First MTP Joint Arthrodesis

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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Template arthrodesis with radiographs

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • MTP plating system

2

Room setup and equipment

  • standard OR table with radiolucent end

3

Patient positioning

  • supine position with a bump under the ipsilateral buttock
G

Joint Exposure

1

Mark a dorsolateral incision

  • center the dorsolateral incision over the first MTP joint in the interval between the medial and lateral common digital nerves

2

Extend the incision

  • span the incision from a point just proximal to the IP joint of the hallux to 3 to cm proximal to the MTP joint
H

Deep Dissection

1

Expose the synovium

  • deepen the dissection along the medial aspect of the EHL tendon through the extensor hood and the joint capsule
  • perform a thorough synovectomy

2

Inspect the MTP

  • locate osteophytes and loose bodies
  • determine the extent of articular damage
I

Joint Resection and Decompression

1

Remove the articular surface

  • remove a thin section of articular surface from the distal first metatarsal and proximal phalanx with a sagittal saw

2

If shortening required

  • resect more bone from the metatarsal head
  • use a sagittal saw to resect the medial eminence
J

Metatarsal Head Preparation

1

Place K-wire

  • drive a 0.062 K wire in a proximal direction at the center of the metatarsal head

2

Determine the appropriate reamer

  • compare the diaphyseal width of the metatarsal with the inner width of the reamer

3

Prepare the canal

  • engage the power reamer with the K wire
  • drive the K wire in a proximal direction
  • shave the metatarsal subchondral surface and metaphysis to the cup shaped convex surface
  • remove any excess bone along the periphery with a rongeur

4

Increase the surface area for arthrodesis

  • remove the K-wire
  • use the K-wire to perforate the prepared metatarsal head in multiple places to increase the surface area for arthrodesis
K

Proximal Phalangeal Preparation

1

Place the K-wire

  • center a 0.062 K-wire on the base of the proximal phalanx
  • drive the K-wire distally

2

Prepare the surface

  • use the smallest convex cannulated phalangeal reamer to prepare the surface
  • use larger reamers to enlarge the phalangeal surface so that it matches the size of the prepared metatarsal surface

3

Remove the K-wire

4

Increase the surface area of the joint surface

  • collect cancellous bone shavings throughout the entire process and place in a small cup to place in between the prepared surfaces
L

Joint Alignment and Internal Fixation

1

Place autograft

  • place the autograft between the joint surfaces
  • coapt the cancellous joint surfaces to the desired amount of varus, valgus, doriflexion, plantarflexion and rotation

2

Place the joint in the appropriate position

  • the optimal position is 20 to 25 degrees of dorsiflexion , 10 to 15 degrees f valgus and neutral rotation
  • all angular measurements relate the axis of the first metatarsal shaft

3

Place provisional fixation

  • temporarily stabilize the arthrodesis site with 1 or 2 crossed 0.062 K-wires

4

Apply the plate

  • use a rongeur to smooth the the dorsal aspect of the first metatarsal and proximal phalanx to allow the plate to sit flush on the bone

5

Place Screws

  • place bicortical self-tapping screws to fix the plate to the metatarsal
  • use locking screws in the instance of osteopenic bone
  • fix the plate to the proximal phalanx with a screw placed in compression
  • remove the K-wire
  • place a cross-compression screw to augment the fixation construct
N

Wound Closure

1

Irrigation and Hemostasis

  • copiously irrigate the wound

2

Close capsule

3

Superficial wound closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin

4

Dressing

  • wrap the foot in a gauze and tape compression dressing after surgery
Postoperative Patient Care
 

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