1st MTPJ Revision and Fusion: Surgical Treatment for Hallux Rigidus
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Questions and Answers

What is the primary issue with the 1ST MTPJ IMPLANT SYNTHETIC CARTILAGE IMPLANT?

  • Subsidence is not common
  • It does not mimic the modulus of elasticity of cartilage
  • It is not suitable for hallux rigidus treatment
  • Subsidence is very common (correct)

    • What is the 'gold standard' for hallux rigidus surgical treatment?

  • 1st MTPJ implant
  • Lapidus procedure
  • Synthetic cartilage graft
  • 1st MTPJ fusion (correct)

    • What is the recommended positioning for 1st MTPJ fusion?

  • Intraoperative loading to determine optimal positioning (correct)
  • 20° abducted and 20° dorsiflexed
  • 15° abducted and 15° dorsiflexed
  • 10° abducted and 10° dorsiflexed

    • What is the primary benefit of the Lapidus procedure?

    <p>All of the above</p> Signup and view all the answers

    Why do patients often dislike double fusions (1st MTPJ and 1st TMTJ)?

    <p>The outcome is often unpredictable</p> Signup and view all the answers

    What is the typical presentation of a patient with hallux rigidus?

    <p>All of the above</p> Signup and view all the answers

    What is the goal of arthrodiastasis in the treatment of hallux rigidus?

    <p>To stretch the periarticular soft-tissue structure</p> Signup and view all the answers

    What is the purpose of penetrating the subchondral plate in chondroplasty?

    <p>To allow bleeding and formation of fibrocartilage</p> Signup and view all the answers

    What is the indication for Valenti resection arthroplasty?

    <p>Low functional requirements</p> Signup and view all the answers

    What is the Lapidus procedure?

    <p>A fusion procedure involving the 1st MTPJ</p> Signup and view all the answers

    What is the result of penetrating the subchondral plate in chondroplasty?

    <p>Formation of fibrocartilage</p> Signup and view all the answers

    What is the function of the plantar phalangeal base in arthrodiastasis?

    <p>To provide a base for the proximal phalanx</p> Signup and view all the answers

    What is the primary characteristic of Stage 1 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Limited dorsiflexion with weightbearing</p> Signup and view all the answers

    Which procedure is used to remove osteophytosis from the metatarsal head and proximal phalanx?

    <p>Cheilectomy</p> Signup and view all the answers

    What is the treatment goal for Stage 4 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Joint-Destructive procedure</p> Signup and view all the answers

    What is the indication for a Kessel & Bonney Decompression osteotomy?

    <p>Adolescents with early hallux rigidus</p> Signup and view all the answers

    What is the result of drilling subchondral bone in a Cheilectomy procedure?

    <p>Stimulation of bleeding and fibrocartilaginous ingrowth</p> Signup and view all the answers

    What is the primary characteristic of Stage 3 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Severe flattening of the first metatarsal head</p> Signup and view all the answers

    What is the purpose of a Youngswick Decompression osteotomy?

    <p>To allow for shortening and plantarflexion of the metatarsal head</p> Signup and view all the answers

    What is the consequence of performing a Kessel & Bonney Decompression osteotomy?

    <p>Revision fusion becomes more difficult</p> Signup and view all the answers

    What is the primary goal of a Joint-Salvage procedure?

    <p>To allow for joint movement and reduce pain</p> Signup and view all the answers

    What is the characteristic of Stage 2 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Flattening of the first metatarsal head with osteochondral defect</p> Signup and view all the answers

    What is the primary concern when considering 1st MTPJ fusion for a patient who is a smoker?

    <p>Increased risk of non-union</p> Signup and view all the answers

    What is the primary goal of recommending orthotics for a patient with 1st MTPJ arthrosis?

    <p>To offload the joint and reduce pressure</p> Signup and view all the answers

    What is the likely diagnosis for a patient with no ROM in the 1st MTPJ with forefoot loaded and 50° when unloaded?

    <p>Structural rigidus</p> Signup and view all the answers

    What is the primary advantage of arthrodiastasis over chondroplasty in the treatment of hallux rigidus?

    <p>It addresses biomechanical causes of the condition</p> Signup and view all the answers

    What is the primary indication for recommending Gastroc recession?

    <p>To address sagittal plane deformity</p> Signup and view all the answers

    What is the primary difference between Valenti and Keller resection arthroplasty?

    <p>The extent of proximal phalanx resection</p> Signup and view all the answers

    What is the likely treatment for a patient with Stage 3 1st MTPJ arthrosis who does not want surgery?

    <p>Orthotics and stretching regimen</p> Signup and view all the answers

    What is the primary concern when considering 1st MTPJ fusion for a patient with a prior bunion surgery?

    <p>Prior surgery may affect joint alignment</p> Signup and view all the answers

    Which surgical technique is often considered a joint salvage procedure?

    <p>Valenti resection arthroplasty</p> Signup and view all the answers

    What is the primary goal of penetrating the subchondral plate in chondroplasty?

    <p>To stimulate bleeding and fibrocartilage formation</p> Signup and view all the answers

    Which technique is used to remove cartilage erosions that are often present in hallux rigidus?

    <p>Chondroplasty</p> Signup and view all the answers

    What is the primary benefit of using a mini-rail external fixation in arthrodiastasis?

    <p>It promotes more extensive soft-tissue stretching</p> Signup and view all the answers

    What is the primary goal of a Youngswick Decompression osteotomy?

    <p>To shorten and plantarflex the first metatarsal</p> Signup and view all the answers

    What is the consequence of performing a Cheilectomy procedure on a deteriorated joint?

    <p>Increased joint movement with increased pain</p> Signup and view all the answers

    What is the primary benefit of Kessel & Bonney Decompression osteotomy?

    <p>It changes the posture of the hallux</p> Signup and view all the answers

    What is the treatment goal for Stage 3 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>To salvage or destruct the joint</p> Signup and view all the answers

    What is the primary characteristic of Stage 2 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Flattening of the first metatarsal head with osteochondral defect</p> Signup and view all the answers

    What is the purpose of a Joint-Salvage procedure?

    <p>To salvage the joint and preserve its function</p> Signup and view all the answers

    What is the primary goal of a Cheilectomy procedure?

    <p>To remove osteophytosis from the metatarsal head and proximal phalanx</p> Signup and view all the answers

    What is the characteristic of Stage 4 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Obliteration of the joint space with exuberant dorsal osteophytosis</p> Signup and view all the answers

    What is the treatment goal for Stage 1 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>To perform a Joint-Salvage procedure</p> Signup and view all the answers

    What is the primary benefit of a Joint-Salvage procedure?

    <p>It preserves the joint function and reduces pain</p> Signup and view all the answers

    What is the primary purpose of resection arthroplasty in the treatment of hallux rigidus?

    <p>To remove the majority of the MTPJ</p> Signup and view all the answers

    What is the primary benefit of using a mini-rail external fixation in arthrodiastasis?

    <p>To stretch periarticular soft-tissue structures</p> Signup and view all the answers

    What is the primary goal of penetrating the subchondral plate in chondroplasty?

    <p>To allow bleeding and formation of fibrocartilage</p> Signup and view all the answers

    What is the primary difference between Valenti and Keller resection arthroplasty?

    <p>The extent of the resection</p> Signup and view all the answers

    What is the primary goal of 1st MTPJ arthrodesis?

    <p>To fuse the joint and eliminate pain</p> Signup and view all the answers

    What is the primary characteristic of Stage 1 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Mild cartilage erosion and minimal bone loss</p> Signup and view all the answers

    What is the treatment goal for a patient with Stage 1 1st MTPJ arthrosis who does not want surgery?

    <p>Orthotics and stretching regimen</p> Signup and view all the answers

    What is the likely diagnosis for a patient with a painful 1st MTPJ with forefoot loaded and 50° when unloaded?

    <p>Functional limitus</p> Signup and view all the answers

    What is the recommended treatment for a patient with Stage 3 1st MTPJ arthrosis who is a smoker and does not want surgery?

    <p>Orthotics and stretching regimen</p> Signup and view all the answers

    What is the next step in treatment for a patient with Stage 2 1st MTPJ arthrosis who has already undergone bunion surgery?

    <p>Cheilectomy</p> Signup and view all the answers

    What is the primary concern when considering 1st MTPJ fusion for a patient with a prior bunion surgery?

    <p>Altered biomechanics</p> Signup and view all the answers

    What is the treatment goal for a patient with Stage 3 1st MTPJ arthrosis who wants to maintain range of motion?

    <p>Cheilectomy</p> Signup and view all the answers

    What is the primary indication for a Cheilectomy procedure in Hallux Rigidus?

    <p>Limited dorsiflexion with weightbearing</p> Signup and view all the answers

    What is the consequence of performing a Kessel & Bonney Decompression osteotomy on an adult?

    <p>Revision fusion may be more difficult</p> Signup and view all the answers

    What is the primary benefit of a Youngswick Decompression osteotomy in Hallux Rigidus?

    <p>Shortening and plantarflexion of the 1st metatarsal</p> Signup and view all the answers

    What is the characteristic of Stage 3 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Severe flattening of the first metatarsal head</p> Signup and view all the answers

    What is the primary goal of a Joint-Salvage procedure in Hallux Rigidus?

    <p>Preserve the joint</p> Signup and view all the answers

    What is the consequence of performing a Cheilectomy procedure on a deteriorated joint?

    <p>Increased patient symptoms</p> Signup and view all the answers

    What is the primary indication for a Kessel & Bonney Decompression osteotomy?

    <p>Adolescents with Hallux Rigidus</p> Signup and view all the answers

    What is the primary goal of arthrodiastasis in the treatment of Hallux Rigidus?

    <p>Stimulate fibrocartilaginous ingrowth</p> Signup and view all the answers

    What is the treatment goal for Stage 4 in the Drago, Oloff, & Jacobs Classification of Hallux Rigidus?

    <p>Joint-Destructive procedure</p> Signup and view all the answers

    What is the primary benefit of a Joint-Salvage procedure in Hallux Rigidus?

    <p>Preservation of the joint</p> Signup and view all the answers

    What is the primary advantage of the traditional dorsomedial approach in surgical procedures for hallux rigidus?

    <p>Provides better visualization of the MTPJ from medial to lateral</p> Signup and view all the answers

    What type of anesthesia is typically required for more proximal procedures in hallux rigidus surgery?

    <p>General anesthesia</p> Signup and view all the answers

    What is the primary purpose of using an ankle tourniquet in distal procedures for hallux rigidus?

    <p>To reduce bleeding during the procedure</p> Signup and view all the answers

    What is the primary benefit of a medial approach in surgical procedures for hallux rigidus?

    <p>Permits access to the MTPJ from medial and dorsal</p> Signup and view all the answers

    What is the primary purpose of capsulotomy in surgical procedures for hallux rigidus?

    <p>To facilitate exposure of the MTPJ</p> Signup and view all the answers

    What is the primary advantage of using epinephrine in hemostasis during hallux rigidus surgery?

    <p>Reduces bleeding</p> Signup and view all the answers

    What is the primary purpose of reefing/plication of the medial joint capsule during closure?

    <p>To tighten stretched or weakened tissues</p> Signup and view all the answers

    What is the postoperative course for soft tissue procedures?

    <p>Weightbearing as tolerated in a postoperative shoe until incision is healed</p> Signup and view all the answers

    What is the primary concern in postoperative care for soft tissue procedures?

    <p>Protection of the incision</p> Signup and view all the answers

    What is the purpose of adductor tendon transfer?

    <p>To provide additional support to the joint</p> Signup and view all the answers

    What is the Akin procedure?

    <p>A type of osteotomy</p> Signup and view all the answers

    What is the primary indication for a Distal Akin osteotomy?

    <p>Abnormal HAIA</p> Signup and view all the answers

    What is the purpose of a Proximal Akin osteotomy?

    <p>Correcting abnormal DASA</p> Signup and view all the answers

    What is the primary benefit of using a screw in an Oblique Akin osteotomy?

    <p>Increased stability</p> Signup and view all the answers

    What is the typical postoperative course for proximal phalangeal osteotomies?

    <p>Weightbearing as tolerated in a postoperative shoe</p> Signup and view all the answers

    What is the primary concern when performing a Proximal Akin osteotomy to correct abnormal HAIA?

    <p>Risk of shortening the proximal phalanx</p> Signup and view all the answers

    What is the primary difference between a Cylindrical Akin osteotomy and a Sagittal Z osteotomy?

    <p>Indication for the procedure</p> Signup and view all the answers

    What is the primary advantage of the traditional dorsomedial approach in surgical procedures for hallux rigidus?

    <p>Allows access to the MTPJ from medial and dorsal</p> Signup and view all the answers

    What is the primary purpose of using an ankle tourniquet in distal procedures for hallux rigidus?

    <p>To reduce bleeding in the distal portion of the procedure</p> Signup and view all the answers

    What is the primary benefit of a medial approach in surgical procedures for hallux rigidus?

    <p>Allows access to the MTPJ from medial and dorsal, avoiding neurovascular bundles</p> Signup and view all the answers

    What is the primary purpose of using epinephrine in hallux rigidus procedures?

    <p>To reduce bleeding at the operative site</p> Signup and view all the answers

    What is the primary characteristic of a capsulotomy in line with the skin incision?

    <p>It is the most common approach</p> Signup and view all the answers

    What is the primary difference between a Mayo block and general anesthesia in hallux rigidus procedures?

    <p>The level of sedation required</p> Signup and view all the answers

    What is the purpose of the Reverdin-Laird osteotomy?

    <p>To correct PASA</p> Signup and view all the answers

    What is the characteristic of the Biplanar Austin osteotomy?

    <p>It allows for mild plantarflexion and sagittal correction</p> Signup and view all the answers

    What is the primary purpose of the Youngswick-Austin osteotomy?

    <p>To plantarflex and shorten the first metatarsal</p> Signup and view all the answers

    What is the characteristic of the minimally invasive bunionectomy (MIS)?

    <p>It uses a burr to make a percutaneous transverse osteotomy</p> Signup and view all the answers

    What is the postoperative course for distal metatarsal osteotomies?

    <p>Weightbearing as tolerated in a post-operative shoe until bone is healed</p> Signup and view all the answers

    What is the primary advantage of the Reverdin-Laird osteotomy?

    <p>It is adjustable and forgiving</p> Signup and view all the answers

    What is a specific complication of the Scarf osteotomy that can cause elevation of the capital fragment?

    <p>Troughing</p> Signup and view all the answers

    What is the primary benefit of using 2 screws in the Kalish osteotomy?

    <p>Improved stability</p> Signup and view all the answers

    Which osteotomy can correct PASA if the base is rotated laterally?

    <p>Scarf osteotomy</p> Signup and view all the answers

    What is the primary concern in postoperative care for metatarsal shaft osteotomies?

    <p>Non-weight-bearing</p> Signup and view all the answers

    What is the primary benefit of the Scarf osteotomy over a DMO?

    <p>Easier correction of IMA</p> Signup and view all the answers

    What is the primary advantage of the Kalish osteotomy over the Scarf osteotomy?

    <p>It requires less soft tissue dissection than the Scarf osteotomy</p> Signup and view all the answers

    What is the specific complication of the Scarf osteotomy that causes elevation of the capital fragment?

    <p>Troughing</p> Signup and view all the answers

    What is the primary difference between the Kalish osteotomy and the Scarf osteotomy in terms of PASA correction?

    <p>The Kalish osteotomy can correct PASA without rotating the base laterally, while the Scarf osteotomy requires lateral rotation</p> Signup and view all the answers

    Why is the Scarf osteotomy considered to be controversial?

    <p>It is unclear whether it can correct higher IMAs than the DMO</p> Signup and view all the answers

    What is the typical postoperative course for metatarsal shaft osteotomies?

    <p>NWB for 2 weeks</p> Signup and view all the answers

    What is the primary benefit of the Reverdin-Green-Laird modification in distal metatarsal osteotomies?

    <p>Spares the sesamoid articulations</p> Signup and view all the answers

    What is the characteristic of the Biplanar Austin osteotomy?

    <p>Has a different direction of wire compared to uniplane Austin</p> Signup and view all the answers

    What is the postoperative course for distal metatarsal osteotomies?

    <p>Weightbearing as tolerated in a postoperative shoe until bone is healed (4-6 weeks)</p> Signup and view all the answers

    What is the primary purpose of the Youngswick-Austin osteotomy?

    <p>Plantarflexes and shortens the first metatarsal</p> Signup and view all the answers

    What is the characteristic of the minimally invasive bunionectomy (MIS)?

    <p>Uses a percutaneous transverse osteotomy</p> Signup and view all the answers

    What is the primary difference between the Austin and Biplanar Austin osteotomies?

    <p>Direction of wire</p> Signup and view all the answers

    What is the primary treatment option for a patient with a hallux varus deformity?

    <p>1st MTPJ fusion</p> Signup and view all the answers

    What is a common complication of fibular sesamoidectomy?

    <p>Iatrogenic hallux varus</p> Signup and view all the answers

    What is the primary goal when treating a patient with a hallux varus deformity?

    <p>To restore normal joint alignment</p> Signup and view all the answers

    What is a common characteristic of a patient with a mild hallux varus deformity?

    <p>Difficulty finding shoes that fit</p> Signup and view all the answers

    What is the primary concern when revising a hallux varus deformity?

    <p>Over-correction</p> Signup and view all the answers

    What is the primary benefit of considering multiple variables when treating a patient with a hallux varus deformity?

    <p>Increased success rate of treatment</p> Signup and view all the answers

    What is the main reason for performing a closing base wedge osteotomy from a more proximal location?

    <p>To increase the 'swing' of the metatarsal and correct larger deformities</p> Signup and view all the answers

    What is the primary consequence of removing a wedge of bone during a closing base wedge osteotomy?

    <p>Shortening of the bone</p> Signup and view all the answers

    What is the main advantage of performing a closing base wedge osteotomy over a distal head procedure?

    <p>It is more anatomic</p> Signup and view all the answers

    Why is it difficult to fixate the bone during a closing base wedge osteotomy?

    <p>Due to the proximity to the TMTJ</p> Signup and view all the answers

    What is the ideal characteristic of a patient who would benefit from a closing base wedge osteotomy?

    <p>A patient with a long first metatarsal</p> Signup and view all the answers

    What is the main challenge during a closing base wedge osteotomy?

    <p>Cutting within the metaphyseal bone</p> Signup and view all the answers

    What is the primary benefit of making majority of DMO cuts at an angle?

    <p>To spare the articulation of the sesamoidal apparatus</p> Signup and view all the answers

    What is the limitation of unicorrectional DMO in terms of plane correction?

    <p>It can only correct in the transverse plane</p> Signup and view all the answers

    What is the purpose of using Kirshner wires in DMO?

    <p>To guide the osteotomy cut</p> Signup and view all the answers

    What is the difference between unicorrectional and bicorrectional DMO in terms of corrections?

    <p>Unicorrectional DMO corrects in one plane, while bicorrectional DMO corrects in two planes</p> Signup and view all the answers

    What is the result of not making a transverse cut in DMO?

    <p>The metatarsal head will not rotate</p> Signup and view all the answers

    What is the advantage of DMO in terms of healing?

    <p>It heals faster than cortical bone</p> Signup and view all the answers

    What is the purpose of resecting the proximal osseous shelf in unicorrectional DMO?

    <p>To reduce the intermetatarsal angle</p> Signup and view all the answers

    What is the difference between uniplanar and biplanar corrections in DMO?

    <p>Uniplanar corrections are in one plane, while biplanar corrections are in two planes</p> Signup and view all the answers

    What is the benefit of adjusting the metatarsal length in DMO?

    <p>It allows for axial lengthening or shortening</p> Signup and view all the answers

    What is the direction of the correction in biplanar DMO?

    <p>It follows the direction of the wire</p> Signup and view all the answers

    Study Notes

    Hallux Rigidus and 1st MTPJ Implant

    • Synthetic Cartilage Graft: 1st implant to mimic the modulus of elasticity of cartilage, but subsidence is very common, occurring within 3 weeks post-op.

    1st MTPJ Fusion

    • Considered the "gold standard" for hallux rigidus surgical treatment
    • Definitive positioning is critical for proper function post-operatively
    • Optimal positioning: 15° abducted and 15° dorsiflexed
    • Lapidus procedure: realigns a structurally pathologic 1st metatarsal, shortens the first ray, and "decompresses" the joint

    Drago, Oloff, & Jacobs Classification

    • Stage 1: Functional Limitus - limited dorsiflexion with weightbearing, normal ROM with non-weight-bearing, and little/no degenerative changes
    • Stage 2: Adaptation - flattening of the first metatarsal head, osteochondral defect, pain on end ROM, limited passive ROM, small dorsal exostosis, and subchondral sclerosis
    • Stage 3: Deterioration - severe flattening of the first metatarsal head, dorsal osteophytosis, asymmetric joint space narrowing, degeneration of articular cartilage, crepitus, and subchondral cystic formation
    • Stage 4: Anklylosis - obliteration of joint space, exuberant dorsal osteophytosis, < 10° ROM, degeneration of articular cartilage, deformity/malalignment, and total ankylosis

    Surgical Treatment Options

    • Joint salvage procedures:
      • Cheilectomy: joint clean up procedure, removal of osteophytosis, can be primary procedure, often used with others
      • Youngswick: decompression osteotomy of metatarsal head, allows for shortening and plantarflexion
      • Kessel & Bonney: decompression osteotomy of phalangeal head, changes posture of hallux
      • Arthrodiastasis: external fixation with mini-rail, stretches periarticular soft-tissue structure, and gives cartilage a "rest"
      • Chondroplasty: addresses cartilage erosions, rarely done in isolation
    • Joint destructive procedures:
      • Resection arthroplasty
      • Interpositional implant arthroplasty
      • Valenti Keller Hemi-implants
      • Silastic implants
      • Cartiva
      • Total joint replacement
      • 1st MTPJ arthrodesis
      • Lapidus

    Case Studies

    • Case #1: 71-year-old female with 1st MTPJ arthrosis, mild elevatus, pronatory changes, horizontal calcaneal inclination angle, and NC arthrosis with sag; treatment options include 1st MTPJ fusion, NC fusion, gastroc recession, and orthotics/stretching regimen
    • Case #2: 66-year-old female with functional limitus, NC sag, and previous bunion surgery; treatment options include orthotics and cheilectomy
    • Case #3: 63-year-old female with 1st MTPJ arthrosis, structural rigidus, and smoking history; treatment options include 1st MTPJ fusion### Drago, Oloff, & Jacobs Classification
    • Stage 1: Functional Limitus
      • Limited dorsiflexion with weightbearing
      • Normal ROM with non-weight-bearing
      • Little/no degenerative changes
      • Biomechanical derangement (pronation)
      • 1st ray insufficiency
      • Treatment: Joint-Salvage procedure
    • Stage 2: Adaptation
      • Flattening of the first metatarsal head
      • Osteochondral defect
      • Pain on end ROM
      • Limited passive ROM
      • Small dorsal exostosis
      • Subchondral sclerosis
      • Periarticular lipping of the first metatarsal head, proximal phalanx, & sesamoids
      • Treatment: Joint-Salvage procedure
    • Stage 3: Deterioration
      • Severe flattening of the first metatarsal head
      • Dorsal osteophytosis
      • Asymmetric joint space narrowing
      • Degeneration of articular cartilage
      • Crepitus
      • Subchondral cystic formation
      • Pain on full ROM
      • Treatment: Joint-Salvage or Joint-Destructive procedure
    • Stage 4: Anklylosis
      • Obliteration of joint space
      • Exuberant dorsal osteophytosis with loose bodies
      • < 10° ROM
      • Degeneration of articular cartilage
      • Deformity/Malalignment
      • Total ankylosis may occur
      • Treatment: Joint-Destructive procedure

    Hallux Rigidus Surgical Treatment Options

    • Joint salvage procedures
      • Cheilectomy
      • Decompression osteotomy
      • Youngswick - distal metatarsal osteotomy
      • Kessel & Bonney- phalangeal osteotomy
      • Arthrodiastasis
      • Chondroplasty (rarely used in isolation)
    • Cheilectomy
      • Joint clean up procedure
      • Removal of osteophytosis from the metatarsal head and proximal phalanx
      • Can be the primary procedure
      • Often used with other procedures
      • Can be coupled with chondroplasty if a chondral defect is present
    • Surgical Approach
      • Medial approach
      • Traditional dorsomedial approach
    • Capsulotomy
      • In line with the skin incision (most common)
      • Numerous other options (Linear, T-shaped, Inverted L-shaped, Oblique, Vertical, U-shaped, H-shaped, L-shaped)

    Proximal Phalangeal Osteotomies

    • Distal Akin
      • Medial closing wedge of the head of the proximal phalanx
      • Corrects increased hallux abductus interphalangeus angle (HAIA)
    • Oblique Akin
      • Corrects abnormal DASA and/or interphalngeus
    • Proximal Akin
      • Medial closing wedge of the base of the proximal phalanx
      • Corrects abnormal DASA
    • Cylindrical Akin
      • Corrects shortening of a congenitally long proximal phalanx
    • Sagittal Z osteotomy
      • Corrects shortening or lengthening of the proximal phalanx

    Anasthesia and Hemostasis

    • Anesthesia
      • Depends on the procedure
      • Distal first ray work only: Mayo block and IV sedation (MAC with local)
      • More proximal: general anesthetic
    • Hemostasis
      • Epinephrine
      • Ankle tourniquet for distal procedures
      • Thigh tourniquet for proximal procedures

    Postoperative Course

    • Weightbearing as tolerated in a post-operative shoe until bone is healed (2-3 weeks for soft tissue procedures, 4-6 weeks for osteotomies)
    • More WB protection may be warranted for poor bone quality
    • Post-op course based on protection of incision as there is no osteotomy to protect from displacement (soft-tissue procedure only)

    Distal Metatarsal Osteotomies

    • Austin (Chevron) Osteotomy
      • Corrects IMA with translation of the metatarsal head
    • Biplanar Austin
      • Corrects IMA (transverse)
      • Allows for mild plantarflexion (sagittal)
    • Bicorrectional Austin
      • Corrects PASA
    • Youngswick-Austin
      • Corrects IMA
      • Plantarflexes & shortens the first metatarsal
      • Removal of a dorsal rectangle
      • Useful for long & mildly elevated 1st metatarsals
    • Minimally invasive bunionectomy (MIS)
      • Percutaneous transverse osteotomy
      • Capital fragment shifted laterally and fixated with percutaneous screws### Anatomy of the Medial Column and Soft Tissue Surgical Procedures
    • Demonstrate knowledge of the anatomy of the medial column
    • Soft tissue surgical procedures are performed at the first MTPJ (metatarsophalangeal joint)

    Osteotomies for Bunion Correction

    • Osteotomies can be performed in the proximal phalanx of the hallux and distal first metatarsal for bunion correction
    • Metatarsal shaft osteotomies, proximal first metatarsal procedures, and first metatarsal cuneiform joint arthrodesis can also be used for bunion correction

    Distal Metatarsal Osteotomies (DMO)

    Basic Concepts

    • Most DMO cuts are made at an angle, increasing stability and allowing for more metaphyseal bone contact, which leads to faster healing
    • Cuts at an angle spare the articulation of the sesamoidal apparatus, but do not allow for correction of frontal plane deformities
    • Transverse cuts are required to correct frontal plane deformities and allow the metatarsal head to rotate

    Key Concepts of DMO

    • The amount of obtainable correction depends on metatarsal width, as the metatarsal head can only be slid so far before stability is lost
    • DMO is a versatile procedure that can achieve multiple corrections depending on procedure selection and angle of cut
    • Corrections can be unicorrectional (one correction in the transverse plane), bicorrectional (two corrections in the transverse plane), uniplanar (correction in one plane), or biplanar (corrections in two planes)

    Unicorrectional and Bicorrectional DMO

    • Unicorrectional DMO involves one transverse plane correction, reducing the intermetatarsal angle (IMA) and performing medial eminence resection
    • Bicorrectional DMO involves two transverse plane corrections, reducing both the IMA and PASA (proximal articular set angle)

    Uniplanar and Biplanar Corrections

    • Uniplanar corrections involve reduction of the intermetatarsal angle in the transverse plane only
    • Biplanar corrections involve reduction of the intermetatarsal angle in the transverse plane and angling the cut to allow for plantarflexion or dorsiflexion in the sagittal plane

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    Hallux Rigidus .pdf
    Bunion Surgery Procedures PDF

    Description

    Test your knowledge on the 1st MTPJ implant and fusion, including the challenges of revision, the importance of definitive positioning, and the risks of subsidence. This quiz covers the surgical treatment of hallux rigidus, a common condition affecting the big toe joint.

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