Abstract
Background
Arthroscopy of the first metatarsophalangeal joint (1st MTPJ) is technically demanding, with limited joint space and difficulty achieving reliable distraction representing key challenges. Traditional methods to provide joint distraction during 1st MTPJ arthroscopy most commonly rely on finger trap traction, which may provide inconsistent distraction and require additional setup.
Purpose
We describe a novel technique for 1st MTPJ arthroscopy using a lesser metatarsophalangeal joint plantar plate repair distractor highlighting its potential advantages over conventional distraction methods.
Methods
The technique is presented in a 30-year-old female with persistent 1st MTPJ pain who underwent arthroscopic evaluation and treatment following failure of conservative management. Standard anteromedial and anterolateral portals were established. A lesser metatarsophalangeal joint plantar plate repair distractor was utilized to achieve controlled joint distraction. Arthroscopy was then performed using a 2.7 mm scope with synovectomy, osteochondral lesion debridement, and micro-drilling. The distractor provided a controlled, consistent, and reproducible joint space, allowing for improved visualization and access to intraarticular pathology which contributed to an optimal working environment, reducing the risk of iatrogenic cartilage injury. The patient demonstrated improvement in pain and range of motion postoperatively.
Conclusion
The use of a lesser metatarsophalangeal joint plantar plate repair distractor represents a practical and reproducible alternative to traditional traction techniques for 1st MTPJ arthroscopy. This method avoids many limitations of finger trap distraction, simplifies operative setup, and provides improved control during instrumentation. It may serve as a useful adjunct for surgeons seeking more consistent and optimal joint distraction in small joint arthroscopy.
Introduction
Arthroscopy of the first metatarsophalangeal joint (1st MTPJ) has evolved considerably since Ferkel and Van Buecken presented the first formal case series at the Arthroscopy Association of North America annual meeting in 1991, reporting 83% good or excellent clinical results. Despite this early work, widespread adoption has remained limited, and the procedure is still relatively uncommon compared to arthroscopy of larger joints. , Advances in small joint arthroscopic technology, including the development of 1.9 mm and 2.7 mm arthroscopes with improved optics, have expanded both the feasibility of the procedure and its range of indications. ,
Current indications for 1st MTPJ arthroscopy include mild to moderate hallux rigidus, osteochondral lesions of the metatarsal head or proximal phalanx, loose body removal, synovitis, arthrofibrosis, sesamoid pathology, gouty tophi debridement, septic joint drainage, and select cases of hallux valgus correction. ,,, Compared to open approaches, arthroscopy offers several potential advantages such as reduced bleeding, lower infection risk, improved cosmesis, faster recovery, and better visualization of the curved articular surfaces of the metatarsal head and proximal phalanx, which can be difficult to fully access through a standard open arthrotomy. In a systematic review of 14 studies including 405 patients and 419 halluces, Artioli et al. reported improvement in range of motion from a mean of 25.15° preoperatively to 71.3° postoperatively. The overall rate of temporary or permanent sensory loss was 3%, and the reoperation rate was 4.28%.
Despite these advantages, many surgeons still consider 1st MTPJ arthroscopy technically demanding. This is largely due to the limited joint space, the proximity of neurovascular structures to standard portals, and the difficulty of achieving reliable joint distraction. , Standard portal placement typically involves dorsomedial and dorsolateral portals positioned approximately 5 mm on either side of the extensor hallucis longus tendon at the level of the joint line, with an optional medial portal for access to plantar structures and the sesamoids. ,, A 2021 retrospective series of 36 consecutive cases reported an 11.1% rate of iatrogenic dorsal sensory nerve injury. Cadaveric studies have shown that the dorsomedial hallucal nerve may lie as close as 4 mm from the dorsomedial portal, highlighting the importance of precise technique. ,
Adequate joint distraction remains one of the most important and challenging steps of the procedure. The traditional method involves placing a finger trap on the hallux and applying traction through a pulley system, counterweight, or ankle distractor frame. ,, Davies and Saxby described this approach in their 1999 series using dorsomedial and dorsolateral portals with a 1.9 mm, 30° arthroscope. Several modifications have since been described. These include a cotton bandage tension loop attached to a Guhl noninvasive ankle distractor, an external positioning arm combined with coban and a Kocher clamp, and simplified setups that allow multi-positional traction without pulleys or weights. ,, Some authors have also evaluated plantarflexion as an alternative to formal distraction. One cadaveric study found no significant difference in metatarsal head chondral surface accessibility when comparing plantarflexion to distraction, with values of 55.9% and 58.0%, respectively. Invasive techniques using mini external fixation devices have also been described, though these may limit intraoperative joint motion.
Despite these variations, no single method has become standard. Each approach has limitations, including reliance on assistants, inconsistent traction force, potential soft tissue injury, or the added morbidity associated with pin fixation. Clinical outcomes following 1st MTPJ arthroscopy have generally been favorable. One series reported that 88.2% of patients were satisfied or very satisfied at final follow-up. A systematic review of minimally invasive cheilectomy, including arthroscopic techniques, reported a complication rate of 6.1%. However, joint distraction continues to be a limiting factor affecting both efficiency and broader adoption of the procedure.
In this report, we describe a novel technique for 1st MTPJ distraction using the lesser metatarsophalangeal joint plantar plate repair distractor from the Stryker Gravity Plantar Plate Repair System [Wright Medical Memphis, TN, USA] [ Fig. 1 ]. The utilization of a lesser metatarsophalangeal joint plantar plate repair distractor provides excellent working area around the first MTPJ as the distractor creates a wide working space due to the angulation of the arms of the distractor from the pivot point [ Fig. 2 ]. This is due to the pivot point of the distractor being significantly further away from the Kirschner wires (approximately 8 cm) when compared with a classic Hintermann distractor [ Fig. 3 ] (approximately 3.5–4.5 cm). The distractor is applied directly over 0.062 Kirschner wires which are applied in a bi-cortical manner into the first metatarsal head and the base of the proximal phalanx of the hallux. This allows for controlled and reproducible distraction without reliance on an assistant and through the device allows the surgeon to “click-in” their desired amount of distraction necessary for passage of arthroscopic instrumentation into the first MTPJ [ Fig. 4 A & 4 B]. This technique will simplify the setup and help maintain joint distraction during first metatarsophalangeal arthroscopy.
Intra-operative photograph of the lesser metatarsophalangeal joint plantar plate repair distractor from the Stryker Gravity Plantar Plate Repair System spanning the first metatarsophalangeal joint prior to arthroscopy.
The classic Hintermann retractor.
Image showing the large working area with use of the lesser metatarsophalangeal joint plantar plate repair distractor during arthroscopy of the first metatarsophalangeal joint.
A&B. Intra-operative photographs of the lesser metatarsophalangeal joint plantar plate repair distractor spanning the first metatarsophalangeal joint with arthroscopic instrumentation within the joint displaying controlled distraction without the dependence on an assistant or finger traps to provide distraction of the joint.
The lesser metatarsophalangeal joint plantar plate repair distractor from the Arthrex Complete Plantar Plate Repair System (CPR) [Arthrex Naples, FL, USA] alternatively can be utilized as it provides these same advantages for 1st MTPJ arthroscopy distraction.
Case report
A 30-year-old healthy female presented with persistent right first metatarsophalangeal joint pain refractory to nonoperative management. Physical examination revealed pain and discomfort to the dorsal aspect of the 1st MTPJ with residual clicking with active range of motion of the joint and a positive axial grind test. There was no pain on end range of motion of the 1st MTPJ. The patient had a positive intra-articular diagnostic injection to the 1st MTPJ of 0.5% bupivicaine plain with short term resolution of her symptoms. Pre-operative magnetic resonance imagining of the right foot revealed sclerosis of the 1st metatarsal head with associated focal bone marrow edema of the 1st metatarsal head. The patient elected to undergo arthroscopic intervention after failure of conservative treatment.
The procedure was performed under intravenous sedation through monitored anesthesia care with the patient in the supine position. A local infiltrative block consisting of 20 mL of 0.5% bupivacaine plain was administered to the operative site in Mayo block fashion. Based on previously described techniques, standard anteromedial and anterolateral portals were placed at the level of the dorsal 1st MTPJ, adjacent to the extensor hallucis longus tendon, with the anteromedial portal just medial to the tendon and the anterolateral portal just lateral to it.
The joint was insufflated with 1% lidocaine with epinephrine. Small stab incisions were made at the portal sites using a No 11 blade, and blunt dissection was carried down to the joint capsule with a curved hemostat.
A 0.062 Kirschner wire was then applied from dorsal to plantar at the head of the first metatarsal and another 0.062 Kirschner wire was then applied from dorsal to plantar in the proximal phalanx of the hallux making sure the wires cross the plantar cortex of the first metatarsal and proximal phalanx of the hallux, however taking care not to transect the flexor hallucis longus tendon. The Stryker Gravity Plantar Plate Repair System Distractor was then applied with standard technique using the Kirschner wires with the distractor seated against the skin to prevent bending of the wires with distraction. The device was then used to distract the first metatarsophalangeal joint and improve visualization and access to the joint and an intra-articular pathology. Following adequate distraction, a 2.7-mm arthroscope was introduced through the anteromedial portal. Continuous irrigation was initiated and intra-articular inspection demonstrated moderate synovitis throughout the joint. A 3.5-mm full-radius shaver was introduced through the anterolateral portal and a thorough synovectomy performed [ Fig. 5 ]. An osteochondral lesion was then noted located at the central-lateral aspect of the first metatarsal head [ Fig. 6 ]. A curette was then utilized to excise the unstable and devitalized cartilage to the lesion with subsequent use of the previously mentioned shaver to contour and stabilize the lesion margins [ Fig. 7 A & 7 B]. Micro- drilling of the osteochondral lesion was then performed using a threaded 0.062″ Kirschner wire to promote marrow stimulation [ Fig. 8 A & 8 B]. Further continuous irrigation of the joint was again performed to remove debris.
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