Minimally Invasive Percutaneous Dorsal Cheilectomy With Hallux Metatarsophalangeal Joint Arthroscopy

Tyler Gonzalez

♦ INTRODUCTION AND BACKGROUND

Similar to open cheilectomy, minimally invasive percutaneous dorsal cheilectomy (MIDC) is indicated for removal of the dorsal osteophyte of the metatarsal head and proximal phalanx to relieve pain and stiffness in patients with mild to moderate hallux rigidus.¹ The touted benefits of MIDC include less pain, less stiffness, improved cosmesis, and comparable functional outcomes to an open procedure.²,³,⁴,⁵ Several studies have looked at MIDC showing improved functional outcomes and pain with quick return to work and normal shoe wear.⁴,⁵,⁶ Early results of this new technique are encouraging with high patient satisfaction and low complication rates.⁷,⁸

♦ CONTRAINDICATIONS

Advanced articular surface osteoarthritis as shown clinically by a positive grind test
Pain with mid-arch motion or plantar pain suggesting inferior sesamoid degeneration
Night pain or pain that occurs at rest
Absence of dorsal osteophyte
Any sign of infection

♦ PATIENT HISTORY AND PHYSICAL EXAMINATION

A detailed history of present illness should be preformed.
Patients with hallux rigidus usual present with pain over the dorsal osteophyte and pain with shoe wear.
They may complain of pain going up stairs and hills, and pain with stepping up on their toes and with walking. They may express limited range of motion of the toe.
Specific activities such as running, hiking, and dancing may be limited due to limited range of motion of the toe.
Examination should include the following:
- Standing physical examination.
- Detailed neurovascular examination.
- Examination of the hallux MTP joint should include range of motion in dorsiflexion and plantarflexion as well as evaluation of the presence of dorsal osteophyte should be recorded.
- Pain at the extremes of motion or mid-arch should be recorded.
- A grind test should be preformed.

♦ IMAGING STUDIES

Obtain standing, weight-bearing plain radiographs of the foot in anteroposterior (AP) and lateral views to evaluate severity of articular degeneration (Figure 21.1).
Advanced imaging such as CT and MRI is usually not indicated for mild to moderate hallux rigidus. If there is a concern for osteochondral lesion or cystic changes with the metatarsal head, then an MRI should be done.

♦ PREPARATION AND PATIENT POSITIONING

This procedure is often performed in the outpatient setting.
The patient is positioned supine, with the limb free to allow for dorsoplantar rotation and lateral fluoroscopy. The other leg is frog-legged out of the way of the surgeon, the operative limb, and the fluoroscopy machine (Figure 21.2).
The heel hangs off the end of the table perpendicular to the mini C-arm, which is always positioned on the side of the surgeon’s dominant hand (adjacent to the patient’s right foot for a right-handed surgeon) regardless of which foot is being operated on.