Providing two case studies, these authors discuss failed hemi-implant arthroplasties secondary to malalignment and loosening treated with explantation and conversion to a two-component total joint prosthesis.
Researchers have described multiple procedures for end-stage hallux rigidus, with one such procedure being a great toe hemi-implant arthroplasty, which shows favorable midterm outcomes while maintaining joint motion.1-8 Hemi-implant arthroplasty requires an acute attention to detail as malalignment of the implant at the time of insertion can lead to persistent pain, prosthetic component loosening and metallic wear debris, resulting in failure.9-11 When these complications occur, salvage procedures are often limited to a stemmed implant or arthrodesis of the first metatarsophalangeal joint (MPJ).
A literature review of salvage procedures for hemi-implant failure of the first MPJ revealed only cases describing explantation of the hemi-implant with bone block arthrodesis but never a total joint prosthesis.10,11 Many surgeons perform first MPJ arthrodesis after a failed implant, either due to believing it is the gold standard for hallux rigidus or because after explantation, rarely is there enough bone stock for reimplantation, thus making arthrodesis with bone block a viable option.11,12 Gross and colleagues also note that revision first MPJ arthrodesis has a prolonged recovery period, lower satisfaction scores and higher rate of non-unions, all of which need to be considerations prior to moving forward with surgery.11
Usuelli and colleagues state many patients initially prefer implant placement as they would like to keep motion in the first MPJ.12 For certain patients, we believe this remains true even after failed hemi-implants.12 To our knowledge, this is the first description of the salvage of failed hemi-implant with conversion to a two-component total first MPJ prothesis in the literature.
Pertinent Insights On Two Patients Who Needed Arthroplasty Revision
The first case involves a 59-year-old woman who had a revision of a first metatarsal osteotomy with conversion to a hemi-implant (BioPro First MPJ Hemi Implant, BioPro) due to the development of grade 1 hallux rigidus in 2013.13,14 The patient developed persistent pain to her forefoot and avascular necrosis secondary to loosening of the implant and compensatory gait (Figure 1). In 2016, the patient had explantation of the hemi-implant with conversion to a two-component total joint prosthesis (Movement Great Toe System, Integra LifeSciences) and shortening osteotomies of her second, third and fifth metatarsals (Figure 2,3). The patient was weightbearing on a flat foot immediately after surgery with a transition to regular shoe gear at four weeks. She healed uneventfully. At a 16 month follow-up, the patient had mild stiffness but no pain to her great toe and resolved forefoot pain. She has been able to return to her activities in the professional dog show circuit.
The second case involves a 56-year-old woman with grade 3 hallux rigidus who had a hemi-implant arthroplasty (BioPro First MPJ Hemi Implant) in 2008.13,14 Unfortunately, this failed to relieve her great toe joint pain due to collapse of the first metatarsal head with intramedullary cyst formation (Figure 4). In order to maintain some motion, the patient ultimately had explantation of her hemi-implant with conversion to a two-component total joint prosthesis (Movement Great Toe System) in 2016 (Figure 5). This patient was also immediately weightbearing and in regular shoe gear around four weeks. The patient healed uneventfully. At a 13-month follow-up, she related mild stiffness to her great toe but no pain and the ability to return to her activities.
What You Should Know About Implant Revision
When surgeons ensure appropriate indications and accurate implant placement, metallic hemi-implant arthroplasty of the first MPJ has similar outcomes as first MPJ arthrodesis.15-19 Unfortunately, hemi-implant arthroplasties that fail leave few options beyond implant removal with either reimplantation of a thicker hemi-implant or a soft tissue interpositional arthroplasty, conversion to stemmed one-piece silicone-type prosthesis or arthrodesis with use of a structural bone graft. Due to the loss of a majority of the first metatarsal head coupled with the failed hemi-implant, the treatment options in our patients were reduced to only a structural bone block distraction arthrodesis of the first MPJ. This is a very morbid procedure with a lengthy recovery period, consisting of non-weightbearing for at least eight weeks and partial weightbearing in possible excess of six months’ time with a high risk of symptomatic nonunion.20
Instead, in an effort to provide some motion along with a quicker return to activity, we first performed explantation of the hemi-implant arthroplasty with resection of the metatarsal head to viable bone. The now healthy bone easily accepted the two-component total joint prosthesis due to the modularity between the metallic stemmed first metatarsal head and metallic polyethylene-capped stemmed base of the proximal phalanx component. Both patients noted complete relief of preoperative pain and were happy with the functional level of their great toe joint at greater than 13 months postoperative follow-up.
While the short-term results are promising, there are concerns that exist regarding any possible future salvage options for the first MPJ should two-component prostheses fail. These options remain limited to a revision with another two-component total joint prosthesis, structural bone block distraction arthrodesis or partial first ray amputation.18,19 Ultimately, we advocate for long-term surveillance to provide additional insight to efficacy of the above approach.
Dr. Thompson is a second-year podiatric medicine and surgery resident within the Gundersen Medical Foundation in La Crosse, Wis. He has no conflicts of interest to disclose.
Dr. Roukis is attending staff in the Orthopaedic Center at the Gundersen Health System in La Crosse, Wis. He is Past President and Fellow of the American College of Foot and Ankle Surgeons. He is a consultant for DePuy Synthes, FH ORTHO, Integra and Novastep. He receives royalties from CrossRoads Extremity, Novastep and Stryker Orthopaedics.
- Townley C, Taranow W, Townley C, et al. A metallic hemiarthroplasty resurfacing prosthesis for the hallux metatarsophalangeal joint. Foot Ankle Int. 1994; 15(11):575-580.
- Kissel C, Husain Z, Wooley P, et al. A prospective investigation of the BioPro hemi-arthroplasty for the first metatarsophalangeal joint. J Foot Ankle Surg. 2008; 47(6):505-509.
- Sorbie C, Saunders G, Sorbie C, et al. Hemiarthroplasty in the treatment of hallux rigidus. Foot Ankle Int. 2008; 29(3):273-281.
- Konkel K, Menger A, Retzlaff S, et al. Result of metallic hemi-great toe implant for grade III and early grade IV hallux rigidus. Foot Ankle Int. 2009; 30(7):653-660.
- Giza E, Sullivan M, Ocel D, et al. First metatarsophalangeal hemiarthroplasty for hallux rigidus. Int Orthop. 2010; 34(6):1193-1198.
- Salonga C, Novicki D, Pressman M, et al. A retrospective cohort study of the BioPro hemiarthroplasty prosthesis. J Foot Ankle Surg. 2010; 49(4):331-339.
- Clement N, MacDonald D, Dall G, et al. Metallic hemiarthroplasty for the treatment of end-stage hallux rigidus: Mid-term implant survival, functional outcome and cost analysis. Bone Joint J. 2016; 98-B(7):945–51.
- Cook E, Cook J, Rosenblum B, et al. Meta-analysis of first metatarsophalangeal joit implant arthroplasty. J Foot Ankle Surg. 2009; 48(2):180-190.
- Ghalambor N, Cho D, Goldring S, et al. Microscopic metallic wear and tissue response in failed titanium hallux metatarsophalangeal implants: Two cases. Foot Ankle Int. 2002; 23(2):158-162.
- Garras D, Durinka J, Bercik M, et al. Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty. Foot Ankle Int. 2013; 34(9):1227-1232.
- Gross C, Hsu A, Lin J, et al. Revision MTP arthrodesis for failed MTP arthroplasty. Foot Ankle Spec. 2013; 6(6):471-478.
- Usuelli FG et al. Bone-block arthrodesis procedure in failures of first metatarsophalangeal joint replacement. Foot Ankle Surg. 2017;23(3):163-167.
- Roukis TS, Dawson DM, Erdmann BB, et al. A prospective comparison of clinical, radiographic, and intra-operative features of hallux limitus and hallux rigidus. J Foot Ankle Surg. 2002; 41(3):76-95.
- Elliot AD, Borgert AJ, Roukis TS. A prospective comparison of clinical, radiographic, and intra-operative features of hallux rigidus: long-term follow-up analysis. J Foot Ankle Surg. 2016; 55(3):547-561.
- Kim P, Hatch D, DiDomenico L, et al. A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint implant and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus. J Foot Ankle Surg. 2012; 51(1):50-56.
- Erdil M, Elmadag N, Polat G, et al. Comparison of arthrodesis, resurfacing hemiarthoplasty and total joint replacement in the treatment of advanced hallux rigidus. J Foot Ankle Surg. 2013; 52(5):588-593.
- Voskuiji T, Onstenk R. Operative treatment for osteoarthritis of the first metatarsophalangeal joint: Arthrodesis versus hemiarthroplasty. J Foot Ankle Surg. 2015; 54(6):1085-1088.
- Gibson J, Thomson C, Gibson J, et al. Arthrodesis or total replacement arthroplasty for hallux rigidus: A randomized controlled trial. Foot Ankle Int. 2005; 26(9):680-690.
- Brewster M. Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature. J Foot Ankle Surg. 2010; 49(6):546-552.
- Da Cunha RJ, Karnovsky SC, Fragomen AT, Drakos MC. Distraction osteogenesis and fusion for failed first metatarsophalangeal joint replacement: case series. J Foot Ankle Int. 2018; 39(2):242-249.