After bilateral first MPJ hemiarthroplasty fails in an active 45-year-old woman, these authors note how a revisional fusion led to a pain-free result and discuss how better recognition of an underlying biomechanical pathology may have prevented multiple procedures.
First metatarsophalangeal joint (MPJ) arthroplasty is a topic that researchers still debate with success and longevity outcomes varying widely depending upon the study.1 The most obvious risk associated with any first MPJ joint sparing procedure is the risk of failure of the surgical intervention, which would then require revisional surgery. Surgical revision becomes more complicated in the case of the failed implant arthroplasty as the surgeon must account for a loss of bone stock, implant wear on the bone and surrounding soft tissue and decreased healing potential.2
One may use this case to make the argument for a joint destructive index procedure, sparing the patient the eventual need for revisional surgery.3,4
A 45-year-old active woman with no significant past medical history had bilateral first MPJ hemiarthroplasty with an outside orthopedic foot and ankle specialist. The surgeon performed bilateral correction simultaneously. She returned to ambulation in athletic shoe gear at six weeks and immediately had significant pain bilaterally, greater in the left foot than the right foot. She was unresponsive to attempted conservative care consisting of orthotics, steel shank use, injections and physical therapy.
The patient presented to our institution four months postoperatively with severe and consistent pain with ambulation. There was severely limited range of motion with pain bilaterally, more symptomatic in the left foot than the right foot. She displayed radiographic signs of joint jamming, implant malalignment and implant loosening.
We had an extensive conversation with the patient discussing both conservative and surgical care. In regard to conservative treatment, we offered joint injections of cortisone and amniotic tissue with manipulation under anesthesia to the patient as an initial treatment, given that she was only four months postoperative. We also discussed revisional first MPJ fusion starting with her more symptomatic left foot with possible bone grafting based on the residual deficit. The patient opted for a left first MPJ joint injection under ultrasound guidance in the office on her first visit.
The patient presented two weeks later with an almost immediate return of pain after the injection had worn off. She wanted to move forward with the definitive revisional first MPJ fusion on the more symptomatic left side. We performed this five months after the index procedure, utilizing a 3.0 interfragmentary screw with dorsal locking plate construct. We deemed interpositional bone grafting unnecessary intraoperatively although we biologically augmented the site with a bone morphogenetic protein-2 allograft saturated with autogenous bone marrow. She was ambulatory immediately post-op in a short pneumatic walking boot and her postoperative course was unremarkable. Her pain progressed and she transitioned to athletic shoes with an ankle brace and physical therapy once we appreciated osseous consolidation radiographically at six weeks postoperatively.
Three months after the left side revision, the patient had the same revisional procedure on the right side. We utilized the same construct. Again, we deemed interpositional bone grafting unnecessary intraoperatively although we utilized the same biologic augmentation. The patient again bore weight immediately in a pneumatic walking boot and returned to athletic shoes with an ankle brace and physical therapy after radiographic consolidation occurred six weeks postoperatively.
Pathobiomechanics And Implant Failure: What You Should Know
Failure to recognize and address underlying biomechanical pathology can result in suboptimal results and early failure in joint preserving procedures. This patient had intrinsic hallux equinus pathobiomechanics that the surgeon did not address at the index procedure. This in turn led to early implant failure and the need for reoperation as the biomechanics went unchanged and were further exacerbated by overstuffing the joint through implant placement. Had the previous surgeon performed a joint modifying osteotomy in accord with the implant in an effort to mitigate the retrograde pull of the proximal phalanx of the hallux on the metatarsal, the implant survivorship likely would have been much stronger. This patient’s case also supports the consideration toward initial definitive surgical correction as the procedure of choice as the natural course of joint sparing procedures, in many cases, is progressive degeneration and an eventual need for definitive fusion.5
The choice between joint sparing and joint destructive procedures in the realm of hallux limitus/rigidus is one of constant debate. The selection of joint sparing procedures is usually based upon patient preferences for maintenance of motion in the joint and the surgeon acquiescing to this request, rendering the likely need for revision at some future date.
Patients often do not have education that functional outcomes of fusion are equitable if not superior to joint sparing procedures.6 It is the duty of the surgeon to inform patients of options available to them and guide them to the most logical definitive procedure that will give them a predictable outcome. Correctly and intentionally evaluating individual patients as to their specific inherent pathobiomechanics and subsequent guidance toward definitive surgical solutions according to their specific mechanical deficit can help alleviate complications, and the need for early revision that we presented in this case.
Dr. Matthews is a Fellow in Reconstructive Foot and Ankle Surgery at the Weil Foot and Ankle Institute in Des Plaines, Ill.
Dr. Sorensen is a Fellow in Reconstructive Foot and Ankle Surgery at the Weil Foot and Ankle Institute in Des Plaines, Ill.
1. Coughlin MJ, Mann RA. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. J Bone Joint Surg Am. 1987;69(1):68-75.
2. Gross CE, Hsu AR, Lin J, Holmes GB, Lee S. Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013:6(6):471-478.
3. Gibson JNA, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus. Foot Ankle Int. 2005;26(9): 680-690.
4. Gross CE, Hsu AR, Lin J, Holmes GB, Lee S. Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013:6(6):471-478.
5. Coughlin MJ, Shurnas PS. Hallux rigidus grading and long- term results of operative treatment. J Bone Joint Surg Am. 2003;85(11):2072-2088.
6. Raikin SM, Ahmad J, Pour AE, Abidi N. Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J Bone Joint Surg Am. 2007;89(9):1979-1985.