The first MPJ is exposed through a standard bunion incision dorsal medially. The longitudinal capsulotomy is performed with care to maintain the insertion of the flexor brevis tendon attachment at the base of the proximal phalanx. The flexor halluces brevis insertion extends distal along the plantar aspect of the proximal phalanx thus allowing careful resection of the articular surface while maintaining flexion stability of the great toe.

Resection of the artcular surface of the base of the proximal phalanx is performed with sagital saw. A sufficient amount of bone to allow placement of the implant can be performed freehand or with available cutting guides. Remodeling of the metatarsal head is performed by resecting the osteophytes that may be present. Subchondral drilling of the metatarsa head and release of the sesmoids should be performed if necessary to gain joint motion.

The size of the implant is determined by using the OrthoPro sizer template. The implant should be flush with the cortex and not overlap margins of the remaining base of the phalanx. Implants are available in small, medium, large and extra large. The template allows the medullary canal to be marked through a hole that is dorsally eccentric for placement of the implant. Access of the canal is created with a starting awl. Trial implants have been designed with pin holes at the dorsal margins that allow grasping with bone forceps for better for 

The joint is put through a range of motion. Sufficient joint dorsiflexion and decompression can be obtained by remodeling the metatarsal head and further resection of the proximal phalanx as necessary. Modest manual traction of the toe should demonstrate separation of the joint with minimal tension. Insufficient joint decompression can result in continued hallux limitus postoperatively.