Surgery 1-25-08: First Ray/MTPJ

First Ray
− Transverse plane instability
o As you get an increase of hallux abductus, as the toe moves this is how you get retrograde
movement of the 1st metatarsal
− How to assess for transverse plane instability
o Extract the hallux away to pull off the retrograde force of the base of the proximal phalanx of
the 1st metatarsal , and push in on 1st metatarsal
− See if the metatarsal moves in at the met-cuneiform joint, or if it reduces
o Meaning does it have any mobility on the transverse plane
− This is clinically important- a lot of times may have to cut the Adductor tendon cause it comes down
the lateral side of the joint and pushes the 1st metatarsal out
o If 1st met doesn’t move at all, usually a squaring off at the met-cuneiform joint- much more
aggressive (breaking bone) to reduce intermetatarsal angle

First MTPJ Range of Motion

− Route technique, dynamic Hicks test, transverse plane motion
− Be expected to know in clinic
− After evaluating the first met-cuneiform joint, go the to first MPJ- determine
ROM (plantarflexion and dorsiflexion), quality of motion (rotates into valgus
or not), crepitation or no crepitation, and axis
o When you dorsiflex the toe, when someone has hallux abducto valgus,
you will see when you dorsiflex the toe many times it will want to
drift back towards second toe

Determine the maximum plantarflexion and dorsiflexion

− STJ in neutral position and locking of midtarsal joint, normally 65-
75 of dorsiflexion
− Bisect the 1st metatarsal and the proximal phalanx; place thumb
over IPJ (not distal) and measure angle ROM
− When do this you get retrograde pressure similar to midstance
Why important?
− In bunion surgery when you dissect through fascia and capsule,
you get loss ROM early post operatively
− If limited may need to do something intraoperatively to plantarflex the metatarsal (on tilt down) or
shorten to increase ROM

Quality of Motion
− Evaluate the toe in a deviated position as well as a corrected position
− Want to see if there is pain when you move the toe
− Pain can be indicative of arthritis in the joint; grinding of bone (CREPETATION)
o Indicative of degenerative joint disease
o So: Pain / crepitation = articular destruction
− Sometimes when move the big toe joint there may not be crepetation, but pain with ROM- pain in
joint = Synovitis
o So: Pain / no crepitation = synovitis
− Poor quality in corrected position only can be indicative of articular deviation
o Meaning you try to put to in straight position and DF and tries to go back towards 2nd toe; can
mean there is deviation in the articular cartilage

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 Surgery 1-25-08: First Ray/MTPJ
Axis of Motion
− Dependent upon soft tissue contracture as well as osseous mal-alignment on the first metatarsal head
or base of proximal phalanx
− When someone has hallux ABductus, the hallux is deviated towards the 2nd toe; usually indicative of
soft tissue contracture on lateral side of 1st MPJ
o Adductor tendon has over pulled on lateral side vs. Abductor tendon on medial side
o 1st met has moved medial, proximal phalanx has moved lateral, over pull of the adductor (2
heads that insert into base of proximal phalanx)- have all pulled the proximal phalanx over
on to the transverse plane
o When the toe rotates into valgus, you will see that the ABductor on medial side can no
longer pull the toe over and becomes more of a plantarflexor rather than a straight
abductor
o Tracking- gradual drift of hallux toward 2nd toe throughout ROM

Meaning as you DF the toe, it slowly deviates towards 2nd toe
o Trackbound- try to DF and cannot without it snapping back towards 2nd toe

Tracking-
− STJ in neutral position and lock the mid-tarsal joint and start to DF the toe
− As you DF the toe, see a gradual deviation of the hallux towards the 2nd toe
o Indication of soft tissue contracture
o Hallux ABductus- release the ADuctor tendon to treat the HA angle
− Will see a relatively high or elevated hallux abductus angle (HA angle)

Trackbound-
− Unable to dorsiflex the hallux without immediate deviation of hallux toward the 2nd toe
− When patients have this, much more associated with deviation of cartilage on 1st met head
− Indicative of a high PASA
− Good articular cartilage on 1st met head is deviated towards 2nd met; slow progress
o Referred to as a structural deviation of articular cartilage on 1st met head
o These patients will have a trackbound joint
o Clinically important to determine which kind of bunionectomy/procedure to conduct

First MTPJ: Valgus Rotation

- When doing MPJ range of motion (being tracking or trackbound), you notice it rotates into valgus
- As bunion deformities progress  valgus rotation (worst type of bunion)
o Usually higher lateral deviation of the sesamoids: LATERALIZED SESAMOID
- Usually indicative that there is instability of 1st ray; hypermobile
o Peroneus longus- PF and lock MTJ and prevent from everting

Most cases of valgus rotation- peroneous longus doesn’t work efficiently; reason we do
fusions of the met-cuneiform joint (to give mechanical advantage back to peroneus
longus)

Will give you frontal plane EVERSION of the 1st met (turns toward 2nd met), and
sesamoids rotate into first interspace

Toe will rotate into valgus

Sometimes cannot remove the valgus from the toe, unless you remove the FIBULAR
SESAMOID (as well as other adjunct procedures)
• One complication = over correction of bunions; over-pull on medial side
(Hallux Varus deformity)
• Determine by taking a sesamoid-axial x-ray @ midstance
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 Surgery 1-25-08: First Ray/MTPJ
Clinical: Hallux Interphalangeal Joint
- Look at the IPJ of the great toe, see if it is adducted, sometimes hyperextended, or hammering of the
hallux (rare instance)
- Sometimes when fixing a bunion, you are going to have to break the proximal phalanx to make it
straight

Weight Bearing Exam

- Want to check during weight bearing; will be an increase in amount the proximal
phalanx will deviate, severe splaying of the 1st met (increase intermetatarsal angle)
- Also look at EHL with weight bearing
- Many times patients with bunions, or 1st MPJ deformities, that in an off weight
bearing position, it may appear the EHL tendon may be contracted but with weight
bearing it is gone
- Check this because EHL lengthening may not be relevant in the surgery

Hallux Purchase (whether if toe is on ground or not)

- With severe bunion deformity (rotation into valgus), the great toe will not be totally on the ground, or
could be from previous bunion surgery, or bunions associated with hallux limitus
- Importance: will change how you position the metatarsal to get the bone back down on the ground or
get toe out of valgus

Pre-Operative X-Rays
- Need to be taken weight bearing and what is referred to as angle and base of gait
- Want foot foot for biomechanical evaluation and see position of the 1st met relative to hind foot

X-Ray Views- 3 views for Bunion deformities:

Most angular
measurements
Anterior-posterior (or Dorsal
Plantar; DP View)

Foot against the

Lateral View plate, good for
assessing 1st met
to hindfoot

Good for patients

Sesamoid Axial that exhibit good
valgus deformity

(Rest of lecture was similar to Dr. Rice’s lecture; review slides)

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