Metatarsophalangeal fusion for hallux valgus: indications and effect on the first metatarsal ray J.L. HUMBERT,* MD; C. BOURBONNI.RE;t C.A. LAURIN4 MD, FACS, FRC5[C] Arthrodesis of the metatarsophalangeal plasty because it increases weight- the toe may be completely nonfunc- joint was performed in 31 cases of bearing on the first metatarsal ray tional. Other disadvantages are that severe hallux valgus. With the surgical technique used, which is described and, as Kelikian1' noted, relieves the metatarsus varus remains un- in detail, internal fixation and plaster metatarsalgia. In a study of 50 men altered and that the hallux valgus cast immobilization were not necessary. with metatarsophalangeal fusion of may persist if the metatarsus varus is Analysis of the results suggested that the big toe Joseph9 showed that loss severe. Indeed, severe metatarsus the operation is indicated for severe of metatarsophalangeal dorsiflexion varus and metatarsalgia are relative deformities in elderly patients, preferably contraindications to the Keller oper- women. The basic metatarsal deformity did not impair the "take-off" position was corrected by the procedure. of the foot as long as motion at the ation. interphalangeal joint was sufficient. In the Mayo intervention, removal L'arthrodese de l'articulation metatarso- phalangienne a Ste pratiquee dans 31 Moynihan,1' reviewing arthrodeses of the metatarsal head seriously alters cas d'hallux valgus severe. Avec Ia followed up for 10 years, found a the foot's weight-bearing pattern.6 technique chirurgicale utilisee, laquelle greater success rate and more per- Arthrodesis is free of most of these est decrite en detail, Ia fixation interne manent results than have been re- drawbacks. The main objection to et l'immobilisation a l'aide d'un plitre ported for the Keller operation. anthrodesis is the loss of motion: n'ont pas et6 necessaires. L'analyse however, while other procedures pre- des resultats indique que l'operation Arthrodesis v. arthroplasty est indiqu6e pour les difformites serve mobility, the joint motion is not importantes chez les patients &ges, Anthrodesis of the first metatarso- necessarily normal or painless. Since les femmes de pref6rence. La difformite phalangeal joint is satisfying mainly the principal function of the foot is m6tatarsienne essentielle a ete corrigee because it avoids many of the pitfalls painless weight-bearing and walking,10 par cette intervention. and complications sometimes noted joint stability may occasionally take There is understandable controversy following arthroplasty for hallux precedence over abnormal or painful concerning the indications for artliro- valgus. joint mobility.11 None the less, patient desis of the first metatarsophalangeal With the McBride arthroplasty selection is all important. joint in the treatment of hallux val- there is a distinct possibility of re- gus.1 In a review of several operations aligning the proximal phalanx onto Review of a series of arthrodeses for this condition Maschas2 claimed a portion of the metatarsal head that We undertook the following review that there is no place for fusion as a is devoid of normal articular carti- in an attempt to answer four basic primary intervention and that it is lage. Campbell1 has attributed the questions about fusion for hallux val- rarely indicated as a salvage proce- not uncommon recurrence of hallux gus. First, does the operation per- dure. Tupman3 advocated fusion for valgus following the McBride opera- manently correct the deformity and hallux valgus if there is a splay foot tion to a disruption between the bur- provide normal function? Second, is or a short first metatarsus, or follow- sal flap and the abductor hallucis a special, more demanding, postoper- ing unsuccessful Keller arthroplasty. tendon. He has also stressed that dis- ative regimen necessary? Third, is Others have been more enthusiastic.4 figuring iatrogenic hallux varus may the metatarsus primus varus cor- Mann' proposed fusion as a first occur as a result of the unopposed rected? This is the critical question operation in all middle-aged and eld- action of the abductor hallucis in view of the etiologic importance erly persons with moderate to severe muscle; clawing of the great toe and of metatarsus varus in the disability deformities. Henry and Waugh6 and a dorsal intraphalangeal bunion may and deformity of hallux valgus, as others"'.14 claimed that anthrodesis is also occur following unintentional Nicod stressed.13 Fourth, when there more effective than Keller arthro- section of the flexor hallucis brevis is severe metatarsus varus will anthro- muscle. desis of the metatarsophalangeal joint From the department of orthopedics, The Mitchell arthroplasty corrects lead to hallux varus? This serious University of Montreal, H6tel-Dieu de Montrdal the metatarsus primus varus only in iatrogenic complication could theo- *Resident in orthopedic surgery, Edouard the distal part of the first ray, as retically occur since the fusion is per- Samson program Carr and Boyd15 noted. Campbell1 formed with no attempt to compen- tMedical student, McGill University referred to delayed healing at the sate at the site of fusion for the varus IProfessor of surgery and director, osteotomy Edouard Samson program in orthopedic site with this procedure. deformity of the first metatarsus. surgery, University of Montreal The deservedly popular Keller Reprint requests to: Dr. C.A. Laurin, operation shortens the big toe and Patients D6partement d'orthopedie, H6tel-Dieu de Montreal, 3840, rue St-Urbain, permanently impairs its control; if Of 31 persons who underwent me- Montrdal, PQ H2W 1T8 too much of the phalanx is resected tatarsophalangeal fusion for excessive CMA JOURNAL/APRIL 21, 1979/VOL. 120 937 hallux valgus without modification of cortex at the point of attachment of with such depth and width as to the operative technique 8 are not the extensor hallucis brevis muscle, provide a snug fit within the phalan- considered in this review because of a very useful landmark. Since the geal trough. The axis of the tongue a follow-up period of less than 2 angle of the trough and the plantar corresponds to the long axis of the years, and 5 were lost to follow-up or surface of the foot must be precisely first metacarpus. Care is taken to had inadequate preoperative roent- 900 to avoid fusion in any degree of protect the relatively fragile base of genograms. Of the others, 16 were rotation, a pituitary rongeur is used the tongue. It is preferable to prepare interviewed and reassessed clinically to complete the trough. The plantar the phalangeal trough first since the and radiologically, and 2 were re- phalangeal attachment of the meta- metatarsal tongue could be accident- assessed from the answers to an elab- tarsophalangeal capsule is incised to ally fractured at its base during crea- orate questionnaire mailed to them. facilitate the introduction of the tip tion of the phalangeal trough. The The 5 men and 13 women had a of the pituitary rongeur under the remaining articular cartilage on the mean age of 54.8 years (range 38 proximal phalanx. The phalangeal tip of the metatarsal tongue is then to 77 years), and the average follow- trough is then deepened to 1 cm in excised. up period was 42 months (range 24 line with the axis of the phalanx. The metatarsal tongue is then in- to 74 months). Since 16 underwent When the articular cartilage is excised serted in the phalangeal trough, with bilateral arthrodesis the total number from the proximal phalanx on either complete correction of the angular of procedures was 34. side of the trough the medial and deformity between the metatarsus and lateral capsules must remain attached the proximal phalanx. Because the Surgical technique to the phalanx to permit eventual bony shortening is fully compensated Litigation is not uncommon fol- stable closure. by the correction of the angular de- lowing operations on the foot, prob- The head of the first metatarsus is formity at the metatarsophalangeal ably because the surgical challenge then shaped like a tongue, or lug, joint, the soft tissues on the lateral is often underestimated. Careful dis- section and attention to detail are as vital for the foot as they are for the hand. It is obviously wrong to dissect a hand but to attack a foot. Although the "tongue-and-trough" method of fusion (Fig. 1) is not original, certain technical details war- rant special attention. The metatar- sophalangeal joint is exposed through a single dorsal midline incision medi- al to the bowstringing long extensor tendon. It is important to leave the lax lateral capsule and conjoint tendon intact. The medial capsule is II incised vertically 0.5 cm from its phalangeal attachment; the capsule and periosteum are reflected proxi- mally in continuity with the abductor hallucis muscle; this muscle is inevi- tably noted to have migrated laterally and under the metatarsophalangeal joint and has long lost its ability to abduct the joint. The bursal and capsular flap is dissected in continuity with the abductor hallucis muscle, which must be freed from the medial A sesamoid bone to facilitate medial and dorsal mobilization of the flap and prevent medial and dorsal dis- placement of the bone at the time of capsular closure. Iv A trough is then prepared precisely III in the middle of the proximal end of the proximal phalanx; an ordinary rongeur is used to excise the dorsal side of the joint are under immediate Results no deformity (Fig. 2). A good result tension; the intact lateral metatar- Postoperative results were grouped met all of the following criteria: the sophalangeal capsule and conjoint as excellent, good or poor. For an patient was partially satisfied with tendon thus provide immediate sta- excellent result all of the following the operation and would unequivocal- bility. Similar soft tissue tension must criteria were met: the patient was ly accept it again; the pain was less- then be achieved on the medial side completely satisfied and would accept ened, but local discomfort or mild of the arthrodesis.