1st mtp joint
One of a variety of commercially available dorsal plates for first metatarsophalangeal arthrodesis is placed across the top of the first metatarsophalangeal joint. Provisional joint fixation and positioning A small Hoke osteotome is then used to fish scale both articular surfaces. Any surrounding debris is removed with a rongeur, and the entire joint space is irrigated with sterile saline.Ī 1.6 K-wire is then used to fenestrate the articular surfaces of both the first metatarsal and the proximal phalanx. The ability to place the joint into appropriate alignment is confirmed. If necessary, the dorsal aspect of the proximal phalanx is smoothed with a rongeur. This is essential for matching the surfaces of the metatarsal head and the base of the proximal phalanx. The correct placement of the guide wire is again verified with intra-operative fluoroscopy.Ī convex (or “cone”) reamer is placed over this guide wire and the proximal phalanx is sequentially reamed beginning with the smallest size reamer, gradually stepping up to the size that matches the final cup reamer previously used on the metatarsal head.
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The guide wire in the first metatarsal is then removed and placed in the center and down the canal of the proximal phalanx. The metatarsal surface is sequentially reamed with progressively smaller reamers until no cartilage remains and the contours of the metatarsal head are well-matched by the reamer. The largest concave (or “cup”) reamer, commonly 24 mm in diameter, is selected and placed over the guide wire. The author commonly introduces a mixture of autologous bone marrow aspirate concentrate (BMAC) and demineralized bone matrix into the joint space to potentially increase the rate of fusion. The tourniquet is released before closure of the wound at the end of the surgery. An Esmarch bandage is used to exsanguinate the entire limb and a thigh tourniquet is inflated to between 250 to 275 mmHg. At this time intravenous antibiotics are administered. The first tarsometatarsal joint, the interphalangeal joint, and the first metatarsophalangeal joint are assessed.Īt the author’s institution, the surgery is commonly performed under sedation in conjunction with regional anesthesia (typically a spinal block and either an ankle or popliteal block for post-operative pain).Īfter positioning, the leg is prepped and draped in the usual sterile fashion.
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Weight-bearing AP and lateral radiographs are obtained. Arthrodesis can also be difficult in female patients based on shoewear preferences and possibly less tolerated in patients with pre-existing interphalangeal joint arthritis or first tarsometatarsal arthritis. Ĭontraindications for surgical treatment are active infection and severe, peripheral vascular disease. Patients are counseled to wear rocker-bottom shoes or use carbon shoe inserts equipped with a Morton’s extension (which minimizes plantar loading of the hallux). Ĭonservative treatment to reduce pain includes activity modification, footwear modification, or steroid injections. A similar procedure, the Keller resection arthroplasty, is less invasive than arthrodesis and more suited to elderly patients susceptible to surgical complications. By contrast, cheilectomy is recommended if osteophytes are present, pain only occurs at maximum dorsiflexion and plantarflexion, and if radiographic evaluation shows less severe joint space narrowing.īecause arthrodesis restricts joint motion, interpositional arthroplasty may be indicated in patients who wish to preserve some joint motion. The stage (or grade) of hallux rigidus is determined according to the Clinical-Radiographic System for Grading Hallux Rigidus developed by Coughlin and Shurnas . Arthrodesis is indicated primarily in grades III and IV, in which the clinical examination demonstrates significant crepitus and pain at the mid-range of motion, and radiolographic evaluation shows substantial joint space narrowing. The decision to fuse the first metatarsal and the proximal phalanx depends on the stage of the disease. Hallux rigidus is also seen in inflammatory disorders including rheumatoid arthritis and gout. Arthritis of the first metatarsophalangeal joint, commonly called hallux rigidus, may occur for a variety of reasons: trauma, hallux valgus (bunion), and an elevated first metatarsal are the most typical.