Pertinent Insights On Treating Second MPJ Pathology

Christopher L. Reeves, DPM, FACFAS, Amber M. Shane, DPM, FACFAS, Larissa McDonough, DPM, AACFAS, and Francesca Zappasodi, DPM, AACFAS

   In later stages, when the metatarsal head has undergone changes in shape and degeneration, surgeons have discussed multiple surgical modalities in the literature. More conservative initial approaches include simple joint debridement, arthroplasties and decompression osteotomies of the metatarsal. As the condition evolves to a later stage in which joint preservation is no longer possible, procedures such as implant arthroplasty and even metatarsal head resection are viable options for surgeons to consider.

   Literature regarding the indications, efficacy and complications of arthrodesis of the lesser metatarsophalangeal joint is deficient both in amount and long-term data. While there are currently limited studies, a more recent study reported a statistically significant reduction in pain after lesser metatarsophalangeal joint arthrodesis.8 The authors proposed that the procedure obviates the need for plantar plate repair and flexor tendon transfers while having complication rates similar to first metatarsophalangeal joint arthrodesis procedures.

   Just as important as any surgical approach, a strict and well-communicated postoperative course is imperative for success. One would typically remove sutures after two weeks and Kirschner wires at three to four weeks. Depending on the procedure, allow passive range of motion after the first four to six weeks postoperatively.

Case Study: When A Patient Has Hallux Valgus With A Contracted Second Toe And Second MPJ Instability

A 64-year-old male with diabetes presented to our clinic with complaints of an aching, throbbing right forefoot of six months’ duration. He noted that pain improved when he was non-weightbearing and was aggravated with continued activity. He also complained of a hammered second toe with a callus on the plantar aspect of his right forefoot that was painful.

   Upon physical examination, there was a hallux abductovalgus deformity present with subsequent overcrowding of the second digit. The patient had mild discomfort with palpation over the prominent medial eminence of the first metatarsal. The second toe had a rigid dorsal contracture located at the proximal interphalangeal joint. The contracture extended proximally and also involved the metatarsophalangeal joint. A Lachman vertical stress test demonstrated laxity and exquisite tenderness at the metatarsophalangeal joint. There was a diffuse hyperkeratotic lesion beneath the second metatarsal head and a prominence of the second metatarsal head. Surprisingly, the first ray was stable with range of motion both with and without the windlass mechanism activated.

   An AP radiograph demonstrated a hallux abductovalgus deformity with a short first metatarsal. In addition, there was an increased intermetatarsal angle between the first and second metatarsals. Upon evaluation of the metatarsal parabola, we noted that the second metatarsal was elongated. Medial deviation of the second toe on the corresponding metatarsal head and mild joint space widening were also apparent. The lateral radiograph demonstrated a dorsal contracture of the second toe at the proximal interphalangeal joint. In addition, the first metatarsal was slightly elevated in comparison to the lesser metatarsals.

   The patient had exhausted previous conservative modalities that included diabetic shoes with accommodative toe box and inserts, routine manual debridement of callosities and keratolytic creams. This particular patient did not have taping and strapping due to his diabetes and the risk of skin tearing. With the patient’s consent, we then devised a surgical plan.

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