Great Toe (1^st MTP) Medial Capsulorraphy

Indication

When correcting a bunion (hallux valgus), it is usually necessary to tighten the thick soft-tissue (joint capsule) on the inside (medial aspect) of the great toe. The capsule is the soft tissue that provides resistance against bending your toe to either side. With a bunion, the capsule on the inside stretches out over time and the big toe drifts towards the little toes.

The part of bunion surgery that reshapes or changes the capsule tissue is called a capsulorraphy. It is performed at the joint at the base of the big toe where bunions occur. This joint is known as the first metatarsophalagneal joint (1^st MTP joint). The great toe medial capsulorraphy (tightening of the capsule) is usually performed as part of a bunion correction surgery in which the end of the great toe metatarsal bone is first cut, (reshaped) as in an osteotomy (“bone cut”) procedure. Then the great toe medial joint capsulorraphy is completed to help maintain the new improved position of the great.

Procedure

The procedure is typically performed by cutting the skin on the inside of the great toe. In some cases, surgeons can perform an incision on the top of the toe and expose both sides of the joint allowing a release of the tight lateral (outer) side and a tightening of the loose (inside) capsule tissue. The tissue is exposed and then the capsule is split. Once the joint is exposed, it is inspected and any problems are addressed. It is not uncommon to release the joint capsule on the outside (lateral) aspect of the joint, as this is often tight. With the bunion in a corrected position (big toe is straightened), the medial joint capsule is repaired in such a way that it is tightened to help maintain the new position of the great toe. If the capsule has been stretched out, then some of the excess capsule tissue may need to be removed. The skin is then closed.

Potential complications

• Wound Infection.
• Nerve injury. There is a small sensory nerve that supplies the inside of the toe (near the base of the toenail) that may be injured or irritated by scar tissue during this surgery. This may result in some numbness along the inside of the big toe.
• Failure of the repair. The repaired joint capsule may stretch out over time, contributing to a return of the bunion deformity. This is more common in cases where inadequate bony correction was performed.
• Loss of blood supply to the great toe metatarsal bone (avascular necrosis of the 1^st metatarsal head). This is rare because care should be taken not to disrupt the major blood supply of the metatarsal bone. .

Previously edited by Anthony Van Bergeyk, MD and Eric Malicky, MD 

Edited September 16th, 2023

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