Emerging Insights On The First MPJ Arthrodesis

Shelby Swanson, BA, Andrea Dyack, BS, BA, and Michael S. Lee, DPM, FACFAS

   Fixation typically occurs with two crossing 3.5 mm cortical screws. Place one screw from proximal-medial to distal-lateral and the second from distal-medial in the phalanx into the proximal-lateral aspect of the first metatarsal. Place the screws using a lag technique. Be sure to provide considerable compression and stable fixation when placing the screws in a bicortical fashion. Stack the screws on top of one another to provide uniform fixation throughout the fusion site. Surgeons may utilize other types of screw fixation using a similar construct based on surgeon preference.

   The senior author recommends capsular closure using a running 3-0 vicryl and skin closure using a 4-0 nylon stitch. One should ensure limited subcutaneous closure in order to prevent soft tissue irritation medially. Patients wear a controlled ankle motion (CAM) boot postoperatively and stay non-weightbearing for at least four weeks. In weeks four through eight, patients typically may bear weight on the heel only in a CAM boot. At or around eight weeks, the patient progresses to regular shoe gear based on radiographic healing.

In Conclusion

When it comes to considering first MPJ arthrodesis in the management of hallux rigidus, one should carefully weigh the patient’s age, overall health status, prior surgeries and exhaustion of conservative efforts. For the active patient whose quality of life is deteriorating due to first MPJ osteoarthritis and for whom conservative treatments have failed, we recommend first MPJ arthrodesis with crossed screw fixation.

   It is clear from the current literature that first MPJ arthrodesis is a cost-effective method of reducing first MPJ pain and gaining overall patient satisfaction. With constant advances in fixation techniques and materials, union rates are very high.

   More importantly, first MPJ arthrodesis maintains postoperative function and quality of life, and the procedure offers reproducible and predictable results.

   Ms. Swanson is a third-year podiatric medical student at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa.

   Ms. Dyack is a third-year podiatric medical student at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa.

   Dr. Lee is in private practice at Capital Orthopaedics and Sports Medicine, PC. He is an Associate Clinical Professor at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa. Dr. Lee is a Fellow and Past President of the American College of Foot and Ankle Surgeons.


I am happy to report 100% fusion rate with my great toe joint fusions. I'd like to share my technique and present a case I am considering doing currently:

Here are my surgical pearls for fusion of the first metatarsal phalangeal joint:

Like the authors, I use a technique to remove cartilage from the two bones with a rotary burr. I find it very helpful to have a baby lamina spreader to assist in distraction of the joint in order to simplify access. My instrument of choice is the Synthes brand baby lamina spreader.

I fenestrate the bones with a 0.045 wire, which allows more holes than a 0.062 wire.

I prefer using cross 3.0 mm cannulated screws.

I too use the lid of the screw set to ensure the proper 15 to 20 degrees of dorsiflexion. I temporarily fixate with cross guide wires and an additional 0.062 k-wire.

I prefer to put the plantar screw in from proximal medial to distal lateral and then add the more dorsal screw from distal medial to proximal lateral.

I find this to be a very rewarding surgery as most patients are in a lot of pain prior to performing this surgery, hence the need for this aggressive joint destructive procedure.

Here is an interesting case. I have a 64-year-old female with posterior tibial tendon dysfunction secondary to back surgery with a unilateral flat foot and severe hallux abducto valgus. She underwent a distal osteotomy for hallux valgus four years ago. In under one year, her hallux valgus was back as bad as before surgery.

She has an IM angle of 14 degrees, a short first met and HA of 60 degrees.

I am considering an opening base wedge osteotomy with a Wright Medical plate and staging three to six months later a fusion of the first MPJ. I feel as though an opening wedge osteotomy will work but the forces due to her posterior tibial tendon dysfunction and severe pronation will cause the bunion to return like after her last surgery.

Any experience combining a first metatarsal osteotomy with an arthrodesis? Any insight would be appreciated.

Lawrence Silverberg, DPM
blog: www.bestpodiatristnyc.com

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