The patient is positioned supine on a standard operating room table. The patient’s foot and ankle are anesthetized with a local or regional block supplemented with general anesthesia if desired. Traction is not normally utilized but can be helpful if joint entry is difficult. Noninvasive traction can be accomplished with the use of sterile finger traps (Fig. 21-1). The traps can be suspended from a pulley system with or without weight attached. Alternatively, an assistant can provide the necessary joint distraction to enter the joint. Invasive traction can involve the use of a mini external fixation device with one pin in the proximal metatarsal and the other pin in the distal aspect of the proximal phalanx, however, manipulation of the joint will then be made more difficult. A supramalleolar pneumatic or Esmarch tourniquet is used to aid in hemostasis. In the former case, it is generally inflated to 250 mm Hg (or 100 mm Hg above the systolic blood pressure). Instruments required during the procedure include a small joint arthroscope (2.7 mm, 30 and 70 degree), syringe with saline, small joint shaver (2.7 mm), probe, an array of small joint basket forceps, graspers and scissors, and angled ringed curettes (Fig. 21-2).

In general, two arthroscopic portals are utilized, the dorsomedial and the dorsolateral portals. These portals lie on either side of the extensor tendon apparatus at the level of the joint line (Fig. 21-3). An accessory third portal has been described⁶ and is located directly medially. Because most individuals have a slight physiologic valgus at the MTPJ, the dorsomedial portal is established first, as this side of the joint is relatively wider. Initially, the first metatarsophalangeal joint is insufflated with approximately 5 cc of saline. Then, a scalpel is used to incise the skin. Knowledge of the anatomy of the dorsocutaneous sensory nerve branch is requisite. This nerve lies over the dorsomedial aspect of the first metatarsal head just above the midline medially (Fig. 21-3). A mosquito clamp is used to spread down to the capsule. A blunt obturator is used to perforate the joint capsule and to enter the joint itself. The 30-degree, 2.7-mm arthroscope is then inserted. Inflow and is provided at a pressure of approximately 20 mm Hg. A 22G needle can be used to provisionally establish the lateral portal (Fig. 21-4). Outflow is also accomplished through the camera via a rotating bridge setup. A small joint (2.7 mm or smaller) shaver is introduced to clear debris and to aid in joint visualization (Fig. 21-5). The portals are used interchangeably throughout the procedure and it is not uncommon to repeatedly switch sides to accomplish the desired view.