High Utility of the 1st Metatarsal Phalangeal Joint Fusion

Radiographic analysis of hallux valgus and first tarsometatarsal joint correction after isolated first metatarsophalangeal joint arthrodesis

Arthrodesis of the first metatarsophalangeal joint is a common surgical procedure used to treat a variety of forefoot pathologies. The purpose of this study was to evaluate radiographic outcomes for hallux valgus and first tarsometatarsal joint alignment after first metatarsophalangeal joint arthrodesis. A retrospective radiographic analysis of the first intermetatarsal angle, hallux valgus angle, first metatarsal-cuneiform angle, and medial cuneiform-first metatarsal angle was performed preoperatively and postoperatively. One hundred eighty-eight procedures met inclusion criteria. Significant radiographic improvements were noted in first intermetatarsal angle (4.38°, P < 0.0001), hallux valgus angle (16.01°, P < 0.0001), first metatarsal-cuneiform angle (5.96°, P < 0.0001), and medial cuneiform-first metatarsal angle (5.68°, P < 0.0001). Significant radiographic improvements (P < 0.0001) were also noted when subjects were subdivided into first intermetatarsal angle ≤ 15° and > 15° for all measured angles. An isolated first metatarsophalangeal joint arthrodesis corrects both hallux valgus deformity and first tarsometatarsal alignment. These findings support that additional first ray procedures may not be required when performing a first metatarsophalangeal joint arthrodesis for hallux valgus.

Sagittal Plane Alignment for First Metatarsal Phalangeal Arthrodesis Correlated with Postoperative Function: What is the Optimal Position?

There have been many reports describing the proposed alignment of a first metatarsal phalangeal arthrodesis to obtain optimum function. Most of these recommendations are based upon historical and anecdotal evidence. Furthermore, there are few reports directly comparing alignment to patient reported function. We studied radiographic sagittal plane alignment in a group of 60 patients (80 feet) who had undergone a first metatarsal phalangeal joint arthrodesis (20 of the 60 had bilateral arthrodesis) to better understand how this component of the arthrodesis position translates to real world function. The patients in this study had completed a functional survey in 2022 at a mean of 28.4 (median 27.8; range 13.2-45.7) months with very high satisfaction for return to activities of daily living and recreational sports. We measured the sagittal plane position of the first metatarsal relative to the proximal phalanx in this cohort with known post operative activity data. We found that a mean (standard of deviation) sagittal plane angle (angle between the anatomic axis of the first metatarsal and the proximal phalanx) of 15.4 (SD 7.4) degrees and a proximal phalanx head to ground height of 12.7 (SD 3.3) mm was present in this group. Comparing the functional and positional results we conclude that this sagittal plane position provides a good recommendation for alignment.

Arthroscopic Sesamoidectomy and Plantar Metatarsal Head Bone Shaving in Management of First Metatarsal Head Metatarsalgia After First Metatarsophalangeal Fusion

First metatarsophalangeal arthrodesis has been used to treat end-stage arthritis of the great toe (e.g., gout, post-traumatic, infection), severe hallux valgus deformity, hallux valgus caused by neuromuscular disorders, rheumatoid forefoot deformity, primary hallux varus, and rigid plantarflexion deformities, as well as a salvage procedure for failed previous operation of the great toe. As with any arthrodesis procedure, proper positioning of the hallux in first metatarsophalangeal arthrodesis is of utmost importance for good clinical outcome. The chief problem tends to be sagittal alignment. In case of the significant dorsiflexion malunion of the fusion site with excessive plantar pressure of the first metatarsophalangeal joint and abutment of the hallux to the shoebox, corrective osteotomy is indicated. If there is isolated excessive plantar pressure of the first metatarsophalangeal joint without hallux problem, arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head is another surgical option. The purpose of this technical note is to describe the details of arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head.