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.
Three weightbearing radiographs of the right foot demonstrated joint space narrowing of the first MPJ with sclerosis and marginal erosions to the distal phalanx of the right hallux. There was gross osseous deformity of the distal first metatarsal bone with severe joint impingement. There was a lack of range of motion in repeated attempts to force the joint into stress dorsiflexion. There were traumatic signs of arthrosis to the first MPJ. X-rays revealed evidence of severe arthropathy to the medial first MPJ.
My diagnosis was stage IV hallux rigidus of the right foot.
At the time of the first visit, I gauged the preliminary treatment to reduce his pain. I injected 1.5 cc of 1% xylocaine, 0.5% bupivacaine and 0.5 cc of methylprednisolone-40 under ultrasound guidance to the first MPJ of the right foot. The patient received adequate counseling regarding conservative versus surgical treatment for his complaint. The patient noted that his previous physician had already given him at least four injections over the last year to combat the pain. At this point, he wanted to discuss surgical outcomes and treatments.
I thoroughly discussed the planned surgery with the patient. We agreed on a total joint replacement of the first MPJ. This would provide the patient with the best long-term result without undergoing full arthrodesis/fusion, which the patient did not want. I discussed all risks, benefits, alternatives and complications with the patient in complete detail prior to surgery and prior to obtaining surgical consent.
I made a 6 mm linear incision to the dorsal aspect of the first MPJ, extending it from the hallux to the midshaft of the first metatarsal, dissecting carefully to avoid neurovascular structures. I performed an inverted-T periosteal incision, reflecting all capsular and periosteal surfaces. A thorough examination identified the amount of arthritic bone that had to be removed from the joint and where the osteotomies were to occur.
Using a sagittal saw, I resected redundant arthritic bone from the hallux and first metatarsal head. The amount of bone was consistent with the preoperative diagnosis of stage IV hallux ridigus. The bone removed showed severe arthrosis and sclerosis upon resection.
I resected the remainder of cartilaginous surfaces of the joint according to the surgical plan to replace the first MPJ, using the ReFlexion Total Joint Implant (Osteomed). I used Osteovation Bone Void Filler (Osteomed) to fill in gapping between the implant surface and the resected bone surface of both the hallux and first metatarsal. Intraoperative fluoroscopy confirmed implant placement. I loaded the first ray and put the joint through an aggressive range of motion that showed dorsiflexion of 55 to 60 degrees.
Upon complete replacement of the joint, I irrigated the site with NSS-bacitracin, and re-approximated redundant capsular structures with 2-0 vicryl. Subcutaneous closure occurred with 3-0 vicryl and skin closure occurred with 3-0 Ethilon (Ethicon) in a horizontal mattress technique.
Upon closure, I dressed the surgical site with betadine, an Adaptic 4x4 dressing, Kling and Coban. I placed the hallux in a slightly dorsiflexed position and in slight abduction. I discharged the patient home with an Equalizer Pneumatic Short Leg walking boot (Ossur).
I saw the patient three days after surgery and he experienced no complications. Pain was minimal and the patient actually stated that the pain from the surgery was easier than living with the pain from the joint. At two weeks, I removed the sutures and allowed the patient basic walking exercise. At six weeks, he had full clearance to begin impact, elliptical and treadmill jogging.
At three months, I fully discharged the patient. His final range of motion was at 55 degrees dorsiflexion with impact running on the pavement.
Dr. Lullove is in private practice in Boca Raton and Delray Beach, Fla. He is a staff physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.