Revision of 1st MTPJ Arthrodesis

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A quick enquiry for our bone cutters - have a patient who has undergone 1st MTPJ arthrodesis for mild HAV courtesey of one of our orthopaedic butchers and is now having midfoot and knee pain as a result - she is a very active 60 y/o. Haven't seen any x-rays as yet, but what are the outcomes for revision surgery which is geared towards restoring some joint function at the MTPJ - such as TJRs?

Many thanks

 

Hi Mark

Fraught with problems, not least because the arthrodesis will have shortened the bone and the surrounding soft tissue will have conformed according to Davies's law. Implant is probably the most popular solution, but no perfect implant has been discovered for the complexity of the 1st MTPJ, particularly because the sesamoid articulation is likely to have been compromised. Ultimately, it depends on how painful the complaint is, and whether she wishes to undergo further surgery which could not guarantee a 100% improvement and which, given the current longevity of the western races would need replacing at least once.

All the best

Bill

 

Bill's right. Leave it.
It's a very difficult thing to un-fuse a joint, especially a weight bearing one.

The other unknowns is what the capsule and EHL look like. Sometimes the care taken to preserve soft tissue structures during other procedures is not necessarily taken with a fusion.

Normally a revision surgery after a fusion is another fusion.

Steve

 

ThNks chaps - suspected as much, if there's one area in foot surgery that's rife for development it's 1st MTPJ replacements - always surprised to see the stylistic v hinge implant used in TJR procedures as they seem so inadequate when you consider what they stand in for. Surely these days of precision engineering it's not beyond some enterprising designer to put together a double pegged ball joint which more closely resembles the met head? I know a few of our resident surgeons still fuse 1st MTPJ - but when used in cases where more dynamic procedures could help maintain some function - I would almost suggest that this is tantamount to malpractice,

 

Hi Mark:
Yes, that all makes sense. You would think!!! I do have to say that I et very good results with the "V" hinge type.

On the other side of the discussion; I think implant engineers would tell you that the goal of designing an implantable is not really to duplicate the appearance of what you are replacing, but to design a long lasting functional replacement. You would think that the original human design would be the best, but apparently there is some disagreement!


Steve

 

I agree with Steve and Bill. Revision surgery is always an uphill battle. I think your (Mark's) suggestion of malpractice is a little strong and I am hopeful that you are not called as an expert witness for any HPC investigations of surgeons! Surgery does not restore normal function in any case, revision or in a primary procedure. Patients do not have a 'normal' foot following surgery - they have a surgically altered foot, no matter what procedure you are doing.

Implants come in all shapes and sizes, but none restore normal function and all are 'joint destructive' type procedures. If a patient has severe arthritic changes at the joint, the surgeon should discuss their surgical options, the patient's expectations and likely outcomes. It is a fairly complex process and should be considered on a case by case basis. Fusion is a viable option in the right patient.

 

Mark:

I perform 1st metatarsophalangel joint (MPJ) arthrodesis procedures fairly frequently and think it is an excellent procedure for patients with moderate to end-stage DJD of the 1st MPJ. 1st MPJ arthrodesis procedures are very widely and commonly done here on the west coast of the USA. You must remember that the pain from chronic 1st MPJ DJD causes gait alterations also and generally more so than in a well-done 1st MPJ arthrodesis procedure. I have patients running marathons and doing iron-man triathlons with my 1st MPJ arthrodeses. I don't see these procedures as causing a loss of function but rather see these procedure as improving gait function. I think that you will find that the available literature on comparing arthrodesis procedures to 1st MPJ implants or Keller procedures shows that the 1st MPJ arthrodesis procedure is not only more functional but more long-lasting and with fewer complications. However, these procedures should not be done if a simpler, less joint destructive procedure or other conservative approach can produce a better result.

From your short description, I agree with the others that doing a revision on a 1st MPJ arthrodesis may be difficult but still may be the best choice for the patient if the hallux is not in a sufficiently dorsiflexed position post op. I would first, however, try a foot orthosis with a reverse Morton's extension to attempt to relieve their midfoot and knee pain since they are likely now to have much greater 1st ray dorsiflexion stiffness due to the 1st MPJ arthrodesis.

More information on the patient would help us help you more. Weightbearing photographs or xrays, especially lateral photos on an orthoposer, to see how dorsiflexed the hallux is from the ground during weightbearing would be very helpful.

By the way, I would be very careful before I start suggesting that a procedure is "malpractice" unless you have the full story behind the case. Try putting yourself in the position of the health professional that has one of their patients seeing another health professional and the words "malpractice" come out of their lips in their discussion with the patient. I'm sure you wouldn't want another podiatrist seeing one of your patients suggesting that "malpractice" had occured during the treatment you had performed just because this procedure isn't one that they perform for their own patients. There are many ways to "skin a cat" when it comes to effective and ethical patient treatment.