Emerging Insights On The First MPJ Arthrodesis

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

1. Clutton HH. The treatment of hallux valgus. St. Thomas Rep. 1894;22:1.
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3. Hyer CF, Glover JP, Berlet GC, Lee TH. Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg. 2008; 47(1):13-18.
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7. Sharma H, Bhagat S, DeLeeuw J, Denolf F. In vivo comparison of screw versus plate and screw fixation for first metatarsophalangeal arthrodesis: does augmentation of internal compression screw fixation using a semi-tubular plate shorten time to clinical and radiologic fusion of the first MTPJ? J Foot Ankle Surg. 2008; 47(1):2-7.
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Drsilversays: August 11, 2011 at 11:11 pm

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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