Revising A Failed First MPJ Implant In A Patient With Chronic Pain

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Author(s): 
Stephen L. Barrett, DPM, MBA, and Julie Lee, DPM

These authors offer pertinent insights on treating a 45-year-old woman who complained of severe pain years after receiving a total first metatarsophalangeal joint (MPJ) implant.

A patient presented with a chief complaint of severe pain in her left foot and noted that she had a total first metatarsophalangeal joint (MPJ) implant procedure in 2008, two years prior to presentation. She was 45 years old and had normal height to weight proportion.

   The patient related that after her first surgery for a painful first MPJ, she had some improvement one day and pain the next day. However, after several months, she developed constant, significant pain. At the time of her presentation in January 2010, she was still wearing a surgical shoe because she was unable to wear a regular shoe. Her gait was significantly altered. She did not have any current psychological manifestations.

   She had already seen five other specialists including orthopedic surgeons, who all recommended fusion of the first MPJ. Multiple pain management specialists had treated the patient for chronic pain. She had received a diagnosis of complex regional pain syndrome (CRPS). She was reluctant to undergo fusion surgery, remained unsatisfied and presented for diagnosis and treatment.

What The Examination Revealed

The patient had a very positive Tinel’s sign and provocation sign of the common peroneal nerve in the left leg. She had no tenderness on her common peroneal nerve at the level of the fibular neck on her right side. The Tinel's sign caused a distal radiation into her entire foot. She also demonstrated a significant Tinel’s sign of the left medial ankle over the tibial nerve.

   The patient could not tolerate even the lightest touch in the first MPJ area. She had a well-healed surgical scar on the dorsal aspect of her first MPJ, which she was unable to tolerate even the lightest touch. She had hypersensitivity on the plantar aspect of her left foot.

   Her motor strength was greatly decreased to the point where she could not even raise her hallux, demonstrating no extensor hallucis longus function. She also had no eversion or inversion motor strength. She had full motor strength 5/5 on the right side of all muscle groups.

   A review of radiographs demonstrated that she had significant hypertrophic bony development and involution of a short-stemmed Swanson Silastic implant (Wright Medical Technology) without grommets. She was unable to tolerate any examination regarding range of motion of the first MPJ because of allodynia. There was no limitation of dorsiflexion at the ankle joint with her knee extended. Her skin texture was normal and there was abnormal temperature.

   Based on the exam, we diagnosed her with the following conditions in her left lower extremity: CRPS, entrapment of the common peroneal nerve, tarsal tunnel syndrome and a failed first MPJ implant.

A Guide To First MPJ Treatment And Pain Relief

We explained to the patient that her first MPJ had developed as a primary pain generator due to detritic synovitis and chronic inflammation. She subsequently developed entrapment of her tarsal tunnel and common peroneal nerve. This entrapment contributed to her chronic pain syndrome due to compensation from the pain at the level of the first MPJ. In addition to her change in gait, postoperative swelling and the long periods of immobilization contributed to her multiple nerve entrapments. She was unable to undergo Pressure Specified Sensory Device (PSSD, Sensory Management) neurosensory testing because she would not be able to tolerate the testing due to the hypersensitivity in her left foot.

   We performed the following procedures:
1. Neurolysis/decompression of left common peroneal nerve
2. Neurolysis/decompression of the tibial nerve, medial plantar nerve, lateral plantar nerve and medial calcaneal nerve with endoscopic tarsal tunnel decompression
3. Revision arthroplasty with replacement of the Swanson short-stemmed implant with grommets.

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