Dorsomedial Approach to the First MTP Joint

What it exposes. The dorsomedial approach gives direct, extensile access to the first metatarsophalangeal (MTP) joint — the medial eminence, the metatarsal head articular surface, the base of the proximal phalanx and the sesamoid complex — through a single incision that can be extended proximally or distally. It is the workhorse exposure for the majority of hallux valgus corrective procedures, cheilectomy and first MTPJ arthrodesis. Why dorsomedial. The approach avoids the weight-bearing plantar skin and the plantar medial neurovascular bundle while giving excellent visualization for corrective osteotomies and joint-preserving or fusion procedures. It is familiar to all foot and ankle surgeons and has a low complication rate when the dorsomedial cutaneous nerve is protected. Primary indications. - Hallux valgus corrective surgery — distal soft tissue procedure (modified McBride), chevron (Austin), scarf, proximal metatarsal or Akin osteotomy, and medial eminence resection with capsular plication

• Cheilectomy for hallux rigidus (dorsal osteophyte resection and joint debridement)
• First MTPJ arthrodesis for severe hallux rigidus, inflammatory arthritis or failed previous surgery
• Synovectomy and debridement in inflammatory arthropathies (rheumatoid, gout)
• Removal of loose bodies, osteochondral lesions or dorsal exostoses, and biopsy or curettage of benign bone lesions of the metatarsal head Contraindications. Active infection or ulceration over the proposed incision; severe peripheral vascular disease with inadequate skin perfusion; previous surgery with extensive scarring requiring a different approach; isolated plantar pathology better addressed plantarly; and the need for extensive lateral release that may demand a separate lateral incision. Alternative approaches. A pure medial approach (isolated medial eminence resection in very mild cases, limited exposure); a plantar medial approach (sesamoid pathology or extensive plantar release); a lateral approach (rarely used alone, combined for complete lateral release in severe hallux valgus); and minimally invasive percutaneous techniques for chevron or Akin osteotomies in selected patients (a different skill set). Position & landmarks. The patient is supine with a sandbag under the ipsilateral hip to internally rotate the leg and bring the medial forefoot into view, the knee slightly flexed over a bolster, the ankle in neutral or slight plantarflexion, and the foot at the end of the table. A thigh or ankle tourniquet is applied; the foot is prepped and draped free. Palpable bony landmarks are the first metatarsal head, the MTP joint line (felt by moving the hallux), the medial eminence, the proximal phalanx base and the metatarsal shaft. Key soft-tissue landmarks are the dorsomedial cutaneous nerve (often visible or palpable as a thin cord crossing dorsomedially), the extensor hallucis longus (EHL) tendon laterally and the abductor hallucis tendon plantar-medially. The incision is a longitudinal or gently curved line centered over the joint, 3 to 5 cm long, placed just dorsal to the abductor hallucis tendon (about 5 to 10 mm dorsal to the most medial prominence).

Work down through the layers along the dorsomedial aspect of the hallux, protecting the dorsomedial cutaneous nerve at every step, retracting (never dividing) the EHL and abductor hallucis, and entering the joint with a longitudinal or Y-shaped capsulotomy.

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Structures at risk, by layer

Nerve injury management. If a clean transection is recognised intra-operatively, consider primary repair or bury the ends in muscle or bone to minimise neuroma; suspected postoperative neurapraxia is observed and documented; an established painful neuroma is managed with desensitisation, local anaesthetic injection and, if refractory, surgical exploration with proximal-stump burial. Extensile options. Extend proximally along the dorsomedial border of the first metatarsal shaft for scarf, proximal metatarsal osteotomy or shaft pathology — the EHL tendon and the more variable proximal nerve branches must be identified and protected. Extend distally along the dorsomedial proximal phalanx for arthrodesis, Akin osteotomy or Keller-Brandes resection arthroplasty — the nerve continues distally and the EHL insertion becomes relevant. A combined lateral release can usually be done through the same incision by retracting the metatarsal head laterally, or through a separate small first web-space incision in severe deformities. In revision surgery, previous incisions and scarring increase the difficulty of nerve identification and may demand a more extensile or alternative exposure. Complications

Closure and aftercare. The capsule is closed with absorbable suture (pants-over-vest or imbrication for plication), subcutaneous tissue approximated, and skin closed without tension. Postoperatively the patient is weight-bearing as tolerated in a postoperative shoe, with elevation for 48 to 72 hours; early active and passive range of motion begins at 7 to 14 days, sutures are removed at 10 to 14 days, normal footwear resumes at 6 to 12 weeks, and full return to sport at 3 to 6 months, protecting the capsular repair throughout.

• Chevron (Austin) osteotomy for mild hallux valgus — distal metatarsal osteotomy for mild deformity.
• First MTPJ arthrodesis — fusion for severe hallux rigidus, inflammatory arthritis or salvage.
• Cheilectomy — dorsal osteophyte resection and joint debridement for hallux rigidus.
• Distal soft tissue procedure (modified McBride), scarf osteotomy, proximal metatarsal osteotomy and Akin phalangeal osteotomy.
• Medial eminence resection with capsular plication; synovectomy for inflammatory arthropathy.
• Removal of osteochondral lesions or loose bodies; biopsy or curettage of benign bone lesions (for example intraosseous ganglion, enchondroma).
• Keller-Brandes resection arthroplasty (historical, rarely performed). Most hallux valgus operations combine soft-tissue balancing, osteotomy and an Akin procedure through this single extensile incision; a lateral release can be added through the same incision or via a separate first web-space incision.

Global epidemiology. Hallux valgus affects approximately 20 to 30 percent of adults worldwide, with a higher prevalence in women and in populations that wear constrictive footwear. First MTPJ arthrodesis and cheilectomy are among the most common forefoot procedures performed by orthopaedic foot and ankle surgeons globally. Guidelines, registries and global practice. AAOS and AOFAS clinical practice guidelines emphasise the importance of nerve protection and proper capsular management in hallux valgus surgery; NICE and BOA guidance highlights the need to counsel patients about nerve injury risk; EFORT and national foot and ankle societies recommend the dorsomedial approach as the standard for most first MTPJ procedures. Registry data from the NJR, AJRR and national foot and ankle registries show low revision rates for properly performed chevron osteotomy and arthrodesis when nerve complications are avoided. Universally accepted technical principles are early identification and protection of the dorsomedial cutaneous nerve, capsular plication to maintain correction, avoidance of excessive medial release to prevent hallux varus, and deformity-matched procedure selection.