How To Salvage A Failed First MPJ Implant

By Graham A. Hamilton, DPM

Weighing The Possible Salvage Options

   Despite the failure associated with use of first metatarsophalangeal joint silicone prostheses, there is a paucity of literature on how to salvage these failures. Salvage can be particularly difficult in younger, active patients. Options include implant removal and synovectomy; implant removal with reinsertion of an alternate implant; or bone block distraction arthrodesis.    For older, more sedentary people with low physical demands, implant removal with synovectomy is an option. However, both the surgeon and the patient must remember that this option does not provide a functional forefoot even for patients who are only minimally active. When considering this implant removal procedure, one must counsel patients on the strong possibility of lesser metatarsal overload symptoms and postoperative need for orthoses.    In a study of 11 failed silicone first MPJ implants, 10 patients received a mean 4.9 years of follow-up and seven patients had excellent clinical results.9 The authors observed a general clinical trend toward toe extension and used pressure studies to show increased load on the lateral forefoot.9 Other authors also observed postoperative lesser metatarsalgia in active patients who had received resectional arthroplasty.20,21    Another option for salvage is implant replacement. Koenig published a three-year follow-up study of 10 patients who received revisional arthroplasty after silicone implant removal and reinsertion of a dual-component great toe device.10 In that study, the author did not mention the ages of the study cohort and defined success as one or more years with no pain from the first MPJ.10 How these revised implants would perform over a longer period is difficult to determine. Gaining patient acceptance of this option may also prove difficult because patients with implant failure are usually extremely reluctant to have another prosthesis inserted. In addition, for any subsequent implant replacement, bony subsidence about the silicone implant would make it challenging to maintain positional stability of the new prosthesis.

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