Researchers have discussed arthroscopic procedures of almost every joint in the body and the first metatarsophalangeal joint (MPJ) is no exception. However, first MPJ arthroscopy is one of the newer and less described arthroscopic procedures. Despite a plethora of evidence documenting the benefits for first MPJ arthroscopy, very few surgeons are actually utilizing the technique.
As Frey noted in 2009, one can employ arthroscopy for surgical intervention as well as for diagnostic purposes.1 Frey explained that surgeons can perform first MPJ arthroscopy for the treatment of osteophytes, hallux rigidus, chondromalacia, osteochondral lesions (OCD), loose bodies, arthrofibrosis and synovitis secondary to hyperextension and hyperflexion injuries.1 Van Dijk and colleauges in 1998 published the first series looking at the benefits of first MPJ arthroscopy in athletes.2 In eight of 12 patients with dorsal impingement and three out of four patients with osteochondritis dissecans, the authors cited good or excellent results at a minimum two-year follow-up.
Especially for athletes undergoing arthroscopy, the diminished risk of fibrosis will aid in restoring range of motion. Conversely, we all know too well that range of motion is often sacrificed with open arthrotomies such as cheilectomy or bunionectomy. The benefits of first MPJ arthroscopy are best described by Lui, who stated that arthroscopy has potential advantages of reduced surgical trauma, reduced postoperative pain and better cosmetic results in comparison to extensile exposures.3,4 Lui, like Van Dijk, has pioneered small joint arthroscopy.2-4
Other studies have reported additional arthroscopic indications for pigmented villonodular synovitis, sesamoidal disorders, hallux varus, hallux valgus, ganglion cysts, gouty arthritis with tophi and intra-articular fractures.1-10
One contraindication presented by Debnath and colleagues in 2006 is an osteophyte larger than five mm due to the difficult nature of isolating the dorsal capsule.5 The lead author of this column agrees with Debnath and coworkers that the presence of medial, lateral or dorsal osteophytes of any significance requires an open procedure. Ideal patients for first MPJ arthroscopy are those without any osteophytes, who fall into the category of stage I-II hallux limitus.
A Closer Look At First MPJ Arthroscopy Techniques
With increasing demands for minimally invasive surgery, early weightbearing and considerations of patient satisfaction, let us take a closer look at pertinent indications and techniques when considering first MPJ arthroscopy in athletes.
Similar to performing ankle arthroscopy, one should ensure supine positioning of the patient undergoing a first MPJ arthroscopy. In 2012, Ahn and colleagues described a distraction method in which “distraction is applied to the great toe with a finger trap suspended from a pulley attached to a shoulder holder apparatus.”6 Vaseenon and Phisitkul in 2010 describe a similar technique with a Chinese finger trap with traction of two kg over a pulley attached to the surgical table.”7
Surgeons typically perform arthroscopic procedures without a tourniquet as most studies relate it is unnecessary due to inflow pressure ability to control intra-articular bleeding.6 However, Lui describes the use of a thigh tourniquet with the procedure.4 Our team elects to have an ankle tourniquet available but we rarely use it.
Also similar to performing ankle arthroscopy, our team utilizes lidocaine with epinephrine 1% and 1:100,000 using 20 cc within our 1,000 cc IV bag, which assists with intra-articular bleeding.
The senior author of this column uses external fixation for joint distraction, visibility and access. Many authors have utilized finger traps, which in our experience are frankly cumbersome and often impede our work. Instead, we recommend utilizing a mini-rail external fixation system with four half-pins (two in the proximal phalanx and two in the metatarsal). With the guidance of C-arm fluoroscopy, distract the joint five to seven mm so there is ample room for a 2.7/2.9 mm scope.
We then utilize two 18-gauge needles to find the dorsolateral and dorsomedial portals (see photo on page 58). While we rarely use a plantar medial portal, it is reportedly helpful for looking at the sesamoid apparatus.1 For instrumentation, we choose a shaver/burr as large as 3.5 mm. We recommend temperature-controlled thermal wands (radiofrequency ablation) like the OPES™ Electrosurgical System (Arthrex), SERFAS (Stryker) or TAC™-S (Smith & Nephew). All fit within the first MPJ through the portals and do an excellent job of enabling surgeons to reduce intra-articular bleeding, perform synovectomy, and shrink loose capsule.
With multiple intra-articular images there is visualization of the entire joint. The clarity with which we can evaluate the joint is far superior to what we can visualize via an open procedure. The majority of the cases that we are performing at our facility involve stage I-III hallux limitus without any significant osteophytes, post-op fibrosis or acute cartilage damage post-injury (see photos to the right). We utilize diagnostic arthroscopy only in cases for which we have normal imaging and a positive response to diagnostic injections. More often than not, many of these cases will show significant cartilage injuries or defects (see photos to the right).
Reviewing Pertinent Aspects Of The Postoperative Course
In our experience, patients are able to return to weightbearing after one week regardless of specific arthroscopic approach and procedure. We have observed that our patients’ only consistent postoperative complaint is pain near the half-pin sites, which typically resolves in four to six weeks. Frey describes the postoperative duration as avoidance of weightbearing for five to seven days during the greatest period of inflammation.1 We routinely start first MPJ range of motion the day after surgery. Diagnostic scopes with minimal surgical debridement allow for weightbearing the same day as the procedure.
In the aforementioned 1998 study of first MPJ arthroscopy by van Dijk and colleagues, the authors reported good or excellent outcomes for patients with dorsal osteophytes and impinging soft tissues but no significant degenerative changes.2 However, they noted “less favorable” results for patients with hallux rigidus and sesamoid bone removal. In 2012, Ahn and coworkers analyzed the results of 59 cases of first MPJ joint arthroscopy.6 Following the patients for a mean duration of 25 months after the procedure, they found that AOFAS hallux scores increased from 69 preoperatively to 92 postoperatively and 95 percent of patients were satisfied with their procedure. Reportedly only two patients had postoperative complications.
In 2017, Kuyucu and colleagues studied 14 patients with hallux rigidus and focal osteochondral lesions of the first MPJ, who had arthroscopic microdrilling. The patients had a mean preoperative visual analog scale score of 8.14 and an AOFAS hallux score of 48.64, and the postoperative scores were significantly better at 1.86 and 87 respectively. These results showed a decrease in pain and increase in hallux function with virtually no postoperative complications.
Evaluating Procedural Risks Versus Benefits
According to the literature, arthroscopy has statistically encouraging results and appears to be safe and reproducible.
As Debnath and colleagues state, there are several advantages to this type of arthroscopy including minimal soft tissue dissection, avoidance of a large capsulotomy, decreased postoperative pain, less postoperative stiffness and overall improved outcomes in select groups of patients.5 However, there may also be procedure-related complications that include nerve injury from poorly placed portals, iatrogenic articular cartilage injury, instrument breakage, inadequate fluid management, compartment ischemia, infections, effusion, complex regional pain syndrome, and persistent pain and stiffness.5
Vaseenon and Phisitkul noted that surgeons may employ the first MPJ arthroscopy to address decreased soft tissue and iatrogenic nerve damage by performing arthroscopic arthrodesis.7 They discussed the use of a two- versus three-portal technique pending gross deformity and cartilage assessment. The two-portal technique uses the standard dorsal portals medial and lateral to the extensor hallucis longus (EHL) and the three-portal technique adds the medial inferior portal.
The authors demonstrated a slightly higher success rate (97 percent) with the three-portal technique in comparison to the two-portal technique (94 percent) due to improved cartilage removal.7 Following debridement of cartilage and resection of osseous prominences, several authors have discussed varying methods of fixation including crossed K-wires, crossed cannulated and non-cannulated screws, single screws and monorail external fixation.11-14
The senior author of this column prefers open procedures for classic hallux rigidus cases. As many of us who treat athletes have seen throughout our careers, thousands of soldiers and athletes by definition have stage II hallux limitus, but they also may have severe cartilage defects that one does not see within the non-athletic community (see bottom photos above). There may be some minor subchondral pitting without the presence of osteophytes on imaging.
We have not found that heroic efforts to salvage the first metatarsal or even the proximal phalangeal cartilage with grade III-IV chondromalacia have ever truly provided long-term satisfactory results in athletes. Just as we have seen with open cheilectomies or arthrotomies in athletes, long-term results with open techinques are poor. These patients with stage III-IV hallux rigidus will ultimately go on to a fusion within a year or two of the first cheilectomy or, worse, be subjected to multiple cheilectomies or heroic misadventures in cartilage restoration or implant arthroplasty.
We aim to avoid these mishaps and prefer to reserve those cases for arthroscopic fusions. It is our experience that patients with minimal deformity without metatarsal elevation or deformity, and with no appreciable ankylosis, are perfect candidates for arthroscopic fusions. We will simply denude the remaining cartilage, compress the external fixator and utilize percutaneous screw fixation.
In a select few cases, we will give the patient a choice of fixation options, including the use of external fixation as definitive fixation. On occasion, patients will request to opt out of metal fixation and we instead can utilize 3.5 mm or 4.5 mm absorbable screw fixation. By maintaining the periosteal and capsular structures, we have seen improved fusion rates while reducing post-operative pain.
Arthroscopic first MPJ surgery is a procedure which is increasing in popularity, at least within the literature. Surgeons may employ this procedure for a variety of conditions of the first ray, most commonly hallux rigidus, according to the literature. We mostly prefer using this procedure for hallux limitus stage I-II and stage III with minimal osteophytes. Based on our experience as well as the current literature, this minimally invasive joint procedure is reproducible and has fairly positive outcomes with minimal complications.
When showing a colleague the intra-operative benefits of first MPJ arthroscopy, he whispered “Open it already” or asked questions such as “Are we done yet?” and “Why does this take so long?” Truthfully, small joint arthroscopy requires patience. Arthroscopic procedures are technically challenging and not faster than open procedures. As with any new procedure with a lot of instrumentation, there is a steep learning curve.
However, we must remember why we do these procedures. We want to help our patients by minimizing postoperative fibrosis and pain, facilitating better range of motion and achieving better outcomes.
Dr. Spitalny is a staff podiatrist at the General Leonard Wood Army Community Hospital in Ft. Leonard Wood, MO, and adjunct faculty at the DePaul Podiatric Surgical Residency Program in St. Louis.
Dr. Staples is a third-year resident with the DePaul Podiatric Surgical Residency Program in St. Louis.
Dr. McKee is a third-year resident with the DePaul Podiatric Surgical Residency Program in St. Louis.
Dr. Joseph is a third-year resident with the DePaul Podiatric Surgical Residency Program in St. Louis.
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