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Arthrodesis of the Great Toe Metatarsophalangeal Joint


Indications

  • Chronic joint pain from advanced arthritis

  • Severe deformity that limits activity or footwear

Controversies

  • Arthrodesis is the most commonly performed procedure for advanced symptomatic arthritis or severe deformity of the great toe. The end result is highly predictable, alleviates symptoms, and restores excellent function.

  • Unreliable surgical options include resection arthroplasty, hemiarthroplasty, or total joint arthroplasty.

  • A polyvinyl alcohol implant may be considered in certain specific patients (see Procedure 11 ) but does not provide superior function.

  • Concomitant arthritic changes of the interphalangeal joint are not an absolute contraindication to metatarsophalangeal (MTP) fusion.

  • A first MTP fusion will cause the intermetatarsal angle to narrow by approximately 4°. A simultaneous osteotomy of the first metatarsal base is therefore rarely needed.

  • A sesamoid may be arthritic but rarely has to be excised at the time of the fusion.

Indications Pitfalls

  • High-heeled shoes will be limited to approximately 2 inches after surgery, which may be unacceptable to some patients.

  • Infection, inadequate blood supply, and severe osteopenia are contraindications to the procedure.

Treatment Options

  • A medial longitudinal arch support may decrease pressure on the great toe.

  • A stiff-soled shoe will decrease motion of the great toe during ambulation. Patients have often tried this approach on their own, prior to seeking consultation.

  • A rocker sole, which stiffens the shoe sole and takes stress off of the forefoot, can be added to a walking shoe by a pedorthist or orthotist. Although highly effective, all of the patient’s shoes will require this modification.

  • A cortisone injection may improve symptoms for a short period of time.

Examination/Imaging

  • There is limited and painful motion of the great toe.

  • Large dorsal osteophytes are often present.

  • An incision from a previous surgery may dictate the operative approach.

  • Standing anteroposterior (AP; Fig. 12.1A ) and lateral ( Fig. 12.1B ) radiographs should be taken. Oblique views often provide the best visualization of the joint.

    FIG. 12.1

  • Arthritic changes in the sesamoid may be present but rarely have to be addressed operatively.

Surgical Anatomy

  • Anatomy of the MTP joint of the great toe ( Fig. 12.2 )

    FIG. 12.2

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