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First MTP Joint Arthrodesis

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtain a focused history and performs focused exam

  • check soft tissue
  • differential diagnosis and physical exam tests

2

Interpret basic imaging studies

  • interpret radiographs AP, lateral and sesamoid views

3

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 Week Postoperative Visit
  • wound check and remove sutures
  • check radiographs
  • postop: ~ 4 week Postoperative Visit
  • check radiograph
  • postop: 10-12 week Postoperative Visit
  • remove walking boot if radiographic signs of union are present
  • advance rehabilitation
B

Advanced Evaluation and Management

1

Recognizes concomitant associated injuries

2

Appropriately orders and interprets advanced imaging studies

  • CT Scan

3

Modifies and adjusts post-operative treatment plan as needed

4

Provides comprehensive assessment of complex fracture patterns on imaging studies

5

Recognizes indications for and provides non-operative treatment of an unstable fracture

  • diabetes
  • medical comorbidities
  • non-compliance
C

Preoperative H & P

1

Obtain history and perform basic physical exam

  • history
  • age
  • gender
  • history of present illness [HPI]
  • past medical history [PMHx]
  • social history
  • physical exam
  • range of motion
  • neurovascular status

2

Screen medical studies to identify and contraindications for surgery

3

Orders basic imaging studies

  • weigtbearing AP, lateral and sesamoid views

4

Perform operative consent

  • describe complications of surgery including
  • wound breakdown
  • superficial and deep infections
  • malunion
  • nonunion

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

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • prescribe DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • appropriately orders and interprets basic imaging studies
  • check radiographs of the foot in post op

2

Appropriate medical management and medical consultation

3

Physical Therapy

  • ambulate with a short walking boot

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Capable of evaluating and treating postoperative complications

3

Surgically treats complex complications

 

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