DEFINITION

Disorders of the first ray are a common cause of foot and ankle problems. Arthrodesis of the hallux metatarsophalangeal (MTP) joint is a utilitarian technique in contemporary foot and ankle surgery.

Arthrodesis can effectively address a variety of conditions affecting the hallux, including deformity, inflammatory and degenerative arthritides, spasticity and neuromuscular disorders, and salvage of failed surgeries.

The most important aspect of this procedure is optimal positioning of the toe during first MTP joint arthrodesis.

 

 

ANATOMY

 

The bony anatomy of the first MTP joint includes the rounded first metatarsal head, which articulates with the concave, elliptically shaped base of the proximal phalanx.

 

Two longitudinal grooves separated by the crista, a central prominence, are located on the plantar surface of the metatarsal head. The two sesamoid bones contained in the medial and lateral tendon slips of the flexor hallucis brevis articulate with their corresponding longitudinal grooves on the inferior surface of the first metatarsal head. The flexor hallucis longus (FHL) tendon runs between the two sesamoids, bypassing the MTP joint to insert distally onto the distal phalangeal base.

 

 

 

 

FIG 1 • Anterior (A) and lateral (B) views of the first MTP joint.

 

The extensor hallucis brevis tendon inserts into the dorsal MTP capsule and the extensor hallucis longus runs distally to insert onto the distal phalanx.

 

The strong, fan-shaped collateral ligaments of the MTP joint originate medially and laterally from the metatarsal head and run distally and plantarward to the base of the proximal phalanx. The metatarsosesamoid ligaments fan out in a plantar direction to the margin of the sesamoid and the plantar capsule.

 

Distally, the two sesamoids are attached by the fibrous plantar plate to the base of the proximal phalanx, stabilizing the joint plantarly (FIG 1).

 

PATHOGENESIS

 

Common forms of degenerative arthritis that affect the hallux MTP joint include hallux rigidus and posttraumatic arthritis. Hallux rigidus may be the result of isolated trauma, with forced hyperextension and resultant chondral injury, or the result of repetitive microtrauma of the articular cartilage. Pathologic alteration in the kinematics of the first MTP joint also may lead to degenerative changes.

 

Chondral erosion or loss is seen dorsally on the metatarsal head and phalangeal base.

 

Inflammatory arthropathies can affect the hallux MTP joint, necessitating fusion. Common causes include rheumatoid

 

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arthritis, gouty arthropathy, lupus, and seronegative spondyloarthropathies. Repetitive episodes of synovitis lead to chondral loss and joint narrowing.

 

Progressive hallux valgus or hallux varus with severe deformity, spasticity (secondary to neurologic conditions), soft tissue contracture, or failed implant arthroplasty also may benefit from MTP arthrodesis.

 

NATURAL HISTORY

 

Hallux rigidus and degenerative arthritis present with progressive pain, stiffness, and osteophyte formation of the MTP joint.

 

Initial symptoms of inflammatory arthritides include pain and swelling from MTP synovitis; progressive disease is marked by worsening stiffness, pain, and deformity.

 

Hallux valgus or hallux varus deformities typically are flexible in the early stage, but over time, these deformities tend to become progressively rigid secondary to joint contracture.

 

All of these conditions can produce pain, difficulty with ambulation, and transfer metatarsalgia to the lesser toes.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patient history

 

 

 

Pain and mechanical symptoms on ambulation in hallux rigidus and degenerative arthritis Pain at rest or in the morning with inflammatory arthritis

 

Pain with shoe wear over the hallux or medial eminence (bunion)

 

Some patients complain of the dorsal prominence over the first MTP joint.

 

Physical findings

 

 

Careful interview of the patient to identify contributing medical conditions, shoe wear history, previous

treatment methods, and previous surgical procedures

 

Standing examination of the foot to assess for malalignment of the toe, including varus, valgus, or claw deformity

 

 

 

 

FIG 2 • A. AP weight-bearing radiograph of the first MTP joint. Note the joint narrowing, extensive osteophytes, and the medial subchondral cyst. B. Lateral weight-bearing view of the first MTP joint. A large dorsal osteophyte and plantar joint space narrowing are noted.

 

 

Gait examination to identify dynamic deformity of the foot, including forefoot supination or generalized pes planovalgus

 

Visible shortening of the hallux, failure of the toe to engage the ground, and lesser toe metatarsalgia or keratosis (callus) indicate mechanical unloading of the first ray.

 

Examination of the seated patient allows observation for callus, skin irritation, or presence of dorsal or medial bunion.

 

Palpation elicits tenderness about the joint. Hallux rigidus typically is tender dorsally, whereas the pain with hallux valgus is located medially over the bunion. Advanced degenerative or inflammatory arthritides exhibit diffuse tenderness about the MTP joint, and axial grinding of the phalanx against the metatarsal elicits pain.

 

Manipulation of the joint is performed to assess stability of the collateral ligaments and the relative flexibility or rigidity of varus or valgus toe deformity.

 

Range-of-motion examination often shows limited passive MTP dorsiflexion, with normal or reduced plantarflexion.

 

Skin irritation may be present over the dorsal exostosis or medial bunion.

 

Tingling, hypesthesias, or a positive Tinel (percussion) sign over the dorsal hallucal nerve may indicate nerve compression from synovitis or dorsal osteophytes.

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Standing anteroposterior (AP), lateral, and oblique radiographs are the standard views for evaluation. Additional views, such as a sesamoid view, sometimes are indicated.

 

 

The weight-bearing AP view is obtained to determine the overall alignment of the MTP joint. It also can be assessed for the extent of arthritic involvement, including joint narrowing; flattening of the metatarsal head; and the presence of subchondral sclerosis, erosions, or cystic changes within the metatarsal head, osteopenia, or bone loss (FIG 2A). This view can also facilitate evaluation of

 

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shortening of the first ray relative to the lesser metatarsals. The oblique view also can illuminate these findings.

 

The lateral weight-bearing view can show dorsal metatarsal or phalangeal osteophytes and can be used to evaluate the degree of joint narrowing (particularly plantarly) and the presence of an elevated first metatarsal (FIG 2B). However, the plantar two-thirds of the joint can be obscured by overlapping shadows of the lesser metatarsals.

 

An axial sesamoid view can be an adjunctive radiograph for evaluating the metatarsal-sesamoid articulation for narrowing or cystic changes, although involvement of the metatarsosesamoid joint occurs infrequently, except with severe arthrosis.

 

Additional imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), rarely are necessary. However, such scans may be useful for defining the degree of cyst involvement or avascular necrosis of the metatarsal head, which indicates the possible need for intraoperative bone grafting.

 

DIFFERENTIAL DIAGNOSIS

Arthrodesis is appropriate for surgical correction of the following conditions5,9,10,14: Osteoarthritis or posttraumatic arthritis

Hallux rigidus

Severe hallux valgus, particularly in elderly patients

Hallux varus caused by inflammatory disorders, iatrogenic deformity after previous surgery, or idiopathic involvement

Inflammatory arthropathies, including rheumatoid arthritis, lupus, gout, and seronegative spondyloarthropathies

Soft tissue contracture, as in scleroderma

Deformity secondary to neurologic conditions or spasticity, such as that occurring in patients with diabetes or those who have experienced a stroke

 

 

NONOPERATIVE MANAGEMENT

 

Nonoperative measures to be attempted before MTP arthrodesis include the following:

 

 

Nonsteroidal anti-inflammatory drugs to decrease joint pain and inflammation

 

Judicious use of corticosteroid injections into the hallux MTP joint to relieve synovitis, although repeated injections are not advised

 

The use of silicone gel, cotton wool, or felt pads to relieve pressure from calluses or impingement against the shoe or adjacent toe

 

Strapping or taping of the hallux may be useful for flexible deformities.

 

Comfortable shoe wear with low heels and wide toe box; extra-depth shoes may allow use of an orthotic device. Shoe modifications, such as a stiff sole or metatarsal bar, may unload the forefoot during push-off.

 

A full-length orthotic insole with a carbon fiber or stainless steel extension may limit the motion of a painful MTP joint in hallux rigidus.

 

Custom accommodative orthotic insole with a buildup under the hallux may improve weight bearing of a shortened or dorsiflexed first ray to diminish transfer metatarsalgia.

 

SURGICAL MANAGEMENT

 

In situ hallux MTP arthrodesis is a utilitarian technique with a wide range of indications.2,3,4,5,8,9,10,11,14,15,16,18,19,22

 

Absolute contraindications include active infection of the MTP joint, severe peripheral vascular disease, and poor soft tissue envelope secondary to systemic disease or scar tissue.

 

A relative contraindication to MTP arthrodesis is symptomatic interphalangeal joint arthritis; however, concurrent arthrodesis of both joints has been described.20

Preoperative Planning

 

Radiographs are assessed for extensive bony lysis, erosions, or cysts that may require bone grafting.

 

Severe bone loss, shortening, or failed implant arthroplasty may require distraction of MTP arthrodesis with bulk bone graft, discussed elsewhere.

 

Standard arthrodesis can be performed under general, spinal, or regional anesthesia, such as a popliteal or ankle block.

 

 

We prefer to administer an ankle block in conjunction with intravenous sedation, using a 1:1 mixture of 2% lidocaine and 0.5% ropivacaine, via a 25-gauge needle.

 

Positioning

 

The patient is positioned supine with a roll under the ipsilateral hip.

 

Our preferred technique is use of an Esmarch tourniquet applied over cotton padding at the level of the supramalleolar ankle. Alternatively, the procedure can be performed without a tourniquet or with use of a pneumatic calf or thigh tourniquet.

 

Approach

 

Our preferred approach is a dorsal incision centered over the MTP joint.

 

An alternate approach is the medial midline incision, based on the surgeon's preference or if a previous medial surgical scar exists.

 

 

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TECHNIQUES

• Exposure

 

 

Make a dorsal incision over the MTP joint just medial to the extensor hallucis longus tendon.4,7,8,9,10,14,16,19

 

Carry the dissection down to the joint capsule, avoiding the dorsomedial cutaneous nerve, a terminal branch of the superficial peroneal nerve.3

 

Retract the extensor hallucis longus tendon laterally and perform an arthrotomy directly over the MTP joint.8,9,10,14,16

 

 

 

TECH FIG 1 • Exposure of metatarsal head through dorsal approach. The extensor hallucis longus tendon is retracted laterally with the exposed metatarsal head, showing a large dorsal osteophyte and loss of articular cartilage.

 

 

Perform subperiosteal dissection to raise medial and lateral flaps off the metatarsal head and base of the proximal phalanx, exposing the joint (TECH FIG 1).3,4,19

 

Release the collateral ligaments and the plantar portion of the joint by releasing the plantar plate with a Freer elevator.

 

Remove large osteophytes and loose ossicles with a rongeur.

 

Resect the medial eminence from a dorsal approach with a microsagittal saw or chisel.9,14,19

• Joint Preparation

   

  Prepare the joint surfaces for arthrodesis with a power burr or specialized reamers.

   

  Biomechanically, spherical surfaces provide for improved stability compared with flat cuts.6 Hemispherical surfaces also provide more freedom for positioning the arthrodesis compared with flat saw cuts.

   

  We use specialized reamers that produce similar hemispheric surfaces (TECH FIG 2A).5,8,9,10,14,16

   

  Insert a guidewire axially in the center of the metatarsal head. Use a cannulated, concave-shaped reamer to prepare the metatarsal head.

   

  Remove the wire and then insert it in the proximal phalanx, and use a cannulated convex reamer while plantarflexing the proximal phalanx.3,4

   

   

   

  TECH FIG 2 • A. Technique for joint preparation with specialized reamers. The Kirschner wire is placed in the center of the metatarsal head to ensure concentric joint preparation. B. Joint preparation with power burr. The metatarsal head is shaped hemispherically in a convex manner to fuse with the concave base of the proximal phalanx.

   

   

  An alternative method of joint preparation is to use a power burr, preparing the joint surfaces in a ball-and-cup fashion by removing the chondral surfaces.

   

  Shape the subchondral surface hemispherically, with the metatarsal head convex and the phalangeal base concave (TECH FIG 2B).22

   

  Carefully avoid excessive bony resection, particularly in osteopenic or rheumatoid patients, to prevent additional shortening of the toe.

   

   

  Create multiple drill holes in the metatarsal head and phalangeal base with a Kirschner wire or small drill bit to augment bleeding and bony ingrowth.9,14

   

• Arthrodesis Positioning and Fixation

17

 

After preparing the joint surfaces, position the arthrodesis in 10 to 15 degrees of valgus, 10 degrees of dorsiflexion relative to the sole of the foot, and neutral pronation-supination.

 

Because it can be difficult to determine the plane of the sole with the patient on the operative table, a more predictable method of positioning the toe is to determine dorsiflexion relative to the first metatarsal axis. In most cases, the appropriate angle is about 25 to 30 degrees of dorsiflexion.3-5,12,17,19

 

The hallux is held provisionally with Kirschner wires or partially threaded guidewires from a cannulated screw set.

 

Confirm the positioning radiographically with a mini-fluoroscopy unit and clinically with use of a flat surface to simulate weight bearing (the cover of the screw set tray works nicely).12,16,23

 

The hallux should be slightly off the surface with the heel on the cover (TECH FIG 3A).9,23

 

Placing a finger or screwdriver handle under the heel simulates a shoe with a small heel; in this case, the pulp of the distal hallux should just barely engage the surface.

 

Cannulated or solid screws can be used per the surgeon's preference.23 We use 4.0- or 4.5-mm cannulated screws in most patients. Solid 3.5-mm cortical screws are an alternative (TECH FIG 3B).

 

Insert one guidewire from the medial aspect of the phalangeal base just distal to the metaphyseal flare and advance it across the arthrodesis site through the dorsolateral cortex of the metatarsal neck.

 

A second screw can be considered if the first screw provides insufficient fixation in patients with osteopenia. Place the second wire from the medial aspect of the metatarsal neck, just proximal to the flare of the medial eminence; advance this wire distally and slightly plantarly across the arthrodesis site to engage the plantar-lateral cortex of the phalanx.

 

 

 

TECH FIG 3 • A. Positioning of the first MTP joint. A flat surface is used to position the toe properly. Note the positioning of the toe to allow for adequate clearance during gait. B. Postoperative radiograph shows the crossed-screw technique.

 

 

Check wire position and length with fluoroscopy.

 

Measure the wires percutaneously with the cannulated depth gauge and overdrill them with the cannulated drill bit. Then, countersink the cortex carefully to prevent subsequent cracking with screw

placement.3

 

Place the partially threaded cannulated screw(s) over the guidewire(s) while compressing the hallux manually.

 

Alternatively, insert solid lag screws under fluoroscopic guidance.

 

Our preferred technique also uses a supplementary dorsal plate, which has been shown to provide improved fixation.9,14,21 This is particularly helpful if screws alone provide suboptimal fixation or in patients with osteopenic bone (eg, secondary to rheumatoid arthritis or chronic oral corticosteroid usage).

 

A precontoured hallux MTP fusion plate is selected and applied dorsally.5,8,9,10,16 It may be necessary to

débride any osteophytes that prevent adequate seating of the plate on the arthrodesis site.16 Provisional fixation with pinning is performed and fluoroscopy confirms proper sizing and placement of the plate.

 

The plate is then fixed with 2.7-mm nonlocking screws in the phalanx and metatarsal and augmented with 2.7-mm locking screws if bone quality is a concern.8,14 Whether locking or nonlocking screws provide superior fixation remains controversial, with advocates for each (TECH FIG 4).8,13,14,16

 

Alternatively, a standard minifragment plate can be cut and contoured to fit and then affixed to the dorsal surface of the metatarsal and phalanx with small-diameter screws (eg, 2.7 mm).

 

Close the incision in layers with absorbable suture for the arthrotomy and subcutaneous layers and nonabsorbable monofilament for the skin.

 

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TECH FIG 4 • Dorsal locking plate is used to augment the crossed-screw fixation.

• Alternative Technique: Medial Approach

   

  A medial incision over the hallux MTP joint can be used in the presence of a previous surgical scar, severe soft tissue contracture about the joint, or at the surgeon's preference.23

   

  Carry out dissection at the level of the joint capsule, taking care to avoid the dorsomedial branch of the superficial peroneal nerve with elevation of the flap.

   

   

  Perform a midline arthrotomy to expose the metatarsal head and base of the proximal phalanx. Prepare the joint surfaces with a saw blade.23

   

  To allow for correct positioning, make the cut on the metatarsal head perpendicular to the sole of the

  foot, and avoid resecting excessive bone when making the cut on the proximal phalanx. Then, position the hallux, with attention to all three planes as described earlier.

   

  Perform fixation with the crossed lag screw technique as described earlier, with supplemental dorsal plate fixation as needed.23

• Case Example (Courtesy of Mark E. Easley, MD)

Exposure

 

 

Dorsomedial longitudinal incision over first MTP joint Extensor hallucis longus tendon protected

 

Dorsomedial superficial nerve branch to hallux protected

 

 

Longitudinal capsulotomy Capsule reflected

 

Joint exposure optimized by release of flexor hallucis brevis from base of proximal phalanx while avoiding injury to the FHL tendon (TECH FIG 5)

Joint Preparation

 

Cup-and-cone reamer system

 

Optimally sized cone reamer for first metatarsal head may be centered over first metatarsal head and used to optimally center guide pin (TECH FIG 6A,B).

 

 

First metatarsal head reamed with soft tissues well protected (TECH FIG 6C) Guide pin centered in proximal phalanx (TECH FIG 6D)

 

Proximal phalanx reamed with appropriately sized cup reamer (TECH FIG 6E)

 

Subchondral bone drilled to optimize fusion, with cold saline irritation to limit heat necrosis (TECH FIG 6F)

 

 

Provisional Fixation MTP joint reduced Provisional fixation

 

Toe rotated into neutral position

 

 

Pronation must be avoided (TECH FIG 7A,B). Err into slight supination to avoid pronation.

 

Optimize sagittal plane toe position.

 

An instrument lid may be used to simulate weight bearing.

 

Ideally, with hallux in neutral position, hallux tuft should barely touch or be elevated 1 to 2 mm from the instrument lid that is simulating weight bearing (TECH FIG 7C).

 

 

19

 

 

 

TECH FIG 5 • A 40-year-old man with posttraumatic arthritis of the right first MTP joint. With soft tissues well-protected, MTP joint is released, here showing release of flexor hallucis brevis tendon from base of proximal phalanx, to optimize exposure.

 

 

 

TECH FIG 6 • A-C. Metatarsal head preparation. A. The dedicated cone reamer is optimally positioned on the metatarsal head. B. The guide pin is inserted after optimal reamer position is determined. C. With soft tissues well protected, metatarsal head is reamed over the guide pin. D,E. Proximal phalanx preparation. D. Insertion of the guide pin. E. With soft tissues well protected, the proximal phalanx is reamed with a dedicated metatarsal arthrodesis cup reamer. F. The subchondral surfaces are drilled to promote fusion. In this case, a Kirschner wire was used; however, a drill may be better, as it typically generates less heat.

Cold saline irrigation may limit the risk of heat necrosis.

 

 

20

 

 

 

TECH FIG 7 • A. Hallux pronation should be avoided. B. Hallux with optimal rotation. C. Ideally, with hallux in neutral position, the hallux tuft should barely touch or be elevated 1 to 2 mm from the instrument lid that is simulating weight bearing.

Definitive Fixation

 

Lag screw

 

May be placed from distal-medial to proximal-lateral (TECH FIG 8A)

 

When protecting the dorsomedial sensory nerve, be sure that the hallux does not rotate into pronation.

 

If the screw has a head, be sure to countersink to distal aspect of the head to avoid proximal phalanx fracture when the screw head contacts the proximal phalanx.

 

Hallux should be in neutral alignment (TECH FIG 8B).

 

Although some authors recommend valgus position, neutral position will avoid impingement on the second toe.

 

 

 

TECH FIG 8 • A. Lag screw fixation. In this case, a fully threaded and headed screw was used. The proximal phalanx must be countersunk to avoid stress fracture when the head is fully seated. B. Assessing alignment after lag screw fixation. Although some authors recommend valgus position, neutral position will avoid impingement on the second toe. C. The MTP joint arthrodesis is stabilized with a dorsal plate. In this case, a simple small fragment plate was used. Note that the plate is straight, limiting the risk of dorsiflexion malunion. The provisional fixation Kirschner wire is removed after definitive fixation is complete.

 

 

To optimize stability of the first MTP joint arthrodesis, a dorsal plate may be placed.

 

Numerous different plates are commercially available.

 

In this case, a simple small fragment plate was used (TECH FIG 8C).

Postoperative Care

 

 

Protective weight bearing avoiding forefoot loading for 6 weeks Short-leg cast versus cam boot for 4 weeks

 

Postsurgical shoe for additional 2 to 4 weeks until patient can transition into stiffer-soled shoe

 

 

 

 

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PEARLS AND PITFALLS
	Arthrodesis ▪ To prevent shortening, avoid excessive bone resection. preparation

Fixation

problems

• When arthrodesis is performed on osteopenic bone, requiring additional fixation

with a dorsal locked plate,5,13 additional Kirschner wires or threaded pins3,10 may be necessary to supplement standard fixation.

• Maintain correct positioning of the hallux during insertion of the guide pin. Avoid

bending and shearing of the wire during cannulated drilling.

Guide pin

breakage

• Intraoperatively, the position of the hallux is assessed fluoroscopically and clinically with a flat surface to simulate weight bearing. Proper positioning includes valgus of 10-15 degrees, dorsiflexion of 25-30 degrees relative to the metatarsal shaft (or 10 degrees relative to the sole of the foot), and neutral rotation. Clinically, the hallux should not impinge on the second toe and the nail plate should be aligned with the same plane as the lesser toes.

Hallux positioning

 

 

POSTOPERATIVE CARE

 

In patients with an isolated arthrodesis with good bone quality and solid fixation, weight bearing as tolerated on the heel and lateral border of the foot is allowed in a postoperative hard-soled shoe or fracture boot, restricting weight bearing on the forefoot.9,14

 

If there are concerns about bone quality, suboptimal fixation, or potential noncompliance by the patient, strict non-weight bearing in a boot or below-the-knee cast is maintained for 6 weeks.

 

After 6 weeks, partial weight bearing is advanced, based on evidence of clinical and radiographic healing.

 

 

Full weight bearing usually is achieved by 8 to10 weeks, at which time the patient transitions from the postoperative shoe or boot into sneakers, clogs, or comfortable, lowheeled walking shoes.

 

At 12 to 16 weeks, with additional reduction in swelling, most patients can transition into unrestricted shoe wear; however, some individuals have permanent difficulty wearing fashion shoes or high heels.

 

Prolonged walking and athletic activities usually resumes at 3 to 5 months.

 

Custom-made orthotics with a buildup under the hallux to improve weight bearing of the first ray may dissipate forefoot stresses.

 

OUTCOMES

The clinical results after hallux MTP arthrodesis usually are excellent, with high rates of bony union, patient satisfaction, and pain relief.

Union rates for in situ arthrodesis range from 77% to 100%.4,5,8,9,10,11,14,15,16,19,23

Patient satisfaction rates also are high, regardless of the indications.4,5,7,8,9,10,14,15,16,19,23 MTP arthrodesis causes a rigid lever arm, resulting in an earlier toe-off in the gait cycle and

decreasing the stress on the lesser metatarsals.4,17,19 This stiffness may result in increased stress across the hallux interphalangeal joint.17

After arthrodesis, the first ray shows improved weightbearing capacity, with the foot compensating for

 

the relative stiffness during stance phase.7 Formal gait analysis after fusion demonstrates improvements in propulsive power, weight-bearing function of the foot, and stability during gait.1

 

 

 

COMPLICATIONS

Nonunion rates range from 5% to 22%.5,7,8,9,10,11,14,15,19 Nonunion may not be symptomatic and may not require revision surgery.15

Malunion after MTP arthrodesis can result in mild malalignment that is tolerated, but more severe malposition may be symptomatic.

Excessive dorsiflexion leads to unloading of the hallux and lesser toe transfer metatarsalgia. Positioning the hallux in relative plantarflexion may lead to interphalangeal joint irritation, callus formation, and later interphalangeal arthritis.22

Valgus positioning can lead to painful impingement on the second toe, whereas varus positioning causes impingement of the hallux against the toe box of the shoe.

Subsequent arthritis of the interphalangeal joint may occur in one-third of cases.5,11

Arthritis in the interphalangeal joint is more common than that of the first tarsometatarsal or other midfoot joints.11

However, symptoms may be mild despite radiographic involvement and may take 10 years to develop.

Severe symptoms may require secondary interphalangeal arthrodesis, which leads to extreme stiffness of the hallux.

Iatrogenic nerve injuries of the dorsomedial cutaneous nerve are more common than injuries to the plantar nerves.

These may result in neuroma formation, mild numbness, or persistent dysesthesias that compromise an otherwise successful arthrodesis.

Prevention by proper incision placement and meticulous surgical dissection remains the best strategy.

 

REFERENCES

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2. Castro MD, Klaue K. Technique tip: revisiting an alternative method of fixation for first MTP joint arthrodesis. Foot Ankle Int 2001;22: 687-688.

    

    

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18. Mann RA, Katcherian DA. Relationship of metatarsophalangeal joint fusion on the intermetatarsal angle. Foot Ankle 1989;10:8-11.

     

     

19. Mann RA, Schakel ME II. Surgical correction of rheumatoid forefoot deformities. Foot Ankle Int 1995;16:1-

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20. Mizel MS, Alvarez RG, Fink BR, et al. Ipsilateral arthrodesis of the metatarsophalangeal and interphalangeal joints of the hallux. Foot Ankle Int 2006;27:804-807.

     

     

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