain Road, Suite 280, North Olmstead, OH 44070, USA b 4607 Chouteau, Shawnee, KS 66226, USA
Since the initial description of first metatarsophalangeal arthrodesis with an ivory peg by Clutton in 1894 [1], numerous technique modifications and refinements have been described. Regardless of the technique employed, the procedure continues to be a time-honored procedure for the treatment of various disorders and pathology of the first metatarsophalangeal joint. With the exception of an article by Castro and Klaue [2], who discussed a plantar medial incisional approach for insertion of a screw, most authors recommend a dorsal or dorsomedial incision centered over the joint. Yu and Shook [3] have advocated an interspace release with or without a fibular sesamoidectomy in patients with a severe bunion deformity to aid in relocation of the joint and fixation of the arthrodesis site and eliminate a potentially deforming force. Others have recommended preserving the intrinsic musculature to aid in reduction of the first and second metatarsal splaying following fusion, transforming the abductory force from the adductor hallucis muscle on the phalanx to the metatarsal segment. Although most authors recommend complete disarticulation of the joint using an open technique, an arthroscopic approach to first metatarsophalangeal joint (MPJ) arthrodesis has recently been described with the intent of minimizing traditional dissection [4]. The true benefits of this approach have yet to be fully realized. Various joint resection techniques have also been described. Some authors recommend curettage of the adjacent joint surfaces using rongeurs, curettes, and burrs [3– 6], whereas others describe concentric crescentic saw cuts in the adjacent portions of the joint [7]. Many authors describe straight or traditional saw cuts performed in the metatarsal and phalanx in a manner to allow dorsiflexion and adduction of the hallux [8– 15]. In his initial paper in 1952, McKeever illustrated bone cuts resulting in a ‘‘peg-in-hole’’ construct [8]. More recent literature favors use of specifically
* Corresponding author. E-mail address: [email protected] (G.V. Yu). 0891-8422/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0891-8422(03)00111-3
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designed conical reamers, initially manual and now power driven, to shape the adjacent surfaces of the joint [3,16 – 26]. A recent article by Kennedy and Coughlin describes using such reamers ‘‘backwards,’’ making the phalanx base convex and metatarsal head concave [24] and producing a reverse ‘‘peg-in-hole’’ construct. They believed this precluded the need for plate or screw fixation in patients with poor bone stock. In cases where previous surgery has been performed and a large deficit exists, bone grafting may be the only method of joint preparation applicable [3,26,27]. Brodsky et al used autologous tricortical iliac crest graft with additional cancellous bone for packing into the fusion site in his study of 12 patients [27]. Myerson et al initially used autologous bone from the iliac crest and distal tibia, but switched to allografts, observing in alternative procedures that nonunions were not occurring with the allograft [26]. When significant grafting is required, especially to restore length or major deformity resulting from implant removal, autogenous bone grafts are preferred. Their osteoinductive, osteoconductive, and osteogenic properties make them ideal grafts to minimize delayed union, nonunion, or pseudoarthrosis. Once the adjacent joint surfaces have been prepared, the position of fusion becomes the focus. It is the authors’ opinion that this is the single most important intraoperative consideration made when performing fusion of the first metatarsophalangeal joint. It is the position of fusion that ultimately determines effective function. Throughout the literature, a common theme exists with respect to the position of fusion: 0 degrees in the frontal plane, 20 to 40 degrees of dorsiflexion, and 15 to 25 degrees of abduction of the proximal phalanx in relation to the first metatarsal (see references [4,5,7 –9,11 –13,15,17,19 – 22,24 – 28]). Other authors have emphasized the importance of positioning of the hallux relative to the second toe (see references [3,6,14,22]). Yu and Shook denounce the above-mentioned values, stating that the great toe should be placed in the position that ultimately will position it parallel to the second digit when weight bearing [3]. Some authors have stressed the importance of not overdorsiflexing the first MPJ to prevent dorsal hallux interphalangeal irritation in shoe gear [14,22]. The final step of the procedure involves fixation and stabilization of the fusion site. This is the portion of the arthrodesis that has seen the greatest changes and variations since its first description in 1892 by Clutton. McKeever was the first to describe the use of a screw, placed plantarly through the proximal phalanx into the proximal shaft of the first metatarsal [8]. Screws (cannulated and noncannulated) today continue to be a commonly employed fixation device, whether it is two crossing (see references [3,6,7,11,14,17,18,26,27]) or two parallel screws [4,9,14]. A single screw passing either distal or proximal medially across the joint (see references [14,20,22,23]) has also been described. Castro and Klaue even mentioned passing a screw from plantar proximal to dorsal distal across the fusion site [2]. The authors have at times employed three small cortical or cancellous screws to achieve rigid internal compression fixation. In addition to screws, Kirschner wires (K-wires) or Steinmann pins are commonly used fixation devices for this procedure and can be buried below the fascia, within the subcutaneous tissue, or left external. A single K-wire, although
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risky because of rotatory forces across the fusion site, has been described [13]. Sussman et al refined this technique by adding cerclage wire around the fusion site to enhance compression [15]. More commonly, multiple K-wires or Steinmann pins are used [3,21,25], with Smith et al describing five threaded K-wires placed percutaneously [21]. Plates have also become commonplace in the fixation of first MPJ fusion (see references [3,14,18,19,24]). Coughlin has described the Luhr oral surgery/mandibular plate and its effectiveness [19,24]. Plates are particularly helpful in the cases involving bone grafting [26,27], secondary to their increased stability. When used, plates are commonly used in combination with other fixation devices, such as screws and K-wires [11,17]. Less common fixation devices have been described, including crossing Herbert screws [3,5,14], miniature external fixation devices [3,12,29], absorbable fixation [28], memory compression staples [11], and even suture, such as catgut [10]. Harrison and Harvey, in 1963, advocated no fixation, by simply cutting the first metatarsal head into an ‘‘osteotome’’ blade shape and ‘‘impaling’’ the phalanx onto the metatarsal. This technique known as the ‘‘Brockman technique’’ [12] has not been widely accepted or employed. There is general agreement that fixation is a necessary component of first metatarsophalangeal joint arthrodeses. Cadaveric studies have been performed to determine the arthrodesis fixation type providing the strongest construct. Two studies have found that any construct with a plate was consistently more stable in regard to the load needed for failure [11,17]. Curtis et al believed that the method of joint surface preparation was more important than the fixation method for stability, finding that conical reaming with interfragmentary screws was stronger than planing of the joint surfaces with plate/ screw fixation [20].
Author’s surgical approach to first MPJ arthrodesis Numerous techniques have been developed for the first metatarsophalangeal joint arthrodesis. These techniques have been greatly modified since the 1800s. At the authors’ institution, these techniques are a predictable procedure with good overall results. The following is a detailed description of the surgical technique and considerations employed by the senior author for the past several years. Some refinements have been made in the surgical technique of joint resection and internal fixation not reflected in previous publications by the senior author.
Incisional approach and exposure A dorsomedial linear incision medial to the extensor hallucis longus tendon has consistently provided excellent surgical exposure with minimal damage or irritation to the adjacent neurovascular structures, particularly those located medially. If the surgical scar is of cosmetic concern, a medial incisional approach
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can easily be employed in most cases. A medial incisional approach will provide excellent exposure with a virtually nonvisible scar when viewed from the dorsal aspect of the foot; exposure of the lateral aspect of the joint becomes somewhat more tedious and challenging. Dissection continues through the level of the subcutaneous tissues with the neurovascular structures protected. A longitudinal linear incision through the deep fascia, capsule, periosteum, subperiosteal, and subcapsular completely exposes the base of the phalanx and the entire first metatarsal head (Fig. 1). The extent of dissection circumferentially around the base of the phalanx and the metatarsal head will vary; it is influenced by the rigidity and severity of the deformity and the need for extensive exposure in cases where previous surgical procedures have been performed, resulting in significant alteration of the normal alignment, architecture, and configuration of the joint. The more important areas of surgical exposure include the dorsomedial aspect of the first metatarsal head and neck, the medial aspect of the base of the proximal phalanx, and the lateral aspect of the base. These areas are important for visualization and insertion of internal fixation devices, particularly Kirschner wires and screws. Dorsal exposure becomes important when employing plate fixation. Interspace dissection is not performed unless it is felt that a release of the lateral soft tissue structures or excision of the fibular sesamoid is necessary to achieve correction of the deformity. There have been situations where the senior author felt it was necessary to perform a complete interspace release and remove the fibular sesamoid. In cases with severely increased IM angles, nonreducible following interspace release, proximal osteotomies have been performed (Fig. 2). On occasion, a lengthening of the extensor hallucis longus tendon is necessary; this is usually performed in situations where there is a severe contracture of the hallux in
Fig. 1. Intraoperative photograph showing completed dissection and exposure of the metatarsal head and phalangeal base in preparation for joint resection using a curettage technique.
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Fig. 2. (A, B) Preoperative radiograph of patient with a recurrent HAV deformity and iatrogenic metatarsus primus varus necessitating concomitant osteotomy following soft tissue release and fusion of the first MPJ. Fusion was performed first, and because of persistent splaying, a closing wedge osteotomy was performed with enhanced AO/ASIF internal screw fixation. Postoperative radiograph displays excellent correction of the deformity, including correction of the HAV and MPJ deformities.
the form of hallux valgus or hallux malleus. Likewise, the extensor hallucis brevis may also require release.
Joint resection techniques Any abnormal or exuberant bone formation around the metatarsal head or proximal phalanx base is removed and the peripheral bone recontoured with hand and power instrumentation (Fig. 3). A small needle-nose rongeur and a power burr are indispensable instruments in recontouring and reconfiguring the head of the metatarsal and base of the phalanx particularly when previous surgical procedures have been performed. The articular surfaces are then removed. The most common technique for cartilage resection is based on the principles of curettage, a technique previously
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Fig. 3. (A, B) Intraoperative photographs showing the appearance of the joint following complete disarticulation and exposure. Notice the abundance of exuberant bone formation secondary to extensive degenerative changes. (C, D) Same patient following complete remodeling of all peripheral exostoses from the metatarsal head and phalangeal base. Articular cartilage has not yet been removed from the adjacent joint surfaces and is the next step.
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Fig. 3 (continued ).
published by the senior author. The cartilage from the base of the phalanx is removed with bone curettes and a power burr, preserving the concavity of the phalanx (Fig. 4). The cartilage in the metatarsal head is removed with a rongeur and the head recontoured, preserving its convexity (Fig. 5). The cartilage and subchondral bone plate are usually removed to enhance apposition of raw cancellous bone surfaces, which in turn encourage arthrodesis and discourage delayed or nonunion. Preservation of the convexity of the metatarsal head and concavity of the phalangeal base provides an excellent reciprocal fit and allows the surgeon to easily reposition the toe in virtually any plane should the need arise
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Fig. 4. Appearance following resection of the cartilage from the base of the phalanx and aggressive burring to subchondral bone. Note preservation of the concavity of the base to facilitate positioning on the metatarsal head.
Fig. 5. Removal of the cartilage from the head of a metatarsal using a double action bone rongeur. Convexity of the head is preserved. Aggressive removal is performed to enhance arthrodesis and minimize bone-healing complications, particularly in higher risk patients.
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Fig. 6. Fenestration of the phalangeal base with a small, 1.1-mm wire pass drill. The resultant bone paste is left within the fusion site to help enhance arthrodesis under the presumption that this live bone will be beneficial to the healing process.
based on intraoperative radiograph or clinical assessment. Fenestration of the adjacent surfaces with a small 1.1- or 1.5-mm wire pass drill can be performed at this time or later (Fig. 6). The authors believe that fenestration of the adjacent surfaces with preservation of the resultant ‘‘bone paste’’ within the fusion site encourages consolidation. In certain cases it is desirable to significantly shorten the first ray segment. The most common example is when performing a panmetatarsal head resection for rheumatoid foot deformity or other severe disabling and crippling deformity. In such cases the entire first metatarsal head segment is excised with a power saw and the bone recontoured to create a convex distal stump. A crescentic saw blade can also be used and will create a convexity of the metatarsal segment (Fig. 7). A small section of the phalangeal base can be resected to enhance the fit between opposing surfaces (Fig. 8). In cases where the deformity is primarily in the transverse plane (ie, severe hallux varus or hallux valgus), the crescentic saw is used from a dorsal to plantar direction. In situations where the hallux deformity is in the sagittal plane (ie, severe plantarflexion with a dorsal bunion or severe dorsiflexion as a result of muscle imbalance), the saw enters from a medial to lateral direction. Various conical reamer systems have been developed to produce a peg-in-hole fit when performing a first MPJ arthrodesis (Fig. 9). Though the instrumentation is
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Fig. 7. Use of crescentic saw blade to resect the first metatarsal head and preserve the convexity of the head. This technique is desirable for correction of transverse plane deformity and when shortening of the metatarsal segment is desirable.
ingenious, it requires an exacting alignment to ensure fit between the proximal and distal segments. In addition, all of the reaming systems currently available result in significant shortening to the first ray segment; providing this is desirable, such systems may be beneficial. Otherwise, it has been the author’s experience that reaming systems are more cumbersome and complicated than necessary. The senior author has not found them to be necessary to achieve an excellent outcome when performing first MPJ arthrodesis.
Positioning of fusion The position of fusion is critical to a functional outcome and will be determined by the position of the lesser toes, most importantly the second digit, as well as the
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Fig. 8. Use of crescentic saw blade to resect the phalangeal base. Note minimal bone resection is performed to preserve the length and enhance the fit with the first metatarsal, which is also resected with the same blade. If shortening of the segment is desired it is resected from the metatarsal head.
patient’s expectations and needs. For example, the use of high-heeled shoes postoperatively will require a position of fusion in more dorsiflexion. Otherwise, minimal dorsiflexion is recommended—a few degrees from the ground-supporting surface. Intraoperatively, the foot is loaded against a firm plate with the ankle at 90 degrees; the distal pulp of the toe should make minimal or slight contact with the plate (Fig. 10A). With dorsiflexion of the IPJ, the hallux should be off the ground-supporting surface slightly (Fig. 10B). With regard to transverse plane alignment, the hallux should be parallel to the second toe. It should not be touching the second toe with any significant pressure;
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Fig. 9. (A, B) Conical reamers available for joint resection when performing first MPJ arthrodesis. The authors discourage their use unless shortening is desirable.
likewise, it should not be separated from the second toe significantly. Either extreme may result in irritation of the hallux nail at either its medial or lateral border. Shoe gear may be incompatible, and pressure lesions may develop. The authors emphasize that a specific angular relationship with the first metatarsal is not an effective criteria. A hallux that is fully congruous at the first MPJ but significantly splayed from the second metatarsal will likely appear as a varus
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Fig. 10. (A, B) Intraoperative photo demonstrating simulated weight bearing to ensure proper position of fusion. Note the increased functional dorsiflexion that is achieved by motion at the IPJ of the hallux.
deformity. The position of the hallux with respect to the first metatarsal is not the center of focus when performing first MPJ arthrodesis; rather, the orientation and alignment of the hallux with respect to the second toe is the reference for transverse plane correction. In some cases (ie, rheumatoid arthritis or severe HAV with residual metadductus), it may be difficult to predict the final resting position of the lesser digits because of other concomitant procedures (eg, pan metatarsal head resection or digital fusions with soft tissue releases) (Fig. 11). In these cases, the art of surgery will dominate the science of surgery.
Internal fixation techniques Once the fusion site is properly positioned, temporary fixation is achieved; two small-diameter Kirschner wires are most commonly employed and correspond with the guide pins for various cannulated screw systems (Fig. 12). In
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Fig. 11. (A, B) Pre- and postoperative dorsoplantar radiographs following panmetatarsal head resection with first MPJ arthrodesis. Note the position of fusion in anticipation of the final resting position of the lesser toes. If the hallux had been fused in a rectus attitude, a large space would be present between the hallux and second toe, an undesirable clinical appearance to most patients.
other cases, Kirschner wires, usually 0.062 mm diameter, are used as the final form of fixation. The pins are bent and rotated externally to lock against the outer cortex of the metatarsal, thus maintaining rigid, stable fixation. In other cases, the small Kirschner wires will serve as the guide pins for cannulated screws. The use of multiple Kirschner wires represents one type of fixation that has been beneficial in patients with compromised bone. This is not uncommonly encountered in elderly patients or patients who have previously undergone resection arthroplasty. Two or three, and rarely four, 0.062-mm Kirschner wires are inserted in a crossing technique (Fig. 13). Kirschner wires or Steinmann pins can also be inserted in an axial direction and are typically reserved for patients undergoing concomitant fusion of the interphalangeal joint of the great toe (Fig. 14). The use of Kirschner wires that cross the interphalangeal joint when
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Fig. 11 (continued ).
the HIPJ is not being fused is discouraged because this promotes and encourages degenerative arthritis postoperatively. Kirschner wires are rarely left external to the skin; rather, they are bent and locked against the external cortex of the bone, preventing inward migration while facilitating easy and ready retrieval should they loosen. When possible, visualize the exit points of the Kirschner wires to ensure they do not protrude excessively beyond the cortex of the bone, causing irritation to the surrounding soft tissues. Although this technique does not impart compression at the fusion site, it does provide excellent rigidity and stability to the fusion construct. The authors have not witnessed a higher incidence of bonehealing complications as a result of the use of Kirschner wires in patients with compromised bone. One of the more common and popular techniques is that of cortical or, more commonly, partially threaded cancellous screws. Cannulated screw systems are recommended because they discourage inadvertent migration of the screws in an undesirable direction (Fig. 15A). Though a single cortical or cancellous screw can be effective, two or three crossing screws are preferred. One screw is typically inserted from proximal medial to distal lateral and a second screw inserted from distal medial to proximal lateral. The screw that crosses the fusion site from distal to proximal usually travels in a slightly plantar direction, whereas the screw
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Fig. 12. Intraoperative dorsoplantar radiograph showing temporary fixation of the fusion site with crossing Kirschner wires. Position was adjusted because of slight overcorrection. The Kirschner wires served as guide pins for insertion of cannulated cancellous screws.
inserted from proximal medial to distal lateral usually exits the lateral aspect of the phalangeal base midway between the dorsal and plantar surface (Fig. 15B). If the screw exits in the plantar lateral aspect of the proximal phalanx it tends to irritate the neurovascular structures, necessitating removal at a later date. With regard to the diameter of the screws, the senior author formerly used 4.0-mm screws but has come to favor smaller screws, such as 3.5-mm partially threaded cancellous screws and, more recently, the screws found within the Synthes (Paoli, Pennsylvania) modular hand system (Fig. 16). The final choice of screw type and direction of insertion will be based on the surgeon’s experiences and preferences. The authors favor two or more screws of a smaller diameter rather than fewer screws of a larger diameter. The Kirschner wires introduced to provide temporary fixation frequently serve as pilot holes for drilling before final screw insertion. If there is any question or concern that the two screws will collide within the fusion site, the joint can be disarticulated and the path and direction of the Kirschner wires visualized, ensuring that this will not occur. Collision of screws within the fusion site at the time of insertion is more likely to occur with larger diameter screws that have
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been inserted with a more haphazard and less precise technique. Fluoroscopic visualization of Kirschner wire and screw insertion is often helpful. Plate fixation is usually reserved for more difficult and challenging situations. These include previously failed arthrodesis, fusions requiring an interpositional bone graft, or patients at higher risk for a bone-healing complication, such as those with peripheral neuropathy or diabetes. It should be emphasized that though plates applied dorsally provide excellent rigidity to the fusion construct, they are not as effective as initially thought in imparting significant compression, even when employing eccentric drilling techniques. The technique of applying a dorsal plate with eccentrically drilled holes becomes less effective as more bending in the plate is required; in other words, the greater the metatarsal declination the less effective a dorsal plate will be at providing compression. It can, however, provide excellent stability to the fusion site. It continues to be popular among the orthopedic foot and ankle community. The authors’ technique of plate fixation has been refined over the years to routinely include an interfragmental compression screw crossing, most commonly
Fig. 13. (A, B) Preoperative and postoperative radiographs following first MPJ fusion with crossing buried Kirschner wires, which are locked against the external cortex of the bone to prevent loosening and migration. Postoperative film is 8 months following fusion.
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Fig. 13 (continued ).
from distal medial to proximal lateral. In some cases, a second crossing screw inserted from proximal medial to distal lateral is added in addition to a dorsal plate. The authors attempt to secure the plate to the proximal phalanx with at least three screws and a minimum of four or five screws in the first metatarsal (Fig. 17). The plates and screws of the Synthes modular hand system seem to be the most effective (Fig. 18). The traditional one-quarter tubular and one-third tubular plates do not lend themselves well to various configurations when applied to the first MTP joint arthrodesis site. They also hinder visualization and assessment of the fusion site on subsequent radiographs (Fig. 19). If an interpositional bone graft is required it will be one of an autogenous nature from either the calcaneus or the ilium. At least one, and preferably two, screws are inserted to fixate the plate to the graft. Two or three screws distal to the graft and three or four screws proximal to the graft are desired (Fig. 20). Precise technique is essential to a successful outcome. The use of interpositional bone grafting and plate application is not for the novice surgeon. A higher degree of knowledge, training, and experience is necessary in most cases.
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Fig. 14. Concomitant IPJ fusion of the hallux with two longitudinal small Steinmann pins. A single screw is not recommended because of frontal plane rotational instability. Two longitudinal points of fixation prevent rotation but do not provide compression.
The use of miniature external fixators is also an excellent fixation technique when performing first MPJ fusion (Fig. 21). Although somewhat cumbersome by their nature, they can provide excellent rigid fixation with varying degrees of compression at the fusion site. They may be particularly beneficial when attempting to salvage a previous nonunion in which open resection or bone grafting are not necessary. They have also proven beneficial when salvaging the first MTP joint in situations of previous infection where it is desirable to avoid the placement of internal fixation devices. Current day devices allow ready positioning in multiple planes. In difficult and complicated cases where the establishment of length is an issue, they can be employed to achieve distraction osteogenesis more proximally while providing compression fixation at the joint. Various miscellaneous fixation devices and techniques can also be employed but are not commonly used by the authors. These include traditional staples, more recently introduced compression staples, figure-of-eight tension band wiring
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Fig. 15. (A, B) Intraoperative photograph and postoperative radiograph demonstrating fusion with two 4.0-mm partially threaded cancellous bone screws providing internal rigid compression fixation. Note point of entry of each of the screws from the distal medial and proximal medial aspects of the joint.
(Fig. 22), and cerclage wiring. Though several newer devices are on the horizon, time has proven that traditional techniques are consistent and effective when applied for the proper conditions with exacting technique.
Postoperative management Postoperative management will be guided by several factors, including patient compliance, the indication for the fusion, and the surgical technique employed. The authors prefer non –weight bearing for approximately 4 to 6 weeks with progressive increased weight bearing over several weeks. Though cast immobi-
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Fig. 15 (continued ).
lization is not mandatory it does afford significant protection of the area and is believed to be superior to traditional surgical shoes. Weight bearing is the single most detrimental influence on the bone-healing process. Early or excessive weight bearing and ambulation encourage bone-healing complications, such as a delayed union, nonunion, or pseudoarthrosis. Serial radiographs are taken every 3 to 4 weeks to monitor the consolidation process. When radiographic evidence of migration, fracture, or failure of the internal fixation devices is seen, this strongly suggests an impending bone-healing complication and the need to alter the postoperative care. Patient compliance is critical to the successful outcome of any exacting procedure, including first MTP joint arthrodesis. Compression stockings and wraps are helpful in controlling postoperative edema, which is not problematic. Physical therapy may be helpful in educating the patient to a slightly new gait pattern and resolving edema and sensitivity to the area. Caution should always be given to avoid manipulation of the fusion site. When necessary, custom-molded orthotics are employed to help in the balance and
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Fig. 16. Fusion of the joint with three 2.4-mm cortex bone screws from the Synthes Modular Hand System set.
distribution of weight. A semirigid device with a good layer of shock absorption material is recommended. Should internal fixation devices loosen or cause irritation of surrounding structures, they can be removed, in most cases, easily. Although removal is usually unnecessary, the authors advise all patients during the initial surgical consultation that they may loosen at any time postoperatively, including years after the surgery. Removal can be performed under a local anesthetic block with or without sedation in the office or outpatient setting.
Complications Although a functional outcome is desired and is the norm, complications can and do occur. Most complications are related to a malposition of fusion. Excessive dorsiflexion or plantarflexion as well as abduction or adduction can cause difficulty with weight bearing and ambulation and with the fitting of conventional
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Fig. 17. Intraoperative photograph showing fusion with a Synthes Modular Hand System plate and multiple 2.4-mm cortical screws. An interfragmentary single screw is seen crossing the joint from distal medial to proximal lateral. Three screws are present in the phalanx, and five will be inserted in the metatarsal segment in the plate.
shoe gear. Malposition may manifest itself as increased pressure beneath the first metatarsal resulting in sesamoiditis and lesions at the distal pulp of the toe, or in the case of excessive dorsal flexion, irritation over the interphalangeal joint (Fig. 23). Barring the issue of high-heeled shoes, minimal dorsiflexion is needed when performing a first MTP joint fusion. Some of the motion normally taken up at the metatarsophalangeal joint will be absorbed through the medial column and the interphalangeal joint of the hallux. Malposition usually requires a take-down of the original fusion with repositioning and revision arthrodesis; in some cases, an osteotomy of the first metatarsal may be sufficient. Bone-healing complications, such as delayed union, nonunion, or pseudoarthrosis can be problematic (Fig. 24). Fortunately, most of the literature has borne out that nonunions of this joint fusion are often tolerable by patients. Conservative management includes continued immobilization and non –weight bearing with the use of noninvasive electrical bone stimulation in some cases. Symptomatic cases that fail to achieve successful union will probably require revision arthrodesis with or without an interpositional autogenous corticocancellous graft. Possible sites for procurement of this graft include the calcaneus, the distal tibia, or the anterior or posterior ilium. When performing revision arthrodesis it is critical that the fixation be enhanced. The authors believe that compression is the most valuable component of the revision surgery to achieving arthrodesis.
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Fig. 18. (A – C) Preoperative and postoperative radiographs of a first MPJ fusion with a single interfragmentary screw from distal medial to proximal lateral and a small plate and four screws for enhanced stability. The authors have found this construct to be effective in higher risk fusions. A longer plate affording even more screws within the metatarsal or phalanx are available.
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Fig. 18 (continued ).
The management of complications following first MTP joint arthrodesis must be individualized to each patient. Patients have varying degrees of tolerance for malposition as well as bone-healing complications. Certain patients have much higher expectations and thus it may be more difficult to satisfy, whereas other patients will be grateful for the significant improvement they have achieved even with a failed fusion. Dedication and patience must complement surgical skills and abilities. The approach to management of the complication requires a careful
Fig. 19. (A, B) Traditional one-third tubular plate with five screws with a single interfragmentary screw from proximal medial to distal lateral. Note how the size of this traditional plate hinders visualization of the fusion site in comparison to the plate shown in Figure 18B.
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Fig. 21. Miniature external fixation for revision arthrodesis of the first MPJ. Preoperative conventional bone scan demonstrated a hypertrophic, viable nonunion and, consequently, a conventional open procedure was not performed.
Fig. 20. (A – C). Intraoperative appearance and preoperative and postoperative radiographs demonstrating plate fixation with interpositional corticocancellous bone graft for salvage fusion of the first MPJ. Patient had previously undergone a minimal incision procedure for symptomatic HAV deformity. One screw secures the graft with additional screws eccentrically drilled to enhance compression at the proximal and distal graft host interfaces.
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Fig. 22. Figure-of-eight tension band wiring with multiple Kirschner wires in a patient who has diabetic neuropathy. An additional Kirschner wire has been inserted to stabilize the IPJ of the hallux.
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Fig. 23. (A, B) Postoperative complication of hallux flexus deformity with dorsal irritation of the IPJ. Although position of fusions with respect to dorsiflexion appears acceptable on the lateral radiograph, less dorsiflexion would have been optimal.
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Fig. 24. Nonunion of first MPJ fusion with Herbert bone screws. Although rigid, these screws have been shown to impart less compression than traditional screw fixation techniques.
assessment of the condition, patient’s overall health status, the desired outcome by the patient, and the knowledge, experience, and abilities of the surgeon.
Summary First MTP joint arthrodesis continues to be a time-honored, effective, and valuable procedure as a primary or secondary surgery for various pathologies afflicting the first ray segment. Though commonly thought of as a salvage procedure, it has proven beneficial in the management of primary hallux limitus and rigidus, geriatric hallux valgus deformity, severe arthritis of any etiology, and conditions in which joint instability or deformity are not readily correctable by more traditional approaches. Since its initial description in the 1800s, the procedure has continued to be popular among orthopedic and podiatric surgeons. Success of the procedure is highly dependent on the position of fusion. Though surgeons are often fascinated and at times obsessed with a particular fixation technique, it cannot be overemphasized that this takes a back seat to the importance of achieving proper
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position to meet the needs of an individual patient. Unlike joint resection or implant arthroplasty procedures, which commonly leave the hallux lacking stability and propulsion, first MPJ fusion has been shown to be effective during weight bearing and propulsion. The success enjoyed by the senior author continues to reinforce that motion is not necessary at the first MTP joint for good, pain-free function.
References [1] Clutton HH. The treatment of hallux valgus. St. Thomas Hospital Gazzette 1894;22:1 – 12. [2] Castro CD, Klaue K. Revisiting an alternative method of fixation for first MTP joint arthrodesis. Foot Ankle Int 2001;22:687 – 8. [3] Yu GV, Shook JE. Arthrodesis of the first metatarsophalangeal joint. JAPMA 1994;84:266 – 80. [4] Carro LP, Vallina BB. Arthroscopic-assisted first metatarsophalangeal arthrodesis. Arthroscopy 1999;15:215 – 7. [5] Wu KK. Fusion of the metatarsophalangeal joint of the great toe with Herbert screws. Foot Ankle 1993;14:165 – 9. [6] Lombardi CM, Silhanek AD, Connolly FG, Dennis LN, Keslonsky AJ. First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study. J Foot Ankle Surg 2001; 40:137 – 43. [7] Shute GC, Sferra JJ. Use of crescentic saw for arthrodesis of the first metatarsophalangeal joint. Foot Ankle Int 1998;19:719 – 20. [8] McKeever DC. Arthrodesis of the first metatarsophalangeal joint for hallux valgus, hallux rigidus, and metatarsus primus varus. J Bone Joint Surg 1952;34A:129 – 34. [9] Turan I, Lindgren U. Compression-screw arthrodesis of the first metatarsophalangeal joint of the foot. Clin Orthop Rel Res 1987;221:292 – 5. [10] Chana GS, Andrew TA, Cotteril CP. A simple method of arthrodesis of the first metatarsophalangeal joint. J Bone Joint Surg 1984;66B:703 – 5. [11] Neufeld SK, Parks BG, Naseef GS, Melamed EA, Schon LC. Arthrodesis of the first metatarsophalangeal joint: a biomechanical study comparing memory compression staples, cannulated screws, and a dorsal plate. Foot Ankle Int 2002;23:97 – 101. [12] Harrison MHM, Harvey FJ. Arthrodesis of the first metatarsophalangeal joint for hallux valgus and rigidus. J Bone Joint Surg 1963;45A:471 – 80. [13] Ginsburg AI. Arthrodesis of the first metatarsophalangeal joint. J Am Podiatry Assoc 1979;69: 367 – 9. [14] Trnka H. Arthrodesis procedures for salvage of the hallux metatarsophalangeal joint. Foot Ankle Clin 2000;5:673 – 87. [15] Sussman RE, Russo CL, Marquit H, Giorgini R. Arthrodesis of the first metatarsophalangeal joint. JAPMA 1986;76:631 – 5. [16] Jeffrey JA, Freedman LF. Modified reamers for fusion of the first metatarsophalangeal joint. J Bone Joint Surg 1995;77B:328 – 9. [17] Buranosky DJ, Taylor DT, Sage RA, Sartori M, Patwardhan A, Phelan M, et al. First metatarsophalangeal joint arthrodesis: quantitative mechanical testing of six-hole dorsal plate versus crossed screw fixation in cadaveric specimens. J Foot Ankle Surg 2001;40:208 – 13. [18] Watson AD, Kelikian AS. Cost-effectiveness comparison of three methods of internal fixation for arthrodesis of the first metatarsophalangeal joint. Foot Ankle Int 1998;19:304 – 10. [19] Coughlin MJ, Abdo RV. Arthrodesis of the first metatarsophalangeal joint with vitallium plate fixation. Foot Ankle 1994;15:18 – 28. [20] Curtis MJ, Myerson M, Jinnah RH, Cox QGN. Arthrodesis of the first metatarsophalangeal joint: a biomechanical study of internal fixation techniques. Foot Ankle 1993;14:395 – 9. [21] Smith RW, Joanis TL, Maxwell PD. Great toe metatarsophalangeal joint arthrodesis: a user friendly technique. Foot Ankle 1992;13:367 – 77.
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[22] Shim GS, Pikscher I, Frankel N. First metatarsophalangeal joint arthrodesis with the truncated cone reamer system. J Foot Surg 1992;31:342 – 9. [23] Johansson JE, Barrington TW. Cone arthrodesis of the first metatarsophalangeal joint. Foot Ankle 1984;4:244 – 8. [24] Coughlin MJ. Arthrodesis of the first metatarsophalangeal joint with mini-fragment plate fixation. Orthopedics 1990;13:1037 – 44. [25] Kennedy MP, Coughlin MJ. Peg-in-socket arthrodesis of the first metatarsophalangeal joint. Foot Ankle Int 2002;23:352 – 4. [26] Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297 – 306. [27] Brodsky JW, Ptaszek AJ, Morris SG. Salvage first MTP arthrodesis utilizing ICBG: clinical evaluation and outcome. Foot Ankle Int 2000;21:290 – 6. [28] Niskanen RO, Lehtimaki MY, Hamalainen MJ, Tormala P, Rokkanen PU. Arthrodesis of the first metatarsophalangeal joint in rheumatoid arthritis. Acta Orthop Scand 1993;64(1):100 – 2. [29] Calderone DR, Wertheimer SJ. First metatarsophalangeal joint arthrodesis utilizing a mini-Hoffman external fixator. J Foot Ankle Surg 1993;32(5):517 – 25.
First metatarsophalangeal joint arthrodesis Gerard V. Yu, DPM, FACFASa,*, Paul O. Gorby, DPMb a
23823 Lorain Road, Suite 280, North Olmstead, OH 44070, USA b 4607 Chouteau, Shawnee, KS 66226, USA
Since the initial description of first metatarsophalangeal arthrodesis with an ivory peg by Clutton in 1894 [1], numerous technique modifications and refinements have been described. Regardless of the technique employed, the procedure continues to be a time-honored procedure for the treatment of various disorders and pathology of the first metatarsophalangeal joint. With the exception of an article by Castro and Klaue [2], who discussed a plantar medial incisional approach for insertion of a screw, most authors recommend a dorsal or dorsomedial incision centered over the joint. Yu and Shook [3] have advocated an interspace release with or without a fibular sesamoidectomy in patients with a severe bunion deformity to aid in relocation of the joint and fixation of the arthrodesis site and eliminate a potentially deforming force. Others have recommended preserving the intrinsic musculature to aid in reduction of the first and second metatarsal splaying following fusion, transforming the abductory force from the adductor hallucis muscle on the phalanx to the metatarsal segment. Although most authors recommend complete disarticulation of the joint using an open technique, an arthroscopic approach to first metatarsophalangeal joint (MPJ) arthrodesis has recently been described with the intent of minimizing traditional dissection [4]. The true benefits of this approach have yet to be fully realized. Various joint resection techniques have also been described. Some authors recommend curettage of the adjacent joint surfaces using rongeurs, curettes, and burrs [3– 6], whereas others describe concentric crescentic saw cuts in the adjacent portions of the joint [7]. Many authors describe straight or traditional saw cuts performed in the metatarsal and phalanx in a manner to allow dorsiflexion and adduction of the hallux [8– 15]. In his initial paper in 1952, McKeever illustrated bone cuts resulting in a ‘‘peg-in-hole’’ construct [8]. More recent literature favors use of specifically
* Corresponding author. E-mail address: [email protected] (G.V. Yu). 0891-8422/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0891-8422(03)00111-3
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designed conical reamers, initially manual and now power driven, to shape the adjacent surfaces of the joint [3,16 – 26]. A recent article by Kennedy and Coughlin describes using such reamers ‘‘backwards,’’ making the phalanx base convex and metatarsal head concave [24] and producing a reverse ‘‘peg-in-hole’’ construct. They believed this precluded the need for plate or screw fixation in patients with poor bone stock. In cases where previous surgery has been performed and a large deficit exists, bone grafting may be the only method of joint preparation applicable [3,26,27]. Brodsky et al used autologous tricortical iliac crest graft with additional cancellous bone for packing into the fusion site in his study of 12 patients [27]. Myerson et al initially used autologous bone from the iliac crest and distal tibia, but switched to allografts, observing in alternative procedures that nonunions were not occurring with the allograft [26]. When significant grafting is required, especially to restore length or major deformity resulting from implant removal, autogenous bone grafts are preferred. Their osteoinductive, osteoconductive, and osteogenic properties make them ideal grafts to minimize delayed union, nonunion, or pseudoarthrosis. Once the adjacent joint surfaces have been prepared, the position of fusion becomes the focus. It is the authors’ opinion that this is the single most important intraoperative consideration made when performing fusion of the first metatarsophalangeal joint. It is the position of fusion that ultimately determines effective function. Throughout the literature, a common theme exists with respect to the position of fusion: 0 degrees in the frontal plane, 20 to 40 degrees of dorsiflexion, and 15 to 25 degrees of abduction of the proximal phalanx in relation to the first metatarsal (see references [4,5,7 –9,11 –13,15,17,19 – 22,24 – 28]). Other authors have emphasized the importance of positioning of the hallux relative to the second toe (see references [3,6,14,22]). Yu and Shook denounce the above-mentioned values, stating that the great toe should be placed in the position that ultimately will position it parallel to the second digit when weight bearing [3]. Some authors have stressed the importance of not overdorsiflexing the first MPJ to prevent dorsal hallux interphalangeal irritation in shoe gear [14,22]. The final step of the procedure involves fixation and stabilization of the fusion site. This is the portion of the arthrodesis that has seen the greatest changes and variations since its first description in 1892 by Clutton. McKeever was the first to describe the use of a screw, placed plantarly through the proximal phalanx into the proximal shaft of the first metatarsal [8]. Screws (cannulated and noncannulated) today continue to be a commonly employed fixation device, whether it is two crossing (see references [3,6,7,11,14,17,18,26,27]) or two parallel screws [4,9,14]. A single screw passing either distal or proximal medially across the joint (see references [14,20,22,23]) has also been described. Castro and Klaue even mentioned passing a screw from plantar proximal to dorsal distal across the fusion site [2]. The authors have at times employed three small cortical or cancellous screws to achieve rigid internal compression fixation. In addition to screws, Kirschner wires (K-wires) or Steinmann pins are commonly used fixation devices for this procedure and can be buried below the fascia, within the subcutaneous tissue, or left external. A single K-wire, although
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risky because of rotatory forces across the fusion site, has been described [13]. Sussman et al refined this technique by adding cerclage wire around the fusion site to enhance compression [15]. More commonly, multiple K-wires or Steinmann pins are used [3,21,25], with Smith et al describing five threaded K-wires placed percutaneously [21]. Plates have also become commonplace in the fixation of first MPJ fusion (see references [3,14,18,19,24]). Coughlin has described the Luhr oral surgery/mandibular plate and its effectiveness [19,24]. Plates are particularly helpful in the cases involving bone grafting [26,27], secondary to their increased stability. When used, plates are commonly used in combination with other fixation devices, such as screws and K-wires [11,17]. Less common fixation devices have been described, including crossing Herbert screws [3,5,14], miniature external fixation devices [3,12,29], absorbable fixation [28], memory compression staples [11], and even suture, such as catgut [10]. Harrison and Harvey, in 1963, advocated no fixation, by simply cutting the first metatarsal head into an ‘‘osteotome’’ blade shape and ‘‘impaling’’ the phalanx onto the metatarsal. This technique known as the ‘‘Brockman technique’’ [12] has not been widely accepted or employed. There is general agreement that fixation is a necessary component of first metatarsophalangeal joint arthrodeses. Cadaveric studies have been performed to determine the arthrodesis fixation type providing the strongest construct. Two studies have found that any construct with a plate was consistently more stable in regard to the load needed for failure [11,17]. Curtis et al believed that the method of joint surface preparation was more important than the fixation method for stability, finding that conical reaming with interfragmentary screws was stronger than planing of the joint surfaces with plate/ screw fixation [20].
Author’s surgical approach to first MPJ arthrodesis Numerous techniques have been developed for the first metatarsophalangeal joint arthrodesis. These techniques have been greatly modified since the 1800s. At the authors’ institution, these techniques are a predictable procedure with good overall results. The following is a detailed description of the surgical technique and considerations employed by the senior author for the past several years. Some refinements have been made in the surgical technique of joint resection and internal fixation not reflected in previous publications by the senior author.
Incisional approach and exposure A dorsomedial linear incision medial to the extensor hallucis longus tendon has consistently provided excellent surgical exposure with minimal damage or irritation to the adjacent neurovascular structures, particularly those located medially. If the surgical scar is of cosmetic concern, a medial incisional approach
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can easily be employed in most cases. A medial incisional approach will provide excellent exposure with a virtually nonvisible scar when viewed from the dorsal aspect of the foot; exposure of the lateral aspect of the joint becomes somewhat more tedious and challenging. Dissection continues through the level of the subcutaneous tissues with the neurovascular structures protected. A longitudinal linear incision through the deep fascia, capsule, periosteum, subperiosteal, and subcapsular completely exposes the base of the phalanx and the entire first metatarsal head (Fig. 1). The extent of dissection circumferentially around the base of the phalanx and the metatarsal head will vary; it is influenced by the rigidity and severity of the deformity and the need for extensive exposure in cases where previous surgical procedures have been performed, resulting in significant alteration of the normal alignment, architecture, and configuration of the joint. The more important areas of surgical exposure include the dorsomedial aspect of the first metatarsal head and neck, the medial aspect of the base of the proximal phalanx, and the lateral aspect of the base. These areas are important for visualization and insertion of internal fixation devices, particularly Kirschner wires and screws. Dorsal exposure becomes important when employing plate fixation. Interspace dissection is not performed unless it is felt that a release of the lateral soft tissue structures or excision of the fibular sesamoid is necessary to achieve correction of the deformity. There have been situations where the senior author felt it was necessary to perform a complete interspace release and remove the fibular sesamoid. In cases with severely increased IM angles, nonreducible following interspace release, proximal osteotomies have been performed (Fig. 2). On occasion, a lengthening of the extensor hallucis longus tendon is necessary; this is usually performed in situations where there is a severe contracture of the hallux in
Fig. 1. Intraoperative photograph showing completed dissection and exposure of the metatarsal head and phalangeal base in preparation for joint resection using a curettage technique.
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Fig. 2. (A, B) Preoperative radiograph of patient with a recurrent HAV deformity and iatrogenic metatarsus primus varus necessitating concomitant osteotomy following soft tissue release and fusion of the first MPJ. Fusion was performed first, and because of persistent splaying, a closing wedge osteotomy was performed with enhanced AO/ASIF internal screw fixation. Postoperative radiograph displays excellent correction of the deformity, including correction of the HAV and MPJ deformities.
the form of hallux valgus or hallux malleus. Likewise, the extensor hallucis brevis may also require release.
Joint resection techniques Any abnormal or exuberant bone formation around the metatarsal head or proximal phalanx base is removed and the peripheral bone recontoured with hand and power instrumentation (Fig. 3). A small needle-nose rongeur and a power burr are indispensable instruments in recontouring and reconfiguring the head of the metatarsal and base of the phalanx particularly when previous surgical procedures have been performed. The articular surfaces are then removed. The most common technique for cartilage resection is based on the principles of curettage, a technique previously
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Fig. 3. (A, B) Intraoperative photographs showing the appearance of the joint following complete disarticulation and exposure. Notice the abundance of exuberant bone formation secondary to extensive degenerative changes. (C, D) Same patient following complete remodeling of all peripheral exostoses from the metatarsal head and phalangeal base. Articular cartilage has not yet been removed from the adjacent joint surfaces and is the next step.
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Fig. 3 (continued ).
published by the senior author. The cartilage from the base of the phalanx is removed with bone curettes and a power burr, preserving the concavity of the phalanx (Fig. 4). The cartilage in the metatarsal head is removed with a rongeur and the head recontoured, preserving its convexity (Fig. 5). The cartilage and subchondral bone plate are usually removed to enhance apposition of raw cancellous bone surfaces, which in turn encourage arthrodesis and discourage delayed or nonunion. Preservation of the convexity of the metatarsal head and concavity of the phalangeal base provides an excellent reciprocal fit and allows the surgeon to easily reposition the toe in virtually any plane should the need arise
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Fig. 4. Appearance following resection of the cartilage from the base of the phalanx and aggressive burring to subchondral bone. Note preservation of the concavity of the base to facilitate positioning on the metatarsal head.
Fig. 5. Removal of the cartilage from the head of a metatarsal using a double action bone rongeur. Convexity of the head is preserved. Aggressive removal is performed to enhance arthrodesis and minimize bone-healing complications, particularly in higher risk patients.
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Fig. 6. Fenestration of the phalangeal base with a small, 1.1-mm wire pass drill. The resultant bone paste is left within the fusion site to help enhance arthrodesis under the presumption that this live bone will be beneficial to the healing process.
based on intraoperative radiograph or clinical assessment. Fenestration of the adjacent surfaces with a small 1.1- or 1.5-mm wire pass drill can be performed at this time or later (Fig. 6). The authors believe that fenestration of the adjacent surfaces with preservation of the resultant ‘‘bone paste’’ within the fusion site encourages consolidation. In certain cases it is desirable to significantly shorten the first ray segment. The most common example is when performing a panmetatarsal head resection for rheumatoid foot deformity or other severe disabling and crippling deformity. In such cases the entire first metatarsal head segment is excised with a power saw and the bone recontoured to create a convex distal stump. A crescentic saw blade can also be used and will create a convexity of the metatarsal segment (Fig. 7). A small section of the phalangeal base can be resected to enhance the fit between opposing surfaces (Fig. 8). In cases where the deformity is primarily in the transverse plane (ie, severe hallux varus or hallux valgus), the crescentic saw is used from a dorsal to plantar direction. In situations where the hallux deformity is in the sagittal plane (ie, severe plantarflexion with a dorsal bunion or severe dorsiflexion as a result of muscle imbalance), the saw enters from a medial to lateral direction. Various conical reamer systems have been developed to produce a peg-in-hole fit when performing a first MPJ arthrodesis (Fig. 9). Though the instrumentation is
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Fig. 7. Use of crescentic saw blade to resect the first metatarsal head and preserve the convexity of the head. This technique is desirable for correction of transverse plane deformity and when shortening of the metatarsal segment is desirable.
ingenious, it requires an exacting alignment to ensure fit between the proximal and distal segments. In addition, all of the reaming systems currently available result in significant shortening to the first ray segment; providing this is desirable, such systems may be beneficial. Otherwise, it has been the author’s experience that reaming systems are more cumbersome and complicated than necessary. The senior author has not found them to be necessary to achieve an excellent outcome when performing first MPJ arthrodesis.
Positioning of fusion The position of fusion is critical to a functional outcome and will be determined by the position of the lesser toes, most importantly the second digit, as well as the
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Fig. 8. Use of crescentic saw blade to resect the phalangeal base. Note minimal bone resection is performed to preserve the length and enhance the fit with the first metatarsal, which is also resected with the same blade. If shortening of the segment is desired it is resected from the metatarsal head.
patient’s expectations and needs. For example, the use of high-heeled shoes postoperatively will require a position of fusion in more dorsiflexion. Otherwise, minimal dorsiflexion is recommended—a few degrees from the ground-supporting surface. Intraoperatively, the foot is loaded against a firm plate with the ankle at 90 degrees; the distal pulp of the toe should make minimal or slight contact with the plate (Fig. 10A). With dorsiflexion of the IPJ, the hallux should be off the ground-supporting surface slightly (Fig. 10B). With regard to transverse plane alignment, the hallux should be parallel to the second toe. It should not be touching the second toe with any significant pressure;
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Fig. 9. (A, B) Conical reamers available for joint resection when performing first MPJ arthrodesis. The authors discourage their use unless shortening is desirable.
likewise, it should not be separated from the second toe significantly. Either extreme may result in irritation of the hallux nail at either its medial or lateral border. Shoe gear may be incompatible, and pressure lesions may develop. The authors emphasize that a specific angular relationship with the first metatarsal is not an effective criteria. A hallux that is fully congruous at the first MPJ but significantly splayed from the second metatarsal will likely appear as a varus
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Fig. 10. (A, B) Intraoperative photo demonstrating simulated weight bearing to ensure proper position of fusion. Note the increased functional dorsiflexion that is achieved by motion at the IPJ of the hallux.
deformity. The position of the hallux with respect to the first metatarsal is not the center of focus when performing first MPJ arthrodesis; rather, the orientation and alignment of the hallux with respect to the second toe is the reference for transverse plane correction. In some cases (ie, rheumatoid arthritis or severe HAV with residual metadductus), it may be difficult to predict the final resting position of the lesser digits because of other concomitant procedures (eg, pan metatarsal head resection or digital fusions with soft tissue releases) (Fig. 11). In these cases, the art of surgery will dominate the science of surgery.
Internal fixation techniques Once the fusion site is properly positioned, temporary fixation is achieved; two small-diameter Kirschner wires are most commonly employed and correspond with the guide pins for various cannulated screw systems (Fig. 12). In
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Fig. 11. (A, B) Pre- and postoperative dorsoplantar radiographs following panmetatarsal head resection with first MPJ arthrodesis. Note the position of fusion in anticipation of the final resting position of the lesser toes. If the hallux had been fused in a rectus attitude, a large space would be present between the hallux and second toe, an undesirable clinical appearance to most patients.
other cases, Kirschner wires, usually 0.062 mm diameter, are used as the final form of fixation. The pins are bent and rotated externally to lock against the outer cortex of the metatarsal, thus maintaining rigid, stable fixation. In other cases, the small Kirschner wires will serve as the guide pins for cannulated screws. The use of multiple Kirschner wires represents one type of fixation that has been beneficial in patients with compromised bone. This is not uncommonly encountered in elderly patients or patients who have previously undergone resection arthroplasty. Two or three, and rarely four, 0.062-mm Kirschner wires are inserted in a crossing technique (Fig. 13). Kirschner wires or Steinmann pins can also be inserted in an axial direction and are typically reserved for patients undergoing concomitant fusion of the interphalangeal joint of the great toe (Fig. 14). The use of Kirschner wires that cross the interphalangeal joint when
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Fig. 11 (continued ).
the HIPJ is not being fused is discouraged because this promotes and encourages degenerative arthritis postoperatively. Kirschner wires are rarely left external to the skin; rather, they are bent and locked against the external cortex of the bone, preventing inward migration while facilitating easy and ready retrieval should they loosen. When possible, visualize the exit points of the Kirschner wires to ensure they do not protrude excessively beyond the cortex of the bone, causing irritation to the surrounding soft tissues. Although this technique does not impart compression at the fusion site, it does provide excellent rigidity and stability to the fusion construct. The authors have not witnessed a higher incidence of bonehealing complications as a result of the use of Kirschner wires in patients with compromised bone. One of the more common and popular techniques is that of cortical or, more commonly, partially threaded cancellous screws. Cannulated screw systems are recommended because they discourage inadvertent migration of the screws in an undesirable direction (Fig. 15A). Though a single cortical or cancellous screw can be effective, two or three crossing screws are preferred. One screw is typically inserted from proximal medial to distal lateral and a second screw inserted from distal medial to proximal lateral. The screw that crosses the fusion site from distal to proximal usually travels in a slightly plantar direction, whereas the screw
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Fig. 12. Intraoperative dorsoplantar radiograph showing temporary fixation of the fusion site with crossing Kirschner wires. Position was adjusted because of slight overcorrection. The Kirschner wires served as guide pins for insertion of cannulated cancellous screws.
inserted from proximal medial to distal lateral usually exits the lateral aspect of the phalangeal base midway between the dorsal and plantar surface (Fig. 15B). If the screw exits in the plantar lateral aspect of the proximal phalanx it tends to irritate the neurovascular structures, necessitating removal at a later date. With regard to the diameter of the screws, the senior author formerly used 4.0-mm screws but has come to favor smaller screws, such as 3.5-mm partially threaded cancellous screws and, more recently, the screws found within the Synthes (Paoli, Pennsylvania) modular hand system (Fig. 16). The final choice of screw type and direction of insertion will be based on the surgeon’s experiences and preferences. The authors favor two or more screws of a smaller diameter rather than fewer screws of a larger diameter. The Kirschner wires introduced to provide temporary fixation frequently serve as pilot holes for drilling before final screw insertion. If there is any question or concern that the two screws will collide within the fusion site, the joint can be disarticulated and the path and direction of the Kirschner wires visualized, ensuring that this will not occur. Collision of screws within the fusion site at the time of insertion is more likely to occur with larger diameter screws that have
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been inserted with a more haphazard and less precise technique. Fluoroscopic visualization of Kirschner wire and screw insertion is often helpful. Plate fixation is usually reserved for more difficult and challenging situations. These include previously failed arthrodesis, fusions requiring an interpositional bone graft, or patients at higher risk for a bone-healing complication, such as those with peripheral neuropathy or diabetes. It should be emphasized that though plates applied dorsally provide excellent rigidity to the fusion construct, they are not as effective as initially thought in imparting significant compression, even when employing eccentric drilling techniques. The technique of applying a dorsal plate with eccentrically drilled holes becomes less effective as more bending in the plate is required; in other words, the greater the metatarsal declination the less effective a dorsal plate will be at providing compression. It can, however, provide excellent stability to the fusion site. It continues to be popular among the orthopedic foot and ankle community. The authors’ technique of plate fixation has been refined over the years to routinely include an interfragmental compression screw crossing, most commonly
Fig. 13. (A, B) Preoperative and postoperative radiographs following first MPJ fusion with crossing buried Kirschner wires, which are locked against the external cortex of the bone to prevent loosening and migration. Postoperative film is 8 months following fusion.
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Fig. 13 (continued ).
from distal medial to proximal lateral. In some cases, a second crossing screw inserted from proximal medial to distal lateral is added in addition to a dorsal plate. The authors attempt to secure the plate to the proximal phalanx with at least three screws and a minimum of four or five screws in the first metatarsal (Fig. 17). The plates and screws of the Synthes modular hand system seem to be the most effective (Fig. 18). The traditional one-quarter tubular and one-third tubular plates do not lend themselves well to various configurations when applied to the first MTP joint arthrodesis site. They also hinder visualization and assessment of the fusion site on subsequent radiographs (Fig. 19). If an interpositional bone graft is required it will be one of an autogenous nature from either the calcaneus or the ilium. At least one, and preferably two, screws are inserted to fixate the plate to the graft. Two or three screws distal to the graft and three or four screws proximal to the graft are desired (Fig. 20). Precise technique is essential to a successful outcome. The use of interpositional bone grafting and plate application is not for the novice surgeon. A higher degree of knowledge, training, and experience is necessary in most cases.
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Fig. 14. Concomitant IPJ fusion of the hallux with two longitudinal small Steinmann pins. A single screw is not recommended because of frontal plane rotational instability. Two longitudinal points of fixation prevent rotation but do not provide compression.
The use of miniature external fixators is also an excellent fixation technique when performing first MPJ fusion (Fig. 21). Although somewhat cumbersome by their nature, they can provide excellent rigid fixation with varying degrees of compression at the fusion site. They may be particularly beneficial when attempting to salvage a previous nonunion in which open resection or bone grafting are not necessary. They have also proven beneficial when salvaging the first MTP joint in situations of previous infection where it is desirable to avoid the placement of internal fixation devices. Current day devices allow ready positioning in multiple planes. In difficult and complicated cases where the establishment of length is an issue, they can be employed to achieve distraction osteogenesis more proximally while providing compression fixation at the joint. Various miscellaneous fixation devices and techniques can also be employed but are not commonly used by the authors. These include traditional staples, more recently introduced compression staples, figure-of-eight tension band wiring
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Fig. 15. (A, B) Intraoperative photograph and postoperative radiograph demonstrating fusion with two 4.0-mm partially threaded cancellous bone screws providing internal rigid compression fixation. Note point of entry of each of the screws from the distal medial and proximal medial aspects of the joint.
(Fig. 22), and cerclage wiring. Though several newer devices are on the horizon, time has proven that traditional techniques are consistent and effective when applied for the proper conditions with exacting technique.
Postoperative management Postoperative management will be guided by several factors, including patient compliance, the indication for the fusion, and the surgical technique employed. The authors prefer non –weight bearing for approximately 4 to 6 weeks with progressive increased weight bearing over several weeks. Though cast immobi-
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Fig. 15 (continued ).
lization is not mandatory it does afford significant protection of the area and is believed to be superior to traditional surgical shoes. Weight bearing is the single most detrimental influence on the bone-healing process. Early or excessive weight bearing and ambulation encourage bone-healing complications, such as a delayed union, nonunion, or pseudoarthrosis. Serial radiographs are taken every 3 to 4 weeks to monitor the consolidation process. When radiographic evidence of migration, fracture, or failure of the internal fixation devices is seen, this strongly suggests an impending bone-healing complication and the need to alter the postoperative care. Patient compliance is critical to the successful outcome of any exacting procedure, including first MTP joint arthrodesis. Compression stockings and wraps are helpful in controlling postoperative edema, which is not problematic. Physical therapy may be helpful in educating the patient to a slightly new gait pattern and resolving edema and sensitivity to the area. Caution should always be given to avoid manipulation of the fusion site. When necessary, custom-molded orthotics are employed to help in the balance and
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Fig. 16. Fusion of the joint with three 2.4-mm cortex bone screws from the Synthes Modular Hand System set.
distribution of weight. A semirigid device with a good layer of shock absorption material is recommended. Should internal fixation devices loosen or cause irritation of surrounding structures, they can be removed, in most cases, easily. Although removal is usually unnecessary, the authors advise all patients during the initial surgical consultation that they may loosen at any time postoperatively, including years after the surgery. Removal can be performed under a local anesthetic block with or without sedation in the office or outpatient setting.
Complications Although a functional outcome is desired and is the norm, complications can and do occur. Most complications are related to a malposition of fusion. Excessive dorsiflexion or plantarflexion as well as abduction or adduction can cause difficulty with weight bearing and ambulation and with the fitting of conventional
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Fig. 17. Intraoperative photograph showing fusion with a Synthes Modular Hand System plate and multiple 2.4-mm cortical screws. An interfragmentary single screw is seen crossing the joint from distal medial to proximal lateral. Three screws are present in the phalanx, and five will be inserted in the metatarsal segment in the plate.
shoe gear. Malposition may manifest itself as increased pressure beneath the first metatarsal resulting in sesamoiditis and lesions at the distal pulp of the toe, or in the case of excessive dorsal flexion, irritation over the interphalangeal joint (Fig. 23). Barring the issue of high-heeled shoes, minimal dorsiflexion is needed when performing a first MTP joint fusion. Some of the motion normally taken up at the metatarsophalangeal joint will be absorbed through the medial column and the interphalangeal joint of the hallux. Malposition usually requires a take-down of the original fusion with repositioning and revision arthrodesis; in some cases, an osteotomy of the first metatarsal may be sufficient. Bone-healing complications, such as delayed union, nonunion, or pseudoarthrosis can be problematic (Fig. 24). Fortunately, most of the literature has borne out that nonunions of this joint fusion are often tolerable by patients. Conservative management includes continued immobilization and non –weight bearing with the use of noninvasive electrical bone stimulation in some cases. Symptomatic cases that fail to achieve successful union will probably require revision arthrodesis with or without an interpositional autogenous corticocancellous graft. Possible sites for procurement of this graft include the calcaneus, the distal tibia, or the anterior or posterior ilium. When performing revision arthrodesis it is critical that the fixation be enhanced. The authors believe that compression is the most valuable component of the revision surgery to achieving arthrodesis.
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Fig. 18. (A – C) Preoperative and postoperative radiographs of a first MPJ fusion with a single interfragmentary screw from distal medial to proximal lateral and a small plate and four screws for enhanced stability. The authors have found this construct to be effective in higher risk fusions. A longer plate affording even more screws within the metatarsal or phalanx are available.
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Fig. 18 (continued ).
The management of complications following first MTP joint arthrodesis must be individualized to each patient. Patients have varying degrees of tolerance for malposition as well as bone-healing complications. Certain patients have much higher expectations and thus it may be more difficult to satisfy, whereas other patients will be grateful for the significant improvement they have achieved even with a failed fusion. Dedication and patience must complement surgical skills and abilities. The approach to management of the complication requires a careful
Fig. 19. (A, B) Traditional one-third tubular plate with five screws with a single interfragmentary screw from proximal medial to distal lateral. Note how the size of this traditional plate hinders visualization of the fusion site in comparison to the plate shown in Figure 18B.
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Fig. 21. Miniature external fixation for revision arthrodesis of the first MPJ. Preoperative conventional bone scan demonstrated a hypertrophic, viable nonunion and, consequently, a conventional open procedure was not performed.
Fig. 20. (A – C). Intraoperative appearance and preoperative and postoperative radiographs demonstrating plate fixation with interpositional corticocancellous bone graft for salvage fusion of the first MPJ. Patient had previously undergone a minimal incision procedure for symptomatic HAV deformity. One screw secures the graft with additional screws eccentrically drilled to enhance compression at the proximal and distal graft host interfaces.
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Fig. 22. Figure-of-eight tension band wiring with multiple Kirschner wires in a patient who has diabetic neuropathy. An additional Kirschner wire has been inserted to stabilize the IPJ of the hallux.
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Fig. 23. (A, B) Postoperative complication of hallux flexus deformity with dorsal irritation of the IPJ. Although position of fusions with respect to dorsiflexion appears acceptable on the lateral radiograph, less dorsiflexion would have been optimal.
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Fig. 24. Nonunion of first MPJ fusion with Herbert bone screws. Although rigid, these screws have been shown to impart less compression than traditional screw fixation techniques.
assessment of the condition, patient’s overall health status, the desired outcome by the patient, and the knowledge, experience, and abilities of the surgeon.
Summary First MTP joint arthrodesis continues to be a time-honored, effective, and valuable procedure as a primary or secondary surgery for various pathologies afflicting the first ray segment. Though commonly thought of as a salvage procedure, it has proven beneficial in the management of primary hallux limitus and rigidus, geriatric hallux valgus deformity, severe arthritis of any etiology, and conditions in which joint instability or deformity are not readily correctable by more traditional approaches. Since its initial description in the 1800s, the procedure has continued to be popular among orthopedic and podiatric surgeons. Success of the procedure is highly dependent on the position of fusion. Though surgeons are often fascinated and at times obsessed with a particular fixation technique, it cannot be overemphasized that this takes a back seat to the importance of achieving proper
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position to meet the needs of an individual patient. Unlike joint resection or implant arthroplasty procedures, which commonly leave the hallux lacking stability and propulsion, first MPJ fusion has been shown to be effective during weight bearing and propulsion. The success enjoyed by the senior author continues to reinforce that motion is not necessary at the first MTP joint for good, pain-free function.
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