POSTPROCEDURE DIAGNOSTIC IMPRESSION:
1. Severe hallux valgus, left.
2. Dislocation of the second and third metatarsophalangeal joint, left.
3. Hammertoe deformity second and third digit, left foot.

OPERATIVE PROCEDURE:
1. Fusion of first MTPJ right with autogenous bone graft.
2. Metatarsal head resection second and third, left.
3. Arthroplasty PIPJ second and third, left.

DESCRIPTION OF PROCEDURE: The patient was brought to the OR, placed in the supine position, and made to feel comfortable. After administration of IV sedation, 30 cc of 0.5% Marcaine plain was administered via first ray, second ray, and third ray block to the left foot. The foot was then prepped and draped using sterile technique. An Esmarch bandage was used to exsanguinate all blood from the left foot and ankle. The pneumatic ankle tourniquet was elevated to 250 mmHg. Attention was then directed to the dorsomedial aspect of the first MTPJ, where a 6-cm linear incision was performed extending from the midshaft of the first metatarsal to the midshaft of the proximal phalanx. Sharp and blunt dissection was taken through the subcutaneous tissue being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule and periosteum, a linear incision was performed extending the length of the skin incision. Sharp dissection was then used to reflect the capsule and periosteum from the head, neck, and distal shaft of the first metatarsal and the base of the proximal shaft of the proximal phalanx. Exposure of the joint revealed erosions of the articular cartilage with significant increase in the PASA – it was deemed appropriate for a fusion. Arthrex cannulated reamers were used to remove the remaining articular cartilage and subchondral bone at the head of the first metatarsal with some osteoporosis noted at the base of the proximal phalanx. While reaming the base of the proximal phalanx, approximately 40% of the superior portion of the base of proximal phalanx was destroyed either to the bone being too soft or the reamer not being adequately sharpened. After careful inspection, the surgical site was irrigated with copious amounts of sterile saline. The hallux was placed in slight abduction and dorsiflexion and a 3-0 guide pin was inserted in the plantar aspect of the remaining base of proximal phalanx extending
from distal medial to proximal lateral. A portion of the medial eminence approximately 3-mm portion of bone graft was also removed and fashioned to fit the defect – this was performed after a small resection of the medial eminence was performed. More bone graft was necessary so attention was directed to the second and third metatarsals, where a linear incision was performed at the lateral and dorsal aspect of the second MTPJ extending from the midshaft of the metatarsal to the base of proximal phalanx. Sharp and blunt dissection was taken down to each MTPJ level being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule, a linear incision was performed extending the length of the skin incision – second MTPJ was dissected first and the third and second. Once exposure of the joint was revealed, it was noted to be arthritic at the head of the second metatarsal and inspection of the plantar plate revealed no significant remaining plantar plate for reattachment – it was deemed appropriate for metatarsal head resection, which was performed at approximately the neck level of the second metatarsal. The head was removed in toto and preserved for bone graft. A bone rasp was used to smooth off any remaining bone irregularities. A similar procedure was performed at the third metatarsal head trying to maintain the normal metatarsal parabola. The second metatarsal head was fashioned into an autogenous bone graft with medial and lateral cortical bone intact. After fashioning of all layers of bone graft, they were placed in an appropriate fashion with good bone to bone contact and good filling of the void. A T-plate was then applied along the dorsal aspect of the first MTPJ construct with fashioning of the plate along the dorsal cortex of the head of the first metatarsal and the base of the remaining proximal phalanx. Five screws were placed bicortical with good stability and compression of the fusion site. Surgical site was used to irrigate with copious amounts of sterile saline around the surgical site. A 3-0 Vicryl was used to reapproximate the capsular incision and 4-0 nylon the skin incision. Attention was then directed to the second and third MTPJ levels, where a bone rasp was used to smooth off any remaining bone irregularities. Attention was then directed to the second and third PIPJ level, where a 1.5-cm linear incision was performed with the similar procedure performed on each digit – sharp and blunt dissection was taken through the subcutaneous tissue being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule, a transverse incision was used to enter the joint, the medial and lateral collateral ligaments were transected and the extensor tendon apparatus was freed from the head of the proximal phalanx. A bone cutter was used to remove the head of the proximal phalanx at the level of the anatomical neck. A bone rasp was then used to smooth off any remaining bone irregularities. A 0.045-inch K-wire was then inserted through the middle and distal phalanges and retrograded into base of proximal phalanx. The toe was placed in appropriate position and the K-wire was driven into the corresponding metatarsal shaft. Forefoot loading revealed good reduction of deformities. Kwires were bent, cut, and capped. A 3-0 Vicryl was used to reapproximate the MTPJ incision and 4-0 Vicryl the PIPJ incision. A 4-0 nylon was then used to reapproximate the skin incisions. An 8 mg of dexamethasone phosphate was administered evenly around the surgical sites followed by Xeroform and sterile compressive dressing.