First MPJ Arthrodesis: What The Evidence Reveals

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

   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.

   Once the ulceration was stable with no clinical signs of soft tissue infection, we scheduled a first MPJ arthrodesis. After scrubbing, prepping and draping, we covered the ulcer with Tegaderm (3M) to limit contamination of the clean surgical site. Next, resection of the osteomyelitic portion of the proximal phalanx occurred with use of a bone saw. The hallux length was acceptable so there was no bone grafting. Next, we placed a 4.0 bone screw across the joint surface to stabilize the opposing debrided bone surfaces. A four-hole locking plate and 3.5 mm locking screws further secured the reduction. We then flushed the ulceration and incision site with power irrigation mixed with bacitracin followed by primary closure.

   We allowed the patient heel touch weightbearing in a CAM boot with the use of crutches for the first four weeks and subsequently progressed to full weightbearing in the CAM boot. In the postoperative course, the wound quickly improved and had healed five weeks after surgery. At eight weeks, X-rays revealed a healed fusion site with good alignment and fixation intact. At the final follow-up visit six months later, the patient was very pleased with her function, pain level and healed ulceration.

In Conclusion

The first MPJ arthrodesis has become a reliable procedure with high patient satisfaction and predictable results. The advent of modern osteosynthesis techniques has allowed for early or immediate weightbearing, and high union rates. While implant arthroplasty is continuing to evolve with fourth-generation metatarsal head resurfacing implants, surgeons have not obtained consistent results and complication rates still remain higher than those of arthrodesis.

   Dr. Visser is the Director of the Mineral Area Regional Medical Center Residency Program in Farmington, Mo. and the Director of SSM DePaul Residency Program in St. Louis.

   Dr. Day is a second-year resident at Mineral Area Regional Medical Center Residency program in Farmington, Mo.

   Dr. Sills-Powell is a third-year resident at SSM DePaul residency program in St. Louis.

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