First Metatarsophalangeal Joint Arthrodesis
Thomas F. Smith
Allison J.A. Menke
The first metatarsophalangeal joint (MTPJ) arthrodesis is a time-honored and effective surgical procedure that addresses not only angular deformities of the first ray and arthrosis of the first MTPJ but first ray instability and associated foot functional concerns as well. Since the initial description by Broaca in 1852, the principles of “ankylosis” in an “ideal position” of the first MTPJ as noted by Clutton in 1894 still hold true today (1,2). Clutton recognized early the role of the first MTPJ arthrodesis by stating that it created “the most permanent and satisfactory correction of hallux valgus” (1). Research over the years has produced a more complete understanding of first MTPJ and first ray function within the gait cycle (2,3,4,5 and 6). Combining this practical functional knowledge with improved surgical techniques of dissection and fixation has further reinforced the important place first MTPJ arthrodesis has in aiding correction of first ray pathology. Numerous studies over the years demonstrating satisfactory patient outcomes have only served to further reinforce first MTPJ arthrodesis as both a viable primary and secondary consideration, permitting it to evolve into the widely accepted procedure it is today (4,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 and 34).
The procedure typically bears the name of McKeever, who in 1941 noted patient satisfaction following an unintentional arthrodesis subsequent to a bunionectomy complicated by infection. He then reported successfully performing the procedure as a primary approach for hallux valgus and hallux rigidus (28,35). Patient complaints involving first MTPJ and first ray pathology have been reported secondary to a variety of etiologies (23,26,35,36,37,38,39,40,41,42 and 43). First MTPJ arthrodesis is widely accepted to address many of them including severe or recurrent hallux valgus, failed implant arthroplasty, hallux varus, primary first MTPJ osteoarthritis, posttraumatic arthritis, inflammatory or septic arthritis, and various neuromuscular conditions affecting the first ray, not just hallux valgus and hallux rigidus, as noted by McKeever (2,3 and 4,7,8,10,11 and 12,16,20,21,23,24,25,26 and 27,31,32,33 and 34,37,39,40 and 41, 44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82 and 83). With advancements in technology, a variety of first MTPJ arthrodesis techniques have been developed and continue to be described (15,30,34,37,38,40,44,53,57,60,78,83,84,85 and 86). Special instrumentation for both joint surface resection and fixation specifically designed for the first MTPJ is currently available, facilitating the procedure (7,15,30,40,60,78,84,85). The time-tested techniques for joint surface preparation and simpler forms of stable fixation for first MTPJ arthrodesis remain very effective and cost-effective options as well.