First Metatarsal Pathology: Can An Implant Provide A Long-Term Solution?

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An Overview Of Previous First Metatarsophalangeal Implants

The Keller resection arthroplasty of the base of the proximal phalanx has generally been regarded as the gold standard for recalcitrant pain of the first metatarsophalangeal joint. Described in 1904, it remains the orthopedic procedure of choice due to its preservation of the first metatarsal head.1 However, if one resects too little bone, the result may be a stiff, painful pseudoarthrosis while over-resection of bone results in loss of hallucal function and disrupts the biomechanics of the foot.2,3

In the early 1950s, several investigators began to implant synthetic materials for the first metatarsophalangeal joint.4,5 In separate studies, Swanson and Seeburger utilized metallic implants in the first metatarsal while Joplin incorporated metal in the base of the proximal phalanx.5,6 Eventually, acrylic was tried as a substitute for metal on the proximal phalanx. The findings for these individual materials as well as combinations of the two yielded less than satisfactory results.

In the late 1960s, Swanson, in conjunction with Dow-Corning, introduced the single-stemmed (hemi) silicone first metatarsophalangeal joint implant. In 1974, Dow introduced Silastic-HP® (high performance) for the double-stemmed (total) implant. The newer material was touted to have a greater modulus of elasticity, allowing greater cyclic loading without the accompanying pattern of stress fracture to the bone.7

Although Swanson’s original design has been modified several times, (i.e., Weil/LPT, Lawrence/MHT, LaPorta/Primus, etc.), none of the prosthetic designs to date have demonstrated an ability to reproduce the normal mechanics of the first metatarsophalangeal joint.8 It is for this reason that double-stemmed implants have been referred to as “dynamic spacers” as opposed to joint replacements. This would also include silicone “ball spacers” currently being used in England.9,10

The debate over the biocompatibility of silicone has taken on a new dimension with the release of earlier research showing the dangers of breast implants. Although silastic implants are of a harder consistency, there is a serious rethinking of their role in the foot.

Surgeons placing silicone implants in the first metatarsophalangeal joint have noted not only cystic changes in the surrounding bone, but also reactive synovitis in many of their patients.11,12 Shereff has found bone resorption to be a consistent finding in a review of first metatarsophalangeal joint silicone implants.8 McCarthy, using electron microscopy, found T-lymphocytes in the area of silicone implants within 12 months of implantation. This suggested a much stronger immune response to silicone than previously thought. Numerous authors using a variety of methodologies for evaluation have reported reactive synovitis.13,14 While the definitive etiology of these reactions eludes the medical community, many in the general public remain skeptical regarding the implantation of silicone.

In 1974, Smith and Weil introduced a prosthetic of ultra-high molecular weight polyethylene for the phalangeal component and stainless steel for the metatarsal component of a total joint implant. The intramedullary aspect was affixed with bone cement.15

It has been suggested that the failure of this implant may be traced less to materials than to design. The implant had a central groove in the phalangeal component and a complementary ridge in the metatarsal component. Although this groove provided stability, it effectively violated two of the three cardinal planes in which the joint functions, constraining it to the sagittal plane.9 This same phenomenon occurs with the double-stemmed implants. The forces constrained by the prosthesis are believed to be transferred to the shaft canal interface, creating a stress riser that effectively weakens the cement bond. This leads to microfracture in the bone and, ultimately, implant failure.16-18

In 1981, Johnson and Buck reported on a surface replacement prosthesis, consisting of two components made of stainless steel and polyethylene, fixed with methyl methacrylate.19 Twenty-one procedures were followed with a satisfaction rate of 81 percent. Johnson and Buck concluded the results were encouraging but they were concerned with prosthetic loosening in two cases and dislocation in another.19 In their discussion, they felt “… on an intuitive basis, joint function should be preserved better by a prosthesis than by an ablative joint procedure.”19

In 1990, Koenig introduced a titanium alloy and polyethylene prosthesis utilizing a press fit system of implantation rather than cementing.20 In this process, cortical bone needed to be resected dorsally, distally and plantarly from the metatarsal head in order to accommodate the component. The sesamoid apparatus is left articulating with the base of the metallic component since its plantar articular surface was sacrificed.

The combination of stripping the metatarsal shaft of its cortex and destroying the weightbearing surface of the metatarsal head (along with the sesamoid apparatus) violated sound physiologic and biomechanical principles. This opened the door to implant failure, chronic pain and ultimately destruction of the first metatarsophalangeal joint. Since a large potion of the blood supply to long bones comes from the cortex, there was also an increased risk of avascular necrosis.


1. Keller WL. Surgical treatment of bunions and hallux valgus. NY Med, 80741-2, 1904.

2. Miller RJ, Rattan N, Sorto L. The geriatric bunion correction of metatarsus varus primus and hallux valgus with Swanson total joint implant. Foot Surgery 22(3):263-70, 1983.

3. Mayo C. The surgical treatment of bunions. Ann Surgery 48:300-302, 1906.

4. Borovoy M, Gray W, Rinker A. Total replacement of the first metatarsophalangeal joint. Foot Surgery 2(2):159-164, 1983.

5. Swanson AB, Lumsden RM, Swanson GD. Silicone implant arthroplasty of the great toe. Clin Orthopedics 142:30, 1979.

6. Seeburger R. Surgical implants of alloyed metals in joints of the foot. Am Podiatry Association 54:391-6, 1964.

7. Merkle PF, Soutoo TP. Prosthetic replacement of the first metatarsophalangeal joint. Foot and Ankle 10(6):191-192, 1989.

8. Sgarlato TE. Sutter double-stem silicone implant arthroplasty of the lesser metatarsophalangeal joints. Foot Surgery 28(5):410-413, 1989.

9. Broughton NS, Doran A, Meggit BF. Silastic ball spacer arthroplasty in the management of hallux valgus and hallux rigidus. Foot and Ankle 10(2):61-64, 1989.

10. McAuliffe TB, Helal B. Replacement of the first metatarsophalangeal joint with a silicone elastomer ball shaped spacer. Foot and Ankle 10(5):257-262, 1990.

11. Kampner SL. Total joint prosthetic arthroplasty of the great toe. Clin Orthopedics 142:30, 1979.

12. Cracchiolo AS, Swanson GD. The arthritic great toe metatarsophalangeal joint: a review of flexible silicone implant and arthroplasty from two medical centers. Clin Orthopedics 157:64-69, 1981.

13. McCarthy DJ, Kershisnik K, O’Donnell E. The histopathology of silicone elastomer implant failure in podiatric surgery. JAPMA 76(5):247-265, 1986.

14. McCarthy DJ, Chapman HL. Ultrastructure of collapsed metatarsophalangeal silicone elastomer implant. Foot Surgery 27(5):218-227, 1988.

15. Weil LS, Pollak RA, Goller WL. Total first joint replacement in hallux valgus and hallux rigidus: long-term results in 484 cases. Clin Podiatry 1(1):103-129, 1984.

16. Mondull M, Jacobs PM, Caneva RG, Crowhurst JA, Morehead DE. Implant arthroplasty of the first metatarsophalangeal joint: a twelve-year retrospective study. Foot Surgery 24(4):175-279, 1985.

17. Gudmundsson G, Robertsson M. Silastic arthroplasty of the first metatarsophalangeal joint. Acta Orthop Scand 51(3):575-578, 1981.

18. Verhaar J, Bulstra S, Walenkamp G. Silicone arthroplasty for hallux rigidus: implant wear and osteolysis. Acta Orthop Scand 60(1):30-33, 1989.

19. Johnson KA, Buck PG. Total replacement arthroplasty of the first metatarsophalangeal joint. Foot and Ankle 1(6):307-317, 1981.

20. Keonig RD. Koenig total great toe implant (preliminary report). JAPMA 80(9):462-468, 1990.

This intraoperative photo shows the first metatarsophalangeal joint with the silicone implant removed. Note the erosion of the proximal phalanx and the first metatarsal head. (Photo courtesy of Graham A. Hamilton, DPM)
Addressing the biomechanics of the first metatarsophalangeal joint as well as the first ray are the keys to any surgical correction of the first metatarsal pathology. The Bio-Action implant may facilitate long-term, pain-free range of motion, according to
By Kerry Zang, DPM, Shahram Askari, DPM, A’Nedra Fuller, DPM, and Chris Seuferling, DPM

Addressing the biomechanics of the first metatarsophalangeal joint (MPJ) as well as the first ray are the keys to any surgical correction of first metatarsal pathology. According to Rootian theory, the principal etiologies of hallux limitus are as follows.1
A long first metatarsal or when the position of the first metatarsal head is relative to the second. When the first metatarsal is long, there will be jamming of the metatarsophalangeal joint during the initiation of the propulsive phase of gait. This causes a reduction in the range of dorsiflexion of the hallux and increases the ground reactive forces in the joint, resulting in early arthritic joint changes.2,3
Hypermobility of the first ray. This occurs when pronation of the subtalarjoint removes the mechanical advantage of the peroneous longus tendon on the first metatarsal, unlocking it and allowing dorsiflexion through midstance and propulsion. This leads to improper articulation at the first metatarsophalangeal joint and subsequent arthritic changes.1
Metatarsus primus elevatus. Metatarsus primus elevatus, a dorsally positioned first metatarsal relative to the lesser metatarsals, causes destruction of the joint, similar to hypermobility.
An immobilized first ray. Either bony ankylosis of the first metatarsocuneiform joint or congenital coalition may cause immobility of the first metatarsophalangeal joint. This causes the hallux to accept part or all of the normal first metatarsocuneiform joint motion in its articulation with the first metatarsal.1
Arthritic joint changes and trauma. Generalized degenerative joint disease— whether it is traumatic in origin or brought on by a multitude of other causes (hallux valgus, systemic arthritidies-rheumatoid) — will also stress the range of hallux dorsiflexion during gait. Generalized degenerative joint disease is usually the presenting clinical/symptomatic diagnosis for the patient with hallux limitus, regardless of the biomechanical etiology.
Although not a primary etiology of hallux limitus, the presence and degree of metatarsus primus adductus requires the utmost attention in order to achieve surgical success. Determining the nature of the articulation of the first metatarsocuneiform joint and whether this joint is stable can further affect the overall outcome of a total first metatarsophalangeal joint arthroplasty. In conjunction with resurfacing the diseased articular cartilage, it is necessary to correct any structural abnormalities present. If the joint is unstable, a repositional arthrodesis of the first metatarsocuneiform joint or a repositional osteotomy of the first metatarsal may be required for a successful outcome.

Why First Metatarsophalangeal Joint Implants Fail
Over the years, there have been many first metatarsophalangeal joint implants, hemi and total, that have attempted to resolve the aforementioned pathologies (see “An Overview Of Previous First Metatarsophalangeal Implants” below). Unfortunately, most of these implants have failed to provide long-term relief of symptoms.

There are a variety of reasons for these implant failures. Very few constrained (single component) silicone-based implants — and even some implants made of alloy materials — are capable of withstanding the forces transmitted through the first metatarsophalangeal joint. When this occurs, implant destruction or osseous degeneration about the implant follows.
Joint biomechanics are another issue. The natural anatomy of the first MPJ allows for specific fluidities of motion for given levels of activity. Any implant must likewise adapt for those varying activity levels or the implant will fail.
The complexity of the surgical procedure also factors into the equation. Many first MPJ implant procedures are technically complicated and surgeons may be less likely to choose a total joint replacement when a joint destructive procedure, although less gratifying to the patient, will require less operative time and less potential postoperative complications.

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yiceliseosays: February 21, 2011 at 9:46 am

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kicalasEOsays: February 24, 2011 at 3:24 am

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