The forefoot extends anteriorly from the tarsometatarsal (Lisfranc) joint.&nbsp; It consists of the five metatarsals and five phalanges.&nbsp; The first three tarsometatarsal joints have little motion due to “tight” articulations and strong ligamentous connections.&nbsp; These articulations and the Roman Arch configuration of the proximal second metatarsal is responsible for forming and maintaining the transverse arch of the foot.&nbsp; The fourth and fifth metatarsals heads have more motion at the Lisfranc joint to aid in balance.&nbsp; The plantar aspect of the first and fifth metatarsals make up the medial and lateral legs of the weight bearing “tripod”. &nbsp;

Foot and Ankle

Procedure

The titanium Compression FT (fully threaded) screws come in 2.5 mm Micro, 3.5 mm Mini, 4.0 mm Standard, 5.0 mm Large, and 7.0 mm XL. The variable-stepped thread pitch and headless design helps reduce the risk of profile complications, provides compression, and allows for simplified insertion. Surgeons can now achieve zero-profile, stable fixation. The Compression FT family of screws now offers 5 diameters and 91 screw lengths to fit various orthopedic applications throughout the body.

Compression FT Screws

A long lesser metatarsal can lead to common toe problems. A metatarsal shortening osteotomy can help prevent future complications, including plantar plate tears leading to crossover toe deformities, as well as hammer toes and claw toes. Once these complications have occurred, the surgeon may choose a metatarsal shortening osteotomy to decompress the MTP joint and decrease the tension on dynamic soft tissues.

Metatarsal Shortening Osteotomy 

The Arthrex MIS product portfolio continues to grow with the introduction of the Minimally Invasive Bunionectomy System. This trajectory system helps achieve correction and fixation placement using a percutaneous approach. Designed to work with this specific system, the beveled fully threaded screws are angled to provide zero-profile fixation. Additionally, a dedicated power unit and instrumentation are available. The MIS line is further supported by Medical Education courses focused on minimally invasive techniques.

Minimally Invasive Surgery

Bunionnette

Human

A bunionette is also known as a Tailor’s Bunion. It is a painful lateral bony prominence of the 5th metatarsal head resulting in a widened forefoot. A bunionette can be caused by a large 5th metatarsal head (Type I), lateral bowing of the 5th metatarsal shaft (Type II), or an increase in the 4th and 5th intermetatarsal space (Type III). Bunionettes can often be treated conservatively by selecting shoes with a wide toebox. When conservative treatment fails, surgeons have the option to perform a simple lateral condylectomy or a distal 5th metatarsal osteotomy. In the case of a Type III deformity, the surgeon may choose to do a proximal 5th metatarsal osteotomy. Arthrex makes a variety of products in metal and bioabsorbable materials designed to provide fixation for these osteotomies.

Secondary (C)

Fractures of the foot are common, and the metatarsals are among the bones most commonly fractured.&nbsp; Acute foot fractures on normal bones are usually caused by the dropping of heavy objects on the foot or by stress associated with abnormal repetitive trauma.&nbsp; In deficient bones, insufficiency fractures may result from normal stress. &nbsp;Intra-operative treatment of metatarsal fracture can be treated with a variety of products including but not limited to cannualted screws, solid screws,&nbsp;Trim-It&nbsp;bio pins, locking and non–locking plates. &nbsp;

Metatarsal Fracture Repair

Forefoot Fractures

Arthrex’s contribution to fracture management innovation starts with our unique mission of helping trauma surgeons treat their patients better. When trauma surgeons ask for our assistance in solving posttraumatic surgical problems, Arthrex responds with cutting edge technology, creative innovation, and a sense of urgency as trustworthy partners in evidence-based treatment solutions that make a difference.
Metatarsal fracture repair, Jones fracture repair (using the Jones Fracture Screw) and the Phalangeal fracture repair procedures all aid in the effective treatment of the majority of fracture patterns found within the forefoot. Arthrex has developed the Ankle Fracture Management System to be the most comprehensive set available for the treatment of forefoot injuries.&nbsp;

Hallux rigidus and limitus are debilitating conditions that usually affect older populations. However, they can affect younger patients in a number of situations. The AnaToemic® Phalangeal Hemi-Prosthesis is an ideal option in these cases where a joint sparing procedure is preferable to arthrodesis and an immediate gain in ROM is desired.

AnaToemic® Hemi-Prosthesis

A Moberg osteotomy is a dorsal closing wedge osteotomy of the proximal phalanx of the great toe. It is used for hallux rigidus, grades 2 and 3, often in conjunction with a cheilectomy or other joint-sparing procedure. The osteotomy can be completed with an open or MIS approach, depending on surgeon preference. In either case, fixation can be achieved with Arthrex Compression FT or PT screws or with DynaNite® Nitinol staples.

Moberg Osteotomy

The low-profile MTP system offers a variety of solutions ranging from tools for joint preparation to plates and screws allowing unique compression and fixation when it comes to treating severe hallux rigidus and other MTP pathologies. Whether a primary or revision case, this system enables surgeons to confidently reduce, compress, and lock the 1st metatarsophalangeal joint in the ideal position for arthrodesis.
 
Features and Benefits:
<ul>
 <li>Concave, Convex Reamers facilitate quick and accurate joint preparation.</li>
 <li>Low-profile plates offered in a range of sizes from Petite to Revision in various curvatures to best fit patient anatomy.</li>
 <li>Compression can be achieved uniquely with our MaxForce MTP system that features a patented geared mechanism allowing surgeons to dial in their compression through the plate.</li>
 <li>Compatible with multiple 3.0 mm screw options from zero profile cortical screws to Variable-Angle Locking screws with a 30° cone of variability.</li>
</ul>

MTP Joint Arthrodesis

Hallux Rigidus/Hallux Limitus

Hallus Rigidus and Hallus Limitus, degenerative arthritis and stiffness due to bone spurs affecting the MTP joint at the base of the hallux can be treated using a variety of procedures including OATS, Moberg, Arthroplasty and MPJ Arthrodesis.

Primary (B)

An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx of the great toe. It is used to correct hallux valgus interphalangeus. The Akin osteotomy is usually a component of a primary procedure in which a hallux valgus deformity is corrected. The osteotomy site is fixed with a DynaNite™ Nitinol staple, low-profile QuickFix™ cannulated screw, QuickFix Staples, or Plaple® fixation system.

Akin Osteotomy

A chevron osteotomy is the most common technique used to correct mild to moderate bunion deformities. Traditionally, this procedure has been performed through an open approach. However, since the advent of minimally invasive surgery (MIS), surgeons now have the option to perform a chevron osteotomy through small percutaneous incisions. Following the osteotomy, the capital fragment is shifted laterally and fixated with either Compression FT screws for the MIS approach or Compression PT screws for the traditional open approach.

Chevron Osteotomy

The new Snap-Off Compression FT pins offer solutions for the upper and lower extremities and the trauma setting. The pins' ease of use, variable-stepped thread pitch, and wide range of sizes in diameters of 1.9 mm and 2.4 mm represent an innovative new technology to help treat pathologies including joint arthrodesis, hammertoe, intra- and extra-articular fractures, and nonunions. The pins can be used in conjunction with other Arthrex products to compress bone fragments.

Snap-Off Compression FT Pins

The Lapidus procedure is an arthrodesis of the 1st metatarsocuneiform joint. It is performed most commonly as a method to reduce the intermetatarsal angle (IMA) in the setting of hypermobility or arthritis of the 1st metatarsocuneiform joint.

Lapidus Hallux Valgus Correction

The Mini TightRope® procedure is useful as an alternative or adjunct method for reduction of the intermetatarsal angle. A FiberWire® and button construct is placed across (distally or proximally) the first and second metatarsals. Reduction of the IMA is obtained with a clamp. The Mini TightRope is tightened and tied. The reduced intermetatarsal angle is held at the desired degree of correction. Used alone or in conjunction another procedure, this technique affords a greater degree of strength and security than can be achieved with the soft tissue repair alone. Additionally, the Mini TightRope System provides a more technically straightforward method of maintaining the intermetatarsal angle than with conventional osteotomies while avoiding the complications associated with osteotomies. A buttress plate is available to be placed against the second metatarsal to spread the load of the Mini TightRopes more evenly.

Mini TightRope® Technique for Hallux Valgus

Proximal metatarsal osteotomies work well to achieve reliable deformity correction in patients with a large 1st-2nd intermetatarsal angle. They may help minimize rotation, shortening, and elevation of the metatarsal. A number of osteotomy techniques have been described, including Ludloff, Mau, proximal crescentic, proximal chevron, scarf, opening wedge, and closing wedge, among others.

Proximal 1st Metatarsal Osteotomy 

Hallux Valgus

Arthrex Bunionectomy Website

Resources

Arthrex offers a multitude of fixation options to correct hallux valgus (bunion) deformities.
In the presence of 1st TMT joint hypermobility, surgeons have the option use either the plantar lapidus plate or a traditional dorsal medial lapidus plate. The advantages of the plantar approach include strong and stable tension-side fixation that spares the tibialis anterior tendon.
For patients with a stable 1st TMT joint, surgeons may take a minimally invasive approach using Arthrex's MIS power unit and instrumentation to create the percutaneous incisions for the osteotomy. Fixation is achieved with Compression FT screws.
For surgeons that prefer an open approach to correct the deformity, Arthrex offers the versatile proximal 1st metatarsal osteotomy plate and proximal opening wedge plates.
Finally, if an Akin osteotomy is needed, Arthrex offers DynaNite® Nitinol staples for a stable and reproducible fixation option. Surgeons that would like to take an MIS approach can use Arthrex Compression FT or PT screws to achieve fixation.
References
1. Klos K, Simons P, Hajduk A-S, et al. Plantar versus dorsomedial locked plating for lapidus arthrodesis: a biomechanical comparison. Foot Ankle Int. 2011;32(11):1081-1085. doi:10.3113/FAI.2011.1081.
2. Arthrex, Inc. LA1-00068-EN. Naples, FL; 2018.

The Mini TightRope® is a low profile system designed to correct a number of forefoot deformities including hallux valgus, Lisfranc disruptions, Tailor’s bunion and hallux varus. Comprised of #2 FiberWire and two stainless steel buttons, this device improves foot and ankle patient care with its strength and versatility. A FiberWire and button construct (distal approach) or FiberWire and anchor construct (proximal) are placed across the first and second metatarsals. As the FiberWire is tightened, the IM angle is reduced to a normal value (less than 9-11 degrees). Using the button or anchor construct, the suture is tied over the button, maintaining a secure reduction of the deformity. Used alone or in conjunction with soft tissue repair, this technique affords a greater degree of strength and security than can be achieved with a soft tissue repair alone.

Mini TightRope® Technique for Hallux Varus

Hallux Varus

Hallux varus is a varus deformity of the first metatarsal phalangeal joint.&nbsp; The lateral joint capsule is attenuated or absent while the medial side is contracted.&nbsp; This deformity can be caused by direct trauma.&nbsp; However, it is most often seen as an iatrogenic (sometimes unavoidable) complication of bunion surgery where aggressive medial eminence excision and soft tissue balancing techniques were performed. &nbsp;If the condition is addressed before the onset of arthritis, the surgeon may choose to realign the joint using capsular repair techniques and a Mini TightRope device along the lateral collateral ligaments to support the joint while it heals.&nbsp; If the joint is already arthritic, the surgeon may choose to perform a first MTP joint arthrodesis.&nbsp; &nbsp; &nbsp; &nbsp;

Correction of claw or hammer toe deformity can be achieved using various techniques, including proximal interphalangeal joint arthrodesis (PIPJ). &nbsp;Interphalangeal Joint Fusion can be accomplished using the Arthrex&nbsp;Trim-It&nbsp;Pins and&nbsp;Trim-It&nbsp;Spin Pins.

Interphalangeal Joint Fusion

The PIP dart is made of PEEK material and takes the guesswork out of pin placement for PIP joint fusions. The all-inside PIP dart technique is simple and provides an exact fit of the nonabsorbable implant. Using this unique system, surgeons can fuse the PIP joint without leaving metal or bioabsorbable material across the distal phalanx.

Proximal Interphalangeal Joint (PIP) Dart Implant

The RetroFusion screw is a headless implant designed for PIP arthrodesis that provides compression and strength across the joint. The implant’s proximal and distal threads are arranged in opposite directions to pull the joint together when the implant is inserted.
<ul>
 <li>Opposing threads on implant pull the joint together for maximum compression of the PIP joint</li>
 <li>Better fixation of the joint since actual compression is achieved</li>
 <li>Simple technique that also allows for flexed fusions and no violation of the DIP joint</li>
</ul>

RetroFusion™ PIP Joint Arthrodesis Implant

Hammer Toe/Claw Toe

Hammer toe is a flexible or rigid flexion deformity of the proximal interphalangeal (PIP) joint of the lesser toe. A similar deformity that also involves the distal interphalangeal (DIP) joint is known as claw toe. These deformities result from an imbalance in the dynamic flexion and extension forces that cross the lesser MTP, PIP, and (in the case of claw toe) DIP joints. Surgical treatments of lesser toe deformities have historically been based on altering the relative lengths of the toe and its tendons. Options have included PIP joint resection arthroplasty, PIP joint fusion, tendon transfers, tendon lengthening, and metatarsal shortening.

The majority of plantar plate injuries are treated with traditional lesser MTPJ rebalancing procedures, including sequential release of soft tissue, tendon transfers, metatarsal osteotomies, and temporary MTPJ pinning. These approaches, while quick and inexpensive, do not address the underlying issues of loss of toe purchase and the high incidence of reoccurrence often associated with performing an indirect repair. Direct repair of the plantar plate with Arthrex’s family of solutions delivers improved patient outcomes and higher patient satisfaction scores.
Arthrex’s continuous evolution in plantar plate repair has led to the development of a family of products capable of addressing any stage of lesser toe instability, from a partial plantar plate tear with mid-dorsal plane instability to a complete rupture and attenuation of the plantar plate with a crossover toe deformity. Below is the summary of our current offerings:
<ul>
 <li>CPR™ System With the Mini Scorpion™ and Pigtail Lasso Suture Passer</li>
 <li>CPR System With the Viper™ Suture Passer</li>
 <li>CPR System With Forefoot InternalBrace™ Repair</li>
</ul>
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Plantar Plate Repair

Plantar Plate Tears

The plantar plate is made of a 2 - 5 mm thick layer of connective tissue originating on the plantar aspect of the distal metatarsals and inserting on the plantar base of the proximal phalanx. This stout structure serves as the main stabilizer supporting the MTP joints. Through chronic microtrauma or dynamic imbalance, this tissue can become inflamed, attenuated, tear or rupture. This results in pain, MTP joint instability, crossover toes, or dislocations.