First Metatarsophalangeal Fusions, Implants And Cheilectomies: What Is A Surgeon To Do?

Lawrence Fallat DPM FACFAS

When you attend our scientific meetings, we are inundated with lectures advocating arthrodesis for the arthritic first metatarsophalangeal joint (MPJ).

What happened to joint implants and attempting to restore or preserve function? I know podiatrists still commonly use implants but there are few lectures and articles supporting their use. Implants have served our patients well for decades because they gave good results. What about cheilectomies? Isn't there a place for them anymore?

My perception is that podiatric surgeons commonly used joint implants, either hemi- or total, metal or silastic, until the orthopedic community started fusing the first MPJ. We then followed their trend. The surgeons who perform the arthrodesis procedure report very high patient satisfaction with a return to most activities.

There is certainly a place for fusion for those who have a failed implant or when you encounter a painful end-stage hallux rigidus in an older patient. With these types of scenarios, I will perform an arthrodesis. However, I do not fuse every painful arthritic great toe joint.

Let us compare the procedures. If we fuse the joint, there are risks such as delayed union and nonunion. The great toe should be positioned optimally to permit ambulation. If it is elevated too much, shoes can irritate it. Also the great toe may not touch the ground and that can be annoying to the patient. Then there is the lengthy healing period and some immobilization. One should avoid motion across the joint in order to prevent delayed healing or displacement of the arthrodesis site. Healing of the fusion site can easily take two to three months.

The implant procedure has a much shorter healing period. Postoperatively, we want the patients to have early mobilization in order to preserve the range of motion that we were able to achieve on the operating table. The same is true for the cheilectomy procedure. The range of motion that occurs after removal of the blocking spurs can also help repair the damaged cartilage. Our goal is to reduce or eliminate pain, increase motion and preserve the function of the joint. The cheilectomy works well in those cases where the first metatarsal is not excessively long and is shorter than the second metatarsal.

For an elevatus or a long metatarsal, when one is using an implant or cheilectomy, I have had good results with a shortening plantarflexory osteotomy. I am careful not to shorten or plantarflex the first metatarsal too much because the great toe can ride up on the dorsal distal surface of the metatarsal head and not touch the ground. Also, with a metatarsal osteotomy, I will apply the cast so there is access to the great toe for early range of motion exercises.

Is there anything wrong with the arthrodesis? Not at all. When the procedure is indicated, I use it but I have several procedures to choose from in treating hallux limitus/rigidus. I look at the patient's age, weight, activity level, occupation as well as his or her goals. I balance this information with the information I have obtained from the X-rays. As previously stated, I want to get patients as pain-free as possible and return them to as much activity as possible. If at all possible, I will preserve the first metatarsophalangeal motion.

Currently, the arthrodesis procedure is very popular. Will it survive the test of time? Probably. However, in the next several years, I think we will see more specific criteria and indications for this procedure.

Comments

I have fused a number of joints and used primarily the arthrosurface implant for a number of hemi-implant procedure to allow for joint mobilization. Over the years, I've seen some really good success with the implant. Unfortunately, there are other times when joint spurring recurs around the implant that may eventually lead to a joint fusion. It is important to discuss this scenario with the patient. Many patients are worried about loosing joint mobility and would like to have a functional joint over a fused one. There is a give-and-take with any joint procedure you choose. It is up to us to discuss the possible risks such as recurrent limitus and pain with joint implants. I would like to see more research and reports on the long term prognosis of all the various type of joint implants and compare them to the overall long-term satisfaction of a joint fusion.

Al Kline, DPM

I respectfully have to disagree with this regarding fusion of the first metatarsophalangeal joint. I would certainly be termed a “fusion person.” I use this procedure often and without hesitation. Sure there are complications, but much fewer than that of implant arthroplasty. 1st MPJ fusions were first described in 1894 by Clutton and have been documented much more completely in the literature than implants have. I feel that arthrodesis stabilizes the function of the foot overall, whereas implants destabilize the function of the foot. In my opinion implants have a very narrow list of indications and should be used sparingly. Thanks for a thought-provoking blog.

Patrick A. DeHeer, DPM

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