Can Three Surgical Procedures Address Most First MTPJ Pathology?

I recently discussed with a colleague that I currently employ just three surgical options for my patients that require surgical intervention for first MTP pathology. He seemed surprised to hear this and asked that I elaborate. I went on to list the three procedures: Minimally invasive (MIS) bunionectomy; cheilectomy (both open and MIS); and first metatarsophalangeal joint fusion. We had a good discussion which I will detail below.

For hallux valgus deformity of almost any intermetatarsal angle without the presence of arthritis, I will perform an MIS distal metatarsal osteotomy with or without an Akin osteotomy. The use of distal metatarsal osteotomy to address high IM angle deformities is well documented.¹ With the preservation of the soft tissue envelope/capsule and periosteal sleeve we //can// achieve correction in even the highest IM angles with less pain, less swelling and a faster return to activity, all while maintaining range of motion.² For these reasons I have moved further away from almost any other approach or procedure to address hallux valgus. Additionally, while anecdotal, the results I see in my practice and the satisfaction of my patients is much better in those who had an MIS procedure in comparison to those who underwent non-minimally invasive procedures.

For those patients with mild arthritic changes or a distal dorsal osteophyte of the first metatarsal head, I will perform a cheilectomy, either open or MIS. For those who have arthritic changes to areas of the joint other than just the dorsal first metatarsal, particularly towards the lateral portion of the joint extending in the interspace, I will elect to perform an open cheilectomy. I do so to debride all planes involved to allow for restoration of motion and alleviating the pain associated with the pathology. For those, however, who have a dorsal osteophyte only, I use an MIS approach. Similar to the MIS distal metatarsal osteotomy, the MIS cheilectomy has proven in my practice to offer relief and resolution of symptoms and pathology while also affording less pain, less swelling, a smaller scar, and resultant preservation of range of motion.

Lastly, for moderate-to-severe arthritic changes or in patients who want to minimize their chances of recurrence or need for further surgery in severe hallux valgus, I will utilize a first metatarsophalangeal joint arthrodesis. In my experience, the first MTP fusion is a procedure that allows for resolution of the patient's pain and pathology, is definitive in nature and allows for the patient to continue almost all activities, in even the most active patient population, with no major complications when done right. I find patients are happy and don’t typically seem to miss on the range of motion that is no longer there as long as they experience alleviation of// their pain and discomfort.

While I have come to rely on these three procedures are the ones that I have come to rely on the most to address almost all first MTP pathology, I do think that different patients have different needs and that the art of medicine may look different in the hands of different practitioners and surgeons. Procedures like the Lapidus, for example, play an important role in many practices in helping to treat hallux valgus.

Dr. Ali Rahnama is a fellowship-trained foot and ankle surgeon and an Assistant Professor at the Georgetown University School of Medicine in Washington, D.C. You can follow him on Instagram @DrAliRahnama for interesting cases and educational material. 

Dr. Rahnama discloses relationships with Ossio and Arthrex.

References

1. Oloff LM, Bocko AP. Application of distal metaphyseal osteotomy for treatment of high intermetatarsal angle bunion deformities. J Foot Ankle Surg. 1998;37(6):481-489.

2. Radwan YA, Mansour AM. Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy for correction of mild-to-moderate hallux valgus deformity. Arch Orthop Trauma Surg. 2012 Nov;132(11):1539-1546.