Key Insights On Performing A Revisional Positional First MPJ Arthrodesis

Lawrence A. DiDomenico, DPM, FACFAS, and Zachary M. Thomas, DPM

These authors provide a guide for performing a revisional positional first metatarsophalangeal joint (MTP) arthrodesis with autogenous tricortical cancellous bone graft for a malunion in a 54-year-old patient.

When performing an arthrodesis of the first metatarsophalangeal joint (MTP), the position of the fusion is of paramount importance for a successful outcome. Often, the desire for complete bone-on-bone contact between two surfaces being prepared for arthrodesis requires the surgeon to spend increased tourniquet time fashioning the “perfect” bone apposition while attempting to maintain optimum correction of deformity. Herein, we describe a technique in which surgeons can achieve optimal position of the bone segments and primary direct bone-on-bone contact where possible, and provide subsequent backfilling with an autograft.

   With advances in internal fixation constructs, we are able to confidently neutralize forces across relatively large gaps, backfilling them with autogenous bone graft. Autograft backfilled bone provides the benefit of acting as an osteoconductive scaffold as well as an osteogenic biomaterial, allowing rapid consolidation of the fusion site.1 Backfilling of bone voids is not a new concept. Surgeons routinely backfill bone graft donor sites with low percentages of complications.2-4

A Guide To The Case Presentation

A 54-year-old female presented with a painful second digit and great toe. This patient had three previous surgeries for hallux limitus/rigidus. The first surgery was a cheilectomy. Unfortunately, this procedure did not relieve the symptoms. The second surgery consisted of an attempted arthrodesis of the first MTP with screw fixation. Regrettably, the surgery failed and went on to a nonunion. The third surgery was a revision arthrodesis of the non-union of the first MTP using a locking plate.

   Approximately 18 months after the third surgery (revision surgery), the patient presented for a second opinion of a previous arthrodesis of her right first MTP. The previous arthrodesis consolidated adequately but the previous surgery left the arthrodesis in a dorsiflexed, abducted position. This caused pressure from the overlapping great toe on the second toe as well as pain from the toe box of shoes, causing pressure to the elevated great toe.

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