Dorsal approach to the first metatarsal phalangeal joint (MTPJ)
This approach is useful for tendon injuries and ORIF of the distal metatarsal, first MTP dislocations that are irreducible and proximal phalanx fractures.
The skin incision runs medial to the EHL tendon at the level of the first MTP joint, between the branches of the deep peroneal nerve, the superficial peroneal nerve and the saphenous nerves. It can be extended proximally up to and across the first TMT joint, if needed.
3. Deep dissection
Retract the EHL tendon laterally, and then incise the joint capsule to expose the first metatarsal head and base of proximal phalanx. Sharply release the medial and lateral collateral ligaments from the first metatarsal head. Free the plantar sesamoids with a smooth rounded elevator. Plantar flex the great toe to visualize the articular surfaces of the joint. A mini distractor applied dorsomedially may be useful for visualization.