First MPJ Arthrodesis: What The Evidence Reveals

Author(s): 
H. John Visser, DPM, Jordan P. Day, DPM, and James D. Sills-Powell, DPM

   The techniques in these cases often involve interpositional bone grafting and are more technically challenging concerning fixation, position and post-op recovery. The following case studies will serve to demonstrate examples of these techniques when performing arthrodesis.

Case Study One: Addressing A Failed Silastic Implant

A 57-year-old female got a referral to the office for a painful right first MPJ. She had received an implant arthroplasty 15 years prior. She noticed deviation of the hallux medially along with increasing pain at the MPJ and the ball of her right foot.

   Medications included alprazolam (Xanax, Pfizer), buspirone (BuSpar, Bristol-Myers Squibb), gabapentin (Neurontin, Pfizer), tiotropium bromide (Spiriva, Pfizer) and trazodone (Oleptro, Angelini Labopharm), which she took for anxiety, emphysema and joint pain respectively. She was also tobacco dependent.

   Clinically, there was deviation of the first to third digits medially but the second and third were reducible. Radiographs showed an implant of a Silastic nature without grommets. The implant appeared to have depressed into the first metatarsal head medially.
Her surgery consisted of removal of the failed Silastic implant and intercalary bone graft arthrodesis of the right first MPJ after thorough debridement. We used a dorsal locking plate with 2.7 mm locking screws.

   We allowed heel touch weightbearing in a controlled ankle motion (CAM) boot with the use of crutches for the first four weeks. At the one month follow-up visit, we noted that the right second and third digits began to overlap so we performed capsulotomy and tenotomy. Full weightbearing occurred after four weeks. The X-rays showed consolidation and good alignment of the arthrodesis site at the eight-week follow-up visit. At the 10-week post-op fusion visit, the patient was ambulating well without decreased function and radiographic evidence of fusion at the first MPJ. No complications had occurred despite early weightbearing and a history of smoking.

Case Study Two: When A Patient Has An Ulcer Of Three Years’ Duration Under The First Metatarsal Head

A 57-year-old female received a referral to the office with a three-year history of ulceration below the left first metatarsal head. We performed tibial sesamoid excision in an attempt to heal the ulceration. This lead to a transfer ulceration under the fibular sesamoid. Following fibular sesamoid excision, the ulceration moved under the first metatarsal head. A Keller arthroplasty led to hallux malleus and continued ulceration.

   The X-rays as well as a Ceretec bone scan were positive for osteomyelitis at the base of the proximal phalanx. We performed local wound care and ensured adequate offloading. Cultures revealed methicillin resistant Staphylococcus aureus (MRSA) and Pseudomonas. Consequently, we started the patient on oral antibiotics.

   Her past medical history was significant for type 2 diabetes, cancer and heart disease with stent placement. She was taking atorvastatin (Lipitor, Pfizer), ticagrelor (Brilinta, AstraZeneca), glimepiride (Amaryl, Sanofi-Aventis), insulin glargine (Lantus, Sanofi-Aventis), metoprolol (Lopressor, Novartis) and doxycycline (Vibramycin, Pfizer). She denies ever smoking.

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