A Novel Distraction Technique for First Metatarsophalangeal Joint Arthroscopy Using a Lesser Metatarsophalangeal Joint Plantar Plate Repair Distractor

Arthroscopy of the first metatarsophalangeal joint (1st MTPJ) has evolved considerably since Ferkel and Van Buecken presented the first formal case series at the Arthroscopy Association of North America annual meeting in 1991, reporting 83% good or excellent clinical results.Despite this early work, widespread adoption has remained limited, and the procedure is still relatively uncommon compared to arthroscopy of larger joints.,Advances in small joint arthroscopic technology, including the development of 1.9 mm and 2.7 mm arthroscopes with improved optics, have expanded both the feasibility of the procedure and its range of indications.,Current indications for 1st MTPJ arthroscopy include mild to moderate hallux rigidus, osteochondral lesions of the metatarsal head or proximal phalanx, loose body removal, synovitis, arthrofibrosis, sesamoid pathology, gouty tophi debridement, septic joint drainage, and select cases of hallux valgus correction.,,,Compared to open approaches, arthroscopy offers several potential advantages such as reduced bleeding, lower infection risk, improved cosmesis, faster recovery, and better visualization of the curved articular surfaces of the metatarsal head and proximal phalanx, which can be difficult to fully access through a standard open arthrotomy.In a systematic review of 14 studies including 405 patients and 419 halluces, Artioli et al. reported improvement in range of motion from a mean of 25.15 preoperatively to 71.3 postoperatively.The overall rate of temporary or permanent sensory loss was 3%, and the reoperation rate was 4.28%.Despite these advantages, many surgeons still consider 1st MTPJ arthroscopy technically demanding.This is largely due to the limited joint space, the proximity of neurovascular structures to standard portals, and the difficulty of achieving reliable joint distraction.,Standard portal placement typically involves dorsomedial and dorsolateral portals positioned approximately 5 mm on either side of the extensor hallucis longus tendon at the level of the joint line, with an optional medial portal for access to plantar structures and the sesamoids.,,A 2021 retrospective series of 36 consecutive cases reported