The utilization of a 1st MTPJ fusion for severe
hallux abducto valgus deformities WITH the
presence of pronounced degenerative joint
disease in a young active patient with good bone
stock certainly has a surgical indication. In
many cases that I have seen, the indication for
arthrodesis of the first metatarsal-phalangeal
joint is associated more with late Stage II or
Stage III joint manifestations in hallux limitus
pathology. With these deformities, the
intermetatarsal angle deformities tend to be
normal to near normal in measurement.
The indications for a Lapidus as a medial column
stabilizing procedure is considered with any
evidence of medial column instability in the
development the patient's hallux valgus
deformity. Clinical findings such as joint
gapping between the medial and middle
cuneiforms, the presence of a atavistic
appearance of the medial cuneiform-first
metatarsal joint, evidence of degenerative joint
processes/exostoses at the first metatarsal-
medial cuneiform joint or the concomitant
findings of hallux valgus development with a
Kidner Deformity / Posterior Tibial Dysfunction
may be considered criteria for selection of a
Lapidus procedure.
The fusion of a first metatarsal-phalangeal
joint with a severe hallux valgus deformity,
when there is mild or moderate evidence of joint
destructive processes where salvage is possible
or no pain/crepitus with ranges of motion is
noted is NOT addressing proper consideration for
where pathobiomechanical issues really exist.
The tendency by some to substitute a fusion of
the first metatarsal-phalangeal joint for a
medial column stabilizing procedure such as a
Lapidus, is in my opinion, misguided to my way
of understanding the pathobiomechanical
development in severe bunion deformities.
I believe such surgeons are addressing
the "symptoms at the expense of the etiology."
The arthrodesis of the 1 MTPJ will result in a
reduction of hallux valgus deformity by reducing
or lessening the soft tissue contractures, but
the sacrificing of the 1 MTPJ is counter to my
tendency to preserve joint function whenever
possible. It should also be noted that
arthrodesis of the 1 MTPJ can result in gait and
shoe modifications that the patient may
experience post-operatively and not easily
revised.
The question really is how permanent is
this "fix." I truly question, the "long" term
correction obtained years after the immediate
effects of the 1 MTPJ arthrodesis' soft tissue
realignments and contracture releases as a basis
for severe hallux valgus correction in and of
itself.
It was a wise old doctor who said that with any
new developments in medicine, "never be the
first to use, but never be the last one." I'll
wait on those long-term studies.
Gino Scartozzi, DPM, New Hyde Park,
NYGsdpm@aol.com
