Pertinent Insights On Treating Second MPJ Pathology

Author(s): 
Christopher L. Reeves, DPM, FACFAS, Amber M. Shane, DPM, FACFAS, Larissa McDonough, DPM, AACFAS, and Francesca Zappasodi, DPM, AACFAS

   Taking the clinical and radiographic findings into consideration, we believed it was critical to address the hallux abductovalgus deformity as it was both symptomatic and directly contributing to the development of deformity at the second metatarsophalangeal joint. Correcting the hallux abductovalgus deformity restores the function of the first ray and allows for a resultant reduction in plantar pressure at the second metatarsophalangeal joint complex. Upon discussion with the patient we recommended a correction of the second digit, stabilization of the second metatarsophalangeal joint, and a shortening osteotomy of the second metatarsal. Additionally, we recommended repositioning the first ray with a Lapidus procedure. The patient refused the post-op adherence necessary for the Lapidus. As a result, we decided on an aggressive distal metaphyseal osteotomy to reposition the metatarsal in a more aligned position.

   We addressed the hallux abductovalgus deformity with a distal first metatarsal osteotomy followed by a Weil decompression osteotomy at the second metatarsal head. Prior to fixation of the osteotomy, we transposed the capital segment medially (in the direction of the toe subluxation) to facilitate reduction of the deformity. During this portion of the procedure, a careful inspection of the plantar plate revealed a tear. Before addressing the tear, we first isolated the rigid contracture at the proximal interphalangeal joint, prepped it and performed arthrodesis using an internal implant.

   We proceeded to make a plantar linear incision beneath the second MPJ, which helped us access the plantar plate tear. After careful dissection, we did a primary repair of the tear with the use of an absorbable suture anchor that we tacked into the base of the second toe proximal phalanx while maintaining manual reduction of the deformity. Prior to incisional closure, there was significant clinical and radiographic improvement of the forefoot deformities.

   Postoperative radiographic assessment demonstrated osseous union at the arthrodesis and osteotomy sites as well as maintained stability and congruency at the second MPJ. After surgery, the patient was non-weightbearing for four weeks and gradually progressed into protective weightbearing with a short leg controlled ankle motion (CAM) boot for an additional three weeks. Five months post-op, the patient received a custom molded insert. He experienced alleviation of his painful symptoms and has maintained his correction. At one year post-op, he is satisfied overall with the results of his surgical procedure.

In Conclusion

In general, second metatarsophalangeal joint pathology encompasses a broad spectrum of conditions at this anatomic location. A thorough history and physical exam are always an important base to establish when first evaluating the patient. Ancillary imaging and diagnostic testing can further aid in the determination and confirmation of a particular diagnosis. Integration of all of the resulting information is necessary to accurately identify the clinical pathology and ultimately institute a successful treatment plan for the patient.

   Dr. Reeves practices at the Orlando Foot and Ankle Clinic in Orlando, Fla. He is an Attending Physician with the Florida Hospital East Orlando Residency Training Program.

   Dr. Shane practices at the Orlando Foot and Ankle Clinic in Orlando, Fla. She is an Attending Physician with the Florida Hospital East Orlando Residency Training Program.

   Dr. McDonough is a third-year podiatric surgical resident at Florida Hospital East Orlando in Orlando, Fla.

   Dr. Zappasodi is a second-year podiatric surgical resident at Florida Hospital East Orlando in Orlando, Fla.

References

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