Introduction Indications excision of metatarsal head proximal phalanx metatarsal exostosis distal metatarsal osteotomy soft-tissue correction of hallux valgus 1st MTP arthrodesis dorsal wedge osteotomy for hallux rigidus MTP joint replacement Internervous Plane None the bone is subcutaneous Preparation Anesthesia general block Positioning supine with bump under ipsilateral hip Tourniquet placed on middle of thigh or calf exsanguinate limb by elevation for 3-5 minutes Technique Incision 5-6 cm incision medial and parallel to tendon of extensor hallucis longus (EHL) start 2-3 cm proximal to MTP joint extend distally to the proximal interphalangeal joint Superficial dissection incise deep fascia in line with incision retract EHL laterally retract dorsal digital branch of the medial cutaneous nerve laterally Deep dissection make a U-shaped incision through joint capsule base of the flap should attach at base of proximal phalanx Dangers Tendons extensor hallucis longus lies in lateral edge of wound retract laterally flexor hallucis longus lies in groove on the plantar surface of the proximal phalanx may be injured during subperiosteal stripping Nerves dorsal digital branch of the medial cutaneous nerve