The patient is a 48-year-old woman who initially presented with a 2-year history of left foot pain secondary to hallux MTP joint arthritis and second toe hammertoe deformity. She had been treated with custom orthotics in the past, but was still having daily pain and difficulty with shoewear with a negative impact on her quality of life. Her examination was significant for stiffness at the first MTP joint, with pain throughout the entire arc of motion. In addition, she had a fixed hammertoe deformity of the second toe along with tenderness and instability at the second MTP joint. Initial weight-bearing radiographs demonstrated global first MTP joint space narrowing with a large dorsal osteophyte (Fig. 9.1). One can also appreciate the fixed second hammertoe deformity with subluxation at the second MTP joint. The patient elected to proceed with first MTP joint fusion and second toe distal metatarsal shortening osteotomy with hammertoe correction.

The standard dorsomedial approach described above was used (Fig. 9.2). Circumferential release was performed, and the proximal phalanx plantarflexed fully for preparation of the metatarsal head. A 0.062 inch K-wire was placed down the metatarsal shaft (Fig. 9.3) and central position confirmed with fluoroscopy (Fig. 9.4). A barrel-shaped starting reamer (Fig. 9.5) was then used to remove osteophytes and excessive bone to produce a smooth distal circumferential surface of the distal first metatarsal (Fig. 9.6). The articular surface of the metatarsal head was reamed with the concave reamer. Another 0.062 inch K-wire was then placed in the central position of the proximal phalanx (confirmed with fluoroscopy) and reamed with the convex reamer (Fig. 9.7). Both reamed surfaces were fenestrated using a 2.0 mm K-wire, which concluded the joint preparation portion of this procedure (Fig. 9.8). Wires from our preferred cannulated screw system were then inserted to the level of the joint, one anterograde through the proximal phalanx prepared surface and the other retrograde through the metatarsal head prepared surface (Fig. 9.9). The toe was positioned using the lid of one of the trays as a guide (Fig. 9.10), and the wires were driven across the joint. Fluoroscopic imaging confirmed a satisfactory position of the wires, and after measuring the appropriate-sized screws were inserted. Acceptable toe position was again confirmed at the conclusion of the case (Figs. 9.11 and 9.12). A 2-week postoperative AP radiograph of the foot is shown in Fig. 9.13.