Displaced implant

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Saw this 50 year old female with complaints of pain in the 1st MTPJ.
She gave a history of having a total joint replacement approx. 15 years prior.

A litle surprised at the X-ray!

Let me know what you think should be done.

Steve

 

Whoa! I've never seen such a thing!

My initial thoughts would be to do a fusion with bone graft but it looks as if you'd have to pretty much replace the entire proximal phalangeal portion.

Or perhaps purse-stringing the capsule so it interposes between the proximal implant and the proximal phalanx?

Have you seen her back yet since you posted?

 

Hi Nat:
Thanks for the reply. I was wondering if anyone was going to comment on this.
I believe she is on the schedule for today. Guess I have to think of something!
Steve

 

Steve:

Sorry I didn't reply sooner. I would probably remove both halves of the implant and convert this into a Keller bunionectomy. Maybe a cerclage wiring of the proximal phalanx to bring the pieces into alignment would be the best way to proceed. I think it would be pretty heroic to attempt a fusion at this point unless the proximal phalanx was intact.

About a decade ago, I was sent a 38 year old man who had a Keller procedure and was having chronic 1st MPJ pain. One of the orthopedic surgeons I work with and I did a fusion with an iliac crest bone graft with plating that worked great. But my patient's proximal phalanx was not fragmented. The patient went back to playing basketball after it all healed.

 

Hi Kevin:

I appreciate the feed back.

BTW: The 8 year old I saw with the six toes and metaheads. I did his surgery a week ago and took some intra op and 1 week post op (today). I did post a couple pre-op photos of him.
I'll post them when I get a chance.

Steve

 

Is it necessary to remove the distal half of the implant? It seems as if that removal would make the proximal phalanx lose all structure. The pain is in the joint rather than around the implant, yes?

This patient essentially already has a Keller. If you were to resect any more of the proximal phalanx, the toe would shorten further and she might not be in any less pain.

Perhaps you could leave both halves of the implant in place and interpose a portion of the EHL tendon in between the proximal implant and the bone to act as a natural soft implant? You could suture the EHL to the plantar capsule so it would stay in place.

How did your discussion with the patient go today, Steve?

 

Hi Steve,

I'm looking forward to hearing what the final decision was and the outcome of this!

I'm not yet a qualified surgeon so have limited experience/knowledge on difficult cases like this. The 1st thing I thought of when looking at this was a fusion with iliac crest graft. I admittedly didn't think about the proximal phalanx being fragmented. I don't suppose you have any other x-ray views available out of interest?

I was also wondering if the patient was having any 2nd MTPJ pain? I made the assumption that due to the medial deviation of the 2nd toe noted on the x-ray that the MTPJ is unstable because of overloading due to 1st ray insufficiency (?) and thought the procedure would need to try and address this so thought a keller would be inappropriate? I may be miles off with that!!

Look forward to hearing how this goes,
Regards,
Ryan.

 

Probabaly too late to help, but I did have a patient about five years ago where this had happened, she was refered to Orthopeadics and had the implant removed and an adapted Kellers. Shes fine now no pain and walks with no pain.

 

What was the "adapted" portion of the Keller? Do you know what the modification was?

 

Sadly no, as a private practioner here in UK I'm not privvy to National Health Information ie;Operation Notes or X rays. I am an orthopaedic trained nurse as well as a Pod so I was very curious at the time. If memory serves me right they simply removed what was left of the met head and fused it with wire. I haven't seen the lady for some time but last year she came here for basic nail care and was symptom free.

 

Wow...it seems as if being able to access the health information could be helpful. But you're not permitted???

 

No, you have to be a employee of the NHS and all the Police Criminal Record checks and references that go with it. Personally I think its downright dangerous to rely on the patient to remember all the details of their medical history as half the time they don't know themselves as it's only recently that patients have had access to their own notes! Very much a closed shop where mistakes have been made and covered up. We thank the USA for the Freedom of Information Act.

 

Thread bump, hoping Dr. Steve will follow up!

 

Hi Nat:
Wish I could.......the patient in question has not booked her surgery so I haven't done anything for her yet.
I'm planing on removing the distal segment and evaluating it. Maybe that's all she'll need.
The distal stem is protruding out of the shaft of the proximal phanlanx (shows up better on the lateral which I didn't upload)
I guess we'll have to wait and see if she schedules and when.
Thanks
Steve

 

Graft it, plate/fuse it, and be done with it.

LL

 

Hi LL:

As you may know from previous posts....I'm not a big believer in fusion of the 1st MTPJ.
I know what you mean though about "being done with it" - if the implant head is left she may have problems in the future with this.

I was hoping that if I need to remove both parts I couuld replace with a one piece total.

We may never know if she fails to schedule.

Steve

 

I would take the distal portion of the implant out and leave it at that. I bet the fragments are solid. It appears someone was too aggressive with the mallet.

 

Hi All:
Finally got these uploaded.
Please see original post in this thread for the pre-op radiograph.
She had so much bone cement that her capsule was non existent, thus I had to place a graft over the new implant.
She healed incredibly fast and was back into a shoe in 2 1/2 weeks.
She and I were both very pleased.

Steve

 

Thanks for the follow up. I was wondering how this case turned out. How much difficulty did you encounter removing the distal half of the previous implant?

 

Hi Nat:
Well, the joint was very very tight and the implants were overgrown with reactive bone. Once I got the proximal component out I was able to convince the distal segment to follow suit. It took a bit of convincing from a rongeur and periosteal elevators, but it came free.

Besides the capsule being absent, my main problem was the fact that the stem of the distal component had eroded through the medial side of the proximal phalanx and the stem of the new silastic total joint wanted to go through the same hole. I packed the defect with some autogenous bone and it worked fine.

Steve

 

Well done, Dr. Arbes.

 

Cor.
That was pretty interesting! thanks for posting it.

And yay me because normally looking at photos of surgery makes me go dizzy and feel sick - somehow suspect that career as Podiatric surgeon was never on the cards for me!

 

Charlie70
You'd be surprised what you can get use to!
Steve