Complex Primary Arthrodesis of the First Metatarsophalangeal Joint After Bone Loss

Abstract

Background: Complications associated with a failed Keller procedure or joint replacement include bone loss and shortening of the first ray. We treated failed Keller resection arthroplasty and joint replacement arthroplasty cases with metatarsophalangeal joint arthrodesis, using an interpositional tricortical autograft from the iliac crest and a low-profile titanium plate. Methods: This was a retrospective case note review of the patients treated by four consultant surgeons in a university teaching hospital. A Keller procedure was considered to have failed when patients presented with a short, painful great toe with valgus cock-up deformity. Prosthetic joint replacements were considered to have failed based on the clinico-radiological loosening with associated pain. Metatarsophalangeal joint arthrodesis was carried out using an interpositional tricortical bone autograft and a titanium plate. Patients were assessed for resolution of pain, clinical and radiological evidence of fusion and complications. Ten operated feet in nine female patients, with a mean age of 55.9 (range, 37.8 to 80.2) years were followed for a mean of 12.6 (range, 6 to 26) months. Six patients presented with failed prosthetic joint replacements and four with failed Keller arthroplasty. Results: Full clinico-radiological union was achieved in nine of the ten patients as judged by an independent consultant musculo-skeletal radiologist. Four patients needed removal of implants, one for infection, two for prominent hardware and one for implant failure. Eight of the ten patients were satisfied with the relief of pain. Conclusion: Failed arthroplasty or Keller procedure is a difficult problem to manage. We recommend complex primary arthrodesis with an interpositional iliac crest autograft and a low profile plate as a salvage procedure. Level of Evidence: IV, Retrospective Case Series

Metatarsophalangeal Fusion Techniques with First Metatarsal Bone Loss/Defects

“…If there is approximately 1 cm or more of bone loss, and the first metatarsal head is significantly shorter than the remainder of the cascade, a distraction arthrodesis with or without lesser metatarsal shortening osteotomies should be performed in order to restore the proper biomechanics of the foot. 5 Distraction arthrodesis has a high nonunion rate under ideal circumstances. …”

“…3,4 Resection arthroplasty has been reported to cause excessive shortening of the first ray, which can lead to a weak or floppy toe, cock-up toe deformity, and/or transfer metatarsalgia. 5,6 Arthrodesis continues to be the most successful and reproducible long-term option for reconstruction, with rates of union being described from 56% to 100%. [7][8][9] However, when a nonunion or malunion does occur, it can be a source of significant pain and dysfunction.…”

Revision Forefoot

“…Other indications include threatened skin from prominent hardware, hallux deformity (hallux valgus, varus, or cock-up toe), and transfer metatarsalgia to the lesser rays. [12][13][14][15] Iliac crest provides the gold standard of structural autograft, providing both structural strength and osteogenic potential. With failure of the first MTP arthroplasty or hemiarthroplasty comes varying degrees of bone loss along the first ray, disrupting the cascade of the forefoot and changing the pressure distribution of the foot as a tripod.…”

“…If possible align the allograft cortex parallel to the metatarsal and phalangeal cortex (12). Saline should be used to cool the saw during cutting.…”

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of the Great Toe

“…1 However, a need to resect more bone makes salvage more difficult in the toe, and osteolysis, first reported in 1989, is common with silicone implants. 7,8 The silastic fragments may migrate to regional nodes. The fragments, observed in revision specimens using polarizing microscopy, are thought to be the cause of bone osteolysis around the components.…”