10/08/2015    Don Peacock DPM

Fusion vs. Arthroplasty of the lesser MTPJs

I was taught that fusing a lesser MPJ would
always lead to further pathology. As a result I
have never performed a lesser metatarsal
phalangeal joint fusion. Interestingly, I’ve
never been told exactly why this would be an
issue. There is an article by Michael Tritto DPM
where he describes fusing the second MPJ and
obtaining good results in older patients that
have subluxed 2nd MPJ.

You have several different options to treat this
patient. Determining the exact location of her
pain is vital. Be sure she does not have
generalized metatarsalgia which will need to be
treated more globally. If you place the patient
in Root neutral position and press up on the
second, third and fourth toes you can determine
the metatarsal parabola depth using an
ultrasound. Inflammation under the surrounding
metatarsal heads can be determined or ruled out
to help clarify the pathology distribution.

If the condition is local to the third MPJ she
would do well with a lesser metatarsal implant.
Another option would be to perform an osteotomy
on the lesser metatarsal to decompress the area.
However, most likely she would require further
osteotomies to prevent transfer pain. Typically,
I would perform this minimally invasive and
perform osteotomies on the second and fourth as
well in a localized MPJ deformity.

If the ultrasound displays inflammation under the
second or fourth metatarsal this will need to be
treated in a more global fashion since the pain
is not limited to the 3rd MPJ. I suspect her pain
is more generalized and is affecting her forefoot
globally.

My first inclination would be to perform soft
tissue re-balancing by gastrocnemius recession
and dorsal proximal EDL tenotomy along with a
distally placed FDL tenotomy at the DIPJ level.
The tendon work can be performed minimally
invasive and the gastrocnemius recession
performed in a traditional fashion. This would
reduce her overall pressure in the forefoot and
provide significant pain relief without another
large recovery. The soft tissue re-balancing
option would be your best 1st option and would
certainly be your most definitive minimalistic
effective procedure approach.

Don Peacock DPM, Whiteville, NC

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