Pertinent Insights On Total Joint Replacement Of The First MPJ

Eric Lullove, DPM

This author provides a step-by-step guide to performing total joint replacement of the first metatarsophalangeal joint (MPJ) in a 62-year-old patient with painful stage IV hallux rigidus.

A 62-year-old male presented with a complaint of right foot pain with a duration of over one year. The patient has had pain with increasing severity over that time. The pain is located at the great toe joint of the right foot. He complains that the pain is gripping, searing and throbbing, especially after exercise.

   Two months ago, the patient saw a local podiatrist, who gave him an injection without relief. The patient attempted to get his records from the doctor without results and then filed a complaint with the department of health. When I called to obtain his records for review, I found that the previous doctor was no longer practicing in the area.

   The patient’s past medical history revealed mild osteoarthritis, hypercholesterolemia and gastroesophageal reflux disease. He was taking the drugs citalopram (Celexa, Forest Laboratories), enalapril (Vasotec, Biovail Pharmaceuticals), pravastatin (Pravachol, Bristol-Myers Squibb) and verapamil. He had no known drug allergies. The patient did not smoke and had quit drinking. He exercised four to five times a week.His review of systems was 10 points negative.

   The patient’s lower extremity vascular exam revealed pulses that were palpable bilaterally +2/4 to popliteal. His capillary fill time was immediate. The neurological exam showed intact epicritic sensation bilaterally. His deep tendon reflexes were +2 bilaterally. He had no open lesions, good skin texture/tugor and his temperature was normal.

   As for the musculoskeletal exam, he had a bony prominence on the right dorsal first metatarsophalangeal joint (MPJ). Palpation demonstrated moderate to severe pain to his dorsomedial first MPJ surface. His first MPJ range of motion dorsiflexion was less than 5 degrees with crepitation and clicking. His plantarflexion had been reduced to 10 degrees. The patient’s second through fifth MPJs were normal without crepitation or clicking. His subtalar joint and ankle joint range of motion were normal. As for his gait, the patient had abnormal propulsion in the right foot with antalgia to the first MPJ.

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