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Total Joint after failed 1st MTP Joint arthrodesis

Discussion in 'Foot Surgery' started by Judith004, Sep 3, 2013.

  1. Judith004

    Judith004 Member


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    I have a patient with chronic hallux IPJ pain following a 1st MTP Joint arthrodesis 8 years ago. On x-ray the joint does not look arthritic, but the chronic pain is getting in his way and keeping him from doing things he wants to be doing. I did not perform the arthrodesis, and the orthopedic surgeon who did the procedure keeps telling him that he "shouldn't be having this pain", but has no ideas as to any type of treatment for it. The patient is now convinced he should never have undergone the arthrodesis and he should have gone for a total joint instead.

    All conservative trials have failed, including: Morton's extension, reverse Morton's extension, carbon fiber plates, rocker bottom shoe, Dexamethasone injection into the IPJ, physiotherapy, etc.

    Has anyone here had any experience performing a total joint after an arthrodesis? The hardware was removed several years ago.

    Thanks for your thoughts!
     
  2. Lee

    Lee Active Member

    Hi Judith.

    I have revised a few 1st MTPJ non-unions to implants. It is not a perfect solution in any case and you are right to explore as many conservative options for this patient. If the joint has fused and the patient expects that having an implant is the answer to their prayers, they probably need a reasonable amount of counseling regarding the fact that replacing a fusion with an implant is not going to restore a 'normal' 1st MTPJ feel, function and appearance. My main indication for revising failed 1st MTPJ fusions to implants is non-unions that have failed to respond to conservative care (eg. immobility, bone stimulator, etc...) that either don't want a revision fusion or refuse the post-op immobility or to give up smoking. I feel much more comfortable considering it if they are complaining of specific joint/ non-union pain. I also inject the non-union site with a corticosteroid/ local anaesthetic under mini c-arm guidance and if the patient reports some symptomatic relief (even just for the duration of the LA) I would feel more comfortable with revising it to an implant.

    In the few that I have done, they were all smokers and had at least one attempt at a fusion. The last one I did (about 3-4 weeks ago) had had 2 attempted fusions - the second with a locking plate and calcaneal graft. I revised it to a Swanson and so far, the patient is really happy. Although clinical results are very good so far and the patient has surprisingly good active non-weightbearing range of motion, I'm not holding my breath on it. I suspect she will get a degree of (hopefully) transient transfer metatarsalgia. Some of the other patients I did this for developed this and needed orthoses (one that springs to mind will need them forever I suspect).

    Have any of the conservative treatments helped at all? When you injected the IPJ, did you use LA and did you only inject the IPJ? Was this done under x-ray guidance? Did the patient get any temporary symptomatic relief? Is it a confirmed arthrodesis and what scans/ tests have been performed to investigate the source of pain/ pathology? Is there any sign of motion at the fusion site clinically and is this painful? On the x-rays are there reasonable signs of fusion and is the hardware stable? When was the fusion done and when did the pain develop? What sort of pain is it? Probably the best I advice I could give you is to investigate the source of the pain prior to the patient considering revision surgery - the last thing you (and him) need is a future post-op patient presenting with the same or worse problem.

    If the pain is specific to the IPJ and this has been confirmed by clinical exam, imaging and your injection, you could consider surgery to the IPJ - arthoplasty, fusion or implant to it and leave the 1st MTPJ alone if it's solid? Pre-op counseling worries still apply!

    Hope this helps,
    Lee
     
  3. drsarbes

    drsarbes Well-Known Member

    Well said Lee.
    After 8 years it would be problematic to replace the joint mainly because of disuse atrophy of the tendons and synovium as well as the met sesamoid articulations.

    IMHO the hallux fusion was done too rectus (not dorsiflexed enough given the amount of ROM of the IP joint - which should be evaluated preoperatively)

    steve
     
  4. Stanley

    Stanley Well-Known Member

    Hi Lee,

    If dorsiflexion is required at the first MPJ and there is not enough available then the IPJ takes the brunt of the force.
    I had a patient over 10 years ago that had a fusion of both 1st MPJ's. I forgot what the exact problem was, but I reversed the worst foot with a total 1st MPJ implant (Dow Corning).
    I still see her for routine foot care. She has no problems with the foot with the implant, but her foot with the fusion has become progressively worse. She would like to have the joint implant performed on this foot, but she is too old and frail to have it done.
    I would first try a rocker platform shoe (take a thick soled shoe and grind the area distal to the 1st MPJ) to decrease the need for dorsiflexion of the 1st MPJ, or have a shoe maker add one to an existing shoe.

    Regards,
    Stanley
     
  5. Ryan McCallum

    Ryan McCallum Active Member

    In my opinion, there are two likely explanations for the discomfort.

    It is possible that the hallux has not been fused in an ideal position. I have seen a fair few cases where the hallux has been fused in line with the metatarsal (same declination angle) or just off and as a result, there is not enough "rocker effect" at the joint. This generally increases the forces going through the IPJ and it becomes symptomatic. A lateral weight bearing x-ray will help determine whether this is the case or not. Also, it is not uncommon to note a skin lesion plantar to the IPJ however this is not always the case. I have done a few dorsiflexory osteotomies for these cases and they have thankfully all worked out well.

    The other possible cause could be early degenerative changes within the IPJ however, if this were the case, it is unusual that an intra articulate injection failed to provide any symptomatic relief.

    As Lee stated, in these cases of chronic pain post surgery, it is extremely important to council the patient well and ensure expectations are realistic prior to considering further surgery.

    Good luck.
    Ryan

    Edit: apologies for repetition, I did not see Steve & Stanley's reply before posting that.
     
    Last edited: Sep 8, 2013
  6. Judith004

    Judith004 Member

    I thank you all for your replies. They are very helpful!
     
  7. Judith004

    Judith004 Member

    I wanted to get back to those of you who kindly helped me with this patient. Your information was very helpful. I did measure the angle of the fusion, which was just fine. However, this patient has a rigidly plantarflexed first metatarsal, so even though the angle of the fusion between the first metatarsal and the hallux was perfect, the hallux was actually plantarflexed relative to the supporting surface. We had all been looking at the wrong angle! So, we discussed a dorsiflexory osteotomy of the metatarsal proximal to the site of the arthrodesis, and he will be seeing the orthopedic surgeon next week who performed the initial arthrodesis. ( I am secretly hoping the patient chooses to have the other doctor perform this surgery so if the hallux is now poking out the top of the shoe, he can't come back to me!) But the dorsiflexion of the hallux would be the only complication I could see from this revision, and the IPJ wouldn't have to hyperextend anymore.

    I would not have previously looked at the angle between the hallux and the supporting surface when planning a 1st MTP joint arthrodesis, but I sure will on every one from here, on!

    Again, thank you all for contributing to this learning experience and mostly for helping my patient.
     
  8. Most foot surgeons I know, including myself, have always used the hallux to ground angle to determine the optimum sagittal plane angulation for 1st metatarsophalangeal joint arthrodesis procedures. Possibly this is not the case in your country or area?
     
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